Report to Congress Section 1661 of the National Defense
Authorization Act for Fiscal Year 2008 Phase 1
Supporting Adjustment and Readjustment of Active
Military, Veterans, and Family Members:
IOM’s March 31, 2010
Returning Home from Iraq and Afghanistan: Preliminary Assessment of
Readjustment Needs of Veterans, Service Members, and Their Families
September 2010
I. Introduction
II. Response to IOM’s Recommendations
A. IOM Recommendation 1
1. DoD Response to IOM Recommendation 1
2. VA Response to IOM Recommendation 1
B. IOM Recommendation 2
1. VA Response to IOM Recommendation 2
C. IOM Recommendation 3
1. DoD Response to IOM Recommendation 3
2. VA Response to IOM Recommendation 3
D. IOM Recommendation 4
1. DoD and VA Response to IOM Recommendation 4
E. IOM Recommendation 5
1. DoD Response to IOM Recommendation 5
F. IOM Recommendations 6, 7, and 8
1. DoD Response to IOM Recommendations 6, 7, and 8
2. VA Response to IOM Recommendations 6, 7, and 8
G. IOM Recommendation 9
1. VA Response to IOM Recommendation 9
H. IOM Recommendation 10
1. DoD Response to IOM Recommendation 10
2. VA Response to IOM Recommendation 10
III. Conclusion
IV. Appendices
Appendix A (IOM Recommendation 1): Rigorous DoD Studies on Readjustment Needs
Appendix B (IOM Recommendation 1): Rigorous VA Studies on Readjustment Needs
Appendix C (IOM Recommendation 2): VA Long-term Management Studies
Appendix D (IOM Recommendation 2): VA Conference Presentations and Publications
Appendix E (IOM Recommendation 3): Vet Center and Mobile Vet Center Locations
Appendix F (IOM Recommendation 4): VA Studies - Stigmatization
Appendix H (IOM Recommendations 6, 7, and 8): Related VA Studies
Appendix I. OEF/OIF-Specific Data
Appendix J: Acronyms
To address a 2008 Congressional mandate to study the physical and mental health and other readjustment needs of members and former members of the Armed Forces who deployed in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and their families as a result of such deployment (Public Law 110-181), the Institute of Medicine (IOM) of the National Academy of Sciences published Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members and Their Families on March 31, 2010. This document presents a joint response from the Secretary of Defense and the Secretary of Veterans Affairs in response to the IOM report. This report on the first phase of a two-part study describes data collection methodology, summarizes preliminary findings, and proffers ten recommendations for future research. In general, the Department of Defense (DoD ) and the Department of Veterans Affairs (VA) support the majority of IOM’s recommendations, and are pleased to report that many of the recommended actions are already well underway, with particular emphasis on OEF and OIF Service members and Veterans.
In the sections that follow, comments are provided for each recommendation that include descriptions of the ongoing and completed studies and programs that address the suggested actions. Lists and brief descriptions of studies and publications are included in appendices A through H.
IOM considered data from numerous sources to include:
• searches of peer-reviewed literature;
• data from DoD and VA;
• reports from the Government Accountability Office;
• reports from the Congressional Budget Office;
• reports from the Congressional Research Service;
• reports in the popular press;
• relevant Congressional testimony;
• IOM reports on PTSD, PTSD treatment, the effects of deployment-related stress, and the long-term outcomes related to TBI: and
• six town hall meetings with active duty personnel, Veterans, family members, health-care providers, and community leaders.
Because information on specific readjustment needs of OEF/OIF Service members, Veterans, and their families is limited, IOM included in its review reports and studies on the Service members and Veterans of the Second World War, Korea, Vietnam, and the Gulf War. The authors make it clear that direct comparisons may not be appropriate because many more Service members now survive wounds they would not have survived in earlier conflicts.
Not surprisingly, much of the data included in IOM's chapter on preliminary findings has been reported elsewhere and complete citations are provided in the text. We have culled IOM's preliminary findings for those that are specific to the OEF/OIF conflicts and have included them as appendix I. As they do in the text, the OEF/OIF-specific findings address six areas of interest to include:
• TBI and related blast injuries;
• polytrauma;
• mental health disorders;
• deployment;
• women and minorities; and
• projecting the lifelong burden of war.
We look forward to Phase 2 of the study, “a comprehensive assessment… of the physical and mental health and other readjustment needs of members and former members of the Armed Forces who deployed in OEF or OIF and their families as a result of such deployment” (P.L. 110-181). Among the minimum requirements for Phase 2 outlined in the legislation, DoD and VA are particularly interested in new information on:
• An assessment of the particular impacts of multiple deployments
• An assessment of the full scope of effects of TBI and the efficacy of current treatment approaches
• An estimate of the long-term costs associated with “undiagnosed” injuries such as PTSD and
• “Recommendations for programs, treatments, or policy remedies targeted at preventing, minimizing, or addressing the impacts, gaps, and needs identified.”
II. Response to IOM’s Recommendations
In general, the Department of Defense (DoD ) and the Department of Veterans Affairs (VA) support the majority of IOM’s recommendations, and are pleased to report that many of the recommended actions are already underway, with particular emphasis on OEF and OIF Service members. Comments are provided for each recommendation that include descriptions of the ongoing and completed studies and programs that address the suggested actions.
A. IOM Recommendation 1
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on readjustment needs of returning OEF and OIF [V]eterans, their families, and their communities that explicitly addresses methodologic and substantive gaps in completed and ongoing research. For example, the support of large-scale, independent studies with longitudinal designs, probability sampling, comprehensive clinical assessment of key outcomes, and more fully specified models that include objective biologic measures should be considered.
1. DoD Response to IOM Recommendation 1
DoD and VA agree with this recommendation and have worked steadily to develop and implement the most rigorous scientific investigations possible. In 2007, representatives from DoD, VA, various NIH (National Institutes of Health) institutes (e.g., National Institute of Mental Health [NIMH], National Institute of Neurological Disorders and Stroke [NINDS]), other federal agencies, and subject matter experts, primarily from academia, met as a working group to identify and prioritize research gaps in post-deployment military readjustment literature. This major effort directly informed the planning and development of the largest targeted research funding opportunity for deployment-related mental health and brain injury conditions in U.S. history. Supplemental Fiscal Year 2007 (FY07) DoD funding provided $150 million for Posttraumatic Stress Disorder (PTSD) research and an additional $150 million for traumatic brain injury (TBI) research. In FY09, Congress provided an additional appropriation of $55 million for psychological health (PH) and TBI research. Currently, DoD is investing more than $20.1 million in longitudinal studies on readjustment needs of Warriors and their families. One such study is described below.
Study to Assess Risk and Resilience in Service Members (Army STARRS)
Funded by the U.S. Army, and conducted by NIMH and an interdisciplinary team from four leading academic research institutions, this is the largest study of suicide and mental health
among military personnel ever undertaken. The research team, from the Uniformed Services University of the Health Sciences (USUHS), Harvard University, the University of Michigan, and Columbia University, is internationally known for its expertise and experience in research on military health, health and behavior surveys, epidemiology, and suicide, including genetic and neurobiological factors involved in suicidal behavior. The study will have both a retrospective and a prospective component.
Investigators will undertake a retrospective case-control study, comparing Soldiers with suicidal behavior (cases) to similar Soldiers without suicidal behavior (controls) in order to identify characteristics, events, experiences, and exposures that may be predictive of Soldiers’ suicides. This study design will make it possible to begin generating information on risk and protective factors—and how to determine who is at high risk—very rapidly. Study investigators will produce actionable information that the Army can use to develop and refine interventions to prevent future suicides and address related PH issues.
For the prospective study, investigators will follow a representative sample of approximately 90,000 active duty Soldiers (including mobilized Reserve Component and National Guard Soldiers), from whom they will collect detailed information on psychological and physical health, exposure to adverse events, attitudes, social supports, leadership and unit climate, training and knowledge, employment and economic status, family history, and other potentially relevant domains over the life of the study. Biological specimens (e.g., saliva and/or blood) will be collected for genetic and neurobiological studies. This will provide rich longitudinal information relating Soldiers’ characteristics and experiences to subsequent psychological health, suicidal behavior, and other relevant outcomes and will identify high-risk periods in a military career.
Other Ongoing Studies
In its report, the IOM comments that the “committee is aware of the Millennium Cohort study [and] several studies being conducted by RAND” (p. 156). Two of these studies are summarized briefly below.
The Millennium Cohort Study (MCS)
Launched in the summer of 2001, this study follows a random sample of over 150,000 U.S. military personnel from all Services, including both active duty and Reserve/National Guard members, for up to 21 years. Approximately 50 percent of the cohort has been deployed in OEF and OIF. The MCS study is designed to investigate exposures and health outcomes temporally, to detect outcomes with longer latency, and to ascertain symptom and illness duration, resolution, and chronicity. The unique aspect of this study is its ability to link this data to a wealth of DoD and VA electronic data that includes personnel files, birth and infant health, inpatient and outpatient health care use, pharmaceutical use, vaccination history, deployment
experience, exposures, and mortality. Links with other federal databases (e.g., Centers for Disease Control and Prevention [CDC], National Death Index [NDI], and Social Security Administration [SSA]) are being utilized in this ongoing study.
The study is in its eighth year and current areas of research include investigations differentiated by deployment focusing on diabetes; weight change; hearing loss; migraine headaches; unit cohesion; complementary and alternative medicine and health care use; physical activity and PTSD symptoms; professional care provider occupations; PTSD and depressive symptoms; chronic multi-symptom illnesses and associated co-morbidities; motor vehicle accidents; head trauma; back pain; tendonopathies and other injuries; and cause-specific mortality including suicide.
The impact of military service and deployment health on families will be evaluated through a spousal assessment component in the 2010-11 survey cycle. This study will be the first of its kind to use a large cohort to assess the impacts on spouses and co-resident children, and to evaluate the quality of family relationships.1
Funded by DoD through the Military Operational Medicine Research Program (MOMRP) and conducted at the Navy Health Research Center (NHRC) with co-investigators from all Services and VA, this large study will assess career-span health outcomes beyond military service and serve as a showcase for DoD and VA cooperation.
RAND Corporation’s Deployment Life Study (DLS)
The DLS is a 3-year longitudinal study that began in March 2009 to examine the impact of deployment on the health and well-being of military families. This study will recruit approximately 9,600 Army, Navy, Marine and Air Force families, following them across an OEF/OIF deployment cycle, and assessing a number of outcomes over time. These outcomes include: (i) the emotional and physical health of each family member, (ii) family relationship quality and longevity, (iii) financial well-being and role performance, and (iv) for children, school performance, and social development.
The project will collect longitudinal data from approximately 5,000 (anticipated at follow-up) military families, including the Service member, his or her spouse, and, if one exists, one child 11 years of age or older (with parental consent). The baseline interview will be conducted by phone. Every 4 months after baseline, the respondent will log into a Website to complete an online survey. The project will take place over 36 months for nine waves of data collection, spanning a period of 6-12 months pre-deployment, throughout deployment, and post-deployment.
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1 The study team estimates that 10,000 spouses will be enrolled in this component, and that about half of these will be the spouses of individuals deployed at least once to OEF and OIF.
The project will examine specific behaviors as mediators of the deployment effects, such as: accessing health care or social support services, shifts in the division of labor within the family, changes in communication patterns and style, etc. Investigators will also be able to examine how changes in some outcomes (e.g., the marital relationship) account for changes in other outcomes (e.g., child school performance).
The DLS is being conducted within the RAND Center for Military Health Policy Research, a joint research initiative between RAND Health and the RAND Arroyo Center. This project is funded by the offices of the U.S. Army Surgeon General and the Assistant Secretary of Defense for Health Affairs.
Appendix A lists active DoD-funded longitudinal studies on PH and TBI.2 The list includes studies from the Congressionally Directed Medical Research Programs (CDMRP) FY07 and FY09 rounds as well as other DoD funding entities and mechanisms (e.g., US Army Medical Research and Materiel Command’s (USAMRMC), MOMRP, and Telemedicine and Advanced Technology Research Center [TATRC]).
2. VA Response to IOM Recommendation 1
VA notes the following points regarding research-related limitations the Committee highlighted in the Phase I assessment:
• The question of sampling is critical to validity, as the Committee noted. While samples of convenience may limit generalizability, it is more likely the case that this issue could relate to some smaller, single-site studies, although scientific peer review committees also consider generalizability carefully. Larger studies, especially those being conducted by VA's Cooperative Studies Program (CSP), address the ability to generalize as a working principle. In VA’s large-scale cohort studies, national samples considered to be representative of the population are the norm (e.g., CSP 575, a study of genetic factors related to PTSD in OEF/OIF, randomly assesses from the entire DoD manpower roster [see Appendix B).
• Brief screening instruments have some utility in clinical assessments as well as in overall surveillance of a population. According to VA Office of Mental Health Services, OEF/OIF Veterans coming to VA for the first time are screened for the presence of symptoms of PTSD, depression, and alcohol abuse. The same screening for these conditions is repeated on an annual basis for new or existing Veterans of any service era. Should the Veteran screen positive for any of these conditions, further evaluation and appropriate treatment are provided. Veterans who screen positive for PTSD or
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2 Some studies may appear in more than one appendix.
depression are also assessed for risk of suicidal behavior. This is important information for clinical purposes and may be legitimately reported at the level of surveillance.
• In VA's research portfolio, a small number of studies have examined the validity of the screening instruments directly. However, in the more definitive large cohort studies and clinical trials, the battery of assessments is quite extensive as a rule and they are not dependent upon brief screening measures. In working group recommendations on PTSD methodology, consideration of reliability, validity, including cultural appropriateness and practicality are recommended for outcome measures. (See “Advancing Research Standards for PTSD Interventions,” 2008.)
• Knowledge of VA's research portfolio will be key to further assessment by the Committee and will inform the stated limitations regarding cross sectional vs. longitudinal studies as well as focus in risk/protective factor studies. VA portfolio addresses these concerns by supporting a wide range of efforts. In some cases, specific hypotheses are being tested on a limited set of factors by design; however, in other cases, extensive batteries are used to study risk and protective factors (e.g., CSP 575). See Appendix B.
• VA research program does support cross-sectional approaches in certain cases, but it is also informed by large-scale longitudinal studies. An example of this is CSP 566 (see Appendix B) with multiple post-deployment follow up assessments of an Army cohort with pre-deployment baseline performance prior to service in Iraq.
• VA conducts an appreciable number of studies in the population of Veterans who have served in Iraq and Afghanistan. While some studies may rely on self-report, our Human Subjects Protection Program allows extensive oversight to ensure confidentiality and appreciation of sensitive issues. Examples include: (a) VA's consent process that includes information provided to participants stating that their participation in the research will not affect VA benefits or VA health care, (b) VA clinical researchers are encouraged to obtain a Certificate of Confidentiality, and this information is also conveyed to research participants. VA believes that scientific results from Veterans participating in VA research are not a priori tainted by this limitation.
As a general operating principle, VA closely coordinates post-deployment readjustment research efforts with other federal agencies. The coordination ranges from informal phone calls between offices to co-sponsored meetings and joint solicitations. Notably, VA initially led in convening expert work groups to identify research priorities for the Veterans of Iraq and Afghanistan (see “Mapping the Landscape of Deployment Related Adjustment and Mental Disorders,” 2006). The recommendations from these work groups led to publication of multiple research solicitations focused on identified gaps.
VA and NIMH have issued a series of joint solicitations on readjustment disorders in OEF/OIF Veterans, including: “Intervention and Practice Research for Combat Related Mental Disorders
and Stress Reactions,” “Network(s) for Developing PTSD Risk Assessment Tools,” and, “Clinical Pharmacotherapy for PTSD: Single and Collaborative Studies.” Both VA and NIMH committed funds for these efforts.
Probably the largest interagency effort in the area of substance use/abuse co-morbidities among active duty Service members and Veterans followed discussions with multiple federal funding agencies in 2008. At a co-sponsored meeting in January 2009, VA and its federal partners set the stage for a Request for Applications (RFA) issued by VA together with the National Institute on Drug Abuse (NIDA), the National Institute of Alcohol Abuse and Alcoholism (NIAAA), and the National Cancer Institute (NCI), with a total of up to $7 million committed by all agencies. Proposals in response to this RFA will be evaluated and approved in FY 2010.
A notable gap identified by the federal research funding agencies was the use of common measures and terminology for studies focused on TBI and PH. One major recent effort has therefore been collaborative work toward defining common data elements for PH and TBI. VA research with NIH’s NINDS, the National Institute on Disability and Rehabilitation Research (NIDRR), and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), co-sponsored an initiative to adopt common data elements (CDEs). Scientific experts participated in working groups for specific topic-driven CDEs, which were discussed in a workshop, “Advancing Integrated Research in Psychological Health and Traumatic Brain Injury: Common Data Elements,” held on March 23-24, 2009, with 137 national and international PH and TBI experts.
The process leading to the workshop and the subsequent recommendations by the working groups led to a series of manuscripts (Overview, Agency Background, TBI Definition, TBI Demographics and Clinical Assessment, Biomarkers, TBI Neuroimaging, TBI Outcomes, PTSD, and Operational Anxiety) expected to be published in the Archives of Physical Medicine and Rehabilitation in 2010. The CDEs themselves appear on a Web site launched April 1, 2010, and hosted by NINDS (http://www.nindscommondataelements.org/). The site contains a mechanism to capture feedback and suggestions for the CDEs from the community of users. Four new working groups met in March 2010 to review and adapt the TBI CDEs for pediatric relevance. Manuscripts with recommendations are in progress.
Other Methodology-Directed Activities
VA has long been considered a leader in the area of PTSD research, and in 2006 co-sponsored a work group with NIMH on the topic of clinical treatment research methodology for PTSD studies (“Advancing Research Standards for PTSD Interventions,” 2008; Leon and Davis, 2009). This meeting resulted in recommendations that were disseminated widely to the scientific
community and have been incorporated in the joint solicitations (see above) issued by VA and NIMH.
One notable VA program that has advanced the methodological rigor in clinical research is the CSP. With five coordinating centers and other multiple resource centers, the methodological rigor in CSP studies is developed through a cooperative planning process and scientific peer review in which proponents and methodological/statistical experts meet face-to-face with a review panel to defend the proposal and answer questions about concerns. When a CSP study is approved for funding, it is overseen by multiple bodies including an Executive Committee, Data Monitoring Committee (for safety and data reviews), as well as an Institutional Review Board (IRB). Appendix B lists and briefly describes some of the CSP programs related to the OEF/OIF population.
The CCTA program has made strides to incorporate the methodological rigor of the CSP studies into all clinical trials, irrespective of size. One strong example of this is the CCTA funding mechanism, which pairs the methodological expertise from a CSP coordinating center with a principal investigator to conduct small, early phase interventional work. Although this is a relatively new program, two of the initially approved studies are focused on novel TBI and PTSD treatments for the OEF/OIF population. The goal of the program is to identify treatments that appear to warrant testing at the multi-site CSP level.
VA Deployment Health Research Related to OEF/OIF Veterans
VA has an open solicitation for Deployment Health Services Research to support studies focused on deployment health care needs and services. The solicitation targets three major areas: 1) health delivery system resources, structures, and processes of utilization; 2) population characteristics; and 3) health and satisfaction outcomes. This research also has direct relevance for other Veterans, as well as for civilians experiencing disability due to injury or disease.
B. IOM Recommendation 2
The committee recommends that the Department of Veterans Affairs conduct research to determine the potential efficacy and cost effectiveness of developing protocols for the longterm management of Service members who have polytrauma and traumatic brain injury. The approaches considered should include:
• Prospective clinical surveillance to allow early detection and intervention for health complications,
• Protocols for preventive interventions that target high-incidence or high-risk complications,
• Protocols for training in self-management aimed at improving health and wellbeing,
• Access to medical care to treat complications, and
• Access to rehabilitation services to optimize functional abilities.
1. VA Response to IOM Recommendation 2
VA has been and will continue to address the long-term management of Service members and Veterans who require it. VA has an established research program on polytrauma and TBI, and translates research outcomes into improved clinical care and management. For example, the Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI (QUERI) Coordinating Center works closely with Polytrauma Rehabilitation Centers (PRCs) to identify needs and gaps in care, as well as best practices for TBI with polytrauma and traumatic amputation with polytrauma. In addition, the four PRCs and Defense Veterans Brain Injury Center (DVBIC) have established a joint VA/DoD initiative for ongoing clinical care, research, and service delivery for Veterans and active duty Service members with brain injury.
In June 2009, VA and DVBIC developed a 5-year pilot program to assess the effectiveness of providing Assisted Living (AL) services to Veterans with functional disabilities due to TBI. Veterans placed in private facilities that specialize in rehabilitation services for TBI continue to be monitored by VA care managers, and outcome data are being collected (e.g., demographic and health information, functional status, satisfaction with care, and quality of life). A report of this pilot will be provided to Congress upon the program’s conclusion in 2013.
VA is also presently collaborating with NIDRR on the national TBI Model Systems (TBIMS) project to benchmark rehabilitation and longitudinal functional outcomes with those of other TBIMS Centers, and to collaborate on research initiatives. Lastly, VA's Office of Research and Development (ORD) has numerous priorities for TBI/polytraumarelated research, including investigating long-term care and management of Veterans with polytrauma, blast-related injuries, or TBI.
Appendix C summarizes a sampling of the studies in polytrauma and TBI from VA research portfolio. Appendix D provides key associated bibliographic references.
C. IOM Recommendation 3
The committee recommends that the Department of Defense and the Department of Veterans Affairs quantify the number and distribution of mental health
professionals needed to provide treatment to the full population of returning Service members, Veterans, and their families who suffer from mental health disorders, such as PTSD, major depression, and substance abuse, [so] that they can readjust to life outside of theater. The committee also recommends that the Department of Defense and the Department of Veterans Affairs continue to implement programs for the recruitment and retention of mental health professionals, particularly to serve those in hard-to-reach areas.
1. DoD Response to IOM Recommendation 3
Significant progress has been made to recruit additional mental health personnel in order to meet the growing demand for services in DoD and VA. Between 2007 and the second quarter of 2009, the number of DoD mental health specialists grew 47 percent from 4,129 to 6,061 in military medical treatment facilities (MTFs) and the number of TRICARE Network providers increased 26 percent from 39,587 to 49,807. A gap analysis performed at the end of the third quarter of 2009 revealed that 93 percent of current Service-determined mental health provider “requirements” or “needs” at MTFs were filled. The substantial increase in the numbers of mental health providers is attributable largely to recruitment efforts.
DoD established a mental health recruiting and retention strategy to help develop new programs to attract and retain uniformed and civilian mental health professionals. A Directive-Type Memorandum (DTM) established the Health Profession Incentive Working Group to adjust incentives and pay annually to maximize recruitment and retention of those with high-needs skill sets. DoD developed another DTM (09-009) for the “Implementation of Special Pay for Health Professions Officers (HPOs)” on July 23, 2009, allowing DoD to offer mental health professionals within DoD special pay and bonuses.
This action is expected to enhance significantly DoD’s ability to recruit and retain mental health professionals, particularly psychologists and social workers, through direct accession recruitment. As an additional effort to boost provider availability, DoD entered into a Memorandum of Agreement with the Department of Health and Human Services (HHS) to use uniformed Public Health Service (PHS) mental health providers. More than 70 PHS officers have been hired as a result of this agreement.
Another potential effort on the horizon is the Civilian Health Professions Scholarship Program (CHPS), a recruitment program that would provide health care scholarship funds and related educational expenses to prospective health care professionals in return for a DoD service commitment when the providers have completed their training.
DoD has initiated several joint efforts to improve access to mental health care. These include the following.
• DCoE’s National Center for Telehealth and Technology (T2) has embarked on a program to develop and deliver Web-based telehealth care that will extend the reach of services to underserved military beneficiaries, particularly the Reserve Component and those in historically underserved areas, by leveraging the Services, TRICARE, VA, and civilian provider partnerships;
• DoD provides training to, coordination for, and oversight of a national network of systems delivering psychological health care via technology;
• DoD collaborated with VA's National Center for PTSD in three states–Massachusetts, California, and Hawaii–to create Afterdeployment.org, a Web-based portal focused on post-deployment issues and the PH needs of Service members and their families;
• In coordination with other stakeholders, DoD developed and published common access standards for mental health services;
• To further assist telehealth treatment, a telemental health standard of care was created through the Office of the Chief Medical Officer; and.
• T2 is evaluating a program to deliver PH care through mobile platforms. This program has promise as an effective way to provide needed psychological care to Service members and their families who might not otherwise have access to care. The benefits of the Mobile TeleHealth Unit project include the ability to reach all DoD and VA beneficiaries.
To teach best clinical practices to community-based mental health staff who are addressing the behavioral health needs of military personnel, Veterans, and their families, the Center for Deployment Psychology at the USUHS has established the Military and Veteran Behavioral Health Post-Master's Certificate Program. The program takes from 6 months to 1 year to complete and includes the following required workshops:
• Military Culture, Terminology, and the Deployment Cycle;
• Etiology and Assessment of PTSD and Co-morbid Problems;
• Assessment and Treatment of Sleep Disturbance Associated with Deployment,
• Traumatic Brain Injury Sustained in Combat;
• Assessment and Treatment of Deployment-Related Depression;
• Identification, Prevention, and Treatment of Suicidal Behavior; and
• Evidence-Based Treatment of PTSD: Prolonged Exposure Therapy.
In addition, DoD is developing the Psychological Health Risk-Adjusted Model for Staffing (PHRAMS) for use by medical department personnel within Army, Air Force, Navy, and staff within the Office of Health Affairs to model predicted psychological health staffing requirements. Each Service's medical department and Office of the Assistant Secretary of Defense (Health Affairs) staff provided input for this project.
Using deployment history data from the Defense Manpower Data Center (DMDC) and eligibility, demographic, and medical data from the Military Health System Data Repository (MDR), PHRAMS is able to provide a forecast for the total staffing requirements to meet the annual need for psychological health services by beneficiaries over a 5-year period for each type of specialty provider (e.g., psychiatrists, psychologists, psychiatric nurse practitioners, and clinical social workers) and for others who provide PH services as part of the care they offer (e.g., primary care providers and chaplains).
DoD Health Affairs is working with the Services to determine how Service staffing aligns with the PHRAMS predictions of mental health providers needed for beneficiary psychological services. Currently, a projection of requirements for each mental health specialty has been made for the Services from 2009 through 2014, including mental health specialty providers embedded into operational units and integrated into primary care clinics. The Services will determine the gaps between these requirements and existing providers in order to establish specific hiring and recruitment goals.
2. VA Response to IOM Recommendation 3
VA has increased mental health staff 36 percent in the last 3 years (from 14,208 in FY 2006 to 19,283 in FY 2009) through Mental Health Expansion Initiative (MHEI) funds and has increased the number of Veterans treated for mental health problems by 21 percent in the same time period (from 1,183,819 to 1,428,858). VA is tracking total Core Mental Health Staffing full-time equivalent employee (FTEE) positions funded under annual budget processes and those funded by special purpose and MHEI funds.
Veterans Integrated Service Network (VISN) and facilities are required to maintain a staffing level of greater than 90 percent of the filled and approved mental health staff positions that existed at the end of FY 2009. As of the end of the first quarter of 2010, all VISNs have surpassed this minimum standard, and 20 out of the 21 VISNs have produced a net gain in mental health staffing over that time period.
The Uniform Mental Health Services Handbook delineates the essential components of the mental health program to ensure that all Veterans, wherever they obtain care in the Veteran’s Health Administration (VHA), have access to needed services. The Handbook specifies those services that must be provided at each VA Medical Center and Community Based Outpatient Clinic (CBOC). VA actively employs the use of remote clinical videoconferencing technology to improve access, fill gaps in mental health services, and provide remote national expert consultation to Veterans at any VA facility in the country.
A National Telemental Health Center will be operational by the end of FY10. The Office of Telehealth Services (OTS) and Office of Mental Health Services (OMHS) are currently staffing the center and planning delivery of remote expert consultation services. OTS and OMHS have identified opportunities for the delivery of telemental health services into the home for the care of Veterans with substance abuse problems and for the management of depression using interactive voice response (IVR) technology. VA continues to explore opportunities for using telemental health to fill any gaps identified in mental health services.
VA has a number of initiatives in place to ensure that access and continuity of care is facilitated as close to home as possible. Three VISNs are in the process of negotiating contracts with community providers as part of a 3-year pilot program. Results from this effort will provide valuable information on how VA can develop partnerships with community providers to expand access to mental health services for rural-residing Veterans.
An expansion of the Mental Health Intensive Case Management – Rural Access Network for Growth Enhancement (MHICM-RANGE) initiative has been supported by VA’s Office of Rural Health. This initiative adds mental health staff to CBOCs, enhances telemental health services, and uses referrals to community mental health services and other providers to increase access to mental health care in rural areas. The expansion of MHICM-RANGE has also led to four research studies on clinical policies or programs that improve access, quality, and outcomes of mental health and substance abuse treatment services for rural and underserved Veterans.
OMHS has partnered with the My HealtheVet program office and the Office of Information and Technology (OI&T) to develop online resources designed to complement traditional mental health services, and to expand access to these services to Veterans in rural areas. OMHS is working closely with the Office of Health Information (OHI) and OI&T to develop My Recovery Plan – an online, interactive application designed to support Veteran-centered, evidence-based mental health practices. Sections of My Recovery Plan will be available for self-paced independent work, while other areas will be made available to Veterans in conjunction with work with a provider. Both approaches are expected to facilitate treatment for Veterans in rural areas.
Among the OMHS initiatives in place to assist community and rural health care providers is an Internet Website (www.mental-health.va.gov/College/index.asp) with basic information on assessment and treatment of PTSD. The site is designed for college mental health counselors who, like many community providers, may not have knowledge about military service or experience treating combat-related PTSD and other disorders associated with war. Access to services is supported increasingly by Internet-based resources such as VA OEF/OIF Web site (www.oefoif.va.gov) and the National Center for PTSD’s Web site (www.ptsd.va.gov), as well as a VA presence on social media sites such as Facebook and Twitter.
A two-part VHA Productivity and Staffing study conducted by OMHS in collaboration with the Office of Productivity, Efficiency, and Staffing (OPES) used electronic workload and provider data from psychiatrists and associated mental health providers (psychologists, social workers, nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) working in mental health. The results of the study are being used to establish reasonable productivity and staffing standards, to be completed this year.
To ensure adequate inpatient minimum staffing standards, OMHS established a workgroup to review current utilization of inpatient mental health services across VISNs and Medical Centers, determining the sources of geographic variability in individuals with extended lengths of stay, and evaluating the extent of variability when these individuals are excluded from analyses. Administrative data on utilization and staffing are expected to be translated into staffing guidelines this year.
Vet Centers are community-based counseling centers, within Readjustment Counseling Service (RCS), that provide a wide range of social and psychological services including professional readjustment counseling to Veterans and families, military sexual trauma counseling, and bereavement counseling for families who experience an active duty death. This program also facilitates community outreach and the brokering of services with community agencies that link Veterans with other needed VA and non-VA services. A core value of the Vet Center program is to promote access to care by helping Veterans and families overcome barriers that impede them from using those services.
The Vet Center program has provided services to more than 40 percent (450,162) of all separated OEF/OIF Veterans since the beginning of the wars in Afghanistan and Iraq (cumulative through March 31, 2010). Furthermore, 40 percent of all Vet Center clients do not receive services at any other VA facility. To meet this growing need, the Vet Center program has increased its counseling staff by 103 percent since 2003. In addition, more than 34 percent of Vet Center staff has served in either the Afghanistan or Iraq combat theaters. (See Appendix E for a list of Vet Centers.)
To extend the geographical reach of Vet Center services, RCS has implemented initiatives to ensure that Veterans have access to care. Following the onset of the current hostilities in Afghanistan and Iraq, the Vet Center program hired 100 OEF/OIF Veteran Outreach Specialists to contact their fellow returning Veterans at military demobilization sites, including National Guard and Reserve locations, and in the community. Further, to facilitate access to services for Veterans in hard-to-reach outlying areas, RCS has deployed 50 Mobile Vet Centers (MVCs) across the country. A full time driver/outreach specialist and counselor are attached to each of these vehicles. The placement of the vehicles is designed to cover a national network of designated Veterans Service Areas (VSAs) that collectively cover every county in the continental
United States. The 50 MVCs are used to provide early access to returning combat Veterans via outreach to a variety of military and community events. The vehicles are also extending Vet Center outreach to more rural communities that are isolated from existing VA services.
In FY 2010, the Vet Center program is authorized to employ a total of 1,391 counseling staff in 300 Vet Centers and 50 Mobile Vet Centers. Further, by the end of 2010, RCS will have a qualified family and marriage counselor at every Vet Center. To meet this goal, RCS has partnered with the VHA Healthcare Retention and Recruitment Office to initiate a national recruitment and targeted marketing campaign to find qualified professionals to meet the diverse needs of Veterans, their families, and the community in which they live.
In recent years, RCS and the Vet Center programs have been the subject of program evaluations by several different agencies and organizations. According to the President’s Advisory Committee on Gulf War Veterans’ Illnesses3:
The Department of Defense and VA should follow the model of field-based outreach demonstrated in the Vet Centers when developing health education and risk communication campaigns for active duty service members, Reserve and Guard personnel, and other Veterans. The prompt response by the Vet Centers to the acute PTSD and other post-war readjustment difficulties, such as family and employment problems, illustrate VA’s commitment to early intervention and outreach (p. 1).
Further, the U.S. Medicine Institute for Health Studies, with participants from DoD, Substance Abuse and Mental Health Services Administration (SAMHSHA) and VA, reported “VHA’s Vet Centers have proven a ’best practice’ model in fostering peer-to-peer relationships for those with combat stress disorders. The best way to overcome concerns about stigmatization is through person-to-person contact with someone who has recovered.”4 The Vet Center program is also the gold standard in both internal and external VA surveys measuring Veteran and employee satisfaction.
D. IOM Recommendation 4
The committee recommends that the Department of Defense actively promote an environment to reduce stigma and encourage treatment for mental health and substanceuse disorders in an effort to improve military readiness and ability to serve. The committee
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3 Persian Gulf Veterans Coordinating Board. (1997, March). The Final Report of The Presidential Advisory Committee on Gulf War Veterans’ Illnesses (PAC).
4 U.S. Medicine Institute for Health Studies. (2004, October). Executive Summary- USMI Roundtable Discussion: The Changing Face of Mental Health Services in the Veteran Health Administration.
also recommends that the Department of Defense undertake a systematic review of its policies regarding mental health and substance-abuse treatment with regard to issues of confidentiality and the relation between treatment-seeking and military advancement.
1. DoD and VA Response to IOM Recommendation 4
Both DoD and VA are working actively to reduce stigma and encourage treatment for mental health and substance use disorders (SUDs). Some of the efforts are outlined below.
Real Warriors Campaign
DCoE launched the “Real Warriors, Real Battles, Real Strength” national public awareness campaign in May 2009, emphasizing that seeking help for psychological concerns is a sign of strength. Supporting initiatives have been implemented across the Services to target their individual cultures. To date, the campaign has produced eight Public Service Announcements (PSAs) that aired more than 4,000 times to 1.3 million Service members in 177 countries on the Armed Forces Radio and Television Service (AFRTS). PSAs have also aired domestically on 144 civilian national, regional, and local television networks and stations. Posters for the campaign have been displayed 254 military installations worldwide, and more than 90 organizations have collaborated with the campaign to further its reach. The campaign has been featured on CNN, NBC's Today Show, USA Today, Associated Press, and LA Times.
The Real Warriors Campaign Website (www.realwarriors.net) includes several unique features that help educate and connect Service members, Veterans, and their families to the resources they need to build resilience and access appropriate care for invisible wounds, including: 40 articles on a wide array of topics related to PH, handling deployments, and TBI; a live online chat feature; and online message boards where individuals can connect with others who have shared similar experiences.
Screening, Brief Intervention, Referral and Treatment
Another strategy to reduce stigma is the utilization of the Screening, Brief Intervention, Referral and Treatment (SBIRT) model to identify depression and PTSD in primary care clinics. If the Service member who is seeking care from his or her primary care clinic is identified via this mechanism, the treating physician would present the Service member to a care coordinator for screening and evaluation within the confines of the primary care venue. Substance use and abuse also may be addressed using the same methodology. The SBIRT model targets those with nondependent substance use and provides effective strategies for intervention prior to the need for more extensive or specialized treatment.
The model involves a system within community and/or medical settings, including physicians’ offices, hospitals, educational institutions, and mental health centers. Screening determines the
severity of substance use and identifies the appropriate level of intervention. The system provides for brief intervention or brief treatment within the community setting or motivates and refers those identified as needing more extensive services to a specialist for assessment, diagnosis, and appropriate treatment. Currently, the U.S. Army has 42 primary care clinics assessing and treating depression and PTSD and is in the process of expanding this primary care model. The Air Force and Navy have already integrated mental and primary health care.
Education through Conferences
Recently, the Center for the Study of Traumatic Stress (CSTS) hosted a conference on stigma, bringing together more than 100 national subject matter experts (SMEs) to discuss the current state of knowledge on stigma. SMEs from DoD, VA, and the civilian sector presented on current programs and research, and identified gaps. The conference highlighted stigma because of institutional, external, and internal cultural factors, all of which must be addressed to reduce stigma.
Policy Review
The Office of the Assistant Secretary of Defense (Health Affairs) is currently undertaking a systematic review of policies related to substance use treatment and confidentiality issues mandated by National Defense Authorization Act (NDAA) FY10 Section 596, “Comprehensive Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Abuse Offenders in the Armed Forces.” Some extant policies have already been reviewed and endorsed by the Services.
There have been some relevant policy memoranda issued over the past several years. For example, a policy memorandum co-issued by the Under Secretaries of Defense for Intelligence and Personnel and Readiness and endorsed by DoD leadership including the Secretary of Defense resulted in the immediate revision of Question 21 of SF 86, “Questionnaire for National Security Positions,” regarding prior mental health treatment. The revision explicitly excludes the reporting of counseling that was “strictly marital, family, grief not related to violence by you; or strictly related to adjustments from service in a military combat environment.” These two reasons for seeking services address a substantial percentage of the reasons why a Service member might seek deployment-related counseling in the first place.
Perhaps more important than the specific questionnaire revisions was the language in the memorandum that indicated seeking care to mitigate adjustment difficulties was the responsible thing to do, and not doing so was less responsible. Similarly, “Policy Guidance for Deployment-Limiting Psychiatric Conditions and Medication,” issued by the Assistant Secretary of Defense for Health Affairs in November 2006, indicates that seeking care is the appropriate/responsible action for a Service member to take. While recognizing that psychological fitness for duty in the
context of deployment is very important and may entail higher levels of mental health status in general, the guidance indicates that deployment and psychiatric treatment (to include treatment with psychotropic medications) are not automatically and mutually exclusive
There have been policy enactments and actions that make available models of counseling that do not entail medical record keeping and are inherently more confidential (e.g., the Military OneSource program). A July 2009 DTM entitled “Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Military Personnel” (DTM 09-006) specifies those situations for which Command notification is not required. A DoDI will replace this DTM and provide additional guidance.
Leadership Training
The relationship between treatment seeking and military advancement is now an integral aspect of the Services’ leadership training developed and implemented over the past several years. This training has a strong anti-stigma objective and theme. Again, an essential message is that seeking care for psychological difficulties is the responsible and courageous thing for Service members to do and should be strongly encouraged by all levels of leadership.
See Appendix F for a sample of VA research that is exploring the effects of stigma in the veteran population.
E. IOM Recommendation 5
The committee recommends that the Department of Defense formally assess whether a “third-location decompression” program would be beneficial for US combat troops. Thirdlocation decompression has the potential to allow troops to have time to begin to readjust before returning home and to family responsibilities.
1. DoD Response to IOM Recommendation 5
Third-Location Decompression (TLD) “refers to a process that is designed to allow Service personnel returning from deployment to adapt to the home environment in a graduated way, with the aim of reducing the potential for maladaptive psychological adjustment.”5 It has been used in multiple settings with varying results and, as noted in the IOM report, no published evidence exists that indicates the TLD process is effective. However, DoD and VA agree that TLD
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5 Hughes, J., Hacker, G.H., Earnshaw, N.M., Greenberg, N., Eldridge, R, Fear, N.T., French, C., Deahl, M.P., &Wessley, S. (June, 2008). Use of Psychological Decompression in Military Operational Environments, Military Medicine, p. 1. Downloaded 4/8/10 from http://findarticles.com/p/articles/mi_qa3912/is_200806/ai_n27995836/
programs are worthy of further study, to determine whether they do result in benefits for stressexposed troops (e.g., improved social support, lower rates of PTSD). To this end, DoD will work to ensure analyses of TLD programs and potential benefits are included in research investment strategic plans and future funding opportunities in a way that leverages prior investments and ongoing studies.
F. IOM Recommendations 6, 7, and 8
Recommendation 6: The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on the social and economic effects of deployment and multiple deployments on families. For example, research should examine the effects of multiple deployments on domestic violence and maltreatment of children, as well as on financial well-being.
Recommendation 7: The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund studies to evaluate the effectiveness of mental health treatments currently being provided to women and to identify potential new treatments designed specifically to address women's unique circumstances and stressors, such as sexual harassment and assault, PTSD, and premilitary trauma.
Recommendation 8: The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other federal agencies fund research on culturally sensitive treatment approaches targeted toward minorities. Research is also needed on utilization patterns of currently available services by minority populations and the efficacy of such services to improve health outcomes.
1. DoD Response to IOM Recommendations 6, 7, and 8
As discussed above, DoD has dedicated substantial resources to PH and TBI research, and recognizes that studies on families, women, and minorities are important components of its research program. Broad Agency Announcements (BAAs) (i.e., requests for proposals) reflect the explicit requirements of legislation and input from not only DoD SMEs, but also SMEs from the NIH, VA, and other federal agencies. Funded studies explore novel areas of research or build upon work done by other researchers.
These published BAAs include the following language, which is intended to ensure adequate consideration of families, women, and minorities in all appropriate research.
“Priorities include interventions across the deployment lifecycle for warriors, Veterans, families, caregivers, and communities, particularly those at risk for mental disorders and psychosocial problems. Investigators are encouraged to take into account considerations for special populations, such as gender-specific or racial/ethnic groups as a focus. Consideration of Active Duty, Reserve Component, National Guard, and/or Veteran populations is also encouraged.”6
Currently, more than $48.2 million in DoD funding is invested in 42 active studies focused on families, women, and/or minorities. Specifically
• More than $40.1 million is invested in research on families,
• More than $3.6 million is invested in research on the particular needs of women, and
• More than $2.4 million is invested in research on the needs of minority populations.
The DoD repeatedly re-evaluates the priority focus areas of its research portfolio in light of emerging knowledge, preliminary data from studies in progress, and previous investments, but studies of the specific needs of families, and female and/or minority Service members will remain a priority in future research investments.
A complete list of the studies reviewed appears in Appendix G. Note that some studies are included in more than one appendix.
2. VA Response to IOM Recommendations 6, 7, and 8
VA health care is provided only to Veterans and their families as it relates to the care of the Veteran. By advancing treatment and improving care for the individual Veteran, VA attempts to mitigate the issues faced by spouses and children. The health and well-being of the Veteran’s family is, however, of vital concern to VA.
The overall research agenda is richly described in Conference Proceedings from the Trauma Spectrum Disorders Conference, 2009. The conference focused on the impact of military service on families and caregivers, with sponsorship by DCoE, NIH Office of Research on Women’s Health, and VA Research.
Over 11 percent of OEF/OIF Veterans are women. VA Research supports a robust portfolio of studies related to women Veteran’s health, including studies on diseases prevalent solely or predominantly in women, research focusing on women Veterans, and research addressing the goals of the Women Veterans Health Strategic Health Care Group’s (WVHSHG) to develop a
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6 FY09 PH/TBI Concept Award BAA, pg 2-3; W81XWH-09-PH/TBIRP-CA
comprehensive practice redesign to enhance primary care delivery for women, and redesign of primary care delivery to integrate gender-specific care (Yano, 2009).
The focus of VA-supported research on women Veterans, including those who served in the National Guard and Reserves as well as the regular military in past conflicts and OEF/OIF ranges widely, and includes
• Research aimed at improving the organization and quality of health care for women Veterans;
• Women-specific prevalence and treatment of PTSD;
• The impacts of deployment and military service on physical and mental health of women Veterans;
• Comorbid conditions such as substance use and PTSD among women Veterans;
• Access to mental health care and predictors of mental health care use by women Veterans;
• Special concerns of reintegration for women Veterans;
• Intimate partner violence among women Veterans; and
• The implementation and sustainability of VA’s women’s mental health clinics.
A brief description of many of these studies appears in Appendix H.
VA Research has been laying the groundwork for improved health care services to women Veterans and the development of effective programs and treatments to address the mental health needs and readjustment and reintegration issues related to service in Iraq and Afghanistan. Armed with a growing and comprehensive body of research, VA is prepared to take the next steps in transforming VA health care to women Veterans through a research program focused on intervention, implementation, and dissemination of best practices, especially regarding mental health care. Some of these studies have already been implemented and some completed. The current initiative includes
• An update of the systematic review of women Veterans’ health literature, initially conducted in 2004, with a focus on post-deployment health and mental health issues (expected to be available in summer 2010);
• Another systematic review that focuses solely on mental health issues and treatments, including gender differences. This accumulated evidence will facilitate design of a treatment and outcome pilot and multi-center trial studies;;
• A Long Term Health Outcomes of Women’s Service during the Vietnam Era, a comprehensive 3-year study of an anticipated 10,000 women to assess the prevalence of PTSD and other mental and physical health conditions for women Vietnam Veterans, and explore the relationships between PTSD and other conditions and the Vietnam
deployment experience. The study will include both VA users and women Vietnam Veterans who do not use VA for their health care, and will include both self-report, extensive survey, and medical record data. This large-scale study will help to explain relationships between stressful and traumatic experiences and mental and physical health outcomes in women Vietnam Veterans, and older women in general. It will also look at the relationship of these outcomes to disability and functioning. Knowledge from this study will help VA organize and offer its services, not only for these aging women Veterans, but for future generations of women Veterans as well;
• The first national survey of women Veterans since 1985, already fielded, is now providing VA with comprehensive data on health care needs and VA experiences, differences among cohorts of women Veterans by military era, and women Veterans’ preferences and perceptions about access and quality. Approximately a third of the almost 3,500 survey respondents are OEF/OIF Veterans and their survey data indicates a higher need for mental health services, as well as higher utilization of services. The survey will provide important information to guide future efforts to improve outreach, access, and care of women Veteran;
• A field-based conference planned for July 2010 on “Building the Evidence Base to Improve Health Care and Outcomes for Women Veterans.” One of the goals of the meeting is to foster methodological and other research advances in support of improving the quality and quantity of VA women’s health research in high priority areas, with special emphasis on accelerating movement to interventions and implementation research. Post-deployment mental health is one of the areas of emphasis;
• A women Veterans’ practice-based research network (PBRN) will provide a laboratory for examining new treatments, quality performance and quality improvements, models of care (e.g., integrated mental health and primary care), and provider education and training innovations. One of the initial planned studies will survey a representative sample of women Veterans, including OEF/OIF Veterans, to identify socioeconomic and health status and determine preferences for mental health interventions in primary care settings; and
• VA continues to work with DCoE, as well as various NIH offices (including the Office of Research on Women’s Health) to explore and document the impact of trauma in the military on those who have served, as well as their families and caregivers, by sponsoring annual conferences addressing various issues related to trauma, evaluating the current evidence, and determining research gaps.
VA has devoted significant resources toward the reduction and elimination of health disparities in quality of care and health outcomes in VA, sponsoring special equity research solicitations since the late 1990s. As the largest national health care system, VA offers a unique opportunity to understand and analyze the complex reasons for disparities among different racial, ethnic, and minority populations. VA also offers the ideal setting in which to evaluate and implement C-26
patient-centered and culturally sensitive approaches to care that will meet the needs of diverse populations of Veterans and provide equitable access to quality health care.
VA has an extensive portfolio of research on disparities, and devotes significant resources and infrastructure to this area. VA funds a Center of Excellence for Health Equity Research and Promotion, which has a mission to reduce disparities and promote equity in health and health care among vulnerable groups of Veterans and other populations. VA also funds a Targeted Research Enhancement Program to understand racial and ethnic variations in health outcomes for chronic diseases (e.g., diabetes and hypertension), focusing on patient trust, patient preferences for care, and the incremental effect of patient-level factors on disparities in health outcomes.
A recent solicitation calls for the development and evaluation of interventional studies to reduce ethnic minority health care disparities, including interventions that address provider and patient beliefs and attitudes, patient preferences and knowledge that impact medical decision-making and access to or use of health services, patient-provider relationships, and system-wide or facility-specific policies and characteristics that can reduce variations in treatment or outcomes. VA also supports implementation research through VA QUERI, which works collaboratively with VA’s Office of Quality and Performance (OQP), to translate the findings of disparities research into changes in clinical practice in VA's health care system.
In order to guide future VA research, deliver high-quality care in an equitable manner, and eliminate racial and ethnic disparities in health care, VA directed an Evidence-Based Synthesis Project (ESP) on racial and ethnic disparities in health care within VA to determine 1) the clinical areas in which racial and ethnic disparities are prevalent; 2) what is known about the sources of those disparities; and 3) synthesize that knowledge to determine the most promising areas for future research aimed at improving quality in VA health care.
The synthesis suggests that the reasons for disparities are complex and that variability in study settings and populations, clinical topics and services, data collection methods, and measures sometimes makes it difficult to generate unifying theories that are generalizable across settings and services. However, the review suggested a number of promising areas for future research, including: decision aids and information tools; patient activation interventions; patient-centered communication training; determining sources of variation in clinician judgment by patient race; interventions to promote evidence-based decision-making by providers; and adherence-support interventions (Saha, Freeman, Toure et al., 2008). VA continues to work with other federal agencies to advance research on disparities and minority health, including through the Federal Collaboration on Health Disparities Research, and also as part of ongoing efforts with the DCoE and NIH to improve treatment to OEF/OIF Service members, Veterans, and their families and caregivers.
The committee recommends that Congress appropriate funds and direct the Department of Veterans Affairs to expand the role of its actuary to produce annual long-term forecasts of costs associated with all health and disability benefits that are consistent with the practices of Social Security and Medicare.
1. VA Response to IOM Recommendation 9
VA’s Office of the Actuary (OACT) provides long term projections of veteran population. The veteran population projection is used for VA’s strategic planning (e.g., healthcare) and benefits valuations (e.g., disability). OACT is expanding its projections and advanced modeling activities to support VA strategic planning and policy improvement. All the actuarial projections follow actuarial standards of practice and are consistent with SSA, HHS and other government agency practices.
OACT maintains a model of future benefits for the compensation, pension and burial programs administered by the Veterans Benefits Administration (VBA). The model projects future cash flows, including the effect of Cost of Living Adjustments (COLA), for any future period up to a hundred years. The model covers current VA beneficiaries, as well as Veterans who will become beneficiaries in the future and those who have yet to separate from the military. The model is currently used for financial reporting. The model and the data inputs used for that purpose were audited in 2009 by the external accounting firm of Deloitte and Touche.
Since 1999, VHA has partnered with Milliman, Inc., a premier global actuarial and consulting firm, to develop and support a health care actuarial model to project demand for VA health care. VA's Enrollee Health Care Projection Model (Model) produces annual, 20-year projections of the number of Veterans expected to be enrolled in VA health care, their utilization of VA's health care services, and the expenditures associated with those services. The model methodology is consistent with actuarial principles and practices and accounts for the unique demographics of the Veteran enrollee population and VA health care delivery system.
Each year, VA assesses the expected demand for inpatient and ambulatory medical services based on its most recent experience for both VA and fee-based care provided to enrolled Veterans. Projections are updated to reflect the changing demographics of the enrolled Veteran population including factors such as aging, priority transition, and geographic migration. The methodology and assumptions used in the Model also are reviewed to ensure that the Model is projecting Veteran demand as accurately as possible. In addition, VA conducts a rigorous review to understand health care trends in VA, which may also affect the number of services and
the expected cost of providing these services to enrolled Veterans. Some services, such as longterm care, are not included in the Model, which currently projects approximately 84 percent of VA medical care budget. Actions are underway to include non-modeled services, including long-term care.
VA has successfully collaborated with internal and external stakeholders to enhance the Model. For example, the annual Model update is done in active collaboration with myriad program offices to ensure the Model reflects VA’s current health care delivery system, specific program initiatives to improve service delivery and access, and reflects VA’s vision for its health care system in the future. VA currently has approximately 9.2 FTEE working on the Model and VA’s consulting health actuary, Milliman, dedicates an estimated 8 FTEE to support the Model.
Since 2007, VHA’s model estimates that portion of the Veteran population that represents the number of new OEF/OIF Veterans each year. Through discussion and collaboration with the Congressional Budget Office (CBO) and monitoring recent policy decisions by the administration, VA has revised its model to reflect the current deployment levels and strategy in support of OEF and OIF. This year’s Model uses the same methodology to project OEF/OIF enrollment as the previous Model but reflects an updated OEF/OIF Veteran separation model. Experience supports an increase in the assumed number of Service members required to support a given deployment level. As a result, a given deployment level causes more Service members to be given OEF/OIF status than in the previous model and this leads to more unique OEF/OIF Veterans. In comparison with the 2009 model, the updated model projects more OEF/OIF Veterans.
VA's Enrollee Health Care Projection Model projects OEF/OIF Veteran enrollment and utilization apart from non-OEF/OIF Veterans and the Model is updated annually to reflect VA’s most recent experience in terms of enrollment and utilization.
H. IOM Recommendation 10
The committee recommends that the Department of Defense and the Department of Veterans Affairs oversee coordination and communication of the multitude of programs that have been created in response to the needs of Operation Enduring Freedom and Operation Iraqi Freedom Service members, [V]eterans, and their family members in an effort to maximize their reach and effectiveness. The committee also recommends that there be independent evaluation of these programs with standardized evaluation designs and assessment of outcomes.
1. DoD Response to IOM Recommendation 10
DoD and VA continue to work together and with other federal, state, local, academic, and not-for-profit institutions to oversee the coordination and communication of the multitude of programs that have been created in response to OEF and OIF.
One ongoing effort is participation in the Federal Partners Priority Working Groups led by SAMHSA to leverage a wide range of professionals from federal partners in building an optimal model of programs and best practices dissemination strategy.
In a second effort, the agencies are harnessing technology and social media tools. The use of technology provides Service members and their families access to resources even in the most extreme and remote circumstances while maximizing reach and effectiveness.
The National Leadership Summit on Military Families provides a third example of collaboration, coordination, and communication. A partnership between the Military Community and Family Policy within the Office of the Secretary of Defense (OSD), the Department of Agriculture (USDA), 7 and the University of Maryland, the summit took place on November 9-10, 2009. Summit participants included senior military family policymakers, family program leaders and their staff, military family researchers, representatives from DoD, VA, all military Service components, and other non-governmental partners. Summit participants identified the following priorities
• Categorize and evaluate programs to enhance effectiveness, consistency, and return on investment,
• Develop and implement a strategic communications strategy that reaches Service members, Veterans, and their families with what they need to know, and connects them with those who have the capacity and resources to provide support, and
• Strengthen the ability of DoD and VA to provide for the psychological well-being of military personnel and their families.
DoD is addressing the coordinated outreach of programs through several other mechanisms. The Army and Marine Corps have established outreach and case management programs as well as Warrior Transition Units. The Office of the Assistant Secretary of Defense (Health Affairs) monitors and evaluates these programs to assess their applicability to other services and to ensure the continuum of care for Service members, Veterans, and their families as they navigate the system of care. In a similar effort, VA hired the Federal Recovery Coordinators to work in MTFs and other selected sites in the United States. The goal is to assist in the recovery, rehabilitation, and reintegration into the community of severely injured Service members who are unlikely to return to active duty.
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7 USDA’s Cooperative Extension Service is a key education partner for military families.
Recovery care coordinators are part of the Services’ wounded Warrior programs and also assist the Service members and their families as they navigate the continuum of care. The overall goal of transition and coordination of care is to improve quality of care, including rapid and effective information sharing to support the continuity of care. In order to synchronize department-wide transition efforts for our Service members, DoD stood up the Office of Transition Policy and Care Coordination (now called Wounded Warrior Care and Transition Policy) in October 2008. The goals for this office include ensuring equitable, consistent, and high-quality care coordination and transition support for members of the Armed Forces, including wounded Warriors and their families through appropriate interagency collaboration, responsive policy, and effective program oversight.
Clearly, there is a need for collaborative program evaluations that capture PH and TBI project and program effectiveness information and provide practical evidence to support collaboration and knowledge-sharing across the Services, DoD, and VA. Such evaluation will enable the Military Health System (MHS) to leverage project performance information to enhance care delivery for our Service members, Veterans, and their families. However, the challenge to date has been determining how to take advantage of the Services’, DoD’s, and VA’s respective PH-TBI program portfolio evaluations in order to leverage existing data and reduce duplication. A second challenge is how to pursue a strategic analysis of the full DoD/VA portfolio in order to identify gaps in programs and services, and to collect and disseminate information on evidencebased practices and lessons learned.
As program evaluations can be initiated at different points in a project's lifecycle, it is important to gather additional information from stakeholders to identify what may drive an evaluation. For example, while still in its formative stages, DCoE proposed the development of an annual plan that systematically identifies innovative and necessary programs. This plan prioritizes how best to obligate finite staff and other resources, further evaluating those programs, and identifying important lessons learned across the Services. Furthermore, planning requires gathering sufficient information in order to gain an initial understanding of the projects, their current and planned focus, how they are organized, and where they are located. Finally, there may be specific stakeholder considerations that will further define the information gathering activities.
As these relevant programs are identified and begin to be evaluated, common metrics must be created. Desirable measures have three attributes: 1) importance (i.e., relevance to stakeholders, health importance, applicable to measuring equitable distribution of care, and potential for improvement), 2) scientific soundness (i.e., explicitness and strength of the evidence, reliability, and validity), and 3) feasibility (i.e., explicit definitions and count specifications for its components, and the availability of the data).
2. VA Response to IOM Recommendation 10
Over the past 3 years, DoD and VA have made a significant investment to improve the level of coordination and collaboration between the departments to meet the needs of OEF/OIF Service members, Veterans, and their families. The Departments established the Senior Oversight Committee (SOC), co-chaired by the Deputy Secretaries of both departments, to provide oversight of the many programs and policies established to assist wounded, ill, and injured Service members and Veterans. The SOC meets monthly to address issues related to improving the delivery of benefits and services. As an example, the SOC is currently providing oversight for the expansion of the DoD/VA Disability Evaluation System (DES) Pilot that was established to create a seamless, transparent, and joint disability evaluation system.
To support the efforts of the SOC within VA, the department created the Collaboration Service in October 2008. The mission of the Collaboration Service is to facilitate the development and oversight of joint policies and programs. DoD has created its own organizational structure as well through the Office of Wounded Warrior Care and Transition Policy and the Executive Secretariat under the Under Secretary of Defense (Personnel and Readiness). The level of oversight provided by this new infrastructure has improved the level of coordination between the departments and consequently improved the reach and effectiveness of programs and services created in response to the needs of returning Service members.
VA meets its statutory mandate to evaluate its programs using standardized evaluation designs to collect and analyze data in the assessment of outcomes. VA program evaluations are conducted by independent third parties and follow systematic research designs to ensure that final outcome data are valid and reliable.
VA is currently conducting a 4-year multi-million dollar program evaluation study on mental health services and outcomes in the VHA for Veterans with PTSD, schizophrenia, major depression, bipolar disorder, and substance use disorder, with a particular emphasis on OEF/OIF Veterans. This program evaluation specifically addresses the number and distribution of mental health professionals needed to provide treatment to Veterans returning with PTSD, major depression and substance use disorder through a survey of all VA facilities conducted in May 2007 and again in late 2009. The use of evidence-based treatments, particularly for PTSD, is a focus of the Mental Health study. The evaluation has identified 114,000 OEF/OIF Veterans who received care for the five study diagnoses during FY 04-08. Their utilization of care, outcomes, and costs are being evaluated.
Coordination of care and communication between DoD and VA is essential when transitioning severely ill and injured Service members from DoD to VA's system of care. VA Liaisons for Health Care, strategically placed in MTFs with concentrations of recovering Service members returning from Afghanistan and Iraq, are critical to this process. VA has 33 social worker or
nurse VA Liaisons stationed at 18 MTFs to facilitate the transfer of Service members and Veterans from the MTF to a VA health care facility closest to the Veteran’s home or most appropriate for the specialized services required. These Liaisons have greatly improved the communication between VA and DoD and enhanced the coordination of care as Service members transition from active duty to Veteran status.
VA Liaisons are co-located with DoD Case Managers at MTFs for onsite consultation and collaboration regarding VA resources and treatment options. VA Liaisons educate Service members and their families about VA's system of care, coordinate the Service member’s initial registration with VA, and secure outpatient appointments or inpatient transfer to a VA health care facility as appropriate. VA Liaisons make early connections with Service members and families to promote a positive relationship with VA.
In addition, each VA Medical Center has an OEF/OIF Care Management team in place to coordinate patient care activities and ensure that Service members and Veterans are receiving patient-centered, integrated care and benefits. Members of the OEF/OIF Care Management Program team include: a program manager, clinical case managers, a VBA Veterans service representative, and a transition patient advocate. The program manager, who is either a nurse or social worker, has overall administrative and clinical responsibility for the team and ensures that Service members and Veterans receive case management services if needed. Clinical case managers, also either nurses or social workers, coordinate patient care activities and ensure that all clinicians providing care to the patient are doing so in a cohesive and integrated manner. VBA team members assist Veterans by educating them about VA benefits and assisting with the benefit application process. The transition patient advocate assists the Veteran and family in navigating VA's system of care.
All severely ill and injured OEF/OIF Service members and Veterans receiving care at VA are provided a case manager. All others are screened for case management needs and, based upon the assessment; a case manager is assigned as indicated. The patient and family serve as integral partners in the assessment and treatment care plan. Since many of the returning OEF/OIF Veterans connect to more than one specialty care system, VA introduced a new concept of a “lead” case manager. The lead case manager now serves as a central communication point for the patient and family. Case managers maintain regular contact with Veterans and their families to provide support and assistance to address any health care and psychosocial needs that may arise. To improve communication and coordination internally, a multi-disciplinary Care Management Review Team oversees coordination of patient care activities and integration of services.
The Secretary of Defense and the Secretary of Veterans Affairs agree with most of the recommendations of the IOM report and, as noted, have many projects underway to address the issues raised. We look forward to the phase 2 study, a comprehensive assessment of the physical and mental health and other adjustment needs of Service members and former members who deployed in OEF/OIF and the families of these Service members as a result of such deployment (P.L. 110-181). Among the minimum requirements for the Phase 2 requirement outlined in the legislation, DoD and VA are particularly interested in new information on
• An assessment of the particular impacts of multiple deployments;
• An assessment of the full scope of effects of TBI and the efficacy of current treatment approaches;
• An estimate of the long-term costs associated with “undiagnosed” injuries such as PTSD and mild traumatic brain injury (mTBI); and
• “Recommendations for programs, treatments, or policy remedies targeted at preventing, minimizing, or addressing the impacts, gaps, and needs identified.”
Appendix A (IOM Recommendation 1): Rigorous DoD Studies on Readjustment Needs
Title |
Amount |
Synopsis |
Understanding Resilience in Wounded Warriors and Their Families |
$264,778 |
Examine the natural course of wounded Warrior family functioning. Determine major stressors, family resiliency factors, risk factors related to decreased family functioning, and the impact of clinical intervention to improve family functioning of wounded Warriors. Develop and validate a needs assessment screening tool for supportive services referral. |
Addressing the Needs of Children and Families of Combat Injured |
$497,584 |
Identify immediate and progressive impact of parental combat injury on child, parent and family functioning. Evaluate post-traumatic combat injury impact in five major clinical categories of child and family function: 1) acute child and parent traumatic stress symptoms; 2) levels of parental efficacy (e.g., emotional availability, disciplinary style); 3) parent-child communication; 4) alterations to family schedule and structure; and 5) long-term impact of injury on child, parent, and family function. |
National Warfighter Health and Sustainment Study: Implement Family Member Assessment Component in the Millennium Cohort Study (Family Cohort Study) |
$10,000,000 |
Examine association between deployment stressors and adverse behavioral and related health outcomes for spouses and children of deployed service members. Add a 2010 family impact component to the Millennium Cohort Study. Assess spouse perceptions of deployment stressors, current mental health status, spouse’s perception of mental health and related symptoms of their children and quality of family relationships. |
Family Maltreatment, Substance Problems, and Suicidality: Prevalence Surveillance and Ecological Risk/Protective Factors Models |
$952,491 |
Derive and validate an innovative public health surveillance Air Force (AF) wide system for family maltreatment, suicidality, and problematic alcohol/drug use. A biennial survey of individual, family, workplace, and community functioning along with a supplement specifically designed to assess secretive problems will be given to AF members and spouses worldwide. Develop complex statistical algorithms to estimate secretive problems from data sets. |
A Longitudinal Study of the Impact of Combat Deployments on Military Personnel and Their Families |
$900,189 |
Examine the role of family adjustment and support in promoting resilience among military personnel following combat deployments; model the longitudinal course of adjustment over the course of the deployment cycle using state-of-the-art data analytic techniques. Evaluations will begin about 1 month prior to deployment and continue approximately every 4 months following. Approximately 500 deploying military service members and their spouses will participate. |
Appendix B (IOM Recommendation 1): Rigorous VA Studies on Readjustment Needs
Title |
Synopsis |
CSP #256, “Contribution of Emotionally Traumatic Events and Inheritance to the Report of Current Physical Health Problems in 4042 Vietnam Era Veteran Twin Pairs” |
The Vietnam Era Twin Registry consists of over 7,000 male twin pairs born between 1939 and 1957 with both brothers having served in the United States military during the Vietnam War. This study was designed to determine the contributions of psychological trauma (exposure to combat during the Vietnam War), genetic factors, childhood experiences shared by twin siblings, and unmeasured experiences not shared by twin siblings to the reporting of current physical health problems a mean of 19 years after military service |
CSP #470, “A Randomized, Multi-Center, Controlled Trial of Multi-Modal Therapy in Veterans With Gulf War Illnesses” |
Determine if multi-modal therapy will significantly improve clinical outcomes in Veterans with Gulf War illnesses. The primary endpoint is the proportion of patients improved at one year relative to baseline on the Physical Component Summary (PCS) scale of the Veterans Short Form 36 (SF-36V) questionnaire. |
CSP #475, “Persian Gulf - Antibiotic Treatment Trial of Gulf War Veterans' Illnesses” |
Randomized placebo-controlled trial to determine whether a 1-year course of doxycycline treatment in deployed Gulf War Veterans with illnesses (GWVI) and testing as Mycoplasma species positive will improve their overall functional status as measured by the PCS of the SF-36V questionnaire. |
CSP #494, “A Randomized Clinical Trial of Cognitive-Behavioral Treatment for PTSD in Women” |
This completed study found a psychotherapeutic approach to be advantageous in women Veterans suffering from PTSD, and was specifically cited by the IOM as fulfilling the requirement for methodological rigor in trials (IOM Report on PTSD Treatment Effectiveness). |
CSP #500, “An Epidemiological Investigation Into the Occurrence of Amyotrophic Lateral Sclerosis (ALS) Among Gulf War Veterans” |
Epidemiologic investigation into the occurrence of ALS among Veterans of the Gulf War This study will further define the epidemiology of this neurological disease among younger individuals while determining whether there is a higher than expected occurrence. |
CSP #500A, “National Registry of Veterans With Amyotrophic Lateral Sclerosis” |
In response to concern about the development of ALS among Veterans of the U.S. armed forces, particularly Gulf War Veterans, the Department of Veterans Affairs established a national registry of Veterans with ALS. This Registry will identify living Veterans with ALS, track the progression of their disease, and serve as a vehicle to facilitate study of epidemiological risk factors for ALS in a military context. |
CSP #504, “Risperidone Treatment for Military Service Related Chronic Post-Traumatic Stress Disorder” |
Examine the effects of antipsychotics on PTSD, after other treatments for PTSD have failed. This study is large, with multi-site trials |
Appendix C (IOM Recommendation 2): VA Long-term Management Studies
Title |
Synopsis |
TBI Screening and Evaluation |
All eligible OEF/OIF Veterans who receive medical care within the Veterans Health Administration (VHA) are screened for possible TBI. Those whose screening suggests they may have sustained a TBI are offered further evaluation and treatment by clinicians with expertise in TBI. This study will determine the clinical validity and reliability of VA's TBI Clinical Reminder and Comprehensive TBI Evaluation. |
Clinical Tracking Form (CTF) Study |
VA is collaborating with the DVBIC on this study of individuals who have been diagnosed with TBI while in the military service. The study evaluates enrolled subjects at both DoD and VA sites at 6 months, 12 months, and annually, up to 10 years after enrollment. VA and DVBIC will also collaborate on a more extensive 15-year follow-up study. |
Neurorehabilitation: Neurons to Networks” Center of Excellence at the Houston VA Medical Center (VAMC) |
Study to: 1) improve the diagnosis of mild to moderate TBI using structural and functional neuroimaging; and 2) measure the process and outcome of state-of-the art rehabilitation techniques with validated assessment tools. |
Translational Research Center for TBI and Stress Disorders” at the Boston VAMC |
Center focused on research leading to innovations in the diagnosis and treatment of Veterans with mTBI and stress-related emotional disorders such as PTSD. This includes systematic study of the impact of TBI on the efficacy of exposure-based cognitive therapies for PTSD. |
VA Rehabilitation Research and Development Service (VA RR&D) studies using advanced technology |
Innovative studies using advanced technology aimed at improving the diagnosis and treatment of TBI-related deficits. This includes the development and application of improved methods for both structural and functional imaging of the brain using magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). This research to better “map” the brain changes associated with TBI is leading to a better understanding of the biology of long-term TBI-related deficits and development of more effective evidence-based rehabilitation strategies. VA researchers in San Francisco have developed a computer-assisted intervention to improve selective attention among Veterans with TBI. They are using Functional MRI to track actual improvements in brain function associated with the intervention. |
Blast-Related Health Problem Identification and Polytrauma Taxonomy at the Polytrauma Center at the Tampa VAMC |
Investigate the epidemiology of the less visible complications of polytrauma blast injury (e.g., ear trauma and resultant hearing loss, concussion and resultant cognitive and vestibular deficits, and PTSD). |
Appendix D (IOM Recommendation 2): VA Conference Presentations and Publications
Reference |
Goodrich, G.L., Arditi, A., Rubin, G., Keeffe, J., & Legge, G. The low vision timeline: An interactive history. Paper presented at: International Society for Low Vision Research and Rehabilitation Annual Conference; 2008 Jul 9; Montréal, Canada. |
Brahm, K., Shen, M., Goodrich, G., Katsaros, J., Kirby, J., & Wilgenburg, H. Low vision eccentric viewing training: Computer vs. CCTV model. Paper presented at: International Society for Low Vision Research and Rehabilitation Annual Conference; 2008 Jul 7; Montréal, Canada. |
Goodrich, G.L. Blasts, Brain Injury, and Vision. Paper presented at: International Society for Low Vision Research and Rehabilitation Annual Conference; 2008 Jul 7; Montréal, Canada. |
Goodrich, G.L. Low vision services: Evolution in a time of revolution? Paper presented at: International Society for Low Vision Research and Rehabilitation Annual Conference; 2008 Jul 7; Montréal, Canada. |
Wilgenburg, H.M., Goodrich, G., Brahm, K., Kirby, J., & Ingalla, S. Visual findings associated with traumatic brain injury in military personnel. Paper presented at: International Society for Low Vision Research and Rehabilitation Annual Conference; 2008 Jul 7; Montréal, Canada. |
Polusny, M.A., Erbes, C.R., Arbisi, P.A., Thuras, P., Kehle, S.M., Rath, M., Courage, C., Reddy, M.K., & Duffy, C. Impact of prior Operation Enduring Freedom/Operation Iraqi Freedom combat duty on mental health in a predeployment cohort of National Guard soldiers. Mil Med. 2009 Apr; 174 (4):353-7. PubMed PMID: 19485103. |
Ferrier-Auerbach, A.G., Kehle, S.M., Erbes, C.R., Arbisi, P.A., Thuras, P, & Polusny, M.A. Predictors of alcohol use prior to deployment in National Guard Soldiers. Addict Behav. 2009 Aug; 34 (8):625-31. Epub 2009 Apr 1. PubMed PMID: 19375239. |
Ferrier-Auerbach, A.G., Erbes, C.R., Polusny, M.A., Rath, C.M., & Sponheim, S.R. Predictors of emotional distress reported by soldiers in the combat zone. J Psychiatr Res. 2009 Nov 25. [Epub ahead of print] PubMed PMID: 19939409. |
Kehle, S.M., Polusny, M.A., Murdoch, M., Erbes, C.R., Arbisi, P.A., Thuras, P., & Meis, L.A. Early mental health treatment-seeking among U.S. National Guard soldiers deployed to Iraq. J Trauma Stress. 2010 Feb; 23 (1):33-40. PubMed PMID: 20104591. |
Carter-Visscher, R., Polusny, M.A., Murdoch, M., Thuras, P., Erbes, C.R., & Kehle, S.M. Predeployment gender differences in stressors and mental health among U.S. National Guard troops poised for OIF deployment. J Trauma Stress. 2010 Feb; 23 (1):78-85. PubMed PMID: 20135681. |
Cowper Ripley, D.C., Reker, D.M., Vogel, W.B., Hayes, J.M., Beyth, R.J., Litt, E., Dewald, L., Wang, X., & Wu, S.S. Geographic Access to VHA Rehabilitation Services by OEF/OIF Veterans. Paper presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD. |
Appendix E (IOM Recommendation 3): Vet Center and Mobile Vet Center Locations
State/Territory |
Location |
Alaska |
Anchorage; Fairbanks; Kenai; Wasilla |
Alabama |
Birmingham; Huntsville; Mobile; Montgomery |
American Samoa |
Pago Pago |
Arkansas |
Fayetteville*; Little Rock |
Arizona |
Chinle**; Mesa; Mohave County; Phoenix; Prescott*; Tucson; Yuma; |
California |
Antelope Valley; Bakersfield; Chico; Chula Vista; Citrus Heights; Concord; Corona*; East Los Angeles; Eureka; Fresno*; High Desert; Los Angeles; Modesto; North Orange County; Northbay; Oakland; Peninsula; Redwoods**; Sacramento; San Bernardino; San Diego; San Francisco; San Jose; San Luis Obispo; San Marcos; Santa Cruz County*; Sepulveda; South Orange County; Temecula; Ventura; West Los Angeles |
Colorado |
Boulder; Colorado Springs*; Denver; Grand Junction; Pueblo |
Connecticut |
Fairfield; Hartford; New Haven; Norwich |
District of Columbia |
Washington |
Delaware |
Sussex County; Wilmington |
Florida |
Bay County; Broward County; Clearwater; Collier; Daytona Beach; Fort Lauderdale; Fort Myers; Gainesville; Jacksonville; Jupiter; Lake County; Marion County; Melbourne; Miami; Okaloosa; Orlando*; Palm Beach; Pasco County; Pensacola*; Polk County; Sarasota; St. Petersburg; Tallahassee*; Tampa |
Georgia |
Atlanta; Lawrenceville; Macon*; Marietta; Muskogee County; Richmond County; Savannah |
Guam |
Hagatna |
Hawaii |
Hilo; Honolulu; Kailua-Kona; Kauai; Maui; Western Oahu; Iowa; Cedar Rapids; Des Moines; Sioux City |
Idaho |
Boise*; Pocatello |
Illinois |
Aurora; Chicago; Chicago Heights; East St. Louis; Evanston; Oak Park; Orland Park; Peoria; Quad Cities; Springfield* |
Indiana |
Evansville; Fort Wayne; Gary Area; Indianapolis; St. Joseph County |
Kansas |
Manhattan; Wichita* |
State/Territory |
Location |
Kentucky |
Lexington*; Louisville |
Louisiana |
Baton Rouge; New Orleans*; Rapides; Shreveport |
Massachusetts |
Boston; Brockton; Hyannis; Lowell; New Bedford; Springfield*; Worcester |
Maryland |
Annapolis; Baltimore; Baltimore County; Cambridge; Elkton; Prince Georges County; Silver Spring |
Maine |
|
Michigan |
Dearborn; Detroit; Escanaba*; Grand Rapids; Macomb County; Pontiac; Saginaw; Traverse County |
Minnesota |
Minneapolis/ Brooklyn Park**; Brooklyn Park; Duluth; St. Paul Vet Center |
Missouri |
Boone County; Kansas City; Springfield; St. Louis |
Mississippi |
Biloxi; Jackson |
Montana |
|
North Carolina |
Charlotte; Fayetteville; Greensboro; Greenville*; Onslow County; Raleigh |
North Dakota |
|
Nebraska |
Lincoln*; Omaha |
New Hampshire |
Berlin; Manchester |
New Jersey |
Bloomfield; Toms River; Secaucus; Trenton; Ventnor |
New Mexico |
|
New York |
Albany; Babylon; Binghamton; Bronx; Brooklyn; Buffalo; Harlem; Hicksville; Manhattan; Middletown; Queens; Rochester; Staten Island; Syracuse; Watertown*; White Plains |
Nevada |
Henderson; Las Vegas; Reno |
Ohio |
Cincinnati; Cleveland; Columbus; Dayton*; Parma; Starks County; Toledo |
Oklahoma |
Lawton Red River; Oklahoma City; Tulsa |
Oregon |
Eugene; Deshutes County; Grants Pass; Portland; Salem* |
Pennsylvania |
Bucks County; DuBois; Erie*; Harrisburg; Lancaster; McKeesport; Montgomery County; Philadelphia; Philadelphia (NE); Pittsburgh; Scranton*; Williamsport |
State/Territory |
Location |
Puerto Rico |
Arecibo; Ponce; San Juan |
Rhode Island |
Providence |
South Carolina |
Charleston; Columbia*; Greenville; Horry County |
South Dakota |
Rapid City*; Sioux Falls |
Tennessee |
|
Texas |
Amarillo*; Arlington; Austin; Corpus Christi; Dallas; El Paso; Ft. Worth; Harris County; Houston; Jefferson County; Killeen Heights; Laredo; Lubbock; McAllen; Mesquite; Midland; Midland/ Abilene**; San Antonio**; San Antonio NE; San Antonio NW; Taylor County; |
U.S. Virgin Islands |
St. Croix; St. Thomas |
Utah |
Provo; Salt Lake*; Washington County |
Virginia |
Alexandria; Norfolk; Richmond*; Roanoke; Virginia Beach |
Vermont |
South Burlington; White River Junction* |
Washington |
Bellingham; Everett; King County; Seattle; Spokane*; Tacoma*; Walla Walla County; Yakima Valley |
Wisconsin |
Green Bay; Madison; Milwaukee |
West Virginia |
Beckley*; Charleston; Huntington; Lacrosse County; Martinsburg; Morgantown*; Princeton; Wheeling |
Wyoming |
Casper*; Cheyenne |
* = Vet Center and Mobile Vet Center site; ** = Mobile Vet Center site |
Appendix F (IOM Recommendation 4): VA Studies - Stigmatization
Title |
Amount |
Synopsis |
Stigma, Gender, and Other Barriers to VHA Use for OEF/OIF Veterans |
$520,900 |
Examine individual, institutional, and, most importantly, stigma-related barriers to VA health care. Focus groups with OEF/OIF Veterans will explore the relevance of proposed stigma-related barrier categories, uncover any additional factors that are not addressed within the proposed framework, and use this information to inform the measurement of barriers to care. The study will administer measures of barriers to care and assess health-care use within a national sample of OEF/OIF Veterans and use these data to address study hypotheses. |
Barriers and Facilitators to PTSD Treatment Seeking |
$362,117 |
Compare barriers and facilitators to treatment initiation for PTSD among OEF/OIF Veterans to those among Veterans from the Vietnam era. Study will develop a conceptual framework for future research and interventions on PTSD treatment initiation. |
Telemedicine Outreach for Post Traumatic Stress (TOP) in CBOCs |
$1,948,399 |
Evaluate a telemedicine intervention to improve PTSD outcomes in CBOCs without on-site psychiatrists. The specific aims are to estimate diect costs and compare processes and outcomes of care delivered to CBOC patients with PTSD symptoms randomized to either the TOP intervention or to usual care. |
Appendix H (IOM Recommendations 6, 7, and 8): Related VA Studies
Title |
Amount |
Synopsis |
Predicting Post-Deployment Mental Health Substance Abuse and Services Needs |
$758,021 |
Identify risk and resilience factors that predict development of a psychiatric or substance abuse disorder and associated mental health and/or substance abuse service use within and outside the VHA. Specific objectives are: 1) examine the mental health and substance abuse status, functioning, and service use of post-deployed OEF/OIF military personnel in the two years' post-deployment, 2) identify risk and resilience factors that predict mental health status, functioning, and service use two years after their initial assessment, and 3) identify targets for interventions to promote readjustment and reintegration of post-deployed Veterans. |
Re-Engineering Systems for the Primary Care Treatment of PTSD |
$1,223,812 |
Proposed randomized clinical trial of collaborative care for PTSD in Veterans who are treated in primary care settings to facilitate the management of PTSD and evaluate the effects of the intervention on patient outcomes, provider behavior, and costs. The long-term objectives are to generate information to support implementation research collaborative care for PTSD, and ultimately, implement the collaborative care for PTSD across VHA. |
Relationships and PTSD Study: Detection of Intimate Partner Violence (IPV) |
$897,799 |
Research to provide foundational knowledge about the detection of IPV in a PTSD treatment-seeking sample by examining the documentation of the existence or non-existence of IPV in the clinical record; and to provide additional knowledge about what distinguishes IPV perpetrators common perpetrators in a cohort of men with military related PTSD. |
Appendix I. OEF/OIF-Specific Data8
TBI and Related Blast Injuries
• Estimates of the percentage of OEF/OIF Service members returning with TBI range from 10 percent to 33 percent.
• Some long-term outcomes are apparent at or soon after the time of injury but TBIs that have no physical signs may cause serious long-term effects that can go undetected until the Service member returns home and cannot function as before
Polytrauma
• Frequent co-occurring problems with TBI include
Amputation
Chronic pain
Mental health disorders (e.g., PTSD, Depression)
Polytrauma (i.e., multiple injuries, head injury or cognitive disability, and lower-limb injuries)
Mental Health Disorders
• Major depression
Estimates of self-reported major depression in OEF/OIF active-duty service members range from 5 percent to 37 percent
• Post traumatic stress disorder
OEF/OIF Service members who experience combat exposure and those who are wounded are at higher risk than others
One 2006 government study estimated 17 percent of soldiers and 14 percent of Marines met PTSD screening criteria while deployed (other estimates vary)
Service members not identified during deployment may be identified 3-4 months (or many years) after their return Afghanistan and Iraq
MHS has spent more than $63.8 million in care and $13.1 million in prescription drugs for those with PTSD
Self-report screening, different outcome measurement, and the use of convenience samples in the extant post-deployment studies may underestimate the prevalence of PTSD and depression
Among 199 OEF/OIF Veterans referred to military behavioral health clinicians, those with PTSD or depression were five times as likely to report
_____________________
888 8 Complete citations or attributions are included in the IOM chapter on Preliminary Findings.
problems with family readjustment as those who did not and almost one third of the Veterans reported that their partners were afraid of them.
There is a shortage of mental health professionals
Services available to OEF/OIF service members and veterans are poorly distributed.
• Substance abuse disorder
A recent study of three Army and one Marine Corps units reported that OEF/OIF deployment was associated with higher prevalence of alcohol misuse compared to pre-deployment prevalence.
A study of reserve and National Guard reported that personnel deployed to OEF/OIF were at increased risk for new-onset heavy weekly drinking, binge drinking, and other alcohol-related outcomes.
Military deployment was associated with smoking initiation and more strongly with smoking recidivism
No data were available on drug abuse among OEF/OIF Service members
Deployment
In a survey of OEF/OIF Army spouses conducted in 2004,
78 percent reported loneliness
Over 51 percent reported anxiety
Over 48 percent cited a problem with the military because of the lack of accurate information around the timing of the deployment
Over 42 percent reported depression
41 percent reported difficult in communication with the deployed member
29 percent reported difficulties in household maintenance
Over 23 percent reported fears about personal safety
21 percent reported problems with overall health
18 percent reported effects on jobs
16 percent reported problems with child care
12 percent reported financial problems
Almost 10 percent reported problems with their marriages
Few studies focus on the normative course of reintegration
One longitudinal study of reintegration during OIF reported that couples in a sample of reservists were preoccupied with relational communication and expectation, especially regarding independence, roles, and responsibilities.
Since 2003, family separation has consistently been among the top concerns of Service members stationed in Iraq and Afghanistan and is more strongly related than any other concern to mental health problems
Length of deployment appears to be positively correlated and pay grade appears to be negatively correlated with a plan for divorce on return (so far, there is little evidence that these plans are realized)
Two small studies of OEF/OIF families suggest that symptoms of combat-related trauma are related to marital distress for both partners
No data were found on the effects of deployments on unmarried partners or the parents and other family members of Service members
The effects of OEF/OIF deployments on children who have parents deployed are consistent with those of earlier research, with studies on the current conflict reporting
Depression
Anxiety
More reactions to stress and resource losses
Academic difficulties
An increase in the use of mental health-care services
Effects on child maltreatment and intimate-partner violence are not yet known
Studies suggests that the unemployment rate of OEF/OIF Veterans may be higher than that of other Veterans
DoD's unemployment compensation costs increased 75 percent from 2002 to 2004, suggesting that OEF/OIF Veterans are having difficulty transitioning to the civilian labor market. 58 percent of the increase from 2002 to 2004 is attributed to the Army reserve components
OEF/OIF deployment reduced spousal labor-force participation almost 3 percent overall, with higher rates negatively correlated with the ages of the children.
The relationship between deployment and earnings among reservists is not clear.
Women and Minorities
Although 11 percent of all personnel deployed to Iraq and Afghanistan are women, there is little research specific to that population. Among military women in general:
Over 72 percent of women in one study reported having experienced sexual harassment during their military service
63 percent reported experiences of physical and sexual harassment during military service
43 percent reported rape or attempted rape during military service
Rates of pre-military trauma are higher in women than in men; one study reported 58 percent in women versus 35 percent in men
Among civilians, women have higher rates of depression and anxiety disorders than men. Studies of military populations posted at permanent bases have yielded similar findings.
The distribution of U.S. casualties in Iraq for the first 12 months of conflict show racial equity for minorities
In the military population overall, findings of differences in service delivery or outcomes associated with race or ethnicity are inconclusive.
Projecting the Lifelong Burden of War
• Historically, the number of Veterans receiving disability and pension benefits peak several decades after the war.
• As of 2008, 230,000 OEF/OIF Veterans had filed disability claims.
• The majority of claims have not yet been submitted. One study suggests that 791,000 OEF/OIF Veterans will eventually seek disability benefits.
• Unique aspects of OEF/OIF may result in significant deviations from historical trends (e.g., survivors of very severe injuries need more intensive care then the most severely wounded from prior wars).
Spinal Cord Injury |
|
SF-36V |
The Veterans Short Form 36 Questionnaire |
SME |
Subject matter expert |
SMI |
Serious mental illness |
SOC |
Senior Oversight Committee |
SSA |
Social Security Administration |
STARRS |
Study to Assess Risk and Resilience in Service Members |
SDQ |
Strengths and Difficulties Questionnaire |
SUD |
Substance use disorder |
T2 |
DCoE’s National Center for Telehealth and Technology |
TATRC |
Telemedicine and Advanced Technology Research Center |
TBI |
Traumatic brain injury |
TEAM |
Troop education for army morale |
TRICARE |
not an acronym (the military medical health system) |
TBIMS |
TBI Model Systems |
TLD |
Third-location decompression |
TOP |
Telemedicine Outreach for Post Traumatic Stress |
TRMD |
Treatment-resistant major depression |
UC |
Usual care |
UK |
United Kingdom |
USAMRMC |
US Army Medical Research and Materiel Command |
USDA |
US Department of Agriculture |
USUHS |
Uniformed Services University of the Health Sciences |
VA |
Department of Veterans Affairs |
VA RR&D |
VA Rehabilitation Research and Development Service |
VAMC |
VA Medical Center |
VBA |
Veterans Benefits Administration |
VetPop |
The Veteran Population |
VHA |
Veterans Health Administration |
VISN |
Veterans Integrated Service Network |
VRP |
Vocational rehabilitation program |
VSA |
Veterans Service Area |
WVHSHG |
Women Veterans Health Strategic Health Care Group |