Executive Summary

More than 1.6 million American service members have deployed to Iraq and Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). As of December 2008, more than 4,000 troops have been killed and over 30,000 have returned from a combat zone with visible wounds and a range of permanent disabilities. In addition, an estimated 25-40 percent have less visible wounds—psychological and neurological injuries associated with post traumatic stress disorder (PTSD) or traumatic brain injury (TBI), which have been dubbed “signature injuries” of the Iraq War.

Although the Department of Defense (DoD) and the Veterans Administration (VA) have dedicated unprecedented attention and resources to address PTSD and TBI in recent years, and evidence suggests that these policies and strategies have had a positive impact, work still needs to be done. In 2007, the Department of Defense Task Force on Mental Health concluded that

PTSD and TBI can be quite debilitating, but the effects can be mitigated by early intervention and prompt effective treatment. Although medical and scientific research on how to prevent, screen for, and treat these injuries is incomplete, evidence-based practices have been identified. A number of panels and commissions have identified gaps between evidence-based practices and the current care provided by DoD and VA and have recommended strategies to address these gaps. The window of opportunity to assist the service members and veterans who have sacrificed for the country is quickly closing. It is incumbent upon the country to promptly implement the recommendations of previous panels and commissions and fill the remaining gaps in the mental health service systems.

In terms of prevention, emphasis must be placed on minimizing combat stress reactions, and preventing normal stress reactions from developing into PTSD when they do occur. When PTSD or TBI does occur, the goal of treatment must be to help the service member regain the capacity to lead a complete life, to work, to partake in leisure and civic activities, and to form and maintain healthy relationships.

PTSD and TBI are often addressed together because they often occur together and because the symptoms are at times difficult to distinguish.

PTSD is an anxiety disorder arising from “exposure to a traumatic event that involved actual or threatened death or serious injury.” It is associated with a host of chemical changes in the body’s hormonal system, and autonomic nervous system. Symptoms vary considerably but the essential features of PTSD include:

• Re-experiencing: Such as flashbacks, nightmares and intrusive memories;
• Avoidance/Numbing: Including a feeling of estrangement from others; and,
• Hyperarousal/Hypervigilance:  Including feelings of being constantly in danger.

The challenge for both professionals and veterans is to recognize the difference between “a normal response to abnormal circumstances” and PTSD. Some will develop symptoms of PTSD while they are deployed, but for others it will emerge later, after several years in many cases.

According to current estimates, between 10 and 30 percent of service members will develop PTSD within a year of leaving combat. When we consider a range of mental health issues including depression, generalized anxiety disorder, and substance abuse, the number increases to between 16 and 49 percent.

Traumatic brain injury (TBI), also called acquired brain injury or simply head injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Victims may have a wide range of symptoms such as difficulty thinking, memory problems, attention deficits, mood swings, frustrations, headaches, or fatigue. Between 11 and 20 percent of service members may have acquired a traumatic injury in Iraq and Afghanistan.

Evidence-based practices to prevent PTSD include teaching skills to enhance cognitive fitness and psychological resilience that can reduce the detrimental impact of trauma. In terms of screening, evidence suggests that identifying PTSD and TBI early and quickly referring people to treatment can shorten their suffering and lessen the severity of their functional impairment. Several types of rehabilitative and cognitive therapies, counseling, and medications have shown promise in treating both injuries.

Service members and veterans may access care through the Department of Defense, the Veterans Health Administration, or the private sector. Each health care system has a number of strengths and weaknesses in delivering evidence-based care. For example:

Department of Defense: DoD has developed a number of evidence-based programs designed to 1) maintain the psychological readiness of the forces in order to reduce the incidence of stress reactions; 2) embed psychological services in deployed settings to ensure early intervention when stress reactions occur; and 3) deliver evidence based rehabilitative therapies on base and through TRICARE, a managed care system that uses a network of civilian providers. However, the military, not unlike the civilian health care setting, has a shortage of mental health providers who must be spread about military bases and deployed settings.

Service members who rely on the TRICARE network may have limited access to services. Because of the low reimbursement rates, many of TRICARE’s providers are not accepting new TRICARE patients and because of the shortage of available mental health providers in some areas, enrollees may wait weeks or months for an available appointment.

Veterans Health Administration: VA has undergone significant changes in the past 10-15 years that has transformed it into an integrated system that generally provides high quality care. In response to the increased demand for services to treat OEF/OIF veterans with PTSD, the system has invested resources in expanding outreach activities enhancing the availability and timeliness of specialized PTSD services. Nevertheless, access to care is still unacceptably variable across the VA system.

Some service members continue to face barriers to seeking care. These barriers include stigma and limited access.

Stigma: Service members are affected by three types of stigma:

• Public stigma: The notion that a veteran would be perceived as weak, treated differently, or blamed for their problem if he or she sought help.
• Self Stigma: The individual may feel weak, ashamed and embarrassed.
• Structural Stigma: Many service members believe their military careers will suffer if they seek psychological services. Although the level of fear may be out of proportion to the risk, the military has institutional policies and practices that restrict opportunities for service members who reveal that they have a psychological health issue by seeking mental health services.

Limited Access: Even when service members or veterans decide to seek care, they need to find the “right” provider at the “right” time. Long waiting lists, lack of information about where to find treatment, long distances to providers, and limited clinic hours create barriers to getting care. When care is not readily available, the “window of opportunity” may be lost.

Culturally diverse populations and women face additional barriers. Despite high rates of PTSD, African American, Latino, Asian, and Native American veterans are less likely to use mental health services. This is due, in part, to increased stigma, absence of culturally competent mental health providers, and lack of linguistically accessible information for family members with limited English proficiency who are providing support for the veteran. Women have an increased risk of PTSD because of the prevalence of Military Sexual Trauma.

Family and Peer Support: Family support is a key component to the veteran’s recovery. However, because of the stress of providing care, the veteran’s PTSD puts the family at increased risk of developing mental health issues as well. The current system provides inadequate support for the family in its caregiving role and inadequate access to mental health services that directly address the psychological well being of the spouse, children, or parents.

Support from peers who have shared a similar experience is also important. Peers can provide information, offer support and encouragement, provide assistance with skill building, and provide a social network to lessen isolation. Peer support may come in the form of naturally occurring mutual support groups; consumer-run services; formal peer counseling services. In addition, consumers need to be involved in the development and deployment of services for patients with PTSD and TBI.

Recommendations and Conclusion

The wars in Iraq and Afghanistan are resulting in injuries that are currently disabling for many, and potentially disabling for still more. They are also putting unprecedented strain on families and relationships, which can contribute to the severity of the service member's disability over the course of time. NCD concurs with the recommendations of previous Commissions, Task Forces and national organizations that:

1. A comprehensive continuum of care for mental disorders, including PTSD, and for TBI should be readily accessible by all service members and veterans. This requires adequate staffing and adequate funding of VA and DoD health systems.
2. Mechanisms for screening service members for PTSD and TBI should be continuously improved to include baseline testing for all Service Members pre-deployment and follow up testing for individuals that are placed in situations where head trauma may occur.
3. The current array of mental health and substance abuse services covered by TRICARE should be expanded and brought in line with other similar health plans

It is particularly critical that prevention and early intervention services be robust. Effective early intervention can limit the degree of long term disability and is to the benefit of the service member or veteran, his or her family and society. Therefore, NCD recommends that:

1. Early intervention services such as marital relationship counseling and short term interventions for early hazardous use of alcohol and other substances should be strengthened and universally accessible in VA and TRICARE.

Consumers play a critical role in improving the rehabilitation process. There are many opportunities for consumers to enhance the services offered to service members and veterans and their families. NCD recommends that:

1. DoD and VA should maximize the use of OIF/OEF veterans in rehabilitative roles for which they are qualified including as outreach workers, peer counselors and as members of the professional staff.
2. Consumers should be integrally involved in the development and dissemination of training materials for professionals working with OIF/OEF veterans and service members.
3. Current and potential users of VA, TRICARE and other DoD mental health and TBI services should be periodically surveyed by a competent independent body to assess their perceptions of: a) the barriers to receiving care, including distance, cost, stigma, and availability of information about services offered; and b) the quality, appropriateness to their presenting problems and user-friendliness of the services offered.
4. VA should mandate that an active mental health consumer council be established at every VA medical center, rather than have this be a local option as is currently the case.
5. Congress should mandate a Secretarial level VA Mental Health Advisory Committee and a Secretarial level TBI Advisory Committee with strong representation from consumers and veterans organizations, with a mandate to evaluate and critique VA's efforts to upgrade mental health and TBI services and report their findings to both the Secretary of Veterans Affairs and Congress.

DoD and VA have initiated a number of improvements, but as noted by earlier Commissions and Task Forces, gaps continue to exist.

It is imperative that these gaps be filled in a timely manner. Early intervention and treatment is critical to the long-term adjustment and recovery of service members and veterans with PTSD and TBI. NCD recommends that: 

1. Congress and the agencies responsible for the care of OEF/OIF veterans must redouble the sense of urgency to develop and deploy a complete array of prevention, early intervention and rehabilitation services to meet their needs now.

As this report indicates, the medical and scientific knowledge needed to comprehensively address PTSD and TBI is incomplete. However, many evidence-based practices do exist. Unfortunately, service members and veterans face a number of barriers in accessing these practices including stigma; inadequate information; insufficient services to support families; limited access to available services, and a shortage of services in some areas. Many studies and commissions have presented detailed recommendations to address these needs. There is an urgent need to implement these recommendations.