# Invisible Wounds: Serving Service Members and Veterans

# with PTSD and TBI

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height="3.084722222222222in"}

**National Council on Disability**

**March 4, 2009**

National Council on Disability

1331 F Street, NW, Suite 850

Washington, DC 20004

# Invisible Wounds: Serving Service Members and Veterans with PTSD and TBI

This report is also available in alternative formats and on the National
Council on Disability (NCD) Web site (www.ncd.gov).

Publication date: March 4, 2009

202-272-2004 Voice

202-272-2074 TTY

202-272-2022 Fax

The views contained in this report do not necessarily represent those of
the Administration as this and all NCD documents are not subject to the
A-19 Executive Branch review process.

**National Council on Disability Members and Staff**

**Members**

John R. Vaughn, Chairperson

Chad Colley, Vice Chairperson

Patricia Pound, Vice Chairperson

Victoria Ray Carlson

Robert R. Davila, Ph.D.

Graham Hill

Marylyn Howe

Kathleen Martinez

Lisa Mattheiss

Heather McCallum

Katherine O. McCary

Lonnie Moore

Anne M. Rader

Linda Wetters

Tony Williams

**Staff**

Michael C. Collins, Executive Director

Martin Gould, Ed.D., Director of Research

Mark S. Quigley, Director of External Affairs

Julie Carroll, Senior Attorney Advisor

Joan M. Durocher, Senior Attorney Advisor

Lisa Grubb, Special Assistant to the Executive Director

Geraldine Drake Hawkins, Ph.D., Senior Program Analyst

Anne C. Sommers, Legislative Affairs Specialist

Stacey S. Brown, Staff Assistant

Carla Nelson, Secretary

Table of Contents

[Executive Summary](#_Executive_Summary)
\........................................................................................1

[Section 1: Introduction 8](#section-1-introduction)

[Section 2: Background 13](#__RefHeading___Toc217385000)

[1. Characteristics of Deployed Forces
13](#characteristics-of-deployed-forces)

[2. Experiences of Deployed Forces 14](#experiences-of-deployed-forces)

[Section 3: Post Traumatic Stress Disorder (PTSD) and Traumatic Brain
Injury (TBI) 15](#__RefHeading___Toc217385003)

[1. What is PTSD? 15](#what-is-ptsd)

[2. What is TBI? 19](#what-is-tbi)

[3. Relationship Between PTSD and TBI
20](#relationship-between-ptsd-and-tbi)

[4. Risk Factors for PTSD 21](#risk-factors-for-ptsd)

[Section 4: Evidence Based Approaches for Prevention, Outreach,
Assessment, Diagnosis, and Treatment 24](#__RefHeading___Toc217385008)

[1. Prevention 24](#prevention)

[2. Outreach, Assessment, and Diagnosis
25](#outreach-assessment-and-diagnosis)

[3. Treatment 27](#treatment)

[4. Other Interventions 30](#other-interventions)

[5. Holistic Approach 36](#holistic-approach)

[Section 5: Components of the Health Care System
37](#section-5-components-of-the-health-care-system)

[1. Eligibility 37](#eligibility)

[2. Department of Defense 39](#department-of-defense)

[3. Veterans Health Administration 46](#veterans-health-administration)

[4. Private Sector 49](#private-sector)

[5. Nonprofit and Volunteer Organizations
50](#nonprofit-and-volunteer-organizations)

[Section 6: Barriers to Seeking Care 51](#__RefHeading___Toc217385020)

[1. Stigma 51](#stigma)

[2. Access 52](#access)

[3. Additional Issues for Certain Populations
53](#additional-issues-for-certain-populations)

[Section 7: Family Issues 55](#section-7-family-issues)

[1. Effect of PTSD/TBI on the Family
55](#effect-of-ptsdtbi-on-the-family)

[2. Services for Family Members 57](#services-for-family-members)

[Section 8: Recommendations 59](#__RefHeading___Toc217385027)

[References 63](#references)

# [[]{#_Executive_Summary .anchor}Executive Summary](#OLE_LINK2)

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

> Despite the progressive recognition of the burden of mental illnesses
> and substance abuse and the development of many new and promising
> programs for their prevention and treatment, current efforts are
> inadequate to ensure the psychological health of our fighting forces.
> Repeated deployments of mental health providers to support operations
> have revealed and exacerbated pre-existing staffing inadequacies for
> providing services to military members and their families. New
> strategies to effectively provide services to members of the Reserve
> Components are required. Insufficient attention has been paid to the
> vital task of prevention.

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:

4.  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:

5.  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.

6.  Consumers should be integrally involved in the development and
    dissemination of training materials for professionals working with
    OIF/OEF veterans and service members.

7.  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.

8.  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.

9.  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:

10. 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. 

# Section 1: Introduction

*The war is done for me now. The days of standing in the hot desert sun,
setting up ambushes on the sides of mountains and washing the blood from
my friend's gear are over. The battles with bombs, bullets, and blood
are a thing of the past. I still constantly fight a battle that rages
inside my head.*

Brian McGough, a 32 year-old Army staff sergeant whose convoy was
attacked with IEDs in 2006. From his blog "Inside my Broken Skull."

American service members have sacrificed a great deal in the battles in
Afghanistan and Iraq, and many of those who have returned are still
battling. Only now they are not fighting the enemy around them. They
are, at times, fighting an even more elusive foe within---the
psychological effects of war. This foe is often not recognized or
acknowledged. Moreover, the system that provides treatment for
psychological trauma for veterans is not always well implemented.

More than 1.6 million American service members have deployed to Iraq and
Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF), and over 565,000 have deployed more than once (Veterans
for Common Sense, 2008). As of December 2008, more than 4,200 troops
have been killed and over 30,800 have returned from a combat zone with
visible wounds and a range of permanent disabilities (O'Hanlon and
Campbell 2008). 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)
(Tanielian and Jaycox 2008; Hoge, et al. 2008).

It is common to make a distinction between visible injuries such as
orthopedic injuries, burns, and shrapnel wounds and less visible
injuries such as PTSD. The distinction often is characterized as
"physical" versus "mental" injuries. These terms imply that PTSD somehow
is not physical. However, this is an artificial distinction. PTSD and
other "mental illnesses" are characterized by measurable changes in the
brain and in the hormonal and immune systems. In this report, we use the
terms "visible" and "not visible" to make the distinction.

Although PTSD and TBI have different origins---PTSD is caused by
exposure to extreme stress, whereas TBI is caused by blast exposure or
other head injury---they are closely related. People with TBI are more
prone to PTSD, and many people with PTSD may have co-morbid undiagnosed
mild TBI. Substance abuse, often associated with both injuries,
complicates the situation for many people. Although this report focuses
on PTSD and TBI, these injuries account for only a portion of the mental
health issues affecting our service members including depression,
generalized anxiety disorders, substance abuse, and interpersonal
conflicts.

War is inherently a traumatic experience, but PTSD can be mitigated
through prevention and training programs prior to deployment, effective
stress reduction techniques during operations, and treatment programs
after combat exposure. DoD, VA, and civilian researchers have developed
many strategies to diminish the onset of PTSD and treat both the direct
symptoms of PTSD and its impact on the individual's ability to function.

Despite these strategies, a plethora of evidence points to gaps in the
current health care system for service members and veterans. Media
reports, Congressional inquiries, commissions, and lawsuits have
revealed deficiencies in outreach, access, care coordination, and
treatment. The evidence points to wide variations in access to mental
health services; an inadequate supply of mental health providers;
resistance on the part of some military leaders to adopt new attitudes;
and resistance on the part of the service member or veteran to seek
service because of the stigma associated with psychological disorders.

In the past several years, DoD and VA have developed a number of new
programs, policies, and strategies to address the mental health needs of
service members and veterans of OEF/OIF. For example, Congress extended
the automatic eligibility for services through the Veterans Health
Administration from two years to five; DoD instituted mandatory PTSD
screening upon service members' return from combat as well as a
reassessment 3-6 months later; VA has developed treatment protocols that
incorporate evidence-based practices; the Vet Centers have hired
additional staff to provide outreach; and DoD and VA are working toward
integrating their systems to be more effective.

Although DoD and VA have dedicated unprecedented attention and resources
to address PTSD and TBI in recent years (eg. Defense Centers of
Excellence), and some 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 "Despite the progressive recognition of the burden of mental
illnesses and substance abuse and the development of many new and
promising programs for their prevention and treatment, current efforts
are inadequate to ensure the psychological health of our fighting
forces. Repeated deployments of mental health providers to support
operations have revealed and exacerbated pre-existing staffing
inadequacies for providing services to military members and their
families. New strategies to effectively provide services to members of
the Reserve Components are required. Insufficient attention has been
paid to the vital task of prevention" (US DoD Task Force on Mental
Health 2007).

The situation requires an urgent response. While the intensity of combat
and the number of enemy initiated attacks has fallen since mid 2007,
service members continue to struggle with the wounds of PTSD that they
acquired earlier in the war and that others continue to acquire. Early
intervention and timely rehabilitation is critical to maximizing the
long-term health outcomes of the men and women who served in Iraq and
Afghanistan.

NCD\'s study examines evidence based approaches for prevention,
diagnosis, and treatment of PTSD, reviews preliminary indications of
many new strategies being implemented by VA and DoD, and concludes that
the extra attention being devoted to this disability is not only
warranted, but has the potential to greatly reduce financial and human
costs for all concerned.

NCD recognizes that these issues have been studied by other governmental
and professional organizations. This report attempts to augment the
recommendations of these previous studies with a focus on barriers to
access to care for citizens with disabilities; the importance of early
intervention and comprehensive rehabilitation to minimize the long term
effects of disability; and the need for continuing consumer involvement
both in the rehabilitation of individuals and the oversight of the
implementation of the many policy and service delivery changes needed to
effectively address the rehabilitative needs of service members and
veterans.

This report is structured as follows in the succeeding sections:

-   Section 2 provides a brief description of the demographic
    composition of the fighting forces and their experiences in the
    combat theater. Many of these characteristics are associated with an
    increased risk of PTSD.

-   Section 3 describes the symptoms, prevalence and risk factors for
    PTSD and TBI.

-   Section 4 reviews the evidence-based approaches for preventing and
    treating PTSD and TBI.

-   Section 5 reviews the systems that are in place and discusses how
    they differ from the evidence based approaches described in Section
    4.

-   Section 6 addresses the issue of service members not availing
    themselves of all services.

-   Section 7 describes special issues affecting the families of service
    members and the availability of services to address these issues.

-   Section 8 presents NCD's recommendations.

In preparing this report, NCD gathered information from scientific
journals, professional conferences, commission reports, VA and DoD
protocols and regulations, Congressional testimony, newspaper reports,
advocacy websites and papers, blogs, on-line support groups, and
interviews. These sources represent a range of perspectives including
those of DoD and VA leaders, mental health providers, veterans,
advocates, parents, and spouses.

Some of the information and recommendations were drawn from the reports
of recent task forces and commissions, including the President\'s
Commission on Care for America\'s Returning Wounded Warriors (the
Dole/Shalala Commission); the Task Force on Returning Global War on
Terror Heroes (the Nicholson Task Force); the Veterans Disability
Benefits Commission; the Department of Defense Task Force on Mental
Health; the American Psychological Association's Presidential Task Force
on Military Deployment Services for Youth, Families and Service Members;
and, the US Army Surgeon General's Mental Health Advisory Team's annual
assessment of needs and survey of deployed troops. A complete list of
sources is provided at the end of the report.

[]{#__RefHeading___Toc217385000 .anchor}**Section 2: Background**

+-----------------------------------------------------------------------+
| *Iraq has become an incubator for post traumatic stress disorder      |
| (PTSD) in the American service members. The combat zone in Iraq has   |
| no frontline, no safe zone, and the embattled soldier has little with |
| which to differentiate friend from foe, no warning of when or where   |
| the next improvised explosive device will be detonated. It is hardly  |
| surprising that we are seeing high rates of depression, PTSD, and     |
| other anxiety disorders in service members who have been deployed to  |
| Iraq.*                                                                |
|                                                                       |
| Greenburg and Roy, 2007                                               |
+-----------------------------------------------------------------------+

## Characteristics of Deployed Forces

The United States has had between 122,000 and 171,000 troops in Iraq and
Afghanistan at any one time since major combat operations ended in May
2003 (O'Hanlon and Campbell 2008). Almost 1.6 million American service
members have deployed to OIF and OEF, and almost 565,000 have deployed
more than once (Veterans for Common Sense 2008).

-   28 percent are guard and reserve (Waterhouse and O'Bryant 2008);

```{=html}
<!-- -->
```
-   The average age of an active duty member deployed to Iraq or
    Afghanistan is 27, and the average age of deployed National Guard or
    Reserve troops is 33;

-   60 percent of those deployed are married and over half have
    children;

-   88 percent are male, and 12 percent are female;

-   The troops are from diverse racial backgrounds (22 percent
    African-American, 11 percent Latino, 4 percent Asian, 3 percent
    other) (Maxfield 2006);

-   Half of the 1.6 million service members who have deployed are still
    in the military (Veterans for Common Sense, 2008); and

-   Three-quarters of the forces deployed to Iraq are Army, 15 percent
    are Marine Corps, and 10 percent are Navy and Air Force (O'Bryant
    and Waterhouse 2006).

## Experiences of Deployed Forces

+-----------------------------------------------------------------------+
| *Everyone\'s experience of deployment is a little different, so it\'s |
| unfair to cast all experiences in the same mold. People see stories   |
| of Infantry guys watching their squadmates die and murdering Iraqi    |
| civilians, and assume that I personally have seen levels of Hell of   |
| which I have had no taste. Conversely, people read the blogs of       |
| career soldiers and Pogues, and perhaps get an image of this place    |
| that is a little sunnier than expected. People want to lump our       |
| stories into the either/or. All or none. And that\'s not really       |
| fair.*                                                                |
|                                                                       |
| SPC Freeman stationed in Iraq. From his blog "The Calm Before the     |
| Sand."                                                                |
+-----------------------------------------------------------------------+

From March 2003 to November 2008, 4,203 American service members were
killed in Iraq. Most of the fatalities have been Army soldiers. Forty
percent were caused by Improvised Explosive Devices (IEDs), and 30
percent were the result of other hostile fire. Three percent were from
car bombs. During intense fighting between May and July 2007, there were
162 insurgent attacks per day with over 75 in Baghdad and Al-Anbar
Province alone (O'Hanlon and Campbell 2008)

Many service members are operating under constant threat of death or
injury and seeing the violent death of their comrades and others.
Enemies and civilians are often indistinguishable, and service members
are asked to play dual roles of warrior and ambassador.

Many have been on multiple deployments with relatively little downtime
between deployments. Some operations are 24-hours per day with soldiers
sleeping an average of only five and half hours per day (US Army Surgeon
General 2008). Based on an annual survey conducted by the Army, Soldiers
have recently reported a decline in a range of combat exposures. Despite
this reduction, the soldiers surveyed continue to encounter intense
combat experiences while deployed to Iraq most soldiers have received
incoming artillery, rocket or mortar fire. (US Army Surgeon General
2008).

[]{#__RefHeading___Toc217385003 .anchor}**Section 3: Post Traumatic
Stress Disorder (PTSD) and Traumatic Brain Injury (TBI)**

## What is PTSD?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the
publication that defines the criteria used in diagnosing mental
disorder, classifies PTSD as an anxiety disorder that arises from
"exposure to a traumatic event that involved actual or threatened death
or serious injury" (American Psychiatric Association 1994).

+-----------------------------------------------------------------------+
| *Standing in line at the check out stand the feeling was almost       |
| unbearable, like a low electric current was flowing through my body,  |
| not enough to hurt but enough to make me really uncomfortable. The    |
| people behind me were standing way too close to me, their kid making  |
| way too much noise. I thought of the children I had seen in Iraq and  |
| how I never saw one cry, even the wounded ones.*                      |
|                                                                       |
| *It felt like I was suffocating in the store, near panic, but I was   |
| going to maintain, I could do this, JUST BUY YOUR \*\*\*\* AND GET TO |
| THE CAR.*                                                             |
|                                                                       |
| *Just then was when the boy behind me popped the balloon he was       |
| playing with.*                                                        |
|                                                                       |
| *I was on the floor, clawing at the fake marble colored tiles,        |
| attempting to crawl under a magazine rack. I may have yelled INCOMING |
| I don't know but when I came back into my body everyone was looking   |
| at me.*                                                               |
|                                                                       |
| A 32-year-old OIF Army Veteran. From his blog "This is Your War II."  |
+-----------------------------------------------------------------------+

### Symptoms

Symptoms vary considerably from person to person, but the essential
features of PTSD include the following (description based on Helpguide
2008):

-   *Re-experiencing:* The most disruptive symptoms of PTSD involve
    flashbacks, nightmares, and intrusive memories of the traumatic
    event. The veteran may be flooded with horrifying images, sounds,
    and recollections of what happened. He or she may even feel like it
    is happening again. These symptoms are sometimes referred to as
    intrusions, since memories of the past intrude on the present. These
    symptoms can appear at any time, sometimes seemingly out of the
    blue. At other times, something triggers a memory of the original
    traumatic event: a noise, an image, certain words, or a smell.

-   *Avoidance/Numbing:* Patients with PTSD may attempt to avoid
    thoughts or activities that could remind them of the traumatic
    event. In addition, they may lose their ability to experience
    pleasure and may seem emotionally "flat" or nonresponsive. They may
    feel detached or estranged from others. Often, they have a sense of
    a "foreshortened future" feeling that tomorrow may never exist.

-   *Hyperarousal/Hypervigilance:* Individuals with PTSD may feel and
    react as if they are constantly in danger. This increased arousal
    may disrupt sleep, contribute to irritability and anger, and impair
    concentration. Hypervigilance may coexist with an exaggerated
    startle response.

### The Science

PTSD has a biological basis. It is associated with a host of chemical
changes in the body's hormonal system, immune system, and autonomic
nervous system. Medical research suggests that the intense bursts of
brain activity during traumatic experiences may lay down new neural
pathways in the brain (Johnson 2005).

Individuals respond to traumatic experiences along a continuum. Most
people have a sudden increased arousal and vigilance. This is a "normal
stress response" to danger and generally dissipates with time. For some,
the symptoms intensify, become chronic, and interfere with their ability
to function (Davidson et al. 2004).

The challenge for mental health professionals and the veterans
themselves is to recognize the difference between what has been termed
"a normal response to abnormal circumstances" and PTSD. While it is
important to avoid "pathologizing" normal reactions, it is equally
important to identify when these normal stress reactions are likely to
lead to functional limitations. Early intervention will reduce the
chance that the stress reaction will become chronic PTSD. In addition,
if treatment is delayed, veterans may develop unhealthy coping
strategies and may damage their relationships and social support
network, leaving them very isolated (Hirsel 2007).

The timing of the onset of stress symptoms varies. These symptoms tend
to be heightened by events that elicit memories of the trauma such as
anniversary dates or noteworthy \"time anchors;" media exposure to war
zone events; sights, sounds, or smells that are suggestive of the
warzone; certain melodies or lyrics; experiences involving significant
losses (such as death of a loved one, etc.); or conflicts with authority
(Scurfield 2006).

Some will feel the effects of the trauma while they are still deployed.
This is referred to as a combat stress reaction (CSR). Reports from a
survey of deployed army revealed that a substantial number of military
personnel were experiencing emotional problems during their service in
Iraq. For example, 15 percent of those surveyed screened positive for
acute stress symptoms and 18 percent screened positive on a combined
measure of acute stress, depression, or anxiety. Others may have
symptoms immediately upon return from combat, while others may
experience a delay of six months to many years, or when they leave the
military troops (US Army Surgeon General 2008).

In response to concerns that claims of delayed onset PTSD are attempts
to unfairly receive disability compensation, The Institute of Medicine,
at the request of the Veterans Benefit Administration, conducted a
comprehensive review of the scientific literature and concluded that
"considerable evidence suggests that rates of PTSD increase over time
following deployment." (Institute of Medicine and National Research
Council 2007)

### Comorbidity 

PTSD usually occurs in conjunction with other psychiatric, behavioral
and medical conditions. Several studies have found that more than 80
percent of people who have been diagnosed with PTSD also have a
generalized anxiety disorder, social anxiety disorder, major depressive
disorder, or one of a range of psychiatric or substance-related
conditions. (Institute of Medicine and National Research Council 2007).
The conditions may be triggered by PTSD (e.g., many people turn to
alcohol and drugs in an attempt to self-medicate the symptoms of PTSD),
or preexisting disorders may increase the risk of PTSD.

A growing body of research is finding a link between PTSD and poor
physical health. People with PTSD have more adverse health outcomes in a
number of domains such as self-reported health, morbidity, health care
utilization, and mortality (Institute of Medicine and National Research
Council 2007). Although the psycho-biological mechanism that causes
these adverse general medical health outcomes is not well understood,
the evidence of the relationship is overwhelming. For example,
researchers have found that compared to veterans without PTSD, those
with PTSD have substantially higher post-war rates for many chronic
conditions including circulatory, nervous system, digestive,
musculoskeletal, and respiratory, even after controlling for the major
risk factors for these conditions. (Barrett et al. 2002). They also have
found shorter average life spans (Boscarino 2005).

### Functional Difficulties

PTSD can affect an individual's ability to maintain relationships, work,
and in some cases, interact with their environment and those around
them.

**Relationships:** Research with Vietnam veterans clearly documents the
adverse effects of PTSD on intimate relationships. Vietnam veterans with
PTSD are twice as likely as veterans without PTSD to have been divorced
and three times as likely to experience multiple divorces. Veterans with
PTSD perpetrate domestic violence at greater rates than comparable
veterans without PTSD. (American Psychological Association 2007).

Although many couples are able to withstand the stress of PTSD, some
military spouses, in their blogs, describe a similar dynamic. The
veteran gets anxious and angry over little things, making everyday life
for the family incredibly stressful. Compounding the everyday stress,
the veteran may feel emotionally numb and "put up a wall," becoming
uninterested in social and sexual activities. The spouse, hurt and
stressed, may "snap" at the veteran and the anger escalates as the cycle
continues. In other situations, the veteran with PTSD may have a sharp
temper or violent streak that scares or angers the spouse.

**Work:** A diagnosis of war-related PTSD has been linked consistently
to poor employment outcomes (Smith et al. 2005). Many symptoms of PTSD
can directly affect job performance, such as difficulty concentrating on
job tasks, handling stress, working with others, taking instructions
from a supervisor, or maintaining reliable attendance.

**Interacting with the environment:** For people with PTSD, memories may
be triggered by sights, sounds, smells, or feelings that remind them of
the traumatic event. This reaction may cause them to become isolated.

### Comorbidity 

According to current estimates, between 10 and 30 percent of service
members develop PTSD within a year of combat. When one considers a range
of mental health issues including depression, generalized anxiety
disorder, and substance abuse, the number increases to between 16 and 49
percent (Hoge et al 2004, Milliken et al 2007, Tanielian and Jaycox
2008, US DoD Task Force on Mental Health 2007, Army Surgeon General
2008).

The precise prevalence of PTSD among service members who have returned
from deployment to Iraq and Afghanistan cannot be determined at this
time. The estimates of probable PTSD are affected by a number of factors
including the sensitivity and specificity of the screening instruments
used in the study; the time period after combat when the questionnaire
or assessment is administered; and response bias among service members
who may be reluctant to acknowledge symptoms due to factors such as
stigma or fear of impact on their career.

Although estimates vary, all conclude that a significant number of
service members and veterans are at risk for various degrees of stress
reaction, including for some diagnosable PTSD.

## What is TBI?

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.

### Symptoms

Symptoms of TBI can be mild, moderate, or severe, depending on the
extent of the damage to the brain. The term "mild TBI" is synonymous
with "concussion." (Hoge et al 2008). A person with a mild TBI may
remain conscious or may experience a loss of consciousness for a few
seconds or minutes. Other symptoms of mild TBI include headache,
confusion, lightheadedness, dizziness, blurred vision or tired eyes,
ringing in the ears, bad taste in the mouth, fatigue or lethargy, a
change in sleep patterns, behavioral or mood changes, and trouble with
memory, concentration, attention, or thinking. A person with a moderate
or severe TBI may show these same symptoms, but may also have a headache
that gets worse or does not go away, repeated vomiting or nausea,
convulsions or seizures, an inability to awaken from sleep, dilation of
one or both pupils, slurred speech, weakness or numbness in the
extremities, loss of coordination, and increased confusion,
restlessness, or agitation (National Institute of Neurological Disorders
and Stroke 2008).

Most brain injuries are mild, and many soldiers with mild TBI can
recover with rest and time away from the battlefield. However, the
military estimates that one-fifth of the troops with these mild injuries
will have prolonged---even lifelong---symptoms requiring continuing care
(US Army Surgeon General 2008). They may have cognitive issues such as
difficulty thinking, memory problems, attention deficits, mood swings,
frustrations, headaches, fatigue, or many other symptoms.

### Prevalence

VA only recently began a widespread TBI screening program and DoD has
only recently begun documenting TBIs in each service member's medical
record. As a result, neither DoD nor VA can estimate the prevalence of
TBIs based on screenings. Based on available survey data, an estimated
11 to 20 percent of service members sustained a mild TBI/concussion
while serving in OEF/OIF (US Army Surgeon General 2008, Hoge et al.
2008, Taneilian and Jaycox 2008).

## Relationship Between PTSD and TBI 

PTSD and TBI are often addressed together for two reasons. First, the
symptoms may be similar, so it is difficult to distinguish between the
two injuries. Second, many people with TBI also have PTSD.

Although PTSD is a biological/psychological injury and TBI is a
neurological trauma, the symptoms of the two injuries have some parallel
features. In both injuries, the symptoms may show up months after
someone has returned from war, and in both injuries, the veteran may
"self medicate" and present as someone with a substance abuse problem.
Overlapping symptoms include sleep disturbances, irritability, physical
restlessness, difficulty concentrating, and some memory disturbances.
While there are similarities, there are also significant differences.
For example, with PTSD individuals may have trouble remembering the
traumatic event, but otherwise their memory and ability to learn is
intact. With TBI the individual has preserved older memories, but may
have difficulty retaining new memories and new learning.

Research indicates that people with TBI are more likely to develop PTSD
than those who have not incurred a brain injury (Hoge 2008). Two
scientific theories attempt to explain this relationship. First, TBI can
damage a person's cognitive function and hinder their ability to manage
the consequences of his or her psychological trauma, thus leading to a
greater incidence of PTSD (Bryant 2008). Second, a mild TBI injury in
the combat environment, particularly when associated with loss of
consciousness, reflects exposure to a very intense traumatic event that
threatens loss of life and significantly increases the risk of PTSD
(Hoge 2008).

## Risk Factors for PTSD 

Several factors have been shown to increase the risk of PTSD. Some of
these factors are particularly common to the deployments in Iraq and
Afghanistan, which may account for the high rate of injury among service
members and veterans.

### Characteristics of Deployment

-   *Length of deployment*---Numerous studies document a direct
    relationship between the amount of exposure to combat stressors and
    the likelihood of eventually developing PTSD (Scurfield 2006).

-   *Multiple deployments*---Confirming that the amount of exposure
    increases risk, the MHAT-V found that soldiers have an increased
    risk with each additional deployment; 27 percent of soldiers on
    their third deployment reported serious combat stress or depression
    symptoms, compared to 19 percent on their second, and 12 percent on
    their first deployment (US Army Surgeon General 2008).

-   *Violation of expectations*---When deployment length is longer than
    expected (such as when the length of deployment changes in the
    middle of the deployment) the rate of PTSD increases (Rona et al.
    2007).

-   *Sleep deprivation*---Soldiers who report being sleep deprived are
    at significant risk of reporting mental health issues. It is unclear
    whether sleep deprivation is a symptom or the cause of mental health
    issues. In MHAT-V soldiers reported an average of 5.6 hours of
    sleep, which is significantly less than what is needed to maintain
    optimal performance (US Army Surgeon General 2008).

-   *Inadequate dwell time---*The dwell time, (the time between the end
    of one deployment and a redeployment) has an important impact on
    PTSD (Hoge 2008) The optimal minimum dwell time for active duty
    military is twice the period of the initial deployment (a 1:2
    deployment to dwell ratio) and a 1:5 deployment to dwell ratio for
    National Guard and Reserve troops. (Defense Science Board 2007).
    Thus, a service member deployed for a year should have at least two
    years dwell time before being redeployed. Many of the adaptive
    skills necessary in combat must be \"turned off\" when service
    members come home and \"turned back on\" when they return for their
    next deployment. Evidence suggests that 12 months is insufficient
    time to "reset" the mental health of soldiers after a combat tour of
    over a year (US Army Surgeon General 2008).

-   *Types of combat exposure*---Certain "malignant" types of combat
    exposure also appear to place service members at particular risk.
    For example, McCarroll et al. (1995) found higher levels of PTSD
    symptoms in veterans who had handled human remains compared to those
    who had not.

-   *Training*---Service members who feel unprepared for their work in
    theater and those who perceive the events as unpredictable are more
    likely to develop PTSD (Iverson 2008). Stress-exposure training,
    which involves simulations of dealing with dead noncombatants,
    unconventional combatants, injuries, surprise attacks, and live-fire
    actions, can help prevent combat stress reactions in theater by
    preparing service members in advance for situations they may face in
    combat (Hosek 2006).

-   *Bodily Injury*---Soldiers who sustain bodily injury are more likely
    to develop PTSD than are soldiers who experienced the same event but
    were not physically injured (Koren et al. 2005).

-   *Military Sexual Assault*---Being sexually assaulted while in
    military services leads to PTSD in some, generally female, veterans.
    There is evidence that military sexual assault makes PTSD more
    likely than does sexual assault occurring before or after military
    service (Yeager et al. 2006).

-   *Unit Cohesion*---Many researchers have found that strong unit
    cohesion and leadership reduces the risk of PTSD. High levels of
    unit cohesion seem to increase the resilience of service members to
    cope with military-related stressors (Brailey et al. 2007). However,
    for some, high levels of unit cohesion may be seen later as an
    illusion that has been betrayed, increasing anger and risk of PTSD
    (Brailey et al. 2007).

### Personal Factors

Service members process what happens in combat in the context of the
rest of their lives. As a result, early childhood adversity, previous
trauma, and history of mental illnesses increase the risk of PTSD. Low
education, ethnic minority status, younger age, and lower rank are also
associated with increased risk (Brewin et al. 2000, Riddle et al. 2007,
Iverson et al. 2008).

Two post-deployment factors are associated with an increased risk of
PTSD: lack of social support and "life stress" (Brewin et al. 2000).

[]{#__RefHeading___Toc217385008 .anchor}**Section 4: Evidence Based
Approaches for Prevention, Outreach, Assessment, Diagnosis, and
Treatment**

The goal of PTSD interventions is to address the prevention, diagnosis,
and treatment of PTSD. In terms of prevention, emphasis must be placed
both on minimizing combat stress reactions, and, when they do occur,
preventing normal stress reaction from developing into chronic PTSD.
Preventing all cases of PTSD, however, is impossible. When cases do
arise, assessment and diagnosis leading to timely treatment is crucial.
The goal of treatment is not merely to reduce service members' symptoms,
but to help them regain the capacity to lead complete lives as full
members of their community -- to work, to partake in leisure and civic
activities, and to form and maintain healthy relationships with their
family and friends.

In an attempt to maximize the effectiveness of their treatment programs,
DoD, VA, and the broader psychological community have undertaken studies
to identify the best practices for treating PTSD. The "gold standards"
for identifying best practices are randomized controlled trials (RCT),
which are designed to ensure that any changes in the outcome measure can
be attributed to the intervention rather than to extraneous factors.
Unfortunately, many promising interventions have not been subjected to
RCT studies. In this section, we describe best practices based on
theoretical frameworks and medical research in addition to evidence from
RCTs.

## Prevention

Cognitive fitness and psychological resilience can serve as barriers to
developing PTSD. Although no RCT studies exist that indicate how to
increase this resilience among service members, VA and DoD developed the
following general guidelines based on theoretical frameworks (US
Department of Veterans Affairs and Department of Defense 2004):

-   Provide realistic training that includes vicarious, simulated, or
    actual exposure to traumatic stimuli that may be encountered;

-   Strengthen perceived ability to cope by providing instruction in
    coping skills;

-   Create supportive interpersonal work environments; and,

-   Develop and maintain adaptive beliefs such as confidence in
    leadership, confidence in the meaningfulness of the work, and
    knowledge about the transitory nature of most acute stress
    reactions.

Preliminary evidence suggests that psychological preparation enhances
resilience. For example, in a 2007 survey of deployed soldiers, those
who received pre-deployment "Battlemind" training described in Section 5
reported fewer mental health problems in Iraq than those who did not
receive the training (US Army Surgeon General 2008).

## Outreach, Assessment, and Diagnosis

### PTSD

**Screening:** Early identification of PTSD and other stress reactions
is critical. Quickly referring people to treatment can shorten their
suffering and lessen the severity of their functional impairment.

The effectiveness of screening remains controversial for two reasons.
First, screening troops immediately upon return from combat yields false
positives, meaning that screening misidentifies cases that are normal
combat stress reactions. Medicalizing and pathologizing these reactions
may cause the individual to take on a patient role and symptoms that may
normally dissipate over time with rest, relaxation, and social support
may persist. (DoD response in US Government Accountability Office May
2006).

Second, people may misrepresent their symptoms based on the situation.
For example, service members may not admit to symptoms when they are
screened immediately upon return from Iraq because they are eager to get
back to their families and know that any indication that they need
psychiatric help will delay that process. Service members who plan to
remain in the military may hide symptoms so that they can stay with
their unit. The benefits of PTSD screening 3-6 months after return from
combat clearly outweigh the risks. However, the screening does not
identify all cases.

**Integrate mental health screening and diagnosis into primary care:**
Because veterans are likely to seek care for a general medical ailment,
the primary care physician (PCP) may be the first health-care
professional to engage an individual with PTSD. In a study of 103,788
OEF/OIF veterans seen in VA health care facilities between 2001 and
2005, almost one-quarter received a mental health diagnosis and most
initial mental health diagnoses (60 percent) were made in
non-mental-health clinics, mostly primary care settings (US Department
of Veterans Affairs, Office of Inspector General 2007).

The PCP can play a critical role in referring someone to care, but the
client may not follow through with the recommendations. There are two
models for integrating mental health into primary care that can address
this problem. The first is a model of co-located collaborative care
between a mental health provider and primary care physician. In this
model, if the primary care physician believes the patient has PTSD, that
same day she or he can refer the patient to a mental health clinician
located in the same building. The second approach is a case management
model, in which a primary care physician can refer patients to a mental
health provider, and a case manager will conduct ongoing phone follow-up
to encourage continued engagement in the treatment process and to assist
in negotiating needed adjustments in the treatment plan (US Department
of Veterans Affairs, Office of Inspector General 2007).

### TBI 

The best time to assess the impact of TBI is immediately after the
injury. For severe TBIs, the impact is obvious and the individual is
removed from combat as soon as possible. For mild TBI, many soldiers
just "shake it off" but may encounter problems later. Of the three
approaches to diagnosing mild TBI, all have limitations. For example:

-   **Cognitive Evaluations**---TBI may cause cognitive impairments.
    Thus, it is useful to measure changes in cognitive functioning. A
    baseline cognitive assessment is needed so that in the event of
    exposure to an IED or other types of blasts, service members\'
    cognitive functioning right after the injury can be compared to
    their baseline functioning prior to deployment.

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-   **Neuroimaging**---For most mild TBI patients, magnetic resonance
    imaging (MRI) and computed tomography (CT) scans are inconclusive or
    difficult to interpret (Belanger et al. 2007, Hoge 2008). Other
    imaging techniques such as functional Magnetic Resonance Imaging
    (fMRI), Positron Emission Tomography (PET), and Single Photon
    Emission Computed Tomography (SPECT) show some promise in detecting
    mild TBI, but these findings are preliminary (Belanger et al. 2007).
    Because of their cost, brain scans are not a viable alternative for
    large scale screenings, but can be useful in some cases.

-   **Self-reported History**---Self-reported history of mild
    TBI/concussion is not well correlated with post-deployment symptoms.
    Using self reports for screening is likely to result in mislabeling
    service members as "brain injured" when there are other reasons for
    their symptoms that may require different treatment (Hoge 2008).

## Treatment

### PTSD

Available PTSD treatment can address the primary symptoms of PTSD by
helping clients bring under control the vivid re-experiencing of the
trauma and the continual re-appraisal of the event so that they can feel
better about themselves and their actions. (Brewin 2007). In addition to
addressing the symptoms, treatment addresses functional limitations such
as relationship and trust issues, anger management, feelings of
alienation, sleep disturbances, and other limitations.

In 2004 VA and DoD jointly released a set of clinical guidelines for
treating PTSD. The guidelines included individual psychotherapy, group
therapy, and pharmacotherapy recommendations based on a review of
efficacy studies (US Department of Veterans Affairs and Department of
Defense 2004).

### Individual Psychotherapy

The aforementioned guidelines recommend that the therapist explain to
the client the range of available and effective therapeutic options and
then the therapist and client should jointly agree on an approach. The
guidelines strongly recommend the following four evidence-based
practices:

**Exposure therapy:** The client repeatedly confronts feared situations,
sensations, memories, or thoughts in a planned, often step-by-step
manner. With repeated, prolonged exposure to previously feared
situations, the fear tends to dissipate. ET usually lasts from 8 to 12
sessions depending on the trauma and treatment protocol.

Exposure therapy may be very intimidating for clients to contemplate and
can be time consuming and emotionally wrenching for them to complete.
The client may have homework in which they write down a nightmare,
script a new ending and read the script repeatedly. During the therapy,
the client may begin to have more symptoms before the symptoms begin to
subside. Thus, it is important to have a strategy to ensure that the
client will continue through the entire therapeutic protocol.

In addition, although exposure therapy is highly successful in reducing
the key symptoms associated with PTSD, such as intrusive memories, it
does not address other issues such as feelings of detachment from
others, excessive anger and feelings of alienation. To treat these, the
therapist must draw on other therapeutic approaches.

**Cognitive restructuring:** The client identifies upsetting thoughts
about the traumatic event, particularly thoughts that are distorted and
irrational, and learns to replace them with more accurate, balanced
views. For example, veterans may feel they are to blame for failing to
save a fallen comrade even if they did everything they could. Cognitive
restructuring helps them look at what happened in a healthier way.

**Stress Inoculation Training:** This treatment includes a variety of
approaches to manage anxiety and stress and to develop coping skills.
The client is taught deep muscle relaxation, breathing control,
assertiveness, role playing, thought stopping, positive thinking and
self-talk.

**EMDR (Eye Movement Desensitization and Reprocessing):** EMDR
incorporates elements of exposure therapy with eye movements or other
forms of rhythmic, left-right stimulation, such as hand taps or sounds.
For example, in EMDR the client talks about the traumatic event while
visually following the therapist's finger back and forth. Eye movements
and other bilateral forms of stimulation are thought to work by
"unfreezing" the brain's information processing system and allowing the
individual to reprocess the memory.

In 2006, the Institute of Medicine (IOM) concluded that, based on
results from RCT, the only proven effective intervention is exposure
therapy (Institute of Medicine and National Research 2007). The IOM
committee noted that this finding does not mean that exposure therapy is
the only therapy that should be used. The committee used very strict
criteria for evaluating the studies and recognizes that some
interventions may be useful but have not been tested. Additional
research on evidence-based interventions clearly is needed.

### Group Therapy

In group therapy, four to twelve clients are led by a mental health
professional and can share their thoughts, find comfort in knowing they
are not alone, and gain confidence by helping others resolve their
issues. Little research has been done to validate its effectiveness, or
to delineate those characteristics of group therapy that lead to
improved clinical outcomes. The VA/DoD guidelines recommend that this
therapy be done in conjunction with individual therapy (US Department of
Veterans Affairs and Department of Defense 2004).

### Pharmacotherapy

In terms of pharmacotherapy, evidence indicates that certain
medications, especially selective serotonin reuptake inhibitors (SSRIs)
such as Prozac and Zoloft, are effective at relieving core symptoms of
PTSD. The VA/DoD guidelines recommend the use of these and several other
medications that have shown some efficacy. They recommend against the
use of benzodiazepine and typical antipsychotic drugs such as
Chlorpromazine, Haloperidol, and Thioridazine.

### TBI 

According to the Centers for Disease Control and Prevention (CDC),
treatment for individuals who have sustained mild TBI may include
increased rest, refraining from participation in activities that are
likely to result in additional head injury, management of existing
symptoms, and education about mild TBI symptoms and what to expect
during recovery. For some cases, rehabilitative or cognitive therapies,
counseling, or medications might be used. Currently, there are no
evidence-based clinical practice guidelines that address treatment of
mild TBI (US Government Accountability Office Feb 2008).

## Other Interventions 

### Family Support

Family support is fundamental to a service member's recovery from PTSD.
According to a 2005 DoD survey, 74 percent of DoD active-duty personnel
cope with stress by talking to a friend or family member (Bray et al.,
2006). While there are no randomized controlled studies documenting the
value of this informal support, the evidence that does exist suggests
this support is extremely important. Spouses and family members are
often the first to recognize when service members require professional
assistance and often play a key role in influencing service members to
seek help (US DoD Task Force on Mental Health 2007).

Unfortunately, this support is not always available. In fact, the very
nature of PTSD works to drive this support away. One of the classic
symptoms of PTSD is withdrawal, leading veterans to try to shut out the
very family members and friends who could help them alleviate their
pain. Veterans may be reluctant to open up because they worry that what
they say will upset the family. Sometimes when they do turn to their
family members, they find that those relatives are under a lot of stress
as well, and may not be able to offer needed support.

Providing support and education to the whole family can go a long way
toward effective treatment. Family members must be equipped with the
ability to recognize distress, and the knowledge of how and where to
refer loved ones for assistance (US DoD Task Force on Mental Health
2007).

Family and relationship problems are a serious concern. For example, in
a recent anonymous survey of 532 National Guard members, 292 of whom had
recently returned from deployment in Iraq, 36% of the deployed
acknowledged relationship problems with spouse, 26% relationship
problems with children, and 31% emotional numbness that interferes with
their relationships. Rates of problems for those deployed were three
times greater than for those not deployed. The Army's Mental Health
Advisory Team's 2007 surveys indicated that up to 30% of Soldiers and
Marines are considering divorce by the midpoint of their deployment,
with rates highest for those in their fourth or fifth deployment (US
Army Surgeon General 2008). Furthermore relationship problems are a key
factor in the majority of suicidal behaviors among active duty service
members (US DoD Task Force on Mental Health 2007).

After returning home, relationship problems are often the first symptoms
to come to the fore. It is therefore crucial that access to marital and
relationship counseling be free of barriers. Early intervention with
relationship problems can reduce the long term social costs for veterans
and can serve as a means to bring veterans with more severe problems
such as PTSD to the attention of healthcare providers.

DoD and VA might consider developing a formal training course for
families similar to the Family to Family Education program hosted by the
National Alliance on Mental Illness and should continue to utilize the
effectiveness of the Chaplaincy Corps.

### Peer Support

Empirical evidence and theories of PTSD suggest the importance of social
support as a moderator of the effects of trauma. Support from peers who
have shared the experience is particularly important. Peers can provide
information, offer support and encouragement, provide assistance with
skill building, and provide a social network to lessen isolation.

Researchers divide peer support models into three categories: 1)
naturally occurring mutual support groups; 2) consumer-run services; and
3) the employment of consumers as providers within clinical and
rehabilitative settings (Davidson 1999).

**Naturally occurring mutual support groups:** Service members who
return to garrison after their deployment are naturally surrounded by
peers. However, this community of peers may not exist to the same degree
for National Guard members and Reservists. They receive a short
homecoming briefing and usually have 90 days at home before they report
back for weekend training. This separation from other soldiers comes at
a time when support and connections with others who are going through
the same emotional adjustments is critical. This separation may account
for some of the increased prevalence of PTSD among the Guard and
Reserve.

**Consumer-run services:** A variety of peer consumer run models exist
in the community and in the VA system such as: support groups, drop-in
centers, consumer-run organizations; warm lines (peer run telephone
call-in service for support and information), and internet support
groups and message boards. Research on consumer-run services has
consistently yielded positive results. For example, participants of self
help groups have increased social networks and quality of life, improved
coping skills, greater acceptance of mental illness, improved medication
adherence, lower levels of worry, and higher satisfaction with health
(Solomon 2004).

**Consumers as employees:** In a peer employee model, individuals with
mental illnesses are trained and certified and then hired into positions
that are adjunct to traditional mental health services. These positions
include peer companion, peer advocate, consumer case manager, peer
specialist, and peer counselor. Although these models are relatively
new, emerging evidence suggests that adding peer services improves the
effectiveness of traditional mental health services (Solomon 2004). In
addition, the peer provider can alter the negative attitudes of many
mental health consumers toward mental health providers, and of some
providers toward consumers. In recent years, the evidence for the
efficacy and cost-effectiveness of this practice has grown to the point
that the Centers for Medicare and Medicaid Services (CMS) has recently
allowed Medicaid reimbursement for services provided by peer
specialists, and the military in Canada has recently established the
Operational Stress Injury Social Support Program based on a peer support
model (Veterans Affairs Canada 2006).

Peers may also be used as outreach workers. Service members or veterans
who have been deployed during war need not have PTSD or TBI themselves
to understand the barriers to seeking services created by stigma and
military culture. These peers can help identify people who need
professional interventions and facilitate their entry into treatment.

Peer support services should be part of the array of services available.
However, if should not be used as a cost-saving substitute for clinical
services. As a means of insuring quality care, peer services should
implement a credentialing process similar to that of clinical services.
Both Georgia and New Jersey have been successful in developing
credentialing programs for peer support workers.

**Consumers aiding in the development and deployment of services:** In
order for DoD and VA to develop and deploy services that are responsive
to the needs of the consumers, consumers with PTSD and TBI must be
included in the planning processes. There are many possible mechanisms.
VA has initiated a program for local Mental Health Consumer Councils
through which veteran consumers of care, their families and
representatives meet with local professional and administrative leaders
and assist in identifying problems or gaps in service and brainstorming
ways to overcome barriers to care. This program is currently operating
only in selected medical centers, and is a local option.

### Web-based Education and Support

The Internet has become a vital resource for information and
interventions. It allows service members, veterans, and their families
to access resources immediately and anonymously.

**Afterdeployment.org:** In response to a 2006 Congressional mandate to
develop a website for service members, veterans and their families, DoD
has recently unveiled
[www.afterdeployment.org](http://www.afterdeployment.org/). The site has
12 modules, each of which address a post deployment issue including
adjusting to war memories, dealing with depression, handling stress,
improving relationships, succeeding at work, overcoming anger, sleeping
better, controlling alcohol and drugs, helping kids deal with
deployment, seeking spiritual fitness, living with physical injuries,
and balancing your life.

**DE-STRESS:** VA is exploring the effectiveness of melding an
internet-based intervention with professional therapy. In the DE-STRESS
program (DElivery of Self-TRaining and Education for Stressful
Situations), veterans use a web site to access information and complete
a series of homework assignments that monitor, manage and treat PTSD
symptoms. The work done on the Web site is self-paced and self-directed
and takes approximately eight weeks to complete. The web activities are
complemented by either face-to-face meetings or telephone conversations
with professional therapists. (Litz et al. 2007).

**Other web resources:** Websites hosted by a variety of private,
nonprofit, and governmental organizations offer easily accessible
educational materials such as fact sheets, academic articles, and links
to other sources. Two particularly informative sites are VA's National
Center for PTSD ([http://www.ncptsd.va.gov](http://www.ncptsd.va.gov/))
and Mental Health America's "Operation Healthy Reunion"
(<http://www.nmha.org/reunions/info.cfm>).

Online support groups offer veterans a relatively anonymous place to
share their questions, concerns, frustrations, and fears and hear
reactions from people in similar situations. Several MSN groups have
emerged such as Iraq War Wives, Aftermath of War: Coping with PTSD, and
Iraq War Veterans.

### Other Nonmedical Interventions

A variety of other nonmedical interventions have shown some promise, but
their efficacy is not fully established. These interventions include
acupuncture, exercise, and mindful meditation (Hollifield et al. 2007,
Stathopoulou et al. 2006, Chartier 2007).

### Employment and Housing

Veterans with psychological health issues such as PTSD and TBI are at
elevated risk of unemployment and homelessness. In addition, evidence
suggests that stable housing and supported employment are effective
interventions for mental health rehabilitation (Martinez and Burt 2006,
Bond 2004). However, availability of housing and employment supports for
veterans with mental health issues is limited.

**Employment:** Individuals with PTSD and mild TBI may have difficulty
holding a job. They may, for example, have difficulty concentrating on
job tasks, coping with stress, exhibiting appropriate emotions, or
controlling anger. In some cases, the employer can make accommodations
such as reducing distractions in the workplace, allowing the employee to
play soothing music, and allowing flexible scheduling (Artman and
Duckworth 2007). In an effort to increase employment options for
veterans, the Department of Labor has initiated the \"America\'s Heroes
at Work\" campaign to educate employers on the issues surrounding the
employment of veterans with PTSD and TBI and strategies to accommodate
their needs (DOL 2008).

In other cases, the employee may need additional support. Although no
employment-related interventions have been developed and tested
specifically for veterans with PTSD and mild TBI, promising strategies
have been established for people with mental illnesses. For example,
substantial evidence indicates that supported employment integrated with
mental health treatment is effective in placing and maintaining people
with mental health issues in competitive employment (Cook et al. 2005).
NCD reviewed strategies for increasing employment among people with
disabilities in *Empowerment for Americans with Disabilities: Breaking
Barriers to Careers and Full Employment* (National Council on Disability
2007).

**Housing:** VA has multiple programs that provide short-term housing
and treatment for homeless veterans including: the Compensated Work
Therapy/Transitional Residence Program; the Homeless Veterans
Reintegration Program; the Domiciliary Care for Homeless Veterans
Program; the Homeless Providers Grant and Per Diem (GPD) Program. The
Department of Housing and Urban Development (HUD) also assists homeless
veterans through a Supported Housing Program funded jointly by HUD and
VA and HUD\'s Section 8 Voucher Program, which specially designates
vouchers for veterans with chronic mental illnesses. VA centers also
coordinate with local government and nonprofit agencies to assist
homeless veterans (US Department of Veterans Affairs 2008).

In 2007, VA estimated that it had served approximately 300 OEF/OIF
veterans in its homeless programs and has identified 1,049 more as being
at risk of becoming homeless. The experience of Vietnam veterans
indicates that the risk of homelessness increases over time. In a survey
conducted in the mid-1980's, more than three-quarters of Vietnam-era
combat troops and 50 percent of noncombat troops who eventually became
homeless reported that at least ten years passed between the time they
left military service and the time they became homeless (Perl 2007).

##  Holistic Approach

The Restoration and Resilience Center at Fort Bliss, Texas integrates
many techniques described above into one program. The participants are
in treatment 35 hours per week for 6-9 months. The treatment includes
daily psychotherapy and daily group therapy combined with holistic
approaches such as yoga, massage therapy and other nontraditional
approaches.

The program also includes a physical component. Participants are
required to walk at least 10,000 steps per day, which includes a
45-minute power walk. They also play water polo three times per week,
which facilitates their interaction with other people. Throughout the
program, the soldiers are also involved in field trips to public places
that they might otherwise avoid because they perceive those places as
too big, too crowded and too noisy. The soldiers are taught ways to
regulate their stress level, so that they can handle the stress of the
crowds and noise in these environments.

The program was established in 2007, so its success has not been firmly
established. However, early indications are very promising. Among the
first set of participants, one-third have graduated and returned to
their units, while only two have dropped out and been medically
discharged from the Army (\"A Soldier's Mind\" 2008).

# Section 5: Components of the Health Care System 

As service members move from pre-enlistment, enlistment, deployment,
post deployment, and separation from the military, they face a variety
of health care systems including the Department of Defense, the Veterans
Health Administration, as well as public and private insurance in the
civilian sector. In order to address the needs of all service members
and veterans, policy makers must address gaps in all the systems. This
section provides a brief overview of the eligibility criteria for each
system and the PTSD and TBI services available.

## Eligibility

Service members (active duty and Guards/Reserves) move through multiple
payers and multiple service systems before, during, and after their
deployment. At different times they may be covered by Civilian insurance
(Medicare, Medicaid, or private insurance), VA, DoD/TRICARE, or they
may, at times be uninsured (Exhibit 1).

**Exhibit 1: Health Care Coverage for Service Members and Veterans**

+---------------+------------------------+----------------------------+
|               | **Active Duty**        | **National Guard and       |
|               |                        | Reserve**                  |
+---------------+------------------------+----------------------------+
| **Active      | Civilian insurance     |                            |
| Duty- Before  | (private, public, or   |                            |
| Enlistment**  | uninsured)             |                            |
|               |                        |                            |
| **G           | VA or TRICARE for      |                            |
| uard/Reserve- | those who are already  |                            |
| Before        | veterans               |                            |
| Activation**  |                        |                            |
+---------------+------------------------+----------------------------+
| **Active      | DoD/TRICARE---For      | DoD/TRICARE---Most care    |
| Duty**        | troops stationed on    | provided by network        |
|               | base, care provided in | providers                  |
| **Activated   | MTF.                   |                            |
| Guar          |                        |                            |
| d/Reserve\*** |                        |                            |
+---------------+------------------------+----------------------------+
| *             | DoD---In-theater       |                            |
| *Deployment** | support, embedded      |                            |
|               | mental health          |                            |
|               | professionals,         |                            |
|               | chaplains, etc.        |                            |
+---------------+------------------------+----------------------------+
| **Post        | DoD/TRICARE            | DoD/TRICARE---180 days of  |
| Deployment**  |                        | premium-free coverage. May |
|               | Also have access to    | buy additional 18-36       |
| **Deactivated | on-base military       | months for \$3,732/yr      |
| Gu            | chaplains, family      | (\$7,984 for family        |
| ard/Reserve** | support groups, etc.   | coverage)^1^               |
|               |                        |                            |
|               |                        | VA---eligible for          |
|               |                        | enrollment for five years. |
|               |                        | Once enrolled, eligible    |
|               |                        | for life                   |
+---------------+------------------------+----------------------------+
| **After       | VA---presumptive       | VA---presumptive           |
| Separation    | eligibility for five   | eligibility for five       |
| from          | years. Ongoing         | years. Ongoing eligibility |
| Military**    | eligibility under      | under certain conditions.  |
|               | certain conditions.    | Once enrolled, eligible    |
|               | Once enrolled,         | for life.                  |
|               | eligible for life.     |                            |
|               |                        | Private                    |
|               | Private                |                            |
|               |                        | Medicare/Medicaid          |
|               | Medicare/Medicaid      |                            |
|               |                        | Uninsured                  |
|               | Uninsured              |                            |
|               |                        |                            |
|               | TRICARE (under certain |                            |
|               | circumstances)         |                            |
+---------------+------------------------+----------------------------+

\*Guard and Reserve members are considered "activated" when they are
called or ordered to duty for more than 30 consecutive days.

### Active Duty

All active duty service members and active Guard and Reserve are
eligible for health care through DoD. This includes direct services
provided in Military Treatment Facilities (MTFs) as well as a managed
care plan (TRICARE) that uses civilian sector providers.

### Veterans 

OEF/OIF veterans are automatically eligible for enhanced enrollment in
VA health care services for 5 years with no copayments. National Guard
and Reserve members who have left active duty and have returned to their
units also receive this enhanced enrollment eligibility. At the end of
the five years, these veterans can continue to use VA services, but
depending on their income and disability status, they may be required to
make applicable copayments.

### Civilian Systems

Among OEF/OIF veterans who are eligible for VA health care, 35 percent
used that care as of December 2007 (Veterans for Common Sense 2008). No
information exists on the 65 percent that did not use VA services. Some
likely relied on civilian coverage and others may have experienced no
perceived need for care. Some may have tried to access VA care, but
encountered barriers to accessing services. Others may be unaware of the
services that are available. The actual number of eligible OEF/OIF
veterans that will use VA services after the 5 year presumptive
eligibility period will be determined by service-connected disability
ratings and other factors. However, based on an analysis of veterans
under 65, it is likely that a significant majority will rely on private
insurance and some will be uninsured (Exhibit 2).

**Exhibit 2: Health Insurance Status of Veterans Under age 65, 2007**

> ![](media/image2.wmf){width="4.815277777777778in"
> height="3.417361111111111in"}
>
> Source: Author's Analysis of the Current Population Survey
>
> Description: Pie chart showing that among veterans under age 65, 17
> percent are enrolled with VA (7 percent use VA only, 10 percent use VA
> in conjunction with other insurance). Most veterans (66 percent) are
> privately insured and do not use VA, 5 percent are enrolled in
> Medicare or Medicaid, and 13 percent are uninsured.

## Department of Defense

DoD provides health care to over eight million beneficiaries, including
active duty personnel, and retirees and their dependents. DoD medical
health system (MHS) has two missions---readiness and benefits. The
*readiness mission* ensures that personnel are ready to deploy, provides
medical services and support to the armed forces during military
operations, and involves deploying medical personnel and equipment to
support military forces throughout the world. The *benefits mission*
provides medical services and support to members of the armed forces,
their family members, and others entitled to DoD health care. (US GAO
2007).

DoD's dual health care mission is carried out through a direct care
system that comprises 530 Army, Navy, and Air Force Military Treatment
Facilities (MTFs) worldwide. Within the direct care system, each
military branch is responsible for managing its MTFs and other
activities. Historically, these separate systems are not well
coordinated. The services generally fail to cooperate with each other
and resist efforts to consolidate their medical departments (US GAO
2007)

DoD also operates a purchased care system that uses civilian managed
care support contractors (TRICARE) to develop networks of civilian
primary and specialty care providers and to provide other customer
service functions, such as claims processing.

**Prevention Programs:** The Army's signature prevention program is the
mandatory Battlemind training program, which is provided in a large
group setting to all Army personnel prior to deployment, and immediately
upon return. In the 45-minute pre-deployment program, soldiers about to
deploy are told what they are likely to see, hear, think, and feel. The
post-deployment program explains the possible impact of deployment on
psychological, social-emotional, and behavioral functioning. It explains
what is "normal" and provides information about available mental health
resources available should service members have difficulties
readjusting. The Battlemind program highlights the problems that can
occur when the skills needed for effective combat are carried over into
the home environment (Exhibit 3).

**Exhibit 3: Combat Skills that Can Cause Problems if Not Adapted to the
Home Front**

  --------------------------------------- -------------------------------
  **Combat Skill**                        **Negative Presentation on the
                                          Home Front**

  **B**uddies (cohesion)                  Withdrawal

  **A**ccountability                      Controlling

  **T**argeted Aggression                 Inappropriate Aggression

  **T**actical Awareness                  Hypervigilance

  **L**ethally Armed                      "Locked and Loaded" at Home

  **E**motional Control                   Anger/Detachment

  **M**ission Operational Security        Secretiveness
  (OPSEC)                                 

  **I**ndividual Responsibility           Guilt

  **N**onDefensive (combat) Driving       Aggressive Driving

  **D**iscipline and Ordering             Conflict
  --------------------------------------- -------------------------------

> Source: Walter Reed Army Institute of Research 2007

Battlemind has shown some success. The Army's most recent survey of
deployed soldiers found that soldiers who received training were less
likely to screen positive for mental health problems while in Iraq (12
percent compared to 21 percent). Soldiers that did not screen positive
were significantly more likely to agree that (a) the training in
managing the stress of deployment was adequate, and (b) the training to
identify service members at risk for suicide was sufficient. However,
even with Battlemind training, one-third of soldiers were not confident
in their ability to help service members get mental health assistance,
and 40 percent were not confident in their ability to identify service
members at risk of suicide (US Army Surgeon General 2008)

**Mandatory Behavioral Health Screenings for PTSD:** Beginning in 1998,
DoD has required service members to complete a Pre-Deployment Health
Assessment (PHA) shortly before deployment and the Post-Deployment
Health Assessment (PDHA) immediately after deployment. Recognizing that
a service member's symptoms may change over time, DoD recently mandated
that the Post-Deployment Health Re-Assessment (PDHRA) be completed six
months after the service member returns home.

Military members complete a brief set of screening questions, which are
reviewed by a mental health professional. The service member is supposed
to be referred for additional services as needed. Although the
screenings potentially can identify individuals who need, but do not
seek, services, they have significant limitations.

-   Implementation of this program varies among military installations,
    and the reviewing providers may lack the necessary training to
    detect and address pathology (US GAO May, 2006).

-   Referrals are inconsistent. A GAO report found that, four of five
    returning troops potentially at risk for PTSD, were not referred for
    further mental health evaluation. Half of those eventually got help
    on their own, but less than 10 percent were referred through the
    military (US GAO May, 2006).

-   Service members may not accurately report their mental health
    concerns.

**TBI Screenings:** DoD admits that it lacks a system-wide approach for
proper identification, management, and surveillance of individuals who
sustain mild to moderate TBI (English 2007). However, quality pilot
programs have been in existence for some time and efforts are underway
to make screening universal.

**Treatment:** In addition to services available through TRICARE
(described in detail below), DoD has a variety of programs designed to
maintain the psychological readiness of the forces that are administered
both within and outside the confines of the Defense Health Program
including, for example:

-   *Military Treatment Facility*: Installation-level military medical
    treatment facilities and the larger military medical centers and
    clinics each develop and implement programs focusing on deployment
    issues. While there are a number of excellent programs, the
    availability, coherence, and quality of such programs varies across
    the system, depending upon the number of mental health professionals
    assigned to the unit, their training and experience, and command
    support for behavioral health programs (US DoD Task Force on Mental
    Health 2007).

-   *Military OneSource:* This initiative offers a 24-hour,
    7-day-a-week, confidential nonmedical information and referral
    system that can be accessed through the telephone, Internet, and
    e-mail. It also offers confidential short-term (up to six sessions
    per year per problem), face-to-face counseling for nonclinical
    problems. If care is sought for a clinical problem for which TRICARE
    provides reimbursement, Military OneSource refers the individual to
    TRICARE or the nearest MTF.

-   *Chaplains:* Military mental health services often are delivered in
    partnership with services provided by military chaplains. This is
    especially true in deployed environments where mental health and
    pastoral services constitute an essential component of deployment
    support. Outside of the deployed environment, military chaplains
    provide marital and individual counseling, and service members may
    seek out chaplains because issues of stigma may be lessened, and
    greater assurances of confidentiality may be offered.

-   *Substance Abuse Prevention and Treatment*: Each military service
    has substance abuse prevention and treatment programs.

-   *Other Organizations:* A number of other organizations provide
    direct or indirect support for the psychological health of military
    members and their families, including Health Promotions Offices,
    Sexual Assault Prevention and Response Offices, Exceptional Family
    Member Programs, Suicide Prevention Programs, and Combat Operational
    Stress Control programs.

This multiplicity of programs, policies, and funding streams provides
many points of access to support for psychological health. However, the
multiplicity may also lead to confusion about benefits and services,
fragmented delivery of care, and gaps in service provision (US DoD Task
Force on Mental Health 2007) and cause considerable variation in mental
health service delivery among the different bases and military services.

In addition, the military has a shortage of uniformed behavioral health
professionals. This shortage is exacerbated by the need to spread these
providers between deployed and nondeployed settings, the high turnover
rate, and the limited ability to rely on civilian professionals
(American Psychological Association 2007). Several commissions and
studies---including the DoD Task Force on Mental Health---have concluded
that the number of mental health care professionals in the military
health care system is too low to meet current needs.

The military is trying to meet this demand for mental health by offering
financial incentives to recruit and retain existing psychologists,
psychiatrists and other mental health professionals, and by offering
expanding internship opportunities for training. Besides bringing on
more professionals to active duty, the Army, Navy and Air Force are all
hiring professionals as civilian contractors or federal employees.

**Psychological Health Services in Theater:** Recognizing that isolating
mental health professionals in offices or clinics may discourage service
members with concerns about the stigma from seeking care, the military
has been embedding mental health providers in units. Each branch has
developed a slightly different approach but all are based on the theory
that keeping service members with their units helps in the recovery
process.

The Army has three tiers of care. The first tier is provided by fellow
service members or uniformed mental health professionals and chaplains
embedded with the troops. In the next tier, the soldier is taken to a
"combat stress control unit" for one to three days of rest, hot food,
hot showers, clean uniforms and medication if needed. The stress control
unit is near the combat unit and can relocate if the combat unit
relocates. Soldiers are treated with the expectation that they will feel
better in a couple of days and go back to work. An advantage of this
approach is that soldiers maintain their identity with their combat unit
and leadership. The third tier is a combat support hospital that
provides more intensive services. If the issue cannot be resolved in
these settings, the soldier is evacuated to Germany or the United
States.

The Marines' Operational Stress Control and Readiness (OSCAR) program
matches psychologists, psychiatrists and mental health technicians with
Marine regiments in the months before a deployment, continuing during a
rotation in Iraq, then back home. The Navy has the "Psychologists at
Sea" program that puts Navy psychologists aboard aircraft carriers.

Despite these new programs, access to behavioral health services in
theater is limited. Compared to 2006, soldiers reported more difficulty
accessing services in 2007. The Army advisory team cites a shortage of
behavioral health personnel in Iraq, with one behavioral health provider
for every 734 soldiers (US Army Surgeon General 2008).

**TRICARE:** TRICARE Prime, the health care plan available to active
duty service members and activated guard and reserve troops, is similar
to a civilian maintenance organization (HMO), where each enrollee is
assigned a "gatekeeper" who provides primary care and authorizes
referrals for specialty care. Beneficiaries receive care from a Military
Treatment Facility (MTF) when available. If services are not available
at the MTF, or the enrollee does not live near an MTF, he or she may
seek care from a provider in the TRICARE network---a network of civilian
health professionals. A point of service option is also available for
care received without a referral, but results in higher out-of-pocket
costs.

Although the TRICARE benefit covers outpatient mental health, service
members who rely on the TRICARE network often have limited access to
services. The DoD Task Force on Mental Health found that many providers
on the TRICARE network provider list were not accepting TRICARE
patients. A recent GAO survey of Reservists, most of whom had prior
experience with private insurance coverage, also highlighted the paucity
of available TRICARE network providers. Although the survey did not
focus on mental health providers specifically, it found that only 12
percent of Reservists felt that the availability of providers and
specialists was better in TRICARE than in the private sector, compared
to 50 percent who felt that availability was better in the private
sector (US GAO Feb 2007).

While there are some areas where TRICARE seems to be providing an
accessible continuum of mental health services, this is not generally
the case. With increased deployments of National Guard and Reserve
members who have time limited TRICARE coverage for themselves and their
families, combined with increasing demand for services from families and
retirees and the deployment of mental health professionals who would
otherwise be providing services on base, the networks are stretched to
their limit. TRICARE has difficulty expanding the network because of low
reimbursement rates and fragmented rules (US DoD Task Force on Mental
Health 2007).

The DoD Mental Health Task Force determined that the TRICARE continuum
of care for mental health services is severely deficient. Intensive
outpatient care, one of the most frequently utilized services in private
and VA care is not covered at all, substance abuse treatment options are
limited, characterized by very poor access, and well below the level
offered even by Medicaid. Crucial early intervention services including
marital/family counseling and early intervention for hazardous substance
misuse are not covered (US DoD Task Force on Mental Health 2007).

Based on recommendations from the DoD Mental Health Task Force, the
Secretary of Defense has undertaken efforts to increase staffing,
increase recruitment and improve the continuum of TRICARE services.

## Veterans Health Administration

VA operates the nation's largest integrated health care system with over
210,000 employees and a budget of \$37.3 billion. In fiscal year 2007,
VA provided health care to approximately 5.6 million veterans at 157 VA
Medical Centers and 875 community-based outpatient clinics nationwide
(US Department of Veterans Affairs 2008). As of April 2007, over
one-third (35 percent) of the 717,000 OEF/OIF veterans, who were
eligible for VA services, sought VA care, most commonly for
musculoskeletal injuries and mental health issues.

VA has undergone significant positive changes in the past 10-15 years.
It has become an integrated system that is, by many measures, producing
the highest quality care in the country (Longman 2005).

This improvement can be credited at least partially to the system being
decentralized, with treatment being shifted to more outpatient settings.
The system is now divided into 21 regional "Veterans Integrated Service
Networks" that administer health services and tailor service delivery to
local needs and conditions. In addition to decentralization, VA also
developed an electronic medical record system (VISTA) heralded as a
model for other providers (Frist 2005). These significant improvements
notwithstanding, VA continues to face challenges in adapting the current
health care delivery to meet the unparalleled incidence of PTSD and TBI
in the returning OEF/OIF veteran population.

There is concern that VA is not geographically accessible to all
veterans. Approximately 39 percent of veterans reside in rural areas.
Although according to VA, over 92 percent of enrollees reside within one
hour of a VA facility, and 98.5 percent are within 90 minutes, this
includes small community based outpatient clinics, which offer very
limited or no mental health services (Cross 2007). Some argue that VA
should consider itself the healthcare provider for all veterans and
provide services both through VA staffed clinics and where necessary,
due to travel time or other factors, through contractual arrangements
with local providers.

**Vet Centers:** In addition to the medical centers and clinics, VA has
209 Veterans Readjustment Centers known as "Vet Centers." They have a
considerable degree of autonomy and thus can tailor services and
staffing to meet the specific cultural and psychological needs of the
veterans they serve. Although the centers get some support from VA
health centers, they are separate entities and guarantee that anything
said at the Vet Center stays at the Vet Center. VA is implementing plans
to expand the number of Vet Centers to 232 within the next two years.

Every Vet Center has at least one VA qualified mental health
professional on staff. In FY 2006, the Vet Center program had 1,066
assigned staff positions of which 159 were outreach specialists and 876
were authorized counseling staff (58 percent of whom were licensed
mental health professionals). Vet Centers are generally small,
storefront buildings with four or five staff members, two-thirds of whom
are veterans (Batres 2007).

One of the distinguishing features of the Vet Center program is its
authority to provide services to veterans' immediate family members. As
noted earlier, family participation can be critical to the success of
treatment. Therefore, family members are included in the counseling
process, to the extent necessary to treat the veterans' readjustment
issues. Veterans\' immediate family members are also eligible for care
at Vet Centers. In addition, Vet Centers offer bereavement counseling to
surviving family members.

**Outreach for OIF/OEF veterans:** VA has invested new resources to
reach out to OIF/OEF veterans. Hundreds of outreach workers, mostly
OIF/OEF veterans have been hired by both the VA medical centers and Vet
Centers. These outreach workers and other VA staff members attend all
demobilization activities for National Guard and Reserve Units, and
attempt to in general make OIF/OEF veterans aware of services and
facilitate their use of services.

**Screening and Assessment:** VA provides screening for mental health
issues, including depression, PTSD, and substance abuse in all primary
care clinics. Recently VA implemented universal screening for TBI for
all OIF/OEF veterans. Patients screening positive on any of the mental
health or TBI screens are further evaluated and triaged to treatment as
indicated.

**Treatment:** VA offers a continuum of care for patients with mental
disorders but not all types of care may be available to each client. For
PTSD each medical center has at least one therapist who specializes in
the care of patients with stress disorders. Most have an
interdisciplinary PTSD team, and at selected medical centers intensive
outpatient, residential or impatient programming is available. A few
medical centers have programs specifically dedicated to female veterans
or veterans with comorbid substance abuse. A few of the largest
Community Outpatient Clinics offer specialized PTSD care, but most offer
only general mental health care, and smaller clinics may offer only
primary care.

As noted earlier in this report, analyses of the effectiveness of PTSD
treatments including the most recent Institute of Medicine report
indicate that the treatments with proven efficacy are intensive and time
consuming to administer. They require specialized training for staff and
the availability of time to provide them to veterans. VA has struggled
to translate the results of these effectiveness studies to widespread
clinical practice across the system. Efforts are ongoing, and VA has
created a special office to try to improve the translation of evidence
based approaches, but they are still unavailable in many locations.

Some locations, particularly smaller clinics rely on "telemental"
therapy, in which clients receive treatment from a remote mental health
professional using video conferencing. While preliminary research
clearly has established that a variety of telemental health modalities
are feasible, reliable, and satisfactory for general clinical
assessments and care, much less is known about the clinical application
and general effectiveness of telemental health modalities employed in
the assessment or treatment of PTSD (Morland et al. u.d)

**Waiting lists and waiting times:** VA recently completed an analysis
of gaps in mental health care throughout the system. This analysis
underscored the reality that access to services is still unacceptably
variable across the VA system, despite considerable augmentation of
programming in the past few years. In response VA is beginning to fund
additional initiatives to fill these gaps. For example in September 2008
VA announced it was adding substance use disorder clinicians to PTSD
teams at a cost of \$13.3 million per year and that it will provide
approximately \$17 million per year to establish Intensive Outpatient
Substance Use Disorder Programs at 28 additional medical centers,
bringing the total number of facilities with these programs to 105.

## Private Sector

A large percentage of veterans, Guard members, and Reservists rely on
TRICARE or private insurance provided by their own, or their spouse's,
employer. As a result, many providers treating these service members are
not part of the military or VA system, and may not be familiar with the
unique needs of the population.

Relative to active duty families, members of the National Guard and
Reserves and their families have limited access to military chaplains,
family support programs, and all other parts of the military landscape
designed to support psychological health. Unfortunately, community
providers may not be sufficiently aware of or sufficiently trained to
fulfill their needs (US DoD Task Force on Mental Health 2007).

The military service branches and VA have undertaken efforts to
disseminate knowledge and best practices to civilian health
professionals. For example, the Center for Deployment Psychology at the
Uniformed Services University of the Health Sciences developed a
two-week intensive training course and a series of seminars, and is
planning to reach out to both military and civilian psychologists,
psychology interns and residents.

Private insurance does not guarantee access to quality mental health
services. The President's New Freedom Commission on Mental Health
identified several obstacles that prevent insured consumers from getting
appropriate care in the private sector. These obstacles include unfair
treatment limitations and cost-sharing requirements placed on mental
health benefits, and a fragmented mental health delivery system
(President's New Freedom Commission on Mental Health 2003). As the
Institute of Medicine points out in *Improving the Quality of Care for
Mental and Substance-use Conditions: Quality Chasm Series* (2006),
mental health care is frequently delivered in ways that are not
consistent with scientific evidence, and often delivered in isolation
from general health care, despite the fact that mental illnesses and
general health problems are frequently intertwined. Patients receive
care from multiple physicians, across multiple sites, and in multiple
delivery systems. These different entities often fail to coordinate care
or share information. This failure to collaborate jeopardizes patients'
health and recovery. Collaboration is especially difficult because
mental health substance-use problems are often addressed by
public-sector programs apart from private-sector general health care.

## Nonprofit and Volunteer Organizations

Numerous nonprofit and volunteer organizations provide creative
approaches to reducing PTSD symptoms and helping service members and
veterans reintegrate into society. These types of programs could play an
important role in encouraging veterans to seek longer-term professional
care or in supplementing traditional therapies. For example:

-   Organizations such as Give an Hour, Operation Comfort, Strategic
    Outreach to Families of All Reservists (SOFAR), the Colorado
    Psychological Association, and The Returning Veterans Project NW
    provide free counseling services.

-   The Wounded Warrior Project has a weeklong adventure program
    including ropes courses, water sports, and a Native American healing
    ritual.

-   The Valley Forge Return to Honor Workshop offers complimentary
    three-day intensive cognitive and experiential reintegration
    workshops.

-   The Merritt Center offers complimentary retreat programs that
    include walks in the woods, sweat lodge ceremony, therapeutic
    massage, release exercises of body and mind and other relaxation
    strategies.

Some programs serve a small geographic area, while others are
nationwide. Each program performs its own outreach based on its
available resources. These programs have no national registry.

[]{#__RefHeading___Toc217385020 .anchor}Section 6: Barriers to Seeking
Care

+-----------------------------------------------------------------------+
| *I served in Baghdad from April 2003 to May 2004...* *September of    |
| 2003 I was sent for treatment ...I met with a Major there a couple of |
| times who put me on three different antidepressants. For those of you |
| who have been there, you know how difficult this is. For one, just    |
| the PTSD and Combat Stress Control is a huge stigma that generally    |
| isn\'t viewed too kindly by the chain of command. Add to this the     |
| fact that I was an NCO in charge of a combat engineer team who prided |
| themselves in their "sapper" skills.*                                 |
|                                                                       |
| *But the other difficult part is actually getting the antidepressants |
| you were prescribed. For us, there wasn\'t a pharmacy anywhere        |
| nearby; you had to go to the Green Zone.*                             |
|                                                                       |
| Lejeune, Chris. From his blog on The VetVoice Diaries.                |
+-----------------------------------------------------------------------+

Researchers have found that among the military service members who have
returned from Iraq and Afghanistan and report symptoms of post traumatic
stress disorder or major depression, only slight more than half have
sought treatment (Tanielian and Jaycox 2008). Barriers to seeking care
fall into two general categories: stigma and access (Hoge et al. 2004).

## Stigma

Three unique types of stigma pose barriers to treatment (Sammons 2005):

**Public Stigma** refers to the public (mis)perceptions of individuals
with mental illnesses. Over half of surveyed soldiers who met criteria
for a psychological health problem thought they would be perceived as
weak, treated differently, or blamed for their problem if they sought
help (Hoge et al. 2004; US DoD Task Force on Mental Health 2007).

**Self Stigma** refers to the individual internalizing the public stigma
and feeling weak, ashamed and embarrassed.

**Structural Stigma** refers to the institutional policies or practices
that unnecessarily restrict opportunities because of psychological
health. Service members repeatedly report believing that their military
careers will suffer if they seek psychological services. They believe
that seeking care will lower the confidence of others in their ability,
threaten career advancement and security clearances, and possibly cause
them to be removed from their unit (US DoD Task Force on Mental Health
2007).

The Army has made a concerted effort to reduce the stigma associated
with psychological health issues and the efforts seem to have had a
positive effect. Based on the Army's annual survey of soldiers in
theater, fewer soldiers who met the screening criteria for a mental
disorder report that stigma affected their decision to seek treatment in
2007 than in 2006. However, the levels remain unacceptably high as over
half of male soldiers in Iraq who meet the screening criteria were
concerned that they "would be seen as weak" and 40 percent believed that
their leaders would blame them for the problem (US Army Surgeon General
2008) (Exhibit 4).

**Exhibit 4: Perceived Barriers to Seeking Mental Health Services, 2006
and 2007**

+---------------------------------------------+-----------+-----------+
| **Factors that Affect the Decision to Seek  | **2006**  | **2007**  |
| Mental Health Treatment**                   |           |           |
+---------------------------------------------+-----------+-----------+
| > I would be seen as weak                   | 53        | 50        |
+---------------------------------------------+-----------+-----------+
| > Members of my unit might have less        | 51        | 45        |
| > confidence in me                          |           |           |
+---------------------------------------------+-----------+-----------+
| > My leaders would blame me for the problem | 43        | 39        |
+---------------------------------------------+-----------+-----------+
| > It would harm my career                   | 34        | 29        |
+---------------------------------------------+-----------+-----------+
| > It would be too embarrassing              | 37        | 34        |
+---------------------------------------------+-----------+-----------+

Source: Data from MHAT-V 2008

## Access

Even when service members or veterans decide to seek care, they need to
find the "right" provider at the "right" time. As described in section
5, this is not always possible. When care is not readily available the
"window of opportunity" may be lost.

In contrast to the data collected by DoD on barriers to mental health
care, there is currently a dearth of information on barriers to care for
OIF/OEF veterans seeking VA care. VA publishes patient satisfaction
data, but by definition this data only reflects the views of veterans
who have overcome whatever barriers that exist and succeeded in gaining
access to care. A feedback loop which includes the systematic collection
of data on the perception of consumers about the ease of access to care
is crucial to identify and decrease barriers to care. No such mechanism
for VA care currently exists.

A recurring survey of a national sample of OIF/OEF veterans, including
those who do not currently utilize VA services could identify barriers
to care, such as: distance from required specialized services;
availability of specified types of service including early intervention
services; bureaucratic obstacles to accessing care; user friendliness;
clinic hours and policies; perceived stigma and concerns with impact on
job or reserve unit status; and lack of information about what services
are available.

## Additional Issues for Certain Populations

### Culturally Diverse Populations

Little attention has been paid to the unique needs of culturally diverse
populations with PTSD. Despite high rates of PTSD, African-American,
Latino, Asian, and Native American veterans are less likely to use
mental health services for several reasons:

**Cultural competency of providers:** A study of Native American and
Latino veterans identified several barriers to VA services: 85 percent
felt "VA care-givers know little about ethnic cultures,\" and 79 percent
felt that "VA care-givers have problems talking with ethnic veterans\"
(Nugent et al. 2000). Although little research on the issue specifically
focuses on veterans, studies in the civilian sector suggest that
individuals are more likely to follow through with therapy if the
clinician and client are matched ethnically (Norris and Alegria 2005).
The scarcity of minority providers makes this unlikely for most nonwhite
veterans. In addition, many intervention materials are unknowingly
embedded with cultural expectations and unsubstantiated assumptions
about such issues as time orientation, social and occupational
commitments, family structure, and gender roles.

**Stigma:** Compared to white veterans, African-American veterans are
more likely to feel shame and guilt for their PTSD. Latinos are more
likely to believe that asking for help will bring dishonor to their
families. These responses are exacerbated because both groups are more
likely to feel that a health provider has judged them unfairly (Norris
and Alegria 2005).

**Linguistic access:** Although most service members and veterans are
fluent in English, their family members may have limited English
proficiency. Given the important role of families in encouraging
veterans to seek services and in locating those services, multilingual
outreach and family support is necessary. VA-wide publications such as
"VA Benefits" are available in several languages. However, most
material, including outreach material, is developed by local or regional
VA entities (such as a Vet Center or a VISN), and those entities develop
materials in languages other than English at their discretion. The VA
Center for Minority Veterans encourages, but cannot require, that
materials be available in other languages.

### Women

Women make up about 10 percent of the US forces in Iraq and Afghanistan.
Some of these women have been returning from Iraq not only with
combat-related trauma, but also with Military Sexual Trauma (MST).
Although estimates vary, between 13 percent and 30 percent of women
veterans experienced rape, and a higher percentage experienced some type
of sexual trauma over the course of their military careers. The sexual
trauma combined with combat trauma makes women far more likely to
experience PTSD (Yeager et al. 2006).

The military's response to individual reports of MST, and the barriers
that women face in reporting this trauma, is beyond the scope of this
report. VA has established a number of programs to address the impact,
including Military Sexual Trauma counseling, Women Veterans Stress
Disorders Treatment Teams, and MST centers.

# Section 7: Family Issues

+-----------------------------------------------------------------------+
| *There is a child in my life who thinks I am a hero, a point which is |
| certainly debatable. He was simply happy that I returned home in one  |
| piece---at least he thought I was in one piece---and ready to start   |
| our lives over from the point at which we left off. However, it fast  |
| became apparent to him that I am not the same person he knew before I |
| left, and he is confused by that. He wants the \"old me\" back and so |
| do I. It is painful and disappointing for both of us.*                |
|                                                                       |
| An Army Reservist who returned from Iraq and Kuwait. From her blog    |
| "Citizen Soldier Sojack in OIF."                                      |
+-----------------------------------------------------------------------+

Service members return home to various types of support systems that may
include parents, spouses, children, and significant others. These
support systems are critical to the well-being of the veteran with PTSD
and TBI. However, they are particularly at risk because family members
often do not have access to psychological and informational support
services. Providing these services is particularly important for several
reasons:

-   Family members are often the first to identify that the veteran is
    having difficulty, and are often instrumental in motivating the
    veteran to seek professional services. In addition, family members
    provide critical social and emotional support for the veteran, and
    may relieve some stress by taking care of many of the veteran's
    day-to-day responsibilities (US DoD Task Force on Mental Health
    2007, Hirsel 2007).

-   PTSD can create a circular momentum where the service member's PTSD
    increases the stress in the spouse, which puts stress on the
    relationship, which then intensifies the PTSD symptoms in the
    soldier.

-   The veteran\'s PTSD impacts the psychological health of other family
    members and caretakers. This has important implications for the
    well-being of these individuals, as well as for their ability to
    support the service member (Galovski and Lyons 2004).

## Effect of PTSD/TBI on the Family

More than 60 percent of service members are married, and almost 50
percent have children.

For some, returning from deployment is a joyous experience. For others,
reintegrating back into the family is difficult. It is not uncommon that
at the beginning both the spouse and service member have unrealistic
expectations of a rapid return to "normal." Both partners soon realize
that the service member is not the same as when that service member left
and that the family also has changed---spouses have become more
independent and developed new routines, and children have gotten older.
New family roles and routines must be negotiated (American Psychological
Association 2007).

This situation is more challenging for service members who return home
with PTSD or depression. The natural tension is exacerbated by the
service member's emotional numbness, their apparent disinterest, their
reduced ability to solve problems, and their often violent temper.
Studies have shown that veterans with psychological injuries are less
sure about their role in the household, and are more likely than others
to report feeling like a guest in their own home. Those with PTSD are
more likely to report that their children acted afraid, or did not act
warmly to them (Sayers 2008).

In some cases parents, spouses, and children display symptoms of PTSD
because they are upset by the service member's symptoms---a phenomenon
known as *secondary traumatization*.

Children are at risk for *intergenerational transmission of trauma* and
addressing the concern can be delicate. For example, research shows the
following (Ochberg and Peabody 2008):

-   When a family silences a child, or teaches him/her to avoid
    discussions of events, situations, thoughts, or emotions, the
    child\'s anxiety tends to increase. He or she may start to worry
    about provoking the parent\'s symptoms. Without understanding the
    reasons for their parent\'s symptoms, children may create their own
    ideas about what the parent experienced, which can be even more
    horrifying than what actually occurred.

-   Overdisclosure can be just as problematic. When children are exposed
    to graphic details about their parent\'s traumatic experiences, they
    can start to experience their own set of PTSD symptoms in response
    to the horrific images generated.

-   Children who live with a traumatized parent may start to identify
    with the parent and begin to share in his or her symptoms as a way
    to connect with the parent.

-   Children may also be pulled to reenact some aspect of the traumatic
    experience because the traumatized parent has difficulty separating
    past experiences from present.

## Services for Family Members

Despite the challenges that families face, they often have difficulty
obtaining mental health services. VA provides support for families only
through the Vet Centers described in Section 5. These centers provide
some psychological health services and support groups. However, the
availability of services varies among the different centers. The VA
mental health care system may incorporate marital/family interventions
when they are focused on improving relationships and reducing veterans\'
symptoms, but does not offer services targeted at improving the
psychological well being of the spouse and children. Marital counseling
or family counseling is not readily accessible at many VA facilities.

DoD provides psychological support for families throughout the
deployment cycle through MTFs, TRICARE, and several nonmedical programs.
However, access to on-base services is limited. Many mental health
professionals and chaplains are deployed at the same time that family
members need their services. As a result, family members are often
referred to the TRICARE network where it may be difficult to find a
therapist who is accepting new patients or who has an available
appointment time that is not too far in the future. The Army Task Force
on Mental Health found that children had particularly constrained access
to clinical treatment services, especially adolescents with substance
abuse problems (US Army Surgeon General 2008).

Military bases also have nonmedical support services. The armed services
vary in what services they offer and how they overlap and coordinate
with on base mental health services. Each unit has a Family Readiness
Group (FRG), made up of family members, volunteers, and soldiers, that
offers family members access to information and social support.

Military OneSource offers confidential resource and referral services
that can be accessed 24-hours per day via telephone, the Internet, and
e-mail. OneSource provides confidential family and personal counseling
services in local communities across the country, at no cost, for up to
six sessions per person per problem.

Paradoxically, although the on-base capacity to support psychological
health is reduced during deployment in an effort to devote resources to
supporting the health of deployed service members, this reduction
contributes to the distress of deployed service members who worry about
family members at home who cannot obtain needed assistance. Only 21
percent of soldiers serving in Iraq are satisfied with the type of
support the military is providing to their families, and only 22 percent
think the Family Readiness Group has helped their family. (US Army
Surgeon General 2008).

[]{#__RefHeading___Toc217385027 .anchor}**Section 8: Recommendations**

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, strain that 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.

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:

4.  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:

5.  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.

6.  Consumers should be integrally involved in the development and
    dissemination of training materials for professionals working with
    OIF/OEF veterans and service members.

7.  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.

8.  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.

9.  Congress should mandate a Secretarial level VA Mental Health
    Advisory Committee and a Secretarial level TBI Advisory Committee
    with strong representation form 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:

10. 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.

**Acknowledgement**

The National Council on Disability wishes to express its appreciation to
Nanette Goodman for her work in researching and drafting this document,
and to Richard A. McCormick, PhD., []{#OLE_LINK2 .anchor}Daniel Mont,
PhD., Laura McDonald, and Shelley Carson, PhD, for their comments on
earlier versions of the paper.

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