Invisible Wounds: Serving Service 

Members and Veterans

with PTSD and TBI

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 ........................................................................................1

Section 1: Introduction ........................................................................................................8

Section 2: Background ......................................................................................................13

1. Characteristics of Deployed Forces.......................................................................13

2. Experiences of Deployed Forces...........................................................................14

Section 3: Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) ...15

1. What is PTSD?.......................................................................................................15

2. What is TBI? ...........................................................................................................19

3. Relationship Between PTSD and TBI....................................................................20

4. Risk Factors for PTSD ...........................................................................................21

Section 4: Evidence Based Approaches for Prevention, Outreach, Assessment, 

Diagnosis, and Treatment.................................................................................................24

1. Prevention...............................................................................................................24

2. Outreach, Assessment, and Diagnosis .................................................................25

3. Treatment ...............................................................................................................27

4. Other Interventions.................................................................................................30

5. Holistic Approach ...................................................................................................36

Section 5: Components of the Health Care System ........................................................37

1. Eligibility..................................................................................................................37

2. Department of Defense..........................................................................................39

3. Veterans Health Administration .............................................................................46

4. Private Sector.........................................................................................................49

5. Nonprofit and Volunteer Organizations .................................................................50

Section 6: Barriers to Seeking Care .................................................................................51

1. Stigma.....................................................................................................................51

2. Access ....................................................................................................................52

3. Additional Issues for Certain Populations..............................................................53

Section 7: Family Issues ...................................................................................................55

1. Effect of PTSD/TBI on the Family..........................................................................55

2. Services for Family Members ................................................................................57

Section 8: Recommendations ...........................................................................................59

References ........................................................................................................................63
1

Executive Summary

More than 1.6 million American service members have deployed to Iraq and 

Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 

As of December 2008, more than 4,000 troops have been killed and over 30,000 have 

returned from a combat zone with visible wounds and a range of permanent disabilities. 

In addition, an estimated 25-40 percent have less visible wounds—psychological and 

neurological injuries associated with post traumatic stress disorder (PTSD) or traumatic 

brain injury (TBI), which have been dubbed “signature injuries” of the Iraq War.

Although the Department of Defense (DoD) and the Veterans Administration (VA) have 

dedicated unprecedented attention and resources to address PTSD and TBI in recent 

years, and evidence suggests that these policies and strategies have had a positive 

impact, work still needs to be done. In 2007, the Department of Defense Task Force on 

Mental Health concluded that

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 
2

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 
3

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 
4

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 
5

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 predeployment 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:
6

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. 
7

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 evidencebased 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.
8

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.
9

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. 
10

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 
11

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, online 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 
12

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. 
13

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

1. 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);

• 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).
14

2. 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). 
15

Section 3: Post Traumatic Stress Disorder (PTSD) and 

Traumatic Brain Injury (TBI)

1. 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.”

A. 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. 
16

• 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. 

B. 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 
17

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)

C. 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 substancerelated 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 
18

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).

D. 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. 
19

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. 

E. 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.

2. 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.

A. 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 
20

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. 

B. 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). 

3. 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.
21

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).

4. 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.

A. 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 
22

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 
23

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).

B. 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). 
24

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.

1. 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;
25

• 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).

2. Outreach, Assessment, and Diagnosis

A. 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 
26

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).

B. 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. 

• 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 
27

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). 

3. Treatment

A. 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 reappraisal 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).

1. 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, 
28

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. 
29

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.

2. 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).

3. 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.

B. 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 
30

guidelines that address treatment of mild TBI (US Government Accountability Office Feb 

2008).

4. Other Interventions 

A. 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 
31

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. 

B. 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 
32

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, consumerrun organizations; warm lines (peer run telephone call-in service for support and 

information), and internet support groups and message boards. Research on consumerrun 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 
33

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. 

C. 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. 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 SelfTRaining 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 
34

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) 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. 

D. 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).

E. 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 
35

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 employmentrelated 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). 
36

5. 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, onethird 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).
37

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. 

1. 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 DutyBefore 

Enlistment

Guard/ReserveBefore 

Activation

Civilian insurance (private, public, or uninsured)

VA or TRICARE for those who are already veterans 

Active Duty 

Activated 

Guard/Reserve*

DoD/TRICARE—For troops 

stationed on base, care 

provided in MTF.

DoD/TRICARE—Most care 

provided by network providers

Deployment DoD—In-theater support, embedded mental health 

professionals, chaplains, etc.

Post 

Deployment 

Deactivated 

Guard/Reserve

DoD/TRICARE

Also have access to onbase military chaplains, 

family support groups, etc.

DoD/TRICARE—180 days of 

premium-free coverage. May buy 

additional 18-36 months for 

$3,732/yr ($7,984 for family

coverage)1
38

VA—eligible for enrollment for 

five years. Once enrolled, eligible 

for life

After Separation 

from Military

VA—presumptive eligibility 

for five years. Ongoing 

eligibility under certain 

conditions. Once enrolled, 

eligible for life.

Private

Medicare/Medicaid

Uninsured

TRICARE (under certain 

circumstances)

VA—presumptive eligibility for 

five years. Ongoing eligibility 

under certain conditions. Once 

enrolled, eligible for life. 

Private

Medicare/Medicaid

Uninsured

*Guard and Reserve members are considered “activated” when they are called or 

ordered to duty for more than 30 consecutive days. 

A. 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. 

B. 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.

C. 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 
39

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

VA only, 7%

Private, 66%

Medicare or Medicaid, 

5%

Uninsured, 13%

VA and other, 10%

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. 

2. 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 
40

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 predeployment 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

Buddies (cohesion) Withdrawal

Accountability Controlling

Targeted Aggression Inappropriate Aggression

Tactical Awareness Hypervigilance

Lethally Armed “Locked and Loaded” at Home
41

Emotional Control Anger/Detachment

Mission Operational Security (OPSEC) Secretiveness

Individual Responsibility Guilt

NonDefensive (combat) Driving Aggressive Driving

Discipline 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 ReAssessment (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). 
42

• 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 
43

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.
44

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 
45

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). 
46

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. 

3. 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 communitybased 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. 
47

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. 
48

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 
49

$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. 

4. 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 
50

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. 

5. 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. 
51

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). 

1. 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, 
52

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 

Mental Health Treatment 2006 2007

I would be seen as weak 53 50

Members of my unit might have less 

confidence in me 51 45

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

2. 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. 
53

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. 

3. Additional Issues for Certain Populations

A. 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 
54

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. 

B. 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.
55

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-today 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).

1. Effect of PTSD/TBI on the Family

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

children. 
56

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.
57

• 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.

2. 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 onbase 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.
58

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).
59

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. 
60

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 evidencebased practices do exist. Unfortunately, service members and veterans face a number 

of barriers in accessing these practices including stigma; inadequate information; 
61

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.
62

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., Daniel Mont, PhD., Laura McDonald, and Shelley Carson, PhD, for 

their comments on earlier versions of the paper. 
63

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