National Research Action Plan August 2013

i

Executive Summary 

On August 31, 2012, President Obama issued an Executive Order (the Order) directing the 

Departments of Defense (DoD), Veterans Affairs (VA), Health and Human Services (HHS), and 

Education (henceforth referred to as “the agencies”), to develop a National Research Action Plan 

(NRAP) on posttraumatic stress disorder (PTSD), other mental health conditions, and Traumatic 

Brain Injury (TBI) “to improve the coordination of agency research into these conditions and 

reduce the number of affected men and women through better prevention, diagnosis, and 

treatment.”

Section 5 of the Order highlights how a limited understanding of underlying mechanisms of 

PTSD, the long-term consequences of TBI, and warning signs for tragic outcomes such as 

suicide is hampering progress in prevention, diagnosis, and treatment. Therefore, the NRAP 

includes research strategies to accelerate discovery of underlying mechanisms and rapidly 

translate this understanding into actionable tools for prevention, early diagnosis, and better 

treatment. The Order also calls for the establishment of a comprehensive longitudinal study of 

100,000 service members focused on PTSD, TBI, and related injuries. To attain these goals, the 

Order urged research agencies to improve data sharing as appropriate and with appropriate 

privacy and confidentiality protections, and harness new tools and technologies (e.g., electronic 

health records). Importantly, the Order directs the NRAP to improve coordination between 

agencies and ultimately reduce the number of affected individuals.

In this NRAP, the agencies outline coordinated research efforts to accelerate discovery of the 

causes and mechanisms underlying PTSD, TBI, and other co-occurring outcomes like suicide, 

depression, and substance abuse disorders. It describes research to rapidly translate what is 

learned into new effective prevention strategies and clinical innovations: biomarkers to detect 

disorders early and accurately; and efficacious and safe treatments to improve function and 

quality of life and to promote community participation and reintegration. The NRAP also 

describes research to accelerate the implementation of proven means of preventing and treating 

these devastating conditions. Many collaborative efforts are already under way. 

To achieve these goals, the NRAP agencies have identified key cross-cutting research priorities 

spanning conditions that will be pursued over the next 12 months. Examples of these priorities 

include the need to:

 Perform ongoing portfolio analyses of existing and emerging diagnostics, therapeutics 

and outcome measures for PTSD, TBI, and related injuries using the agencies’

“Interagency Research Continuum Approach” model.

 Continue to develop processes to standardize, integrate, and share data as appropriate. 

The recent directive from the White House Office of Science and Technology Policy on 

Increasing Access to the Results of Federally Funded Scientific Research and the recent 

Executive Order on Making Open and Machine Readable the New Default for 

Government Information posit that open sharing of machine-readable data fuels scientific 

discovery and innovation, and specify that public agencies will be held accountable for 

ensuring their data are standardized, integrated, and shared where appropriate. 

 Initiate a process to define a minimum set of general and topic-specific common data 

elements (CDEs) that can be adopted for PTSD and suicide prevention research to 
National Research Action Plan August 2013

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potentially integrate with the Federal Interagency TBI Research CDEs. The agencies 

commit to reporting on progress in reducing delays and barriers currently impeding the 

timely sharing of data resources created and owned by federal agencies. 

 Increase the inventory of scarce research resources (e.g., tissue samples, blood, and 

cerebrospinal fluid), facilitating access for scientific purposes (with appropriate human 

subjects’ protections related to privacy and confidentiality). To accomplish this, the 

agencies will leverage existing pathology archives to initiate development of a virtual 

tissue (brain) repository for PTSD, TBI, and suicide research. Activities will also include 

(1) incorporating appropriate agreements either between the investigator and resourcing 

agency (material transfer agreement) or between agencies (interagency agreement) and 

(2) processes for securing consent to obtain brain tissue from donor (premortem) or 

representative (postmortem).

 Build new tools and technologies to understand the underlying mechanisms of PTSD, 

TBI, suicide, and other conditions. Appropriate NRAP-participating agencies will 

continue to fund innovative research for the Brain Research through Advancing 

Innovative Neurotechnologies Initiative. The DoD will leverage the Brain Research 

through Advancing Innovative Neurotechnologies initiative efforts and continue to fund 

complementary work.

 Adapt existing research initiatives to maximize their impact. The comprehensive 100,000 

service member study called for by the Order (Army STARRS) has been established. The 

agencies will explore the feasibility of a longitudinal follow-up of Army STARRS to find 

actionable factors that can be used to improve early detection, and effective prevention 

and treatment of suicide, PTSD, TBI, and comorbidities. The follow-up study will 

include the ability to consent for the donation of postmortem brains and begin to establish 

necessary procedures for timely collection and preservation of tissue.

 Continue to leverage existing and emerging information technology to improve existing 

care for individuals with PTSD, TBI, suicidality, and other conditions. Agencies already 

harnessing information to answer research questions will continue to evolve the learning 

health care system model and provide lessons learned to agencies interested in 

developing this model.

 Utilize tools for agencies to coordinate and share the research they support. The agencies 

will identify a common database and explore the feasibility of utilizing it to share the 

research they support with other federal agencies and with researchers outside of the 

federal government, where appropriate. 
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NRAP Vision for the Future 

The agencies anticipate that basic insights, 

garnered through NRAP efforts, will help 

lead to translational advances in the 

prevention, diagnosis, and treatment of 

PTSD, TBI, suicidal behaviors, and cooccurring conditions, including substance 

abuse, in service members, Veterans, and 

their families. Subsequently, better 

preventive and therapeutic interventions 

would be expected to help lead to 

improved health, function, and quality of 

life for people experiencing these 

conditions, and their families.

Funding and Prioritization

The agencies intend to focus and collaborate on 

the topics identified in this document. These 

efforts will be supported within existing agency 

budgets. The agencies will follow their 

established planning, programming, and 

budgeting processes and priorities will be 

supported as feasible within available 

resources. In a time of constrained resources, 

the agencies will continue to direct resources to 

high-priority activities.

The ability to leverage existing and emerging 

information technology will be a key factor in 

successfully coordinating and accelerating research 

under the NRAP. Transparent and accessible 

information about the agencies’ ongoing and 

planned efforts will guide the agencies and 

researchers alike to reduce overlap, eliminate 

redundancies, identify gaps, and focus new 

research questions. Publicly accessible databases 

that contain information about funded grants (e.g., 

National Institutes of Health [NIH] Research 

Portfolio Online Reporting Tools, which is used by 

VA and NIH) act as repositories for government-sponsored research. A new commitment will be 

to analyze the costs, benefits, and utility of moving the DoD’s medical research onto the NIH 

Research Portfolio Online Reporting Tools system as well as related systems such as Electronic 

Research Administration Commons, thus promoting a higher level of transparency and analysis 

across agencies and for the public. Beyond the transparent sharing of data about funded studies, a 

commitment will be made to promote the standardization and sharing of de-identified study level 

(raw) data, with the appropriate consent, confidentiality and privacy protections within legal 

authority. Many smaller studies are able to involve only a modest number of participants; 

therefore, the ability to share study data when appropriate will increase the power for analyses 

and potentially accelerate research progress. In addition, large-scale studies supported by each

agency provide a platform for rich secondary data analyses when study-level data are shared. 

Central repositories such as the Federal Interagency Traumatic Brain Injury Research

Informatics System may be leveraged in these data-sharing efforts. The agencies have begun 

discussions to determine how to more efficiently share data; details can be found in the report.

This NRAP will complement the 2013 Interim Report of the Interagency Task Force on Military 

and Veterans Mental Health (May 2013) to ensure that Veterans, service members, and their 

families receive necessary mental health services and support. Close collaborations between the 

agencies will expedite fulfillment of the strategies outlined in the NRAP. The DoD, VA, HHS,

and the Department of Education understand the 

gravity and urgency of the problems and are committed 

to advancing the health of our military and nation 

through their collective research. To ensure progress 

and success, the agencies will schedule formal joint 

review and analysis of efforts. Further, continued 

analysis of needs using the Interagency Research 

Continuum Approach is planned. The Agency research 

working group co-chairs will be responsible for 

overseeing the formation of any necessary new 

workgroups or initiatives to deliver on the plans of this 

NRAP. Collectively, these activities will support the 

Order’s research goals to prevent suicide, to reduce the 

number of individuals affected by PTSD, TBI, and 

comorbidities, and to improve the quality of life of 
National Research Action Plan August 2013

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those who do experience these conditions through better-coordinated and synchronized efforts to 

accelerate progress in prevention, diagnosis, and treatment.

Key Themes Specific to PTSD, TBI, and Suicide Prevention Research

Beyond the research priorities spanning conditions (presented previously) and looking deeper into specific 

research needs for PTSD, TBI, and or suicide prevention, the themes highlighted here are examples of topics 

described in greater detail in the full report. Please note that the bullets under each research area are organized 

along the Interagency Research Continuum Approach, described earlier, and are not placed in order of 

importance or priority. Also note that all of these research areas are expected to include consideration of cooccurring disorders, including substance use disorders.

PTSD: Biomarkers, Mechanisms, and Treatment Research

 Replicate and confirm emerging data on promising biomarker candidates and other diagnostic tools for 

PTSD, including genome-wide associations, plasma molecules, and methylation patterns. 

 Optimize risk and resilience screening tools and test new PTSD prevention and treatment interventions 

that target underlying mechanisms and causal pathways.

 Enhance current PTSD evidence-based treatment delivery to be briefer, more durable, and more 

efficacious in treating service members, Veterans, and their family members, including individuals with 

multiple mental and physical health issues, including substance abuse.

TBI: Biomarkers, Diagnosis, Mechanisms, and Treatment Research

 Determine whether blast-induced TBI is a unique pathobiological entity and, if so, define the 

neuropathology of blast injury and in a subsequent step evaluate appropriate imaging technologies for 

their ability to identify the blast pathology in histologically characterized brain tissue. Utilize these 

imaging tools in service members and Veterans to determine whether blast, or repetitive blast injury, is a 

risk factor for chronic neurodegeneration or other chronic neurologic disorders.

 Develop a more precise system for classifying and staging TBI to enhance diagnosis and prognosis and 

enable targeted therapies and personalized medicine.

 Support validation studies of proteomic, imaging, neurophysiologic and other potential biomarkers and 

diagnostic tools to improve accurate diagnosis, monitor course of illness and enable evaluation of 

promising pharmacologic and nonpharmacologic treatments, including rehabilitation treatments, for their 

ability to increase functional outcomes such as community participation and reintegration.

Suicide Prevention Research

 Add a longitudinal component to the Army STARRS project to identify modifiable psychosocial and 

environmental risk and protective factors, clinically actionable biomarkers, and neurobiological 

mechanisms for preventing suicide and continue to support the Military Suicide Research Consortium to 

rapidly translate findings and develop effective interventions. 

 Optimize clinical suicide risk assessment tools to guide decisions on intervention, referral, and follow-up.

 Develop and test rapid, brief, and effective prevention and treatment interventions for suicide (including 

suicide ideation and attempts) applicable to a variety of settings, with rigorously designed randomized 

controlled trials that address comorbid problems.
National Research Action Plan August 2013

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Table of Contents

Executive Summary......................................................................................................................... i

List of Acronyms ........................................................................................................................... vi

Background..................................................................................................................................... 1

PTSD: Biomarkers, Mechanisms, and Treatment Research.......................................................... 8

TBI: Biomarkers, Diagnosis, Mechanisms, and Treatment Research ......................................... 15

Suicide Prevention Research......................................................................................................... 23

Comprehensive Longitudinal Mental Health Study ..................................................................... 29

Sharing PTSD, TBI, and Suicide Prevention Research ................................................................ 32

Electronic Health Records and Research and Clinical Care......................................................... 36

Conclusion .................................................................................................................................... 39

Documents Consulted ................................................................................................................... 40

Appendix: The Executive Order................................................................................................ A-1
National Research Action Plan August 2013

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List of Acronyms

Army STARRS Army Study to Assess Risk and Resilience in Servicemembers

BRAIN Brain Research through Advancing Innovative Neurotechnologies

CAP Consortium to Alleviate PTSD

CDC Centers for Disease Control and Prevention

CDE Common Data Element

CENC Chronic Effects of Neurotrauma Consortium

CNS Central Nervous System

DHP Defense Health Program

DoD Department of Defense

ED Department of Education

EHR Electronic Health Record

FITBIR Federal Interagency Traumatic Brain Injury Research

FOA Funding Opportunity Announcement

GWAS Genome-Wide Association Studies

HHS Department of Health and Human Services

HIV Human Immunodeficiency Virus

IOM Institute of Medicine

MHRN Mental Health Research Network

MSRC Military Suicide Research Consortium

mTBI mild Traumatic Brain Injury

MVP Million Veteran Program

NAASP National Action Alliance for Suicide Prevention

NADHAP National Addiction and HIV Data Archive Program

NIDA Brain Research through Advancing Innovative Neurotechnologies

NIDRR National Institute on Disability and Rehabilitation Research

NIH National Institutes of Health

NIMH National Institute of Mental Health

NINDS National Institute of Neurological Disorders and Stroke

NRAP National Research Action Plan

Order Executive Order

PTSD Posttraumatic Stress Disorder
National Research Action Plan August 2013

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RDoC Research Domain Criteria

RePORTER Research Portfolio Online Reporting Tools

TBI Traumatic Brain Injury

TBIMS Traumatic Brain Injury Model Systems Centers Program

TBIMS-NDB TBIMS National Database

TRACK-TBI Transforming Research and Clinical Knowledge in TBI

VA Department of Veterans Affairs

National Research Action Plan August 2013

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Background

Since September 11, 2001, more than 2.5 million service members have deployed to Iraq and

Afghanistan in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New 

Dawn. Military forces sent to fight those wars have exhibited a number of unique features, 

including: (1) an all-volunteer military that has experienced multiple deployments to the war 

zone, (2) substantial use of the reserve components of the military and National Guard, 

(3) deployment of high numbers of women and parents of young children, and (4) a high number 

of military personnel surviving severe injuries that in previous wars would have resulted in 

death. The Armed Forces Health Surveillance Center data list 266,810 cases of TBI occurring in 

the military between 2000–2012. Over 80% of these were the result of non-combat injuries. 

Among combat injuries, blast is a common cause. Military service exposes service members to a 

variety of stressors, including exposures to death, risk to life, sustained threat of injury or actual 

injury, and the day-to-day family stress inherent in all phases of the military life cycle and its 

transitions. Stress is a major contributor to both the onset and exacerbation of substance abuse 

and mental health problems and is related to a variety of negative physical health outcomes. A 

comprehensive assessment of the physical, psychological, social, and economic effects of 

deployment on service members, their families, and communities is provided in the 2013 

Institute of Medicine (IOM) report “Returning Home from Iraq and Afghanistan: Assessment of 

Readjustment Needs of Veterans, Service Members, and Their Families.” 

Though significant and continuing improvements in outer tactical vests (body armor) and 

helmets have limited fatal injuries, many service members return with a traumatic brain injury

(TBI), symptoms or diagnosis of posttraumatic stress disorder (PTSD), suicidal thoughts or 

behaviors, and/or related comorbidities. These comorbidities or co-occurring conditions are

defined herein as mental health disorders, including depression; substance abuse related to 

alcohol, tobacco, and other drugs, including the misuse and abuse of prescription drugs; and 

chronic pain, each of which can complicate the prevention and treatment of PTSD, TBI, and 

suicidal behaviors. One study of returning Veterans who were seen in Department of Veterans 

Affairs (VA) health care facilities revealed that nearly one-third of them received at least one 

mental health or psychosocial diagnosis. Another study estimated that only 23% to 40% of 

returning service members who screen positive for a mental disorder seek mental health care. 

Family members are also impacted by the multiple stressors associated with deployment and 

reintegration. Overall, the need for mental health, and substance abuse, and chronic pain services 

for service members, Veterans, and their family members is anticipated to increase in coming 

years as the Nation endures the effects of more than a decade of military conflict. Additional 

sections of the President’s August 31, 2012 Executive Order (the Order) address steps the 

agencies are taking to improve education and awareness, and access to services and treatment. 

An interagency Task Force (described in the following paragraphs) published their first report on 

these efforts in May 2013. These ongoing efforts are outside the scope of this National Research 

Action Plan (NRAP).

Researchers are attempting to answer questions across the research continuum from basic science 

aimed at understanding the disorders that are the focus of this Order through prevention, 

treatment, follow-up care, and services research directed at improving the delivery and modality 

of care. However, fundamental gaps in scientific knowledge remain that highlight the critical 

need for advancing the research described here. For example, the lack of an objective measure of 
National Research Action Plan August 2013

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mild (mTBI) makes it difficult to adequately diagnose individuals or to determine risk of injury.

Improved techniques are needed to determine when and what symptoms are attributable to the 

traumatic (physical) event, to understand the brain events that give rise to the post-concussive 

syndrome concurrent with PTSD symptoms, and to elucidate the neural basis of the interaction 

between mTBI, PTSD, depression, and suicidality. To this point in time, there has not been a 

definitive study of the neuropathologic effects of blast injury in those who have died.

A significant concentration of the country’s best scientists and resources have led to major 

advances in other threatening health conditions, such as the conversion of human 

immunodeficiency virus infection from a fatal illness to a manageable chronic illness and a 60% 

drop in stroke rates over the past 60 years. A similar concerted scientific attack is warranted to 

determine the neural basis of PTSD and the functional deficits associated with TBI. Without 

such an effort, the burden of illness due to PTSD and TBI in service members, Veterans, and 

their families will continue. Current PTSD pharmacotherapy and medications are inadequate, 

with somewhat limited success in treating individuals with PTSD. Evidence-based approaches

for reducing suicide risk are also limited, and the relationships between PTSD, TBI, suicide, and 

co-occurring conditions are not well understood. Researchers must also evaluate the impact of

context, including the population (e.g., active duty, Reserve/Guard, Veterans, and families) and 

setting (e.g., deployed austere environments versus medical centers) in their studies.

The federal research funding agencies specified in the August 31, 2012 Order including the 

Departments of Defense (DoD), VA, Health and Human Services (HHS), and Education (ED) 

(henceforth referred to as “the agencies”), have distinct but complementary missions; hence, 

their existing funded research programs collectively address a broad range of mental health 

issues and can be successfully leveraged to establish and advance the NRAP to benefit service 

members, Veterans, and their families. The Order (see Appendix) sets the stage for the agencies 

to join forces in identifying related research priorities to better understand and reduce symptoms 

and to maximize function and community reintegration through optimal prevention, screening, 

diagnosis, and treatment advances. This report summarizes the interagency response to Section 5 

in the Order.

Critical to the development of this NRAP was an understanding of the agency-specific activities 

related to the requirements specified in the Order. This background was provided in a Joint 

Review and Analysis meeting (January 2013) on research related to PTSD, TBI, suicide 

prevention, and substance abuse. Agency representation at the meeting included DoD, VA, ED 

(represented by the National Institute on Disability and Rehabilitation Research [NIDRR]), and 

HHS (represented by the National Institute of Health’s [NIH’s] National Institute of 

Neurological Disorders and Stroke [NINDS], National Institute of Mental Health, and National

Institute on Drug Abuse). 

A variety of activities are under way in support of the NRAP, including funded research projects 

within the agencies’ complementary portfolios in PTSD, TBI, and suicide prevention research 

that also address comorbidities such as substance abuse. The DoD’s Systems Biology Initiative

and the Millennium Cohort and Family Cohort Studies, the VA’s Million Veteran Program, and 

NIH’s biomarker and mechanistic research programs all hold promise to inform advancement of

prevention and treatment interventions. Notably, the DoD alone has invested more than $100 

million in TBI biomarker discovery and development since 2007; other agencies have also 

supported this increased focus. The DoD and the Centers for Disease Control and Prevention 
National Research Action Plan August 2013

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Studying the Health of Military Families

The agencies are funding a wide variety of studies 

relevant to military/Veteran family members, including 

research focused on:

 Basic epidemiology to understand risk and 

resilience factors of military families and 

communities

 Suicide bereavement in service members and their 

families

 Developing interventions to enhance resilience, 

address and prevent relationship problems, and 

support families during deployment

 Helping families aid Veterans with PTSD and 

alcohol abuse

 Determining the effectiveness of web-enhanced 

support tools for military families

 Determining the effects of military deployment of 

parents on adolescent mental health

(CDC) are partnering with the Brain Trauma Foundation to develop a clinically meaningful 

classification system of mTBI/concussion that will enable improved clinical assessment of 

current status and prognosis. Suicide prevention research includes the DoD’s Military Suicide 

Research Consortium (MSRC) and the National Institute of Mental Health and Department of 

the Army’s Study to Assess Risk and Resilience in Servicemembers (Army STARRS) program. 

The agencies also support research that contributes to a better understanding of the mental health 

needs of military/Veteran families and the best ways to prevent, treat, and provide services for 

them (see text box). 

On April 2, 2013, President Obama 

announced the NIH Brain Research through 

Advancing Innovative Neurotechnologies 

(BRAIN) initiative. The BRAIN initiative 

will involve the NIH, the Defense Advanced 

Research Projects Agency, the National 

Science Foundation, and several private 

laboratories and foundations working 

toward the next generation of tools for 

decoding the intricate language of the 

brain. This unique project aims to give 

scientists a more complete set of tools and 

information for understanding how the brain 

functions, and how we think, learn, and 

remember both in health and in the context 

of neurological and psychiatric conditions 

that are the focus of the Order and of great 

concern to service members, Veterans, and 

their families.

Research shows that behavioral health disorders, especially substance use disorders (SUDs), 

frequently co-occur in people experiencing the target problems discussed in the Order (TBI, 

PTSD, and suicide). Despite strict prohibitions on illicit drug use in the military, as well as a 

broad, random drug testing program, there are indications of rising rates of drug use (to include 

prescription drug misuse and abuse, as well as heavy alcohol use, and tobacco use), among the 

active duty population. These concerns are not limited to active duty—research shows SUDs are 

rarely treated in young Veterans. Comorbidities can complicate efforts to effectively intervene 

with other, targeted health conditions. However, the results of long-term randomized controlled 

trials have shown that substance abuse prevention can have a positive effect on a wide array of 

behaviors. In addition, SUD treatment can mitigate negative mood and in some cases, treatment 

for PTSD has been shown to improve SUD outcomes, while integrated treatments addressing 

both SUDs and PTSD can improve both conditions. Suicide risk may also be lowered by

treatment of SUDs. 

A few factors complicate the matter of addressing SUDs and conducting research in military or 

Veteran populations: (1) concerns about confidentiality of military medical records; (2) impact of 

zero tolerance policies for illicit drugs and SUDs on the careers of service members; (3) lack of 

appropriate screening and assessment protocols specifically for SUD issues, and (4) uncertainty 
National Research Action Plan August 2013

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about how SUDs may impact a Veterans’ disability claims. Although current illegal drug use is 

less prevalent in Veterans than in the general population, there are still subpopulations for which 

there is concern. For example, research shows that Veterans with PTSD are more likely to 

receive opioid prescriptions and thus may have higher risk of addiction and other negative 

consequences. In addition, the presence of co-occurring disorders, common among Veterans,

often complicates treatment.

It is expected that all initiatives supported by this action plan will address comorbidities when 

they exist including SUDs through coordination, goal setting, and common efforts. The agencies

are independently and jointly funding studies focused on substance abuse research in military 

personnel, Veterans, and their family members. There have also been collaborations established 

that include joint reviews and analyses of portfolios and joint funding opportunities (e.g., 2010 

NIH-VA Request for Applications [RFA] and 2013 NIH-DoD RFA). Substance abuse research 

funded by the agencies spans the research continuum from basic science through implementation 

research. 

Data-sharing efforts include the DoD/NIH Federal TBI Research Informatics System for TBI 

clinical research (a central repository for TBI-related clinical research data that will also link to 

existing databases to facilitate sharing of information), the VA computing infrastructure, and 

NIDRR’s TBI Model Systems National Database (TBIMS-NDB), which contains prospective 

data on the clinical progress and outcomes of individuals with moderate to severe TBI. The VA 

Polytrauma Rehabilitation Centers have partnered with NIDRR to establish a VA TBI Database 

that includes many of the same data elements found in the TBIMS-NDB. The U.S. Army 

Research Institute of Environmental Medicine has developed the Total Army Injury and Health 

Outcomes Database, which is a versatile system that joins multiple personnel and health data sets 

from various DoD agencies and links data on demographics, health outcomes, health habits, and 

chemical exposures. Finally, research may benefit in multiple ways from the use of aggregate, 

de-identified electronic health record data by providing information to better understand the 

scope of a problem being investigated and whether implementation of evidence-based practices 

is effective. 

Recently initiated activities include two joint DoD/VA consortium efforts to support PTSD and 

TBI biomarker studies (the Consortium to Alleviate PTSD, and the Chronic Effects of 

Neurotrauma Consortium), new treatment studies to be generated from the basic research 

biomarker studies, and new treatment response studies to be incorporated into clinical trials. New 

and planned initiatives also include joint agency RFAs for research that are aimed at improving 

the health of service members, Veterans, and their families. 

The agencies have collaboratively developed an interagency approach for strategic research 

planning that builds upon the framework initially developed by the DoD. This “Interagency

Research Continuum Approach” is a research framework within which studies can be organized 

along a progression that includes seven topic areas: foundational science, epidemiology,

etiology, prevention and screening, treatment, follow-up care, and implementation (services)

research (Figure 1). This also facilitates analysis of gaps and identification of future areas 

of focus. Please note that “comparative effectiveness” research (listed under Treatment in Figure 

1) refers to research that evaluates the effectiveness of different treatment options, procedures, or 

tests for specific diseases, conditions, or disorders; for example, the effectiveness of 

psychotherapies for PTSD. 
National Research Action Plan August 2013

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Funding and Prioritization

The agencies intend to focus and collaborate on 

the topics identified in this document. These 

efforts will be supported within existing agency 

budgets. The agencies will follow their 

established planning, programming, and 

budgeting processes and priorities will be 

supported as feasible within available 

resources. In a time of constrained resources, 

the agencies will continue to direct resources to 

high-priority activities.

Figure 1. The Agencies’ Interagency Research Continuum Approach

The integration of research findings into health care systems through evidence-based practices is 

needed to address the Order’s goal of improving access to mental health and substance abuse 

services. The Order established the Military and Veterans Mental Health Interagency Task Force 

to oversee efforts aimed at improving capacity and enhancing quality of care for service 

members, Veterans, and their families. It is anticipated that the efforts of the Task Force will 

enable the service systems to become the platform to integrate and embed emerging evidencebased practices and develop “learning health care systems” in which the health care providers, 

systems, and patients participate in the generation of knowledge on trends in health and illness, 

the testing and identification of best practices, and the assessment of the impact of practice 

changes. 

The Task Force may also identify existing or 

new interagency working groups to address the 

planning, performance, and completion of the 

tasks outlined in the NRAP. Such entities have 

already been utilized with success. However, the 

closer engagement required by the proposed plan 

would benefit from agency-specific/unique 

capabilities in personnel, programs, and funding 

to enhance the translation of research findings to 

clinical use. Coordination of strategic research 

and development plans would enable agencies to 

synchronize program announcements based upon 

the outcomes of research that may be funded by 
National Research Action Plan August 2013

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other agencies in earlier stages (e.g., NINDS funds a discovery project on biomarkers that the 

other agencies could leverage into epidemiological and clinical validation studies across a wide 

patient population).

The sections that follow elucidate the results of the agencies’ Interagency Research Continuum 

Approach to address the research areas specified in the Order. The NRAP describes some of the 

highest priorities for accelerating discovery of the causes and mechanisms underlying PTSD, 

TBI, and other outcomes like suicide, depression, and substance abuse. It describes research to 

rapidly translate what is learned into new clinical innovations including the development of

biomarkers to detect brain disorders early and accurately; highly effective prevention strategies; 

and highly efficacious and safe treatments. The NRAP also describes research to widely 

implement proven means of preventing and treating these devastating conditions. Across these 

efforts, the NRAP strives to achieve the same level of urgency, specificity of deliverables and 

timelines, as well as accountability, as expressed in the Order.

In addition to the detailed research priorities specific to each section of the Order, the agencies 

have identified the following cross-cutting actions that will be pursued within the next 

12 months:

 Perform ongoing portfolio analyses of existing and emerging diagnostics, therapeutics 

and outcome measures for PTSD, TBI, and related injuries using the agencies’

“Interagency Research Continuum Approach” model.

 Continue to develop processes to standardize, integrate, and share data as appropriate. 

The recent directive from the White House Office of Science and Technology Policy on 

Increasing Access to the Results of Federally Funded Scientific Research and the recent 

Executive Order on Making Open and Machine Readable the New Default for 

Government Information posit that open sharing of machine-readable data fuels scientific 

discovery and innovation, and specify that public agencies will be held accountable for 

ensuring their data are standardized, integrated, and shared. 

 Initiate a process to define a minimum set of general and topic-specific common data 

elements that can be adopted for PTSD and suicide prevention research to potentially 

integrate with the Federal Traumatic Brain Injury Research common data elements. The 

agencies commit to reporting on progress in reducing delays and barriers currently 

impeding the timely sharing of data resources created and owned by federal agencies. 

 Increase the inventory of scarce research resources (e.g., tissue samples, blood, and 

cerebrospinal fluid), facilitating access for scientific purposes (with appropriate human 

subjects’ protections related to privacy and confidentiality). To accomplish this, the 

agencies will leverage existing pathology archives to initiate development of a virtual 

tissue (brain) repository for PTSD, TBI, and suicide research. Activities will also include 

(1) incorporating appropriate agreements either between the investigator and resourcing 

agency (material transfer agreement) or between agencies (interagency agreement) and 

(2) processes for securing consent to obtain brain tissue from donor (premortem) or 

representative (postmortem).

 Build new tools and technologies to understand the underlying mechanisms of PTSD, 

TBI, suicide and other conditions. Appropriate NRAP-participating agencies will 

continue to fund innovative research for the BRAIN Initiative. The DoD will leverage the 

BRAIN initiative efforts and continue to fund complementary work.
National Research Action Plan August 2013

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 Adapt existing research initiatives to maximize their impact. The comprehensive 100,000 

service member study called for by the Order (Army STARRS) has been established. The 

agencies will explore the feasibility of a longitudinal follow-up of Army STARRS to find 

actionable factors that can be used to improve early detection, and effective prevention 

and treatment of suicide, PTSD, TBI, and comorbidities. The follow-up study will 

include the ability to consent for the donation of post mortem brains and begin to 

establish necessary procedures for timely collection and preservation of tissue.

 Continue to leverage existing and emerging information technology to improve existing 

care for individuals with PTSD, TBI, suicidality and other conditions. Agencies already 

harnessing information to answer research questions will continue to evolve the learning 

healthcare system model, and provide lessons learned to agencies interested in 

developing this model.

 Utilize tools for agencies to coordinate and share the research they support where 

appropriate. The agencies will identify a common database to explore the feasibility of 

utilizing it to share the research they support with other federal agencies and with 

researchers outside of the Federal government, where appropriate.

The co-chairs (DoD, VA, HHS, and ED) of the Interagency Research Committee (responsible for 

writing this NRAP) or their designees will be responsible for overseeing the formation of any 

necessary workgroups or initiatives to deliver on the plans of this NRAP and provide the Task 

Force with yearly progress reports related to achieving the NRAP goals. 
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PTSD: Biomarkers, Mechanisms, and Treatment Research

In response to a traumatic event, people commonly experience PTSD-like symptoms, e.g., 

hyperarousal or reliving the event. Afterwards, many individuals progressively improve and 

symptoms recede. Those who continue to experience distress may develop PTSD. They may also 

report symptoms that reflect a variety of comorbid conditions including TBI, depression, and 

substance abuse. Symptoms typically vary from person to person. The overall goals of PTSD 

research studies are to (1) reduce the number of individuals who develop PTSD following trauma 

(through early diagnosis and preventive interventions) and (2) reduce the number of individuals 

with chronic PTSD (through treatments that also address substance-related and other 

comorbidities).

Areas of research focus include:

Mechanisms. The mechanisms underlying the development of PTSD and comorbid conditions 

following traumatic exposure need to be better elucidated to enable the identification of

individuals at risk. These mechanisms may be revealed through a variety of research activities 

including neuroimaging, animal studies, post-mortem analyses, and laboratory-based

investigations focused on identifying physiological and neurochemical contributions, and other 

psychological, contextual, and environmental factors, including pre-existing conditions (e.g., 

substance abuse). As cognitive science evolves to reveal how dysfunction in memory, learning,

and attention processes contribute to the development, prevention, and treatment of mental 

illness, researchers need to translate these findings into prediction models and novel prevention 

and treatment interventions. The National Institute of Mental Health (NIMH) has launched the 

Research Domain Criteria (RDoC) project, which will be enhanced to define basic dimensions of 

functioning (e.g., fear circuitry) to be examined across units of analysis from the level of genes 

to neural circuits to behaviors that are predictive of symptoms and/or reflect the etiology or 

persistence of a disorder. Information gathered from the RDoC project will pave the way for 

understanding the mechanisms responsible for phenotypes involved in disorders like PTSD and 

developing and testing new interventions. 

Biomarkers for early diagnosis. Research is needed to identify and characterize biomarkers that 

can predict increased vulnerability to the development of PTSD, indicate changes in the 

spectrum of symptoms associated with worsening function, and demonstrate at the biologic level 

a positive response to intervention. A biomarker (biological marker) is an objectively measured 

indicator that ideally is capable of reflecting normal, at risk, and disease states. Cognitive 

markers, e.g., cognitive tests of attention, memory, and executive functioning, may be among the 

most promising predictors for PTSD. Biosignatures are an extension of the biomarker concept 

that combine different measures across biological, environmental, and social influences that will 

be valuable in identifying the complex origins of disorders such as PTSD. Similar to the way 

physicians assess heart disease risk in patients by coupling blood test panels for cholesterol and 

triglyceride levels with measures of hypertension and high blood pressure, scientists can develop 

a biosignature for PTSD by combining cognitive measures and imaging data, serum and 

cerebrospinal fluid markers, and highly relevant physiological markers for related symptoms.
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Consortium to Alleviate PTSD (CAP) 

The CAP is a new research effort focused on 

biomarker discovery and development with the 

aim of identifying biomarkers for subacute and 

chronic PTSD that can be used for therapeutic 

and outcome assessment. With funding from 

DoD and VA, this represents a major investment 

to advance knowledge related to biomarkers and 

clinical utility. A CAP award is expected to be 

finalized by September 2013.

Researchers funded through the large-scale DoD 

Systems Biology Initiative have identified 

candidate biomarkers that may signal the presence 

of PTSD in humans. Building upon this effort is 

the joint DoD and VA CAP award (see text box), 

which will enable investigators to jointly pursue 

the Order requirements related to establishing 

surrogate and clinically actionable biomarkers for 

early PTSD diagnosis and treatment effectiveness. 

NIMH is also supporting a substantial number of 

research projects focused on identifying 

biomarkers to predict increased vulnerability to PTSD. In addition, with the consent of 

participating Veterans, the VA’s Million Veteran Program is building one of the world’s largest 

databases of genetic, military exposure, lifestyle, and health information, providing a platform 

for biomarker research. Another ongoing program that features a substantial amount of 

biomarker research is Army STARRS, which is described in more detail later in this report.

Biomarkers for targeted treatment. The identification and validation of biomarkers for PTSD 

will ultimately enable practitioners to assess the effectiveness of prevention and treatment 

interventions. Clinicians would be able to match individuals with the most effective prevention 

and treatment protocols based on the individual’s clinical profile, which may include 

medications, psychotherapy, and integrative and complementary medicine treatments alone or in 

combination. Research may also reveal populations at risk for specific comorbidities, 

subsequently enabling the development and testing of interventions to prevent these problems as 

well as effectively treat these conditions if they occur. Thus, another important goal of the NRAP 

is to facilitate the development of more personalized treatments; that is, individually tailored

interventions with measurable responses (see text box “Vision for Moving PTSD Treatment 

Research into Practice”).

Treatments. Psychotherapies and pharmacological medications are widely used to treat PTSD.

When evidence-based psychotherapy treatment for PTSD is provided, up to 60% of patients 

respond successfully. However, individual preferences play an important role in the selection of

intervention. Individuals who do not respond to one treatment may be reluctant to try other

treatments, and preferences relative to the types of therapies available (e.g., pharmacotherapy, 

psychosocial therapy, and complementary and alternative medicine) may have a significant 

impact on overall outcome. The use of combined therapies holds promise to address urgent 

mental health needs. In addition, individuals with PTSD commonly present with substance use 

disorders. Therefore, treatment research described in this NRAP will examine ways to optimally 

treat comorbid conditions (e.g., integrative versus sequential treatments). TBI will also be 

examined as a comorbid condition for the military and Veteran population with PTSD. 

There are no medications developed specifically for the treatment of PTSD. The two medications 

approved by the U.S. Food and Drug Administration for PTSD (the antidepressants sertraline 

and paroxetine) show modest efficacy. Many medications are used “off-label” to treat PTSD 

symptoms but lack scientific evidence that they are beneficial. Few treatment interventions target 

underlying biological causes or mechanisms of the disease. Investment by the pharmaceutical 

industry in new medications for PTSD has declined in recent years. Federal stakeholders will 
National Research Action Plan August 2013

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pursue the development of therapeutics targeting biomarkers and mechanisms uncovered in the 

course of research as well as assess the utility of repurposed or off-label treatments. A wellstudied example of this would be prazosin’s ability to treat sleep disturbances in individuals with 

PTSD (prazosin is approved for treating hypertension). Further, new partnerships (e.g., public–

private collaborations) will be pursued to aid in the identification of potential pharmacological 

targets for the prevention and treatment of PTSD. All of these research efforts would be 

enhanced by the development of a virtual tissue (brain) repository for PTSD. The value of tissuebased study presents opportunities to understand underlying biology impossible to discover in 

vivo.

The agencies’ Interagency Research Continuum Approach for PTSD research and the major 

focus areas in each of the seven topic areas are shown in Figure 2. For the VA, NIMH, and 

NIDA, the numbers of studies represent the numbers of projects active in FY12, and Follow-Up 

Care research for NIMH and NIDA was included in Treatment and/or Services Research. For the 

DoD, the grant numbers represent the cumulative number of active studies funded from FY07–

FY12.

Vision for Moving PTSD Treatment Research into Practice 

The aspirational vision is to provide practitioners with the most effective ways to prevent or treat PTSD in the 

civilian and military populations, including service members, Veterans, and their families. Individuals 

exposed to traumatic events would routinely participate in systematic evaluation on broad dimensions of risk 

with progressively intensive diagnostic evaluations. Individualized and staged interventions would be 

planned to minimize severity of acute stress and prevent the development of PTSD. Results would then be 

weighted/combined in an automated algorithm to determine risk for PTSD and associated comorbidities 

(especially substance related) to inform care and follow-up. Evaluations would inform interventions targeted 

at mitigating negative psychological symptoms and consequences. Individuals seeking care for PTSD would 

undergo a thorough medical, psychiatric, and substance abuse history and assessment to yield a health risk 

profile indicative of the underlying cause/type of impairment. The individual would then be matched to 

receive treatment known to target/address the specific underlying cause/type of his/her disorder. Throughout 

a course of treatment, effectiveness of any administered treatment(s) would be measured. Researchers 

would have knowledge of both fixed and modifiable systems, circuits, and molecules to focus treatment 

development and refinement studies. New interventions thus will move faster from discovery/development to 

use in clinical care, thereby expanding treatment options.
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Follow-Up Plan to Achieve the Vision for PTSD Research:

It is anticipated that findings from ongoing and newly initiated studies will directly inform future 

research specifically in areas of underlying mechanisms and biomarkers that in turn will inform 

prevention and treatment intervention advances. Notably, the agencies are dedicated to 

discussing/sharing new findings, reassessing goals, and informing new collaborative activities 

with each other (e.g., a meeting on biomarkers in high-risk cohorts and joint portfolio reviews). 

As studies conclude, the agencies will review research findings that pertain to prevention and 

health promotion and treatment interventions for PTSD and co-occurring conditions to identify 

those that warrant further investigation or those that are appropriate to implement within health 

care systems. The actions presented in the following time frames form the vision for PTSD 

research. Please note that the bullets within each time frame are organized by the order in the 

Interagency Research Continuum and are not placed in order of importance or priority.

Immediate Actions (within 1 year)

 Fund new exploratory research on structural and/or functional changes in the brain 

immediately following trauma exposure to identify early changes indicative of the future 

development of PTSD and comorbidities.

 Review emerging genomic and molecular findings on causal pathways and changes that 

contribute to PTSD and perform critical replication of preliminary findings. 

 Continue to expand NIMH RDoC efforts by funding new applications to develop and test 

neural system measures that may be applicable to the spectrum of posttraumatic stress

symptoms and comorbid psychiatric conditions. 

 Increase the inventory of scarce research resources (e.g., tissue samples, blood, and 

cerebrospinal fluid), facilitating access for scientific purposes (with appropriate human 

subjects’ protections related to privacy and confidentiality). To accomplish this, the 

agencies will leverage existing pathology archives to initiate development of a virtual 

tissue (brain) repository for PTSD research. Activities will also include (1) incorporating 

appropriate agreements either between the investigator and resourcing agency (material 

transfer agreement) or between agencies (interagency agreement) and (2) processes for 

securing consent to obtain brain tissue from donor (premortem) or representative 

(postmortem).

 Establish preliminary sex-specific risk allele biomarkers for PTSD to enrich and enhance 

risk prediction measures. This will aid in the identification of new targets for the 

development of prevention and treatment interventions.

 Publish program announcements, complete review of applications, and fund studies from

interagency funding opportunities addressing PTSD biomarkers, substance abuse 

prevention, and wellness interventions for service members, Veterans, and their families.

 Convene an interagency biomarker working group to explore early findings from ongoing 

biomarker efforts and plan data-sharing opportunities to facilitate additional analyses of 

both published results and raw data.

 Continue research to improve and optimize the effectiveness and delivery of:

− Current evidence-based prevention and treatment interventions (including 

psychotherapies, combination therapies, and adjunctive treatments) and available 

medications for PTSD and comorbidities; and
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− Service modalities for PTSD and comorbidities (e.g., telemedicine and 

web-based).

 Continue research on the safety and efficacy of medications, psychotherapeutics, and 

combination treatments targeting underlying mechanisms of PTSD and comorbidities.

Short-Term Actions (2–4 years)

 Disseminate findings (e.g., peer-reviewed publications, conferences, and briefings) from 

at least three genome-wide association studies with military, Veteran, or other high-risk 

cohorts to determine genetic patterns associated with PTSD and comorbidities.

 Identify and confirm whether potential biomarkers have clinical value for PTSD by 

utilizing studies that contain phenotypic and genetic data (e.g., Million Veteran Program, 

Marine Resiliency Study, and South Texas Research Organizational Network Guiding 

Studies on Trauma and Resilience).

 Establish a validated PTSD assay from the DoD’s systems biology effort for objective 

diagnosis and monitoring of treatment response.

 Identify brain circuitry changes related to treatment response and disseminate findings

(e.g., peer-reviewed publications, conferences, and briefings) from at least two 

translational trials.

 Leverage results from biomarker research (e.g., data emanating from CAP-funded 

projects) and embed follow-on biomarker studies in select clinical trials to explore 

biological changes or markers that are associated with treatment response to better match 

individuals to treatments. 

 Disseminate findings (e.g., peer-reviewed publications, conferences, and briefings) from 

translational trials that are targeting either (1) a putative mechanism in PTSD with the 

novel use of medications (e.g., CRF [corticotropin releasing factor] antagonist and

mifepristone) or (2) comorbidities with PTSD.

 Conduct research to optimize psychotherapeutic intervention approaches (e.g., 

repackaging, shortening, or integrating them) to achieve more rapid and long-lasting 

benefit.

 Disseminate findings (e.g., peer-reviewed publications, conferences, and briefings) from 

randomized controlled trials aimed at improving and optimizing PTSD treatment (e.g., 

psychotherapeutic and combination psychotherapeutic and pharmacological treatment 

protocols, including those for comorbid conditions).

Long-Term Actions (5–10 years)

Looking to the future, the agencies are striving to deliver research results that will move the field 

closer to realizing the PTSD vision (summarized earlier) of optimal prevention, diagnosis, and 

treatment for each individual. Realizing this vision requires continued investments in relevant 

research and a commitment by the agencies to important high-priority collaborative endeavors in 

the coming years. A forward leaning, aggressive vision is essential to achieve the “long-term 

actions” described here; however, steps toward these items are already under way or as noted in 

the following paragraphs will begin in shorter time frames, and the pace toward full 

implementation will be accelerated under the NRAP. 
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Focus areas for consideration in this longer term horizon include:

 Develop the systematic ability to combine data from valuable DoD, NIH, and VA cohort 

studies for a deep longitudinal view of putative biomarkers, to enhance clinical measures 

and improve the classification and prediction of PTSD. While some analyses can occur in 

shorter time frames, early phase work toward more systematic combined analyses will be 

dedicated to understanding the existing barriers to achieving this objective and 

developing plans for implementation. Over the longer term, efforts will focus on working 

to overcome the barriers and conducting analyses.

 Identify the requirements that would be needed to potentially establish a coordinated 

clinical treatment registry across VA, DoD, and civilian health care systems and clinical 

trials to collect common clinical and other measures that may lead to improved treatment 

outcomes. Ultimately, this effort could enhance clinical measures and improve the 

classification and prediction of PTSD by integrating and analyzing individual-level data 

from prior PTSD risk studies with a large number of acute trauma patients to develop 

models for combining clinical and biomarker data to predict risk of PTSD onset and 

lessen the severity of the disorder in those with PTSD. To achieve this objective from the 

present state of disparate service and research funding systems, early phase work in a 

shorter time frame will be focused on assessing the landscape of such systems, including 

their capabilities and limitations. Later phase efforts will concentrate on the institution of 

commonalities so that analyses can occur. Any such effort would include a clear policy 

process to ensure informed consent of patients.

 Enhance new and emerging infrastructure (e.g., NIMH experimental medicine project for 

Fast Fail Trials in Mood and Anxiety Spectrum Disorders, VA and DoD clinical trials 

infrastructure) to accelerate the testing of novel and repurposed pharmacological 

interventions. This may include partnering with pharmaceutical companies that identify 

compounds that may have the potential to treat underlying PTSD mechanisms. Initial 

work on this objective will include the identification of potential targets. This will be 

followed by further work on partnership development. Partnership development will take 

time to establish the working relationships in a structured way (Cooperative Research and 

Development Agreements for data use, sharing, intellectual property, etc.), as well as 

move compounds to trials.

As new efficacious interventions are developed, the next steps will focus on determining how to 

enhance treatment-seeking behavior and reduce barriers to care, as well as utilizing standardized 

training procedures for professionals to implement evidence-based interventions with fidelity in 

health care systems and evaluate on an ongoing basis.
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TBI: Biomarkers, Diagnosis, Mechanisms, and 

Treatment Research

TBI is a complex and heterogeneous injury that includes a spectrum of severities ranging from 

mild (also known as a concussion) to moderate, severe, and penetrating. It can result in 

temporary symptoms or enduring disabilities, depending on factors such as the severity and 

location of the injury, the age at injury, and the number of injuries over time. Common issues

resulting from TBI include: (1) the post-concussion syndrome of attention/concentration deficit, 

headache, dizziness, sleep disorder, depressed mood, irritability; (2) longer-term difficulties with 

cognition, behavioral and mental health, communication, and sensory processing (common after 

moderate or severe TBI); and (3) chronic traumatic encephalopathy as a result of repeated mTBI, 

which has also been linked with other delayed, neurodegenerative diseases such as Alzheimer’stype dementia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), and Parkinson’s-like 

symptoms. 

Currently 266,810 cases of TBI have occurred in the military 2000–2012. Most of these are mild 

TBI and approximately 15%–20% are deployment related. Most of the combat wounds observed 

in the conflicts in Operation Enduring Freedom/Operation Iraqi Freedom were caused by 

explosive weapons, such as improvised explosive devices. The effects of these blast exposures 

on the brain are not well understood. It is unclear whether blast injury is similar to the 

pathologically characterized impact injuries or acceleration/deceleration injuries. Therefore, any 

existing unique neuropathological features of blast injury are critical to define in order to guide 

research efforts aimed toward helping those exposed to blast TBI in the military. Animal models 

of blast injury could be exceedingly valuable to study relevant injury mechanisms if there is a 

clinically significant human pathology to model. A neuropathology laboratory has been 

established at Uniformed Services University of the Health Sciences (USUHS) for the purpose of 

defining the pathology of blast injury funded by the USUHS-NIH Center for Neuroscience and 

Regenerative Medicine and the U.S. Army Medical Research and Materiel Command. Clear 

consent is required for the comprehensive examination of brain tissue in deceased military 

personnel. Due to the sensitive nature of requesting consent for brain examination at the time of 

death, access to tissue has remained a barrier for understanding blast-related injuries.

Challenges for TBI research and clinical care include imprecise diagnostic tools and criteria used 

to classify the severity and type of TBI; a limited understanding of the impact of co-occurring 

conditions; gaps in understanding of mechanisms underlying injury and recovery, including the 

effects of gender, ethnicity, and socioeconomic background; paucity of research data on the 

social, psychological, and economic impacts of TBI on families and communities; uncertainty 

about the ability of preclinical models to reproduce the spectrum of injuries and co-occurring 

conditions; and a nascent understanding of ways to harness neuroplasticity to increase repair and 

recovery. Notably, a military context that poses a unique challenge is the role of multiple 

mechanisms (“blast-plus”) as compared to single mechanism injuries (e.g., motor vehicle 

accident or sports concussion). To facilitate treatment advances for service members and 

Veterans with TBI, it will be necessary to better understand both the mechanism of underlying 

injury and its long-term health needs.
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Chronic Effects of Neurotrauma 

Consortia (CENC)

The DoD and VA are jointly sponsoring the CENC 

award, which will fund a large consortia to:

 Establish the association of the chronic effects of 

mTBI and common comorbidities;

 Determine whether there is a causative effect of 

chronic mTBI/concussion on neurodegenerative 

disease and other comorbidities; 

 Identify diagnostic and prognostic indicators of 

neurodegenerative disease and other comorbidities 

associated with mTBI/concussion; and

 Develop and advance methods to treat and 

rehabilitate chronic neurodegenerative disease and 

comorbid effects of mTBI/concussion.

A CENC award is expected to be finalized by September 

2013.

Areas of research focus include:

Diagnostic tools and definitions. Current definitions of TBI as well as the tools currently used to 

diagnose it are imprecise. The DoD and CDC, in partnership with the Brain Trauma Foundation, 

have funded an effort to develop a clinically meaningful classification system of 

mTBI/concussion that will enable improved clinical assessment of current status and prognosis. 

The International TBI Common Data Elements (CDEs) Project has recommended a battery of 

instruments to be used in TBI epidemiological and interventions research, but evidence 

demonstrating the utility or superiority of the recommended instruments over other measures is 

limited. NINDS has funded “Transforming Research and Clinical Knowledge in TBI” (TRACK 

– TBI), a pilot project to evaluate the utility and feasibility of the CDEs. DoD has funded the 

data analysis component of TRACK – TBI. These three successful interagency collaborations 

underscore the value and need for additional research to create more precise classifications of 

injury type and severity and more sensitive diagnostic tools to ultimately enable personalized 

medicine for TBI. There is also the opportunity for leveraging emerging imaging modalities and 

body fluid-derived biomarkers for improved diagnostics, but validation will be required before 

they are ready for clinical use.

Biomarkers for identification, management, and treatment effectiveness. Preliminary evidence 

supports the potential for use of bodily fluid (e.g., blood, serum, and cerebrospinal fluid) 

biomarkers to detect mTBI/concussion. Animal studies have indicated that changes in gene

expression in white blood cells may 

identify inflammation related to TBI. 

However, identification of sensitive and 

specific biomarkers requires a more precise 

classification system for TBI, similar to the 

systems used for spinal cord injury and 

cancer. Biomarkers may inform research 

and clinical investigation as well as the

management of both acute and chronic 

stages of TBI. Of particular interest are 

biomarkers indicative of the potential

neurodegenerative effects of TBI, such as 

chronic traumatic encephalopathy and 

dementia. In short, biomarkers to detect 

injury, predict short- and long-term 

outcomes, and monitor response to 

treatment are all needed. Studies are under

way to identify and test biomarkers, but 

none are currently ready for clinical use.

There is an urgent need to systematically evaluate existing and emerging biomarker technologies 

for their ability to improve accurate diagnosis, detect acute and chronic illness, identify patterns 

of recovery, predict outcomes, and monitor the response to treatment. 

Mechanisms. Following TBI, most patients show some degree of functional improvement over 

time. However, relatively little is known about the mechanisms that underlie recovery or about 

ways to harness neuroplasticity to optimize improvements. Research is needed to identify 
National Research Action Plan August 2013

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patterns of brain structure and function that are associated with either recovery or poor response 

to treatment. Given emerging evidence regarding the chronic effects of TBI, a better 

understanding of the relationship between neurotrauma and neurodegeneration is needed for the 

development of effective medical and rehabilitation interventions (see text box on the CENC). 

The nature of brain injuries incurred in the current military conflicts has highlighted the need to 

better understand the effects of repetitive brain trauma on neuropathology, neurological function, 

and mental health. The fielding of blast and impact sensors is anticipated to enable more precise 

identification of those exposed to possible concussive events. Once these devices have been 

validated as accurate in identifying possible events, they can then be correlated with clinical 

findings to determine whether injury severity can be accurately predicted.

Preclinical modeling. While basic science is essential to improving diagnostics and treatments 

for TBI, the ability to model TBI in animals has been less successful. None of the treatments 

found to be effective in preclinical animal models have successfully progressed through a Phase 

III clinical trial for clinical use in humans. The limited human postmortem brain tissue samples 

available for study have not allowed for sufficient comparison with animals. The differences in 

mass, shape, and white/gray matter ratios between rodent and human brains make it difficult to 

reproduce the effects of TBI in a manner that physically and structurally scales from rodents to 

humans. Animal models rarely address the short- and long-term comorbidities and/or chronic 

effects associated with TBI nor do they clearly address the recovery/rehabilitation phase.

Systems biology approaches that integrate animal and human findings with computational 

modeling of injury mechanisms and high performance computing have the potential to enable

previously impossible levels of cross-correlation and analysis of research data. However, 

challenges in collecting human postmortem brain tissue have impeded progress in this area. A 

coordinated military, Veteran, and civilian tissue repository effort to make postmortem tissue 

available for research purposes is critical. Notably, the DoD has established the first DoD brain 

tissue repository to study TBI in service members. To guide the development and validation of 

animal models, especially for blast and mTBI, further postmortem human tissue research will be 

needed, and efforts to encourage donation of postmortem tissue with appropriate consent will 

help to advance this research. 

Treatments. Over 30 clinical trials of TBI pharmacological therapies have failed to produce a 

U.S. Food and Drug Administration-approved treatment for acute TBI. There is limited evidence 

of the effectiveness of both pharmacological and nonpharmacological interventions, including 

rehabilitation treatments, due in part, to underpowered studies and the limited validated

assessment tools that are sensitive enough to detect treatment effects. Research on treatment 

efficacy and effectiveness has also been hampered by difficulties in defining the active 

ingredient of many experience-based treatments that are commonly used in rehabilitation. The 

concurrent application of multiple treatments, including pharmacological and 

nonpharmacological interventions, poses another challenge. Rigorous definitions of 

rehabilitation treatments are needed as well as research regarding the customization of therapies 

to an individual’s injury, predisposing factors, and co-occurring conditions. 

Assessment. The International CDE Project for TBI has recommended a battery of “gold 

standard” outcome measures and assessments for TBI research; however, collectively these take 

several hours to implement. A shorter assessment tool that is both comprehensive and sensitive 

across the range of injury severities is clearly needed. Possibilities include several computer-
National Research Action Plan August 2013

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assisted outcome assessment tools that have recently been developed. The NIH Toolbox for 

Assessment of Neurological and Behavioral Function is a multidimensional set of brief measures 

that assess cognitive, emotional, motor, and sensory function in individuals from 3 to 85 years of 

age. The NINDS-funded Neuro-QOL is a set of self-report measures that assesses the healthrelated quality of life of adults and children with neurological disorders, and the NIDRR-funded 

TBI-QOL measures health-related quality of life specifically for people with TBI. These tools 

have the potential to fill an important gap by providing a comprehensive assessment of 

functional outcomes and quality of life following treatment while also being brief, freely 

accessible, and reliable. However, these tools need further validation before they are ready for 

clinical use in persons with TBI.

Co-occurring and pre-existing conditions. Major challenges to mechanistic and treatment-related 

research on TBI include difficulties in distinguishing the effects of PTSD and other 

comorbidities, such as sensory, endocrine, cognitive, behavioral, and sleep dysfunctions, from 

the central nervous system injury itself. In other words, the symptoms and sequelae of TBI can 

overlap with many other disorders. Of concern are reports of suicide in persons, including 

Veterans who have sustained TBI, who were found to have tau deposits in the brain diagnostic of 

chronic traumatic encephalopathy. Additionally, evidence is emerging that pre-existing factors, 

be they physical, social, cultural, or health-related, have an effect upon the course and outcome 

of TBI. The common approach to intervention—independently treating symptoms associated 

with each diagnosis—is known to be less than optimal and is, in many cases, ineffective. 

Research is needed to identify effective integrated, team-based models of treatment for persons 

with TBI that address both pre-morbid and co-occurring conditions.

Substance abuse is a known co-occurring condition with TBI with detrimental outcomes for 

persons with TBI and their families. For the general population of persons receiving health care 

services, Screening, Brief Intervention, Referral to Treatment (SBIRT) is standard of care for 

alcohol and tobacco, according to U.S. Prevention Services Task Force reports. However, despite 

being standard of care, SBIRT is not always implemented. NIDRR and other agencies within 

Department of Education have funded the development of an adapted SBIRT protocol for 

persons with TBI. Initial studies of this adapted protocol have concluded that the addition of 

multimedia educational components to the standard SBIRT protocol is having an impact on 

knowledge and beliefs, which in turn reduce substance abuse. Additional research investigating 

substance abuse in persons with TBI is needed including, but not limited to, further validation of 

best practices for screening, brief intervention, and referral to treatment.

The agencies’ Interagency Research Continuum Approach for TBI research and the major focus 

areas in each of the topic areas are shown in Figure 3. For the NIH, VA, and NIDRR, the 

numbers of studies represent the numbers of projects active in FY12. For the DoD, the grant 

numbers represent the cumulative number of studies active between FY07 and FY12. 
National Research Action Plan August 2013

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Vision for Accelerating TBI Research to Improve Health Care 

and Outcomes

The aspirational vision for TBI research is to identify evidenced-based therapies that are effective in 

maximizing short- and long-term health and function, community participation and reintegration for 

persons with TBI in civilian and military populations, including service members, Veterans, and their 

families. Effective treatments, including rehabilitation treatments, would be personalized to address the 

specific type of injury and co-occurring conditions (especially substance related), considering patient 

preferences for care. A clinically relevant classification system for TBI across the spectrum of injury 

severities, age, gender, and chronic conditions, including mild single and repetitive injuries would be 

available to advise patients about their diagnosis, prognosis, and treatment options. More sensitive, 

reliable, and efficient tools (“gold standards”) would be available for evaluating the effectiveness of

treatments on an individual’s physical, cognitive, and psychosocial functioning and quality of life.

Follow-Up Plan to Achieve the Vision for TBI Research:

Data generated from ongoing and newly initiated studies are anticipated to directly inform future 

research specifically in the areas of diagnosis, mechanisms, and biomarkers that in turn will 

inform prevention and treatment intervention advances for TBI. The agencies are holding 

regularly scheduled meetings dedicated to discussing/sharing new findings, reassessing goals, 

and updating collaborative activities among the partners. Specific follow-up actions are 

presented in the following time frames. Please note that the bullets within each time frame are 

organized by the order in the Interagency Research Continuum and are not placed in order of 

importance or priority. 

Immediate Actions (within 1 year)

 Complete the current DoD-CDC-Brain Trauma Foundation mTBI/concussion 

classification project to clarify what is known and unknown about mTBI and the critical 

gaps that need to be addressed. Identify a process for developing a clinically relevant 

system to replace the current mild/moderate/severe nomenclature.

 Increase the inventory of scarce research resources (e.g., tissue samples, blood, and 

cerebrospinal fluid), facilitating access for scientific purposes (with appropriate human 

subjects’ protections related to privacy and confidentiality). To accomplish this, the 

agencies will leverage existing pathology archives to initiate development of a virtual 

tissue (brain) repository for TBI research. Activities will also include (1) incorporating 

appropriate agreements either between the investigator and resourcing agency (material 

transfer agreement) or between agencies (interagency agreement) and (2) processes for 

securing consent to obtain brain tissue from donor (premortem) or representative 

(postmortem).

 Facilitate coordination of portfolio analysis and collaboration on research projects of 

shared interest by exploring the possibility of participation of the DoD and NIDDR in the 

NIH Electronic Research Administration system, which provides support for the full life 

cycle of grants administration functions for the NIH, VA, and several other agencies. 

 Determine whether point of injury blast and impact sensors can be correlated to 

mechanism and severity of brain injury.
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 Establish an interagency working group to review and report on existing and novel 

diagnostic tools and treatments for TBI to improve the evidence base for TBI 

management. 

 Coordinate within and between agencies involved in the Brain Research through 

Advancing Innovative Neurotechnologies initiative to ensure a balance of basic and 

translational science so that more maturely developed technologies can be utilized 

clinically as soon as possible.

 Continue to support clinical trials that are evaluating the effectiveness of therapies to 

improve outcomes and quality of life following TBI.

Short-Term Actions (2–4 years)

 Support research focused on systematically characterizing blast neuropathology related to 

military service and comparing and contrasting it to the neuropathology of impact TBI. 

Test neuroimaging technologies to establish a means of identifying pathobiological 

markers of TBI regardless of mechanism in service members and Veterans. If there are 

verifiable and clinically significant differences between blast- and impact-induced TBI, 

develop scalable animal and in vitro models, if feasible, to identify and leverage 

biological pathways for study of therapies and the process of recovery. 

 Develop a better understanding of the quantitative relationship between the level or 

number of repetitions of blast exposure and severity of TBI in animal models and 

humans.

 Determine whether co-occurring and pre-existing conditions exacerbate impact- and 

blast-related neuropathology. 

 Develop initiatives for basic and clinical research focused on increasing the 

understanding of mechanisms of recovery after TBI and discovering ways to harness 

neuroplasticity to improve outcomes.

 Support validation studies of proteomic, imaging, neurophysiologic, and other potential 

biomarkers and diagnostic tools using the TBI CDEs, the FITBIR Informatics System 

and existing TBI clinical networks (e.g., TRACK-TBI, TBIMS, CENC, and VA Centers 

of Excellence). These studies may focus on early diagnosis, neuro-anatomic correlation 

of symptoms, classification of degrees of injury, markers of neural patterns of good 

recovery vs. poor recovery, or biomarkers in studies of therapeutic target engagement. 

 Continue to support the FITBIR Informatics System as a national resource for TBI 

research and enhance the system to include with appropriate consent advanced analytical 

tools, pipelines for importing and exporting data (especially neuroimaging data); 

electronic data capture for emergency rooms, intensive care units, sports, and battlefields; 

and legacy data. 

 Promote collaboration, meta-analysis and sharing of de-identified individual TBI study 

data in CDE format across agencies through the population of existing federal databases

with FITBIR data, where possible, appropriate, and permissible. Activities to support this 

collaboration include implementing the use of global unique identifiers, the TBI CDEs, 

and consent forms that allow for data sharing across agencies for new studies, when 

possible, appropriate, and permissible.
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 Develop efficient, affordable, comprehensive, valid, and sensitive tools for assessing 

functional outcomes and quality of life over time. Evaluate the utility of the NIH Toolbox 

for Assessment of Neurological and Behavioral Function, the Neuro-QOL, and the TBIQOL and other tools that meet scientific standards to improve clinical assessment and 

enable measurement of treatment effectiveness specific to the TBI population.

Long-Term Actions (5–10 years)

 Develop a more precise system for classifying and staging TBI to enhance diagnosis and 

prognosis and enable targeted therapies and personalized medicine. The approach will be 

to (1) support natural history and other prospective, observational studies and (2) share 

data from these studies, with appropriate privacy protections, to enable computational 

analysis of large, high-quality data sets that include impact and blast injuries, military and 

civilian populations, acute and chronic phases, and the entire spectrum of age, severity,

and the continuum of care.

 Determine the acute and chronic effects of TBI as well as the genetic, gender, ethnic, and 

environmental (epigenetic, socioeconomic, and cultural) protective and risk factors that 

influence susceptibility to injury and subsequent outcomes including the development of 

chronic traumatic encephalopathy, Alzheimer’s and other neurodegenerative diseases. 

The approach will be to utilize new and existing longitudinal research initiatives (e.g., 

CENC, TBIMS-NDB, and Million Veteran Program) to study the chronic effects of TBI, 

including medical, neurological, psychiatric, and psychosocial complications, and to 

study genetic and epigenetic protective and risk factors.

 Identify causal relationships between posttraumatic alterations in brain function and 

symptoms, functional outcomes, and quality of life through greater integration of basic 

and clinical research. Integrate preclinical and clinical research to investigate causal 

relationships for all ages, injury types, and severities and for acute, subacute, and chronic 

stages. This will provide a foundation for developing targeted treatments and 

pharmacodynamic biomarkers.

 Evaluate promising pharmacological and nonpharmacological treatments, including 

rehabilitation treatments for their ability to increase functional outcomes such as 

community participation and reintegration.

 Develop and test models for optimal team-based, integrated treatment of TBI and cooccurring conditions to improve upon the existing practice of independently treating 

biological targets and/or symptoms of each condition. 

 Conduct research on the social, psychological, and economic effects of deploymentrelated TBI on military families and on communities. Diverse indicators of family and 

community well-being should be examined.

 Conduct research on the long-term health needs of service members and Veterans with 

TBI and the resources needed for long-term care and planning.
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Suicide Prevention Research

Suicide prevention is a major research priority that benefits from and is dependent on crossagency, collaborative efforts to maximize the ability to effectively address the problem. Suicide 

is the 10th leading cause of death in the United States, claiming twice as many lives per year as 

homicide. Suicide attempts are up to 30 times more common than suicide deaths and are more 

frequent among younger persons. Having made a suicide attempt is one of the most highly 

predictive factors for later suicide death. Individual characteristics, such as a history of childhood 

abuse and mental and/or substance use disorders, can interact with current or ongoing stressors 

(e.g., relationship disruptions, financial or social losses, and shameful experiences) to increase 

suicide risk. Civilian and military suicide rates have been rising in recent years. Because 

individuals become suicidal for many different reasons, and not all individuals in suicidal crises 

will be seen in health care settings, multiple intervention approaches in multiple contexts are 

needed. Interventions are also needed to address how to identify and promote effective helpseeking behavior and reduce/treat underlying co-occurring mental health disorders. 

Research indicates that no single factor has emerged as predictive of suicide in the military 

population. Some factors (such as repeated deployment) that have been hypothesized to be 

contributing to the increase in suicides in recent years have not been demonstrated to drive this 

increase (e.g., many suicides precede deployment). Almost half of the accidental and 

undetermined deaths investigated in the Army during 2006–2009 involved drugs or alcohol, and 

three-quarters of these deaths involved prescription drugs; however, the exact role of substance 

use in these deaths is not understood. Some studies have shown an association between suicide 

and TBI. However, the low base rate of suicide makes disentangling this challenging. Overall, 

factors leading to suicide are extremely complex, and research is under way to better understand 

the role of concussions and other comorbid factors. 

Many individuals who die by suicide are seen in health care systems close to the time of death. 

Evidence demonstrates that providing continuity of care through transitions (within a health care 

system and from military to civilian settings) is important. Other health care system 

improvements that reduce suicide risk for individuals include providing 24-hour crisis services; 

increasing treatment adherence and managing patients with comorbid substance use disorders; 

and for practitioners, providing regular training to frontline clinical staff on the management of 

suicide risk. Other factors that may help reduce suicide have been identified; e.g., limiting access 

to lethal means significantly lowers suicide risk. Furthermore, treatments such as 

psychotherapies focused on mitigating suicidal thoughts among suicide attempters have been 

shown to reduce attempts by half in the 12 months following treatment. Small proof-of-concept 

studies show promise for fast-acting medications (e.g., ketamine) in reducing suicide ideation, 

but more research is needed. Longer-term research is needed to better understand the factors that 

build resilience and offer protection from suicidal behaviors and promote wellness and recovery.

The agencies have an ongoing partnership focused on suicide prevention research efforts1in 

many areas directly relevant to the Order. The U.S. Army and NIMH jointly initiated Army

 

1 When not specified otherwise, the efforts described for suicide prevention research include preventing completed 

suicides as well as suicide behaviors to include suicide attempts and suicide ideation.
National Research Action Plan August 2013

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Military Suicide Research Consortium 

The DoD MSRC represents a unique collaboration among 

the world’s experts in suicide research, including military, 

VA, and academic partners to produce evidence-based 

effective suicide prevention interventions. The MSRC 

complements the Army STARRS epidemiological study. 

The goal of MSRC research is to develop effective risk 

assessment methods, and prevention and treatment 

interventions to decrease suicide among active duty 

service members and Veterans. Funded projects are 

examining strategies to reduce suicide risk, to prevent reattempts, and to understand bereavement among military 

families after a Veteran or active duty member of the

military has died by suicide. In addition, the MSRC has 

developed an extensive data warehouse containing 

thousands of peer reviewed journal articles on military 

and Veteran mental health disorders, risk assessment 

and prevention, focused in particular on suicide and 

suicide-related research. 

Study to Assess Risk and Resilience in Servicemembers (Army STARRS)2to examine how 

psychosocial, biological, and genetic factors convey risk/resilience for suicide, as well as related 

conditions (e.g., mental health disorders and substance-related disorders). The Military Suicide 

Research Consortium (MSRC) was created by the DoD to develop and validate effective

interventions to prevent suicide among active-duty service members and Veterans (see text box). 

The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force is cochaired by the NIH and the National 

Council for Suicide Prevention. The 

Research Prioritization Task Force is 

developing a proposed agenda by 

September 2013 to inform both the public 

and private sectors efforts to reduce 

suicide attempts and deaths in the next 

10 years. The Defense Suicide Prevention 

Office’s Translation and Implementation 

of Evaluation and Research Studies, which 

involves the DoD, military services, VA, 

and NIMH, translates knowledge accrued 

from evaluation and research studies into 

practical guidelines for military leaders, 

chaplains, and clinical and nonclinical 

support personnel, which will benefit 

service members, Veterans, and their 

families. The NIMH is also developing a 

research study portfolio analysis tool that 

will have the capacity to conduct systematic searches and analyses of funded studies among the

agencies and private sector foundations, which will contribute to the Interagency Research 

Continuum Approach for suicide prevention. 

Findings emanating from the VA’s nationwide suicide prevention program, Mental Illness 

Research Education and Clinical Centers, and Centers of Excellence will contribute to an 

understanding of what is working within the VA health care systems and identify factors for 

targeted research. A joint VA-DoD database of suicide history and health care information is 

being developed to serve programmatic evaluation needs. The National Action Alliance for 

Suicide Prevention’s Research Prioritization Task Force will continue to solicit findings on 

research advances from the agencies, including the VA National Centers of Excellence in 

Suicide Prevention. 

The agencies’ Interagency Research Continuum Approach for suicide prevention research, 

including the major focus areas within each topic area, is shown in Figure 4. For the VA, NIMH, 

and NIDA, the numbers of studies represent the numbers of projects active in FY12, and FollowUp Care research for NIMH was included in Treatment and/or Services Research. For the DoD, 

the numbers represent the cumulative number of active studies funded from FY07–FY12.

 

2 Additional details on Army STARRS are presented in the Comprehensive Longitudinal Mental Health Study section of 

this report.
National Research Action Plan August 2013

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National Research Action Plan August 2013

26

Vision to Advance Suicide Prevention 

Research 

The aspirational vision for suicide prevention research is to 

achieve a significant reduction in attempted and completed 

suicides in the civilian, military, and Veteran populations 

through evidence-based prevention and treatment advances.

There is hope that with new knowledge gained from research 

applied to practice, an individual who has made a suicide 

attempt or has suicidal thoughts would receive lifesaving care. 

Such an individual would seek help early through available 

resources such as a 24-hour hotline (Veterans Crisis Line) or 

online resources (Veterans Crisis Line website or VA 

Community Provider Toolkit). Modifiable risk and protective 

factors (e.g., reduced substance use and improved problem 

solving) could be targeted to avert reattempts. Evidence-based 

prevention programs that build resilience, reduce risk, and 

prevent the emergence of suicidal behaviors would be 

implemented in diverse systems of care and populations, with 

positive impact on suicide prevention.

Follow-Up Plan to Achieve the Vision for Suicide Prevention Research:

Critical research to meet the 

priorities of the Order includes 

enhanced use of surveillance data 

and longitudinal studies; testing 

screening approaches; timely and

comprehensive sharing of data

with appropriate safeguards; and 

the development and testing of 

new prevention and treatment

interventions when targets are 

identified. Research focused on 

alcohol and substance use in the 

military, including Veterans and 

their families, is also important.

Beyond the actions identified in 

the following paragraphs, 

additional information relevant to 

suicide prevention activities is 

found in the Comprehensive 

Longitudinal Mental Health Study 

section of this report. The following plan describes how the vision for suicide prevention 

research can be met over time. Please note that the bullets within each time frame are organized 

by the order of the Interagency Research Continuum and are not placed in order of importance or 

priority.

Immediate Actions (within 1 year)

 Develop and test theoretical models to advance the science of understanding precursors 

and causes of suicide and its prevention.

 Increase the inventory of scarce research resources (e.g., tissue samples, blood, and 

cerebrospinal fluid), facilitating access for scientific purposes (with appropriate human 

subjects’ protections related to privacy and confidentiality). To accomplish this, the 

agencies will leverage existing pathology archives to initiate development of a virtual 

tissue (brain) repository for suicide prevention research. Activities will also include 

(1) incorporating appropriate agreements either between the investigator and resourcing 

agency (material transfer agreement) or between agencies (interagency agreement) and 

(2) processes for securing consent to obtain brain tissue from donor (premortem) or 

representative (postmortem).

 Continue the development of integrated surveillance and survey database management 

systems across the DoD and VA. 

 Disseminate findings (e.g., peer-reviewed publications, conferences, and briefings) from 

completed evidence synthesis reviews related to suicide prevention addressing key 

questions such as risk factors and assessment, and prevalence of co-occurrence of suicide 

with mTBI.
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 The MSRC will identify the next set of research studies aimed at developing and testing 

suicide prevention interventions in clinical trials. 

 Disseminate emerging findings and translate findings into next steps for intervention 

research utilizing programs such as the Defense Suicide Prevention Office’s Translation 

and Implementation of Evaluation and Research Studies.

 Initiate novel efforts to create clinical tools with high specificity and sensitivity to 

identify at-risk individuals using minimally intrusive techniques. 

 Evaluate research findings as they become available to determine what type of follow-up 

most effectively enhances treatment adherence and decreases suicidal behavior in highrisk individuals. 

 Continue ongoing investigations aimed at encouraging implementation of evidence-based 

suicide assessment and management techniques in current care delivery settings 

(e.g., counseling and addictions treatment). Future research efforts will focus on 

improving provider training, developing and testing quality improvement measures, and 

assessing patient satisfaction.

Short-Term Actions (2–4 years)

 Empirically establish whether screens for suicide prevention can be used with adult

patients and high-risk young adult/pediatric populations in health care settings 

(emergency medicine, primary care). 

 Develop and test rapid, brief, and effective prevention and treatment interventions for 

suicide applicable to a variety of settings, with rigorously designed randomized controlled 

trials that address comorbid problems.

 Initiate an interagency collaboration between Army STARRS and the MSRC that will 

build upon the strengths of each program and facilitate rapid translation of Army 

STARRS findings into intervention research efforts.

 Develop and test evidence-based “chain-of-care” practices for individuals transitioning 

from inpatient to outpatient treatment and to specialty follow-up care.

 Investigate the utility of psychological autopsies to discover previously unknown risk 

factors or comorbidities for further clinical investigation.

 Develop and test return-to-duty and return-to-work protocols with evidence-based criteria.

Long-Term Actions (5–10 years)

Looking to the future, the agencies are working together to support research to reduce suicide in 

the civilian, military, and Veteran populations. Reaching this goal will only be possible by 

sustaining investments in relevant research and determining the best ways for agencies to focus 

on new high-priority, collaborative endeavors in the coming years. Priorities for consideration in 

this longer-term horizon include the following:
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 Examine long-term outcomes of prevention interventions delivered early in life to 

determine whether these interventions impact behaviors related to suicide through 

existing and future longitudinal studies.

 Conduct multisite, rigorously designed, randomized controlled trials that test rapidacting, brief interventions that address suicide risk factors, prevent suicide ideation and 

attempts, and can be utilized in emergency care settings through existing partnerships 

with consortiums and joint interagency partnerships.
National Research Action Plan August 2013

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Comprehensive Longitudinal Mental Health Study

In addition to the broad research goals of the NRAP, the Order also directs DoD and HHS to 

engage in a “comprehensive longitudinal mental health study with an emphasis on PTSD, TBI, and 

related injuries to develop better prevention, diagnosis, and treatment options. The agencies shall 

continue ongoing collaborative research efforts, with an aim to enroll at least 100,000 service 

members by December 31, 2012, and include a plan for long-term follow-up with enrollees through 

a coordinated effort with the Department of Veterans Affairs.” Ongoing collaborative efforts that 

can be leveraged to address these requirements are highlighted in the following paragraphs.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The Army and NIMH jointly initiated Army STARRS to examine how psychosocial, biological, 

and genetic factors convey risk/resilience for suicide, as well as related conditions. Army 

STARRS’ component studies (Historical Administrative Data Study, New Soldier Study, All 

Army Study, Soldier Health Outcomes Study, and the Pre/Post Deployment Study) examine 

historical and administrative data collected by the Army in conjunction with original data 

collected from soldiers in all phases of Army service. As of late 2012, more than 100,000 

soldiers volunteered to participate in Army STARRS. 

Discussion of emerging findings as well as strategic planning is ongoing involving both 

scientists and federal agencies involved in relevant activities. Meetings held have included the 

DoD and VA and their funded scientists, as well as those funded by NIH. Plans to share Army 

STARRS data with the broader scientific community have also been established to maximize the 

utility of these data to improve the lives of service members, Veterans, and their families.

Army STARRS’ Historical Administrative Data Study provides an example of the types of 

analyses possible utilizing existing aggregate data on soldiers to address questions regarding 

readjustment. The Historical Administrative Data Study includes de-identified data maintained in 

multiple Army and DoD data systems that have been integrated to find factors that protect 

soldiers’ well-being and factors that suggest mental health risk. To ensure confidentiality, 

personally identifiable information is removed, and analyses are performed only on aggregate 

de-identified data.

Follow-Up Plan:

Army STARRS will continue through June 2014. Interim Progress Reports are provided to the 

Secretary of the Army, Chief of Staff of the Army, and Vice Chief of Staff of the Army to 

accelerate dissemination of actionable results to commanders who have the capacity to enact 

needed changes. These Interim Progress Reports include the most recent civilian and VA 

findings to give the appropriate context of actionable results to senior Army leaders. Findings 

will also be published and disseminated through peer-reviewed publications. One goal is for 

Army STARRS’ data to inform new and better targeted diagnostic and intervention tools. 

The action plan for Army STARRS includes several activities to maximize short-term results 

from this unique study and to ensure that the data platform is established as a critical national 

resource now and for the future, with all appropriate governance, intellectual property, and 

custody rights vested in the appropriate federal agency.
National Research Action Plan August 2013

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Immediate Actions (within 1 year)

 Develop tools to better identify elevated risk for suicide or other adverse mental health 

outcomes. The Army might then be able to use this information to develop targeted 

approaches to mitigate risk and ensure the health of soldiers. This research will also 

inform our understanding of suicide in the overall population, leading to more effective 

prevention and treatment interventions for service members and civilians.

 Continue ongoing data collection and analyses, including initial biomarker assays; 

analyses focused on psychiatric and substance abuse disorders to inform better prevention, 

diagnosis, and treatment options; exploring patterns of suicide risk in the New Soldier 

Study, All Army Study, and Pre/Post Deployment Study; comparing data from the 

Soldier Heath Outcomes Studies to matched controls to better understand the acute and 

chronic factors that contribute to suicide attempts and deaths; and disseminating findings.

 Explore the feasibility of a longitudinal follow-up of the comprehensive Army STARRS

to find actionable factors that will lead to early detection and effective prevention and 

treatment of suicide, PTSD, TBI, and comorbidities. The study will include clear consent 

for the donation of postmortem brains and begin to establish necessary procedures for 

timely collection and preservation of tissue.

Short-Term Actions (2–4 years)

 Continue strategic planning for the next phase of Army STARRS.

 Establish data-sharing agreements to enable the project to continue in a manner that 

fosters collaboration across agencies, service branches, and scientists.

Long-Term Actions (5–10 years)

 Conduct a longitudinal follow-up with Army STARRS participants through Army, DoD, 

VA, and civilian records and recontact individuals (regardless of participant status and 

source of health care) to conduct studies focused on identifying surrogate and clinically 

actionable biomarkers, neurobiological mechanisms that may lead to suicidal behavior in 

blast-exposed individuals, and psychosocial and environmental risk factors for risk and 

resilience to suicide, PTSD, TBI, and comorbidities as these conditions may emerge with 

the passage of time and transitions that occur as part of military service. The overall goal 

is to rapidly translate findings and develop effective interventions.

Summary: The ability to monitor some cohort of the more than 100,000 enrolled participants 

over the long term capitalizes on the initial Army STARRS investment. To make this monitoring 

study feasible, data on emerging mental disorders and suicidal behaviors, and service member 

and Veteran health care use need to be integrated. Establishing Army STARRS as a national 

resource offers great hope for better understanding the long-term impact of traumatic events, 

particularly service members’ experiences with combat, related military stressors, and transition 

to civilian life. Finally, the ongoing and planned scientific objectives of Army STARRS are 

directly relevant toward addressing the complex issues of PTSD, TBI, suicide prevention, and 

related comorbidities called for throughout the Order.

Additional Collaborative Efforts

Other ongoing collaborative efforts can be leveraged to address the requirements of Section 5c in 

the Order, including The Millennium Cohort Study (which includes service member and family 
National Research Action Plan August 2013

31

cohorts), and the Million Veteran Program (MVP). Funded by the DoD and supported by 

military, VA, and civilian researchers, the Millennium Cohort Study is the largest prospective 

health project in military history. It was designed to examine the effects of military service on 

physical and mental health outcomes and includes longitudinal cohorts of more than 200,000 

service members and 10,000 spouses. The MVP is a landmark national research program that is 

building one of the world’s largest medical databases by collecting blood samples and health 

information from one million Veteran volunteers. Data collected from the MVP will be stored 

anonymously for research to study how genes affect health. More than 175,000 Veterans have 

already enrolled in the MVP (May 2013), and 50 VA medical centers nationwide are currently 

participating. 
National Research Action Plan August 2013

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Sharing PTSD, TBI, and Suicide Prevention Research

The data-sharing requirements described in the Order impact both sharing of information related to 

funding activities across agencies and, where appropriate, research study-level data. The 

development and adoption of Common Data Elements (CDEs) for research present the potential 

for streamlining information sharing. Within NRAP activities, a task will be to define a minimum 

set of general and topic-specific CDEs that may be adopted in PTSD, TBI, and suicide prevention 

research. The general CDEs may also be applied to research on co-occurring conditions (where 

demographic data are collected, etc.). The effort should result in a minimum set of defined 

demographic CDEs for research purposes to best accomplish study objectives while 

simultaneously facilitating the comparability of data. Of note, these efforts are not focused on

sharing personally identifiable clinical data across providers of care. Instead, the agencies are 

focused on data-sharing activities for research purposes that contain de-identified clinical data 

(e.g., Mental Health Research Network and Federal Interagency Traumatic Brain Injury Research 

[FITBIR] Informatics System) as well as de-identified data generated through primary research. 

Plans must address issues surrounding de-identification and protection from re-identification of 

data. Data sharing plans that are developed must also consider understandable language for

informed consent, individual privacy, confidentiality, agencies’ authority, and other policies 

related to data use and sharing within a research context. 

As data are shared between entities expanding beyond the initial research database, and 

particularly relevant to genetic data, maintaining privacy, confidentiality, and data protection will 

be paramount, especially for the population covered by the NRAP. It is important to consider how 

best to protect the identity and therefore the information of research participants.

In February 2013, Dr. John Holdren, Director of the White House Office of Science and 

Technology Policy (OSTP), issued a memorandum to the heads of executive departments and 

agencies entitled, Increasing Access to the Results of Federally Funded Scientific Research. That 

memorandum requires agencies to develop plans to increase access to the results of federally 

funded scientific research including publications and data. Specifically, it requires agencies to 

develop policies that “maximize access, by the general public and without charge, to digitally 

formatted scientific data created with Federal funds,” with exceptions for protecting 

confidentiality, privacy, and proprietary interests.3 Both the White House memorandum and an 

Executive Order issued in May 2013 on Making Open and Machine Readable the New Default for 

Government Information posit that open sharing of machine-readable data fuels scientific 

discovery and innovation. Consistent with the spirit of this memorandum and Executive Order, 

the DoD, VA, HHS, and Department of Education will pursue improved data sharing for research 

in TBI, PTSD, and related injuries and neurological conditions, and suicide prevention in concert 

with emerging government-wide efforts to increase access to the results of federally funded 

scientific research, aligned with protecting human subjects’ privacy and confidentiality.

Furthermore, responsibility for ensuring data sharing is not limited to data resources created as the 

result of taxpayer-funded extramural research but may extend to data resources created and 

owned by federal agencies themselves. The agencies intend to promote transparency with regard 

 

3 The memorandum also specifies that each agency shall submit its draft plan to OSTP within 6 months of its 

publication. Since the memo was released on February 22, 2013, the estimated response date of the agencies is 

August 22, 2013. All wording regarding data sharing in the NRAP is subject to and could be superseded by the 

final plans of the agencies in response to this OSTP memorandum.
National Research Action Plan August 2013

33

to their federal data repositories where doing so does not supersede the protection of privacy, 

confidentiality, or other legal authority.

Sharing Funding Information Across Agencies

Accessible electronic information about ongoing and planned efforts supported by the federal 

government is a key component to coordinating and accelerating research. Transparent and 

accessible information can guide funding agencies and researchers alike to reduce overlap, 

eliminate redundancies, identify gaps, and focus new research questions. Electronic access to 

funded databases that yields information about grants funded in different areas of research allows 

the entire scientific community to increase understanding of ongoing efforts and hone 

development of the next generation of scientific questions. Publicly accessible databases that 

contain information about funded grants (e.g., NIH Research Portfolio Online Reporting Tools, 

which is used by the VA and NIH) act as repositories for government-sponsored research. Some 

of the DoD research portfolio information is available on publicly accessed websites; however, a 

new commitment will be to move the DoD’s medical research onto the NIH Research Portfolio 

Online Reporting Tools via Electronic Research Administration Commons, thus promoting an 

even higher level of transparency and analysis. The agencies will continue the annual review and 

analysis process; the most recent meeting was held in January 2013. These efforts serve to foster 

interagency collaborations and cross-pollination among researchers, with the ultimate goal of 

accelerating research progress and reducing/preventing redundancy of efforts. 

Sharing De-identified Research Study-Level Data as Appropriate

Access to study-level data for the purpose of secondary data analysis is important for research in 

general. Data sharing with appropriate consent, confidentiality, and privacy protections within 

legal authority allows for an increase in the amount of data that can be combined or compared by 

the community of scientists. Many small-sized studies are able to involve only a modest number 

of participants; therefore, the ability to share data when appropriate will increase the power for 

analyses and potentially accelerate research progress. In addition, large-scale studies supported 

by each agency provide a platform for rich secondary data analyses when data are shared. The 

agencies are committed toward ensuring that data produced with federal funding are shared, 

where appropriate and within legal authority, with consent and proper de-identification to 

prevent risk for identification (protecting individual privacy). 

Examples of study-level, data-sharing efforts include:

 The FITBIR Informatics System has been established to provide a central repository for 

TBI-related clinical research data. FITBIR was funded by the DoD and subsequently 

developed and managed by the NIH. De-identified clinical data are entered into FITBIR 

utilizing the TBI CDEs, which were developed to allow more precise comparisons of TBI 

research data. Research data from newly funded NINDS and Defense Health Program 

TBI clinical research projects are required to be entered into FITBIR. Although not 

required, clinical research data from previously funded projects can also be entered into 

FITBIR. Additionally, the TBI CDE project is developing data standards to allow 

expansion of FITBIR to preclinical work, enabling advancement of preclinical 

knowledge and improved modeling of TBI. This data repository standardizes the 

collection of research data and allows access to researchers outside of the original 

research studies to re-analyze and compare data across studies.
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Vision for Research Data Sharing

De-identified research data sharing, ideally, would be

collaborative and promote team science to more rapidly and 

effectively fill gaps in knowledge that will ultimately improve 

health care and outcomes. The scientific community would 

be able to submit and access research data in a 

participatory manner to test new hypotheses, combine data 

sets for meta-analyses, and compare and contrast findings 

across disorders, the lifespan, and the continuum of care. 

Research data elements would be standardized to the 

greatest extent possible and also aligned with clinical data 

elements to enable greater integration of research and 

clinical practice. 

 The standardization and sharing of de-identified study-level (raw) data by the NIH. Many 

types of research grants supported by the NIH are required to have plans for sharing deidentified data acquired as part of a study. For example, an investigator-initiated 

application with direct costs greater than $500,000 in any single year is required to 

address data sharing. Furthermore, any NIH study conducting genome-wide association 

studies, used to identify common genetic factors that influence health and disease, is 

required by NIH policy to (1) share de-identified data (genotypic and phenotypic) 

through a centralized repository and (2) submit documentation that describes how the 

institutions have considered the interests of the research participants (e.g., privacy and 

confidentiality). The purpose of this NIH policy is to maximize investments and foster 

science for the benefit of the public. This requirement is supported by resources such as 

the NIH genome-wide association studies website (http://gwas.nih.gov).

 The National Institute on Disability and Rehabilitation Research established the 

longitudinal TBI Model Systems National Database (TBIMS-NDB) to provide a data 

repository for clinical data on persons with moderate or severe TBI who receive 

treatment in the Model Systems network of centers. This database has been shown to be 

nationally representative of persons with moderate to severe TBI who receive inpatient 

rehabilitation. It offers decades of information on clinical progress and outcomes 

following TBI. The National Institute on Disability and Rehabilitation Research and the 

VA have also partnered to create a VA Polytrauma Rehabilitation Centers TBI Database 

that includes many of the same data elements found in the TBIMS-NDB.

 The VA computing infrastructure allows for de-identified study data to be accessible to 

VA researchers. While not limited to PTSD or TBI, this environment allows appropriate 

sharing of research data within the VA. Notably, VA study-level data sharing is defined 

in data use agreements and carefully considers safeguarding Veteran stakeholders 

information related to de-identification.

 The NIH Toolbox for the Assessment of Neurological and Behavioral Function 

(http://www.nihtoolbox.org). This brief set of measures, assessing cognitive, emotional, 

motor, and sensory function from 3–85 years of age, meets the need for a standard set of 

measures that can be used as a “common currency” across diverse study designs and 

settings. The NIH Toolbox can be used in many types of research, including research 

seeking to measure changes in neurological and behavioral function over time and 

evaluating intervention and treatment effectiveness.

Follow-Up Plan: 

The overall goal for the NRAP related to 

de-identified data sharing is centered on 

accelerating research progress. The major 

emphasis is on sharing data, as 

appropriate, describing funded research 

studies to facilitate an understanding of

what is being supported across agencies, 

increase transparency in the public 

domain, and reduce redundancy. Planned 

compilation of funded research studies

and common coding of categories of 
National Research Action Plan August 2013

35

research across the spectrum from basic to implementation research will allow researchers to 

search for various topics across agencies to identify ongoing work (e.g., all studies that examine 

PTSD and suicide attempts) and facilitate the next generation of research questions. Joining with 

the NIH and VA, the DoD will pursue utilization of Electronic Research Administration

Commons, IMPAC II, and related systems for research study portfolio management.

The agencies have begun discussions related to determining how to enhance research datasharing efforts as appropriate. Data-sharing efforts will require close and continued collaboration 

between federal agencies dedicated to addressing challenges specific to research to meet the 

overall goal to increase access to study-level data.

Some exemplars of the type of activities that will meet the requirements of the Order are as 

follows:

 Continue to convene the joint DoD/VA/HHS/ED strategic portfolio reviews in the areas 

of TBI, PTSD, suicide prevention, and substance abuse research.

 Explore expansion of the Psychiatric Genomics Consortium 

(https://pgc.unc.edu/index.php) to include PTSD cohorts. Research funded by federal 

agencies may deposit de-identified genotypic and phenotypic data to facilitate metaanalyses, replication, and extension of early findings. 

 Improve the delivery of health care services in the private sector by sharing research 

findings and data through agencies (e.g., Agency for Healthcare Research and Quality), 

consensus development conferences (e.g., NIH Consensus Development Program), and 

practice-based research.

 Develop a minimum set of defined CDEs for adoption and use in PTSD, TBI, and suicide 

prevention research. 

 Plan to expand FITBIR to include preclinical research data. CDEs for preclinical models 

will be developed. Methods will be developed to enable researchers with existing or even 

completed research to more easily align their data with the CDEs, which may be 

expanded to relevant mental health elements. Entry of data into FITBIR is a requirement 

for all DoD-funded TBI research projects and will be a requirement for NIH TBI clinical 

research projects. 

 Facilitate the collaboration of FITBIR with TBIMS-NDB, the International TBI Research 

Initiative, and other related/relevant data repositories that can be leveraged for research, 

as permissible.

 Encourage use of the National Addiction and HIV Data Archive Program (NADHAP) 

(http://www.icpsr.umich.edu/icpsrweb/NAHDAP/) for the purpose of archiving data. 

Researchers can use the NADHAP to upload data sets relevant to substance abuse and 

military and Veteran populations and use data from the NADHAP for the purpose of 

secondary data analysis.

 Encourage use of NIH Funding Opportunity Announcement PAR-13-080, “Accelerating 

the Pace of Drug Abuse Research Using Existing Data.” The purpose of this Funding 

Opportunity Announcement is to invite applications proposing the innovative analysis of 

existing social science, behavioral, administrative, and neuroimaging data to study the 

etiology and epidemiology of drug-using behaviors (defined as alcohol, tobacco, 

prescription, and other drugs) and related disorders, associated HIV risk behaviors, 

prevention of drug use and HIV, and health service utilization. 
National Research Action Plan August 2013

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Electronic Health Records and Research and Clinical Care

An electronic health record (EHR) is an evolving concept defined as a systematic collection of 

electronic health information about individuals or populations. It is a record in digital format that 

is theoretically capable of being shared across different health care settings. In some cases this 

sharing can occur by way of network-connected, enterprise-wide information systems and other 

information networks or exchanges. Current and future sharing capabilities will be limited to the 

extent that the systems can be integrated. EHRs may include a range of data, including 

demographics, medical history, medication and allergies, immunization status, laboratory test 

results, radiology images, vital signs, personal stats such as age and weight, and billing 

information.

EHRs primarily support clinical workflows but may also serve as a data resource that 

supplements research. In addressing the Order’s requirement related to EHRs, the agencies have 

focused on research applications, specifically those related to existing VA and DoD EHRs, such 

as enhancing the ability to query records to understand targeted populations prior to study, 

improving the ability to scope proposed problems and develop hypotheses, and identifying sites 

that can serve as recruiting centers within large systems such as the VA. A fundamental 

requirement of the use of EHR data in research is the protection of an individual’s confidentiality

and privacy. For example, including information on participation in a particular research study in 

the medical record may have far-ranging privacy implications as medical record information is 

shared. Therefore, implementations of EHR use for research purposes must ensure 

confidentiality within the health care setting as well as the research setting while satisfying the 

need for an accurate continuous care record.

EHRs can provide valuable data for tracking and improving patient care. Various population 

health management systems have been implemented to reduce re-hospitalization and 

comorbidities in civilian populations at risk for diseases such as diabetes, chronic obstructive 

pulmonary disease, and cardiovascular disease. Algorithms implemented via such systems 

provide feedback to clinicians to improve patient engagement and are delivered through the 

clinical EHR. It is conceivable that in the future similar strategies could be used to identify 

individuals requiring a particular “prevention” intervention or treatment related to TBI or PTSD,

as well as those eligible for clinical trials. One example of this is the Mental Health Research 

Network (MHRN) established by NIMH. Currently, the MHRN consists of 11 research sites at 

member institutions affiliated with nonprofit, integrated health care delivery systems. MHRN 

member institutions belong to a consortium of 16 health care delivery organizations with 

integrated research divisions known as the HMO Research Network. In addition to MHRN, 

HMO Research Network has attracted other NIH-funded research programs including the Cancer 

Research Network and the Cardiovascular Research Network, as well as several programs 

funded by the Agency for Health Care Research and Quality. 

The parent HMOs for MHRN members provide care for approximately 11 million individuals

and offer substantial resources that are useful for the conduct of mental health research. These 

resources include data for large, well-defined, and diverse patient populations; long-established 

administrative and medical records; long-standing patient privacy and confidentiality 

protections; physician and patient web portals; biospecimen resources; linkages to other data 

systems such as population-based patient registries; and capacity for rapid identification and 
National Research Action Plan August 2013

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Vision for Using Health Data to Improve 

Outcomes 

Ideally, an individual’s EHR would be continuous or accessible 

across care providers, systems of care, and individuals’ 

lifetimes. Individuals would be able to access records in a 

participatory manner to improve accuracy and continuity of care. 

A population dashboard utilizing EHR would be used to monitor 

trends in health and illness in relation to practice changes. EHRs

would also be used by health care providers to identify patients 

meeting certain risk profiles based on trends emerging from 

other patients with similar histories. Research studies aimed at 

improving patient outcomes will build on EHR information with 

appropriate protections and informed consent in research 

studies aimed at improving patient outcomes. Overall, it is 

hoped that data-driven systems would effectively and efficiently 

improve the mental health and substance abuse care of service 

members, Veterans, and civilians. 

accrual of subjects to longitudinal retrospective and prospective cohorts for observational studies 

or clinical trials. To date, MHRN investigators have enhanced a Virtual Data Warehouse to 

harmonize mental health diagnosis and treatment data across all sites of the MHRN, establishing 

standard definitions for key exposures and mental health outcomes. They also developed

procedures for distributing standard programs and aggregating data across sites. Other 

accomplishments include conducting observational studies using the Virtual Data Warehouse to 

analyze practice variation across multiple sites; organizing patient-reported outcomes data across 

sites; implementing a centralized online platform for administration of standardized clinical 

measures across multiple sites; and developing procedures for online electronic informed consent 

and protection of personally identifiable information and transfer of sensitive data. Procedures 

have also been established for the multisite collection of biological specimens, including consent, 

and specimen collection and use. 

Since current International Classification of Diseases diagnostic codes (versions 9/10) do not 

define TBI using the VA/DoD definition, it is difficult for the agencies to use retrospective data 

for epidemiological and systematic 

analyses. Hurdles(e.g., “big data”

approaches to identifying new 

patterns and disease processes and 

time courses) must be addressed 

while preserving individual privacy 

and confidentiality. It is anticipated 

that EHRs might have the capability 

to address these needs and will also 

contribute to the creation of a 

continuous “learning” health care 

system. The VA is currently 

exploring the strategy of point-ofcare research based on clinical care

outcomes obtained directly from 

EHRs and using these outcomes data 

to generate knowledge about 

treatment choices. For example, 

clinicians could utilize the PTSD Checklist in clinical practice and log outcomes from treatment 

over time in the EHR. With appropriate confidentiality and consent procedures, the PTSD 

Checklist results could then be extracted from the medical record to determine the impact of

treatment and inform treatment choices.

EHRs and Research

The Order directs making better use of EHRs to gain insight into the risk and mitigation of 

PTSD, TBI, and related injuries. This is relevant across research activities, and the agencies are 

dedicated to determining potential EHR applicability among ongoing/new efforts and assessing 

where EHR use is feasible and appropriate. However, the work related to meeting the Order

requirement is not in concert with a predetermined time line, as specific barriers may have to be 

addressed (outside the scope of this NRAP) and authority for data use may have to be modified. 
National Research Action Plan August 2013

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While the action plan for addressing the topics of PTSD, TBI, and suicide prevention will be 

coordinated through the agencies respective research offices, agency stakeholders (e.g., Military 

Health System, Tricare Management Activity) and other experts will be required to address the 

objectives for EHR use in research, including medical informatics, privacy, confidentiality of 

records, and information technology. Together, the agencies will work with the Office of the 

National Coordinator for Health Information Technology to advance information and 

cooperation for emerging developments in EHRs related to the support of research, including to:

 Develop a model for a population dashboard(s) that could be voluntarily used in health 

systems utilizing EHRs to monitor trends, patterns, as well as impact of events on 

TBI/PTSD and mental health. 

 Consider expanding the MHRN to include additional health systems and investigators to 

focus on improvements in the prevention and treatment of TBI, PTSD, and mental health 

and substance abuse. 
National Research Action Plan August 2013

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Funding and Prioritization

The agencies intend to focus and collaborate on 

the topics identified in this document. These 

efforts will be supported within existing agency 

budgets. The agencies will follow their 

established planning, programming, and 

budgeting processes, and priorities will be 

supported as feasible within available 

resources. In a time of constrained resources, 

the agencies will continue to direct resources to 

high-priority activities.

Conclusion

The vision for PTSD, TBI, and suicide prevention 

research described here will be achieved through 

close, continued collaborations across agencies 

and throughout the scientific community. Agency 

collaborations will occur formally through joint 

portfolio review and analyses of efforts aligned 

with the NRAP. All of these activities will 

support the research goals outlined in Sections 5a

and 5b of the Order, which include preventing 

suicide; reducing the number of individuals 

affected by PTSD, TBI, and substance-related 

and other comorbidities; and improving the 

quality of life of those who do experience these 

conditions through better coordinated and synchronized efforts to accelerate progress in 

prevention, diagnosis, and treatment. Additionally, Army STARRS and other large collaborative 

efforts (e.g., Millennium Cohort Study and Million Veteran Program) are responsive to Section 

5c of the Order, which directs that the DoD and HHS engage in a comprehensive longitudinal 

mental health study with an emphasis on PTSD, TBI, and related injuries to develop better 

prevention, diagnosis, and treatment options. New large collaborations (e.g., Consortium to 

Alleviate PTSD and Chronic Effects of Neurotrauma Consortium) will also directly respond to 

the Order and contribute to our goal to advance effective diagnosis and prevention and treatment 

interventions. The agencies look forward to fulfilling this NRAP with the anticipation that it will 

directly benefit Veterans, military service members, and their families.
National Research Action Plan August 2013

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Documents Consulted

The following documents were referenced in preparation of this report:

 2013 Interim Report of the Interagency Task Force on Military and Veterans Mental 

Health, Issued in May 2013. 

 Army Health Promotion Risk Reduction Suicide Prevention Report. Issued in July 2010.

 Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury. 

IOM. 2009. Washington, DC: The National Academies Press.

 Increasing Access to the Results of Federally Funded Scientific Research. Memo issued 

in February 2013 by Dr. John Holdren, Director of the Office of Science and Technology 

Policy.

 Making Open and Machine Readable the New Default for Government Information. 

Executive Order issued on May 9, 2013, by President Barack Obama.

 National Institute of Mental Health Strategic Plan. Issued in August 2008.

 Psychological Health and Traumatic Brain Injury Portfolio Review and Analysis Report. 

(Summary of the meeting sponsored by the DHP and held on July 28, 2010, at Fort 

Detrick, Maryland.)

 Psychological Health and Traumatic Brain Injury Portfolio Review and Analysis Report. 

(Summary of the meeting sponsored by the DHP and VA, and held on 

November 30–December 1, 2011, at Fort Detrick, Maryland.)

 Psychological Health and Traumatic Brain Injury Portfolio Review and Analysis Report. 

(Draft summary of the meeting sponsored by the DHP, VA, NIH, and ED, and held on 

January 6–7, 2013, at Fort Detrick, Maryland.)

 Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of

Veterans, Service Members, and Their Families. IOM. 2013. Washington, DC: The 

National Academies Press.

 Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment 

Needs of Veterans, Service Members, and Their Families. IOM. 2010. Washington, DC: 

The National Academies Press.

 Substance Use Disorders in the U.S. Armed Forces. IOM. 2012. Washington, DC: The 

National Academies Press.

 Toward Precision Medicine: Building a Knowledge Network for Biomedical Research 

and a New Taxonomy of Disease. IOM. 2011. Washington, DC: The National 

Academies Press.
National Research Action Plan August 2013

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Appendix: The Executive Order

The White House

Office of the Press Secretary

For Immediate Release August 31, 2012 

Executive Order – Improving Access to Mental Health Services for 

Veterans, Service Members, and Military Families

EXECUTIVE ORDER

IMPROVING ACCESS TO MENTAL HEALTH SERVICES FOR VETERANS, SERVICE MEMBERS, AND 

MILITARY FAMILIES

By the authority vested in me as President by the Constitution and the laws of the United States of 

America, I hereby order as follows:

Section 1. Policy. Since September 11, 2001, more than two million service members have deployed to 

Iraq or Afghanistan. Long deployments and intense combat conditions require optimal support for the 

emotional and mental health needs of our service members and their families. The need for mental 

health services will only increase in the coming years as the Nation deals with the effects of more than a 

decade of conflict. Reiterating and expanding upon the commitment outlined in my Administration's 2011 

report, entitled "Strengthening Our Military Families," we have an obligation to evaluate our progress and 

continue to build an integrated network of support capable of providing effective mental health services 

for veterans, service members, and their families. Our public health approach must encompass the 

practices of disease prevention and the promotion of good health for all military populations throughout 

their lifespans, both within the health care systems of the Departments of Defense and Veterans Affairs 

and in local communities. Our efforts also must focus on both outreach to veterans and their families and 

the provision of high quality mental health treatment to those in need. Coordination between the 

Departments of Veterans Affairs and Defense during service members' transition to civilian life is 

essential to achieving these goals.

Ensuring that all veterans, service members (Active, Guard, and Reserve alike), and their families receive 

the support they deserve is a top priority for my Administration. As part of our ongoing efforts to improve 

all facets of military mental health, this order directs the Secretaries of Defense, Health and Human 

Services, Education, Veterans Affairs, and Homeland Security to expand suicide prevention strategies 

and take steps to meet the current and future demand for mental health and substance abuse treatment 

services for veterans, service members, and their families.

Sec. 2. Suicide Prevention. (a) By December 31, 2012, the Department of Veterans Affairs, in 

continued collaboration with the Department of Health and Human Services, shall expand the capacity of 

the Veterans Crisis Line by 50 percent to ensure that veterans have timely access, including by 
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telephone, text, or online chat, to qualified, caring responders who can help address immediate crises 

and direct veterans to appropriate care. Further, the Department of Veterans Affairs shall ensure that any 

veteran identifying him or herself as being in crisis connects with a mental health professional or trained 

mental health worker within 24 hours. The Department of Veterans Affairs also shall expand the number 

of mental health professionals who are available to see veterans beyond traditional business hours.

(b) The Departments of Veterans Affairs and Defense shall jointly develop and implement a national 

suicide prevention campaign focused on connecting veterans and service members to mental health 

services. This 12 month campaign, which shall begin on September 1, 2012, will focus on the positive 

benefits of seeking care and encourage veterans and service members to proactively reach out to 

support services.

(c) To provide the best mental health and substance abuse prevention, education, and outreach support 

to our military and their family members, the Department of Defense shall review all of its existing mental 

health and substance abuse prevention, education, and outreach programs across the military services 

and the Defense Health Program to identify the key program areas that produce the greatest impact on 

quality and outcomes, and rank programs within each of these program areas using metrics that assess 

their effectiveness. By the end of Fiscal Year 2014, existing program resources shall be realigned to 

ensure that highly ranked programs are implemented across all of the military services and less effective 

programs are replaced.

Sec. 3. Enhanced Partnerships Between the Department of Veterans Affairs and Community Providers.

(a) Within 180 days of the date of this order, in those service areas where the Department of Veterans 

Affairs has faced challenges in hiring and placing mental health service providers and continues to have 

unfilled vacancies or long wait times, the Departments of Veterans Affairs and Health and Human 

Services shall establish pilot projects whereby the Department of Veterans Affairs contracts or develops 

formal arrangements with community based providers, such as community mental health clinics, 

community health centers, substance abuse treatment facilities, and rural health clinics, to test the 

effectiveness of community partnerships in helping to meet the mental health needs of veterans in a 

timely way. Pilot sites shall ensure that consumers of community-based services continue to be 

integrated into the health care systems of the Department of Veterans Affairs. No fewer than 15 pilot 

projects shall be established.

(b) The Department of Veterans Affairs shall develop guidance for its medical centers and service 

networks that supports the use of community mental health services, including telehealth services and 

substance abuse services, where appropriate, to meet demand and facilitate access to care. This 

guidance shall include recommendations that medical centers and service networks use communitybased providers to help meet veterans' mental health needs where objective criteria, which the 

Department of Veterans Affairs shall define in the form of specific metrics, demonstrate such needs. 

Such objective criteria should include estimates of wait-times for needed care that exceed established 

targets.

(c) The Departments of Health and Human Services and Veterans Affairs shall develop a plan for a rural 

mental health recruitment initiative to promote opportunities for the Department of Veterans Affairs and 

rural communities to share mental health providers when demand is insufficient for either the Department 

of Veterans Affairs or the communities to independently support a full time provider.

Sec. 4. Expanded Department of Veterans Affairs Mental Health Services Staffing. The Secretary of 

Veterans Affairs shall, by December 31, 2013, hire and train 800 peer to peer counselors to empower 

veterans to support other veterans and help meet mental health care needs. In addition, the Secretary 

shall continue to use all appropriate tools, including collaborative arrangements with community based 

providers, pay setting authorities, loan repayment and scholarships, and partnerships with health care 

workforce training programs to accomplish the Department of Veterans Affairs' goal of recruiting, hiring, 

and placing 1,600 mental health professionals by June 30, 2013. The Department of Veterans Affairs 

also shall evaluate the reporting requirements associated with providing mental health services and 

reduce paperwork requirements where appropriate. In addition, the Department of Veterans Affairs shall 
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update its management performance evaluation system to link performance to meeting mental health 

service demand.

Sec. 5. Improved Research and Development. (a) The lack of full understanding of the underlying 

mechanisms of Post Traumatic Stress Disorder (PTSD), other mental health conditions, and Traumatic 

Brain Injury (TBI) has hampered progress in prevention, diagnosis, and treatment. In order to improve 

the coordination of agency research into these conditions and reduce the number of affected men and 

women through better prevention, diagnosis, and treatment, the Departments of Defense, Veterans 

Affairs, Health and Human Services, and Education, in coordination with the Office of Science and 

Technology Policy, shall establish a National Research Action Plan within 8 months of the date of this 

order.

(b) The National Research Action Plan shall include strategies to establish surrogate and clinically 

actionable biomarkers for early diagnosis and treatment effectiveness; develop improved diagnostic 

criteria for TBI; enhance our understanding of the mechanisms responsible for PTSD, related injuries, and 

neurological disorders following TBI; foster development of new treatments for these conditions based on 

a better understanding of the underlying mechanisms; improve data sharing between agencies and 

academic and industry researchers to accelerate progress and reduce redundant efforts without 

compromising privacy; and make better use of electronic health records to gain insight into the risk and 

mitigation of PTSD, TBI, and related injuries. In addition, the National Research Action Plan shall include 

strategies to support collaborative research to address suicide prevention.

(c) The Departments of Defense and Health and Human Services shall engage in a comprehensive 

longitudinal mental health study with an emphasis on PTSD, TBI, and related injuries to develop better 

prevention, diagnosis, and treatment options. Agencies shall continue ongoing collaborative research 

efforts, with an aim to enroll at least 100,000 service members by December 31, 2012, and include a plan 

for long term follow up with enrollees through a coordinated effort with the Department of Veterans 

Affairs.

Sec. 6. Military and Veterans Mental Health Interagency Task Force. There is established an 

Interagency Task Force on Military and Veterans Mental Health (Task Force), to be co chaired by the 

Secretaries of Defense, Veterans Affairs, and Health and Human Services, or their designated 

representatives.

(a) Membership. In addition to the Co-Chairs, the Task Force shall consist of representatives from:

(i) the Department of Education;

(ii) the Office of Management and Budget;

(iii) the Domestic Policy Council;

(iv) the National Security Staff;

(v) the Office of Science and Technology Policy;

(vi) the Office of National Drug Control Policy; and

(vii) such other executive departments, agencies, or offices as the Co-Chairs may designate.

A member agency of the Task Force shall designate a full time officer or employee of the Federal 

Government to perform the Task Force functions.

(b) Mission. Member agencies shall review relevant statutes, policies, and agency training and guidance 

to identify reforms and take actions that facilitate implementation of the strategies outlined in this order. 

Member agencies shall work collaboratively on these strategies and also create an inventory of mental 

health and substance abuse programs and activities to inform this work.
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(c) Functions.

(i) Not later than 180 days after the date of this order, the Task Force shall submit recommendations to 

the President on strategies to improve mental health and substance abuse treatment services for 

veterans, service members, and their families. Every year thereafter, the Task Force shall provide to the 

President a review of agency actions to enhance mental health and substance abuse treatment services 

for veterans, service members, and their families consistent with this order, as well as provide additional 

recommendations for action as appropriate. The Task Force shall define specific goals and metrics that 

will aid in measuring progress in improving mental health strategies. The Task Force will include cost 

analysis in the development of all recommendations, and will ensure any new requirements are supported 

within existing resources.

(ii) In addition to coordinating and reviewing agency efforts to enhance veteran and military mental 

health services pursuant to this order, the Task Force shall evaluate:

(1) agency efforts to improve care quality and ensure that the Departments of Defense and Veterans 

Affairs and community based mental health providers are trained in the most current evidence based 

methodologies for treating PTSD, TBI, depression, related mental health conditions, and substance 

abuse;

(2) agency efforts to improve awareness and reduce stigma for those needing to seek care; and

(3) agency research efforts to improve the prevention, diagnosis, and treatment of TBI, PTSD, and 

related injuries, and explore the need for an external research portfolio review.

(iii) In performing its functions, the Task Force shall consult with relevant nongovernmental experts and 

organizations as necessary.

Sec. 7. General Provisions. (a) This order shall be implemented consistent with applicable law and 

subject to the availability of appropriations.

(b) Nothing in this order shall be construed to impair or otherwise affect:

(i) the authority granted by law to an executive department or agency, or the head thereof; or

(ii) the functions of the Director of the Office of Management and Budget relating to budgetary, 

administrative, or legislative proposals.

(c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, 

enforceable at law or in equity by any party against the United States, its departments, agencies, or 

entities, its officers, employees, or agents, or any other person.

BARACK OBAMA

THE WHITE HOUSE,

August 31, 2012