Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans

Vanessa Williamson Policy Director, IAVA 202 544 7692 | [email protected]

For all media inquiries, contact our Communications Department: 212 982 9699 | [email protected]

Invisible WoundsPsychological and Neurological Injuries Confront a New Generation of Veterans

table of contents1 ExecutiveSummary

3 UnderstandingInvisible

Injuries

5 TheScopeoftheProblem

8 TheRippleEffectsof

UntreatedMentalHealth

Injuries

11 TheResponsetothe

MentalHealthCrisis

17 Conclusion

18 RecommendedReadingand

OnlineResources

19 Endnotes

1

issue report, january 2009

executive summaryAsearlyas1919,doctorsbegantotrackapsychologicalconditionamongcombat veterans ofWorldWar I known as “shell shock.”1 Veteransweresuffering from symptoms such as fatigue and anxiety, but science couldofferlittleinthewayofeffectivetreatment.Althoughthereremainsmuchmoretolearn,ourunderstandingofwar’sinvisiblewoundshasdramaticallyimproved. Thanks to modern screening and treatment, we have anunprecedentedopportunitytorespondimmediatelyandeffectivelytotheveterans’mentalhealthcrisis.

AmongIraqandAfghanistanveterans,ratesofpsychologicalandneurologicalinjuriesarehighandrising.Accordingtoa landmark2008RANDstudy,nearly20percentofIraqandAfghanistanveteransscreenpositiveforPostTraumaticStressDisorderordepression.2TroopsinIraqandAfghanistanare also facingneurological damage.TraumaticBrain Injury, orTBI, hasbecomethesignaturewoundoftheIraqWar.TheDepartmentofDefenseistrackingabout5,500troopswhohavesufferedTBIs,3butmanyveteranswithTBIsarenotbeingdiagnosed.AccordingtotheRANDstudy,about19percentoftroopssurveyedreportaprobableTBIduringdeployment.ThesemilderinjuriesaredifficulttoidentifyandareoftennoteasilydistinguishedfromPostTraumaticStressDisorderordepression.Infact,tensofthousandsoftroopsaresufferingfromeithertwoorallthreeoftheseconditions.

Although these statistics are troubling,wehave yet to see the full extentoftroops’psychologicalandneurologicalinjuries.Servicemembersarestilldeployingon longand repeatedcombat tours,which increase the riskofblast injuries andcombat stress.Ratesofmarital stress, substanceabuse,andsuicideareallincreasing.TheannualdivorcerateamongfemaleMarinesis9.2%,almostthreetimesthenationalaverage.DuringtheIraqWar,theArmysuicideratehasincreasedeveryyear,andtheratefor2008islikelytohita27-yearhigh.Untreatedpsychologicalinjuriesarealsoariskfactorforhomelessness;almost2,000IraqandAfghanistanveteranshavealreadybeenseen in theDepartment ofVeteransAffairs’ homeless outreachprogram.Becauseoftheselong-termeffects,theeconomiccostofthenewveterans’mentalhealthcrisishasbeenestimatedinthebillionsofdollars.4

VanessaWilliamsonandErinMulhall

2 invisible wounds | january 2009

PTSD, TBI and major depression are treatable conditions, particularly when the symptoms are recognized early.Unfortunately,manytroopsandveteranshavenotbeenscreenedforneurologicalandpsychologicalinjuriesanddonothaveaccesstohigh-qualityhealthcare.AccordingtoRAND,about57percentofthosereportingaprobableTBIhadnotbeenevaluatedforabraininjury,onlyabouthalfoftroopsscreeningpositiveforPTSDormajordepressionhadsoughthelp,andonlyhalfofthosetroopsreceived“minimallyadequatecare.”

TheDepartmentofDefense(DOD)hastakensignificantstepstoexpandresearchintopsychologicalandneurologicalinjuries.Butinadequatescreeningandshortagesofmentalhealthprofessionalsinthemilitaryarestillkeepingtroopsfromgettingthecaretheyneed.

Insteadofscreeningtroopsthroughaface-to-faceinterviewwithaqualifiedmentalhealthprofessional,theDODreliesonanineffectivesystemofpaperworktoconductmentalhealthevaluations.Asaresult,thereareseriousconcernsaboutthepsychologicalwellnessofmanydeployingtroops.InsurveysoftroopsredeployingtoIraq,20to40percent

stillsufferedsymptomsofpastconcussions,andamongtroopswhoexperiencehighlevelsofcombat,about12percentinIraqand17percentinAfghanistanaretakingprescriptionantidepressantsorsleepingmedications.

Accesstomentalhealthcareforthesetroopsisindangerouslyshortsupply.AccordingtothePentagon’sTaskForceonMentalHealth,themilitary’s“currentcomplementofmentalhealthprofessionalsiswoefullyinadequate.”Onlyabout1in3soldiersandMarineswhoscreenedpositiveforPTSDoncetheygothomereportedreceivingmentalhealthcareintheatre.MentalhealthsupportfortroopsinIraqisactuallydeclining;theratioofbehavioralhealthworkersdeployedtotroopsdeployeddroppedfrom1in387in2004to1in734in2007.

Effectivetreatmentisalsoscarceforthosewhohaveleftthemilitary.TheDepartmentofVeteransAffairs(VA)hasgivenpreliminarymentalhealthdiagnosestomorethan178,000IraqandAfghanistanveterans,almost45percentofnewveteranswhohadvisitedtheVAforanyreason.Intheearlyyearsofthewar,theveterans’mentalhealthsystemwassimplyoverwhelmedbytheinflux,andtheseproblemswereexacerbatedbydisastrousVAmistakes,includingafailuretoprojectthatveteransreturningfromthewarinIraqwouldincreasethedemandforVAmentalhealthcare.

Butinrecentyears,theVAhasmademajorimprovements.Withthehelpofamentalhealthbudgetthathasdoubledsince2001,theVAhastakenkeystepstoaidveteransinneedofmentalhealthcare,includingplacingmentalhealthprofessionalsinprimarycarefacilities,hiringthousandsofnewmentalhealthcareworkers,openingasuicidehotline,andscreeningallnewveteransseekinghealthcareataVAfacilityforTraumaticBrainInjury.Manyveterans,particularlythoseinruralareas,stillhavedifficultyaccessingVAcare,however.EnsuringtheseveteranshavereasonableaccesstoVAfacilities,andfullyintegratingthemanynewVAstaff,programsandcenterswillbeamajorchallengeforthenewSecretaryofVeteransAffairs.

No one comes home from war unchanged. But with early screening and adequate access to counseling, thepsychological and neurological effects of combat are treatable. In the military and in the veterans’ community,however, those suffering fromthe invisiblewoundsofwarare still falling through the cracks.Wemust takeactionnowtoprotectthisgenerationofcombatveteransfromthestrugglesfacedbythosereturningfromtheVietnamWar.

no one comes home from war unchanged. but with early screening and adequate access to counseling, the psychological and neurological effects of combat are treatable.

3 | issue report

understanding invisible injuriesTroops returning from combat may experience awide range of psychological responses. Many veteransexperiencesomelevelofsleeplessness,anxiety,irritability,intrusivememories, or feelings of isolation; the severityofthesesymptomsvarieswidelybetweenindividuals,anda single veteran’s symptoms usually fluctuate over time.If these symptoms become severe or persistent, they areoftendiagnosedaseitherPostTraumaticStressDisorderor major depression. In addition to these psychologicalinjuries, some troops who have suffered concussions intheatremaybeexperiencingtheeffectsofTraumaticBrainInjury, includingmoodchangesandcognitiveproblems.ManyveteransarecopingwithbothpsychologicalinjuriesandTBI,andtheeffectsofthesetwokindsofinjuriescancompoundeachother.

Psychological InjuriesThemostcommonpsychologicalinjuriesexperiencedbynewveteransarePostTraumaticStressDisorderandmajordepression. PostTraumatic StressDisorder, or PTSD, isapsychological condition thatoccurs after an extremelytraumatic or life-threatening event, and has symptomsincludingpersistentrecollectionsofthetrauma,heightenedalertness, nightmares, insomnia, and irritability.5 Majordepression can include persistent sadness or irritability,changes in sleep and appetite, difficulty concentrating,lackofinterest,andfeelingsofguiltorhopelessness.6

BothPTSDanddepressionaretreatable.7Psychotherapy,inwhichatherapisthelpsthepatientlearntothinkaboutthetraumawithoutexperiencingstress,isaproveneffectiveformoftreatment.Thisversionoftherapyoftenincludes“exposure”tothetraumainasafeway—eitherbyspeakingorwritingabout the trauma,or in somepromisingnewstudies,utilizingvirtualrealitytechnology.Therearealso

medicationsthatcanbehelpfulintreatingthesymptomsofdepressionorPTSD,althoughtheydonotaddresstherootcause,thetraumaitself.

Traumatic Brain Injury TraumaticBrainInjurycanbecausedbybulletsorshrapnelhittingtheheadorneck,butalsobytheblastfrommortarattacks or roadside bombs. Closed head wounds fromblasts, which can damage the brain without leaving anexternalmark,areespeciallyprevalentinIraq.About68%of themore than33,000wounded inactionexperiencedblast-relatedinjuries.8

As with psychological injuries, the effects of TBI vary.Symptoms can include emotional problems; vision,hearing,orspeechproblems;dizziness;sleepdisorders;ormemoryloss.Fortroopsexposedtomultipleblasts,TBIscanaccumulate,leadingtoseriousneurologicalproblemsthat are not immediately apparent after the injury. TBIalso increases the risk for other braindisorders, such asAlzheimer’s and Parkinson’s disease.9 Although the vastmajorityofTBIsaremildormoderate,10theeffectsofTBIlingerinabout15percentofcases.11

MuchoftheresearchintoTraumaticBrainInjuryinvolvesdirectheadtrauma,asiscommonlyseenincarcollisionsand sports accidents. The unique brain injuries causedbyexplosionsremainpoorlyunderstood.Therearethreerecognized kinds of blast-related TBI: diffuse axonalinjury(wherechangingpressureoverstretchesbraincells),contusion(bruisingofthebrain),andsubduralhemorrhage(thetearingofveinsaroundthebrain).12ButotherelementsoftheexplosionsinIraq,suchastheelectromagneticpulse,andthelight,heatandsoundfromtheblast“mayravagethebrain inwaysthathaven’t fullybeendocumented.”13Infact, there isnotcurrentlyareliablediagnostic test—suchas,forinstance,anMRI—thatreliablyidentifiesmildTBI.14Evenwiththemostadvancedequipment,theinjuryoftenremainsinvisible.15

TreatmentforTBIdependsontheseverityofthe injury.Severe TBIs,which are often accompanied by other life-threateningwounds,canrequirelong-termhospitalizationand rehabilitation. For those suffering from mild tomoderate Traumatic Brain Injury, rest and avoidanceof additional brain injuries are crucial. Rehabilitation,including retraining to regain lost skills and to improvememory,alsoaidsrecovery.16

many veterans are coping with both psychological injuries and tbi, and the effects of these two kinds of injuries can compound each other.

FIGHTING THe MeNTAL HeALTH STIGMA: IAVA TAKeS ACTION

The stigma associated with psychological injuries is the most serious hurdle to getting Iraq and Afghanistan

veterans the mental health care they need. About 50 percent of soldiers and Marines in Iraq who test posi-

tive for a psychological problem are concerned that they will be seen as weak by their fellow servicemembers,

and almost one in three of these troops worry about the effect of a mental health diagnosis on their career.17

Military culture plays a significant role in this stigma; 21 percent of soldiers screening positive for a mental

health problem said they avoided treatment because “my leaders discourage the use of mental health ser-

vices.”18 Because of these fears, those most in need of counseling will rarely seek it out.19

The Department of Defense has taken some steps to ensure that mental health treatment does not impede

career advancement within the military. In May 2008, the Defense Department announced it would remove

a well-known question on their security clearance forms, which asked if the applicant had sought mental

health care in the past seven years. According to the DOD, “Surveys have shown that troops feel if they

answer ‘yes’ to the question, they could jeopardize their security clearances, required for many occupations

in the military.”20 This change is a significant step in the right direction.

To help combat stigma and ease the readjustment for service-

members returning home from Iraq and Afghanistan, IAVA has

launched a historic national multi-year Public Service Announce-

ment (PSA) Campaign with the Ad Council. Joining such iconic

Ad Council PSA campaigns as “Only You Can Prevent Forest

Fires” and “Friends Don’t Let Friends Drive Drunk,” the ground-

breaking Veteran Support campaign will feature TV, radio, print,

and online PSAs, both in English and in Spanish. The ads direct troops and veterans to the first and only

online community exclusive to Iraq and Afghanistan

veterans, www.CommunityofVeterans.org. This innovative

website helps veterans connect with one another and link

them with comprehensive services, benefits assistance,

and mental health resources. A companion PSA effort

launching in 2009 will engage and support the families

and loved ones of Iraq and Afghanistan veterans, at

www.SupportYourVet.org.


5 | issue report

The Difficulty Distinguishing Mental Health Injuries Amajor challenge to treating troops and veteranswithTBI and/orPTSD is the fact that these two conditionsarehardtodistinguish.PTSDisstronglyassociatedwitha wide array of physical health problems,21 and a 2008studyintheNew England Journal of Medicinehassuggestedthatinfantrysoldiers’lastingsymptomslikefatigueandevendizziness“couldbeattributedlargelytoPTSDanddepression,ratherthanbraininjuriesthemselves.”22Asaresult,itisoftenunclearifaservicememberissufferingprimarily from biological damage to the brain or apsychologicalinjury.

Symptoms of PTSD

Repeatedly reliving the trauma in thoughts or nightmares

Strong startle response

Avoidance of reminders of the trauma

Emotional numbness, loss of interest

Difficulty feeling affectionate

Irritability

Increased aggressiveness, or even violence

Symptoms of Mild or Moderate TBI

Headache

Lightheadedness or dizziness

Blurred vision

Ringing in the ears

Bad taste in mouth

Fatigue or changes in sleep patterns

Behavioral or mood changes

Trouble with memory, concen - tration, attention, or thinking

Restlessness or agitation

PTSD And TBI Share Key Symptoms

Sources: National Institute of Mental Health, National Center for PTSD

the scope of the problemIntheaftermathoftheVietnamWar,theCongressionally-mandatedNationalVietnamVeteransReadjustmentstudyestimatedthatasmanyas31percentofmaleservicememberssuffered from PTSD at some point after their service.27TheprevalenceofpsychologicalandneurologicalinjuriesamongIraqandAfghanistanveteransisequivalenttothatofVietnamveterans,andmayinfactbehigher.

1 in 3 New Veterans Could Face Invisible InjuriesAtleasttwodozenstudieshaveanalyzedthementalhealthissues faced by Iraq and Afghanistan veterans.28 Thesestudieshave shownwide-ranging results, largelybecausetheydifferinthepopulationstheyincluded,thescreening

tool used to define PTSD and depression, and thelength of time after service that the studies

wereconducted.

While each of these studiesprovided some useful data, amore comprehensive study ofveterans’ psychological healthwasdesperatelyneeded.Inearly2008,theRANDCorporationcompleted a landmark inde-pendent study of Iraq andAfghanistan veterans that

offered the most thoroughinformation to date about rates

ofPTSD,TBI,andmajordepressionamong new veterans. According to

the RAND study, 14 percent of IraqandAfghanistan veterans screen positive for

PTSD, 14 percent screen positive formajor depression,and19percentofthosesurveyedreportedaprobableTBI.Manyscreenedpositiveformorethanonecondition.29

ThosewithoutanofficialdiagnosisofPTSDordepressionare not necessarily free from psychological distress.According to theVA’s SpecialCommittee on PTSD, 15-20percent of Iraq andAfghanistan veterans are “at riskforsignificantsymptomsshortoffulldiagnosisbutsevereenough to cause significant functional impairment.”30AccordingtotheDole-ShalalaCommission,appointedbyPresidentBushtoexaminetheproblemsfacingwoundedtroops after the scandal at Walter Reed ArmyMedical

TBI and PTSD may, in fact, compound one another’seffects.Atleastonestudysuggeststhatcombatstresscanhaveavisible,physicaleffectonthebrain,23andveteranswithPTSDwhowereexposedtoblastsare“morelikelytohavelingeringattentiondeficits.”24SoldierswhoreportedaninjurythatcausedthemtoloseconsciousnessarenearlythreetimesaslikelytomeetcriteriaforPTSD.25DepressionisalsocommonlyassociatedwithTBI.26Moreresearchisrequired to better understand the relationship betweenbraininjuryandpsychologicalproblems.

Shared Symptoms

Mood Changes

Difficulty concentrating

Sleep problems


Centerin2007,“56percentoftheactiveduty,60percentofreservecomponent,and76percentofretired/separatedservice members say they have reported mental healthsymptomstoahealthcareprovider.”31Thus,whilemostveterans do not have diagnosable PTSD or depression,manyarestrugglingwithsomeof itssymptoms,suchassleeplessnessoranxiety.

Ratesofmentalhealthinjuriesarestillincreasing,ofcourse,becausetheconflictsinIraqandAfghanistanareongoing.Moreover,itcantakemonthsoryearsforinjuriestorevealthemselves.32 In a studyof 80,000 troops’mental healthevaluations,17.2percentofsoldiersscreenedpositiveforamentalhealthproblemimmediatelyafterreturningfromcombat.Sixmonthsafter thesetroopscamehome, theirrateofmentalhealthproblemswas30.1percent.33

Source: Rand Corporation

PTSD, Depression & TBI: 5.5%

Total PTSD: 14%

Total Depression: 14%

Total TBI: 19%

PTSD & TBI: 1.1%

TBI only: 12.2%

TBI and Depression: 0.7%

Depression only: 4%

PTSD & depression: 3.6%

PTSD only: 3.6%

No condition: 69.3%

Overlapping Invisible Injuries:30% of Iraq and Afghanistan Veterans Screen Positive

for Probable PTSD, TBI, or Major Depression

Rates of mental health injuries are increasing not onlybecause of the time it takes for troops’ psychologicalinjuriestomanifest,however.Longertoursandmultipledeployments are also contributing to higher rates ofmentalhealthinjuries.

Long Tours and Multiple Deployments Exacerbate InjuriesSinceSeptember11,2001,troopshaveregularlyhadtheirtoursextended34andasofJune2008,morethan638,000troops have deployed more than once.35 From spring2007 to summer 2008, active-duty Army combat tourswere officially increased from 12 to 15 months,36 witha guarantee of a year at home between tours. Combattourswere reduced to 12months inAugust 2008,37 butthe deployment schedule still does not allow for therecommendedrestbetweentours,knownas“dwelltime.”

According to the Army’s Mental Health Advisory Team(MHAT), soldiers deployed to Iraq for more than sixmonths,ordeployedmorethanonce,aremuchmorelikelyto be diagnosedwith psychological injuries.38 Even aftergettinghome,thosewhohaddeployedforlongerperiodsarestillathigherriskforPTSD.39

The MHAT recommended increasing troops’ rest timeto 18-36 months, or decreasing deployment length.40

Eventually,theoperationaltempoinIraqandAfghanistanmaychange,given thepassageof theU.S.-IraqStatusofForcesAgreementinNovember2008,41andthepotentialforwarpolicychangeunder theObamaAdministration.Butintheshort-term,multipletoursandinadequatedwelltimewilllikelycontinuetobethenormformanytroopsdeployingtoIraqandAfghanistan.

soldiers deployed to Iraq for more than six months, or deployed more than once, are much more likely to be diagnosed with psychological injuries.

7 | issue report

Certain Groups at Higher RiskSome troops are at higher risk for psychological andneurological injuries, including the combat-wounded,youngertroops,NationalGuardsmenandReservists.

Unsurprisingly,extensiveexposuretocombatisaleadingrisk factor for psychological injury.42 Young troops,who tend to see more combat,43 have higher rates ofpsychological injuries.44 The rates of TBI and PTSDare also higher among hospitalized troops. Accordingto a 2006 study of over 600 hospitalized battle-injuredsoldiers,“earlyseverityofphysicalproblemswasstronglyassociatedwithlaterPTSDordepression.”45AtLandstuhlMedicalCenterinGermany,thefirst-stophospitalforwar-woundedevacueesofIraqandAfghanistan,23percentofpatientsscreenedforaTBItestedpositive.46AtWalterReedArmyMedicalCenterinWashington,D.C.,30percentofwounded troops have some level of TBI.47 Overall, onequarter of troops evacuated from Iraq and Afghanistansufferedfromheadandneckinjuries.48Troopsfacingfinancial49orfamily50troubleswhiledeployedhave higher rates of PTSD. Because these problems arecommon among troops in the reserve component, and

Multiple Deployments Increase Combat Stress

Source: Mental Health Advisory Team V. Adjusted Percents for Male NCOs in Theater 9 Months

First Deployment

SecondDeployment

Third/FourthDeployment

Perc

ent

Scre

enin

g Po

siti

ve f

or

any

Men

tal H

ealt

h P

robl

ems

0%

5%

10%

15%

20%

25%

30%

12

18

27

Longer Tours Increase Soldiers’ Mental Health Problems

Source: Mental Health Advisory Team IV Final Report

Deployed fewer than 6 months

Deployed morethan 6 months

Perc

ent

Scre

enin

g Po

siti

ve f

or

any

Men

tal H

ealt

h P

robl

ems

0%

5%

10%

15%

20%

25%

15

22

perhapsbecause they lack the social safetynetofactive-dutymilitarylife,NationalGuardsmenandReservistsarereportinghigherratesofPTSD.51Thosewhohaveleftthemilitary,andfacesimilarchallengesofreintegratingintocivilianlivesasreservecomponenttroops,alsohavehigherratesofPTSD.52

Although women are technically excluded from combatroles, many female troops have seen combat in Iraqand Afghanistan, and are suffering from PTSD orother psychological injuries as a result. Their ratesof psychological injury appear to be similar to ratesamong men.53 One unique factor in the psychologicalinjuries sufferedby female troops is the threatof sexual

overall, one quarter of troops evacuated from iraq and afghanistan suffered from head and neck injuries.

invisible wounds | january 2009

harassmentandassault.54MilitarySexualTraumaleadstoa59percenthigherriskformentalhealthproblems.55For more information on issues affecting women in the military, see the forthcoming IAVA Issue Report, “Women Warriors: Unique Challenges Facing Female Troops and Veterans.”

the ripple effects of untreated mental health injuries“StressandstressinjuriessuchasPTSDmaycontributetomisconduct inservicemembersandveterans,”accordingto Captain Bill Nash, an expert in the Marine CorpsCombat/Operational Stress Control program.56 Militarystudies suggest that troopswho test positive formentalhealthproblemsaretwiceaslikelyto“engageinunethicalbehavior,” such as insultingor injuringnon-combatantsor destroying property unnecessarily.57 The rates ofmental health problems and substance abuse are highamong Marines discharged under less-than-honorablecircumstances.58Respondingtotheserevelations,theArmyandMarineshaveboostedtraininginbattlefieldethicsandtheRulesofEngagement.59

Are Psychologically Wounded Troops Getting

Discharged Without Benefits?

Between 2001 and 2007, 22,500 troops60 were

discharged from the military with a ‘personality

disorder’. Personality disorder discharges have

also increased by 40 percent in the Army since

the invasion of Iraq. Discharges for misconduct

have increased more than 20 percent, and dis-

charges for drug abuse doubled.61 In some of

these cases, the servicemember may have had

PTSD, Traumatic Brain Injury, or another com-

bat-related mental health injury, and felt “pres-

sured by commanders and peers to accept an

administrative discharge”62 rather than continue

to fight for a medical discharge. According to

Congressman Bob Filner, Chairman of the House

VA Committee, “My concern is that this coun-

try is… ignoring the legitimate claims of PTSD in

favor of the time and money saving diagnosis of

Personality Disorder.”63

The issues resulting from untreated psychologicalinjuries or traumatic brain injuries do not end when aservicemember returnshome.PTSDcanbecrippling forveterans,andcanalsoexactaseveretollontheirfamiliesandcommunities.AccordingtotheInstituteofMedicine,deploymenttoawarzoneincreasestheriskofmaritalandfamilyconflict,alcoholabuse,andevensuicide.64TBIsalsocanhavealongtermimpact;inabout10percentofcases,aconcussioncauses“problemssevereenoughtointerferewithdailylifeandwork.”65

Family ProblemsThe Iraqwarhasputa tremendousburdennotonlyonservicemembers,butalsoonmilitaryfamilies.MorethanhalfofthosewhohaveservedinIraqorAfghanistanaremarried,66 and marital strain is a significant problem.Troops in Iraq are expressing growing concern aboutinfidelity,andmanymoreareconsideringdivorce.67

DespiteaspikeindivorcesatthestartoftheIraqWar,68today’s divorce rates in the active-duty military are notdramatically higher than either the national divorcerate or the divorce rate themilitary had previously seenin peacetime. A RAND study entitled “Families UnderStress”69concludedthatratesofmilitarydivorcein2005hadonlyrisentothelevelsobservedin1996.Inthepastthreeyears,divorcerateshavecontinuedtorise,reaching3.5percentintheArmyin2008—approximatelythesameasthenationaldivorceratefor2005(thelastyearforwhichnationaldataisavailable).70

When military divorce data is broken down by gender,however, a very troubling pattern emerges.Marriages offemaletroopsarefailingatalmostthreetimestherateofmaleservicemembers.71

Femaleservicemembersarebearingthebruntofmilitarydivorces. Infact, theoverallrise indivorceratesbetween2005 and 2008 primarily reflects a rise in the femaleservicemembers’ divorce rates. Between 2005 and 2008,Army women saw an increase in their divorce rate of 2

8

female servicemembers are bear- ing the brunt of military divorces.

9 | issue report

percent,comparedto.1percentformen.IntheMarines,thedivorceratehasjumped3percentforwomen,comparedwith.5percentformen.72

Itiscrucialtounderstandthatmuchofthedataonmilitarydivorce includesonly troops who are still serving —not theapproximately 945,000 Iraq and Afghanistan veteranswhohavelefttheactive-dutymilitary.73Historically,datashow that veterans who suffer from PTSD are likely toexperience“difficultiesmaintainingemotionalintimacy,”andhavea“greatlyelevatedriskofdivorce.”74Acompleteunderstanding of the link between combat deploymentsand divorce requires further study of marriage patternsamongIraqandAfghanistanveteranswhohavecompletedtheirmilitaryservice.

Children of deployed troops are also suffering theconsequencesof longdeployments.More than2millionAmericanchildrenhaveexperiencedaparent’sdeploymenttoIraqorAfghanistan,75atleast19,000childrenhavehadaparentwoundedinaction,and2,200childrenhavelosta parent in Afghanistan or Iraq.76 Children of deployedparents, even those as young as three, have been shownto have increased behavioral health problems comparedwith childrenwithout adeployedparent.77Deployments

mayalsoleadtoanincreaseintheratesofchildabuseinmilitaryfamilies.78

Family problems can continue long after deploymentsend,however.InastudyofIraqandAfghanistanveteransreferred to VA specialty care for a behavioral healthevaluation, two-thirds ofmarried or cohabiting veteransreportedsomekindoffamilyoradjustmentproblem.7922percentoftheseveteranswereconcernedthattheirchildren“did not act warmly” towards them or “were afraid” ofthem. Among those veterans with current or recently-separatedpartners,56percentreportedconflictsinvolving“shouting,pushingor shoving.”80Thesenumbers shouldnot be seen as representative of the veterans’ populationasawhole,butamongveteranswithseverementalhealthissues,familyviolenceisaseriousconcern.81

Substance AbuseAnothereffectoftroops’mentalhealthinjurieshasbeenanincreaseindrugandalcoholabuse.82Unfortunately,troopsmisusingalcoholareoftennotgettingthetreatmenttheyneed.Ontheirpost-deploymenthealthassessmentforms,soldiers report alcohol problems at a rate of almost 12percent.Shockingly,only0.2percentofthesetroopswerereferredtotreatment.83Onelikelyreasonthattroopsarenotreferredtotreatmentisthatalcoholtreatmentisnotconfidential,evenifitissoughtoutbytheservicemember.The military’s current policy ensures that “accessingalcohol treatment triggers automatic involvement of asoldier’s commander,” which can have serious “negativecareerramifications.”84Accordingtothemilitary’sMentalHealthTaskForce,“Concernsthatself-identificationwillimpedecareeradvancement…mayleadservicememberstoavoidneededcare,evenatearlystageswhenproblemsaremost remediable.”85 This policy of automatic commandnotificationremainsperhapsthemostsignificantbarriertotroops’receivingalcoholabusetreatment.

Female Troops Face Much Higher Divorce Rates

Source: Department of Defense data, FY2008, via the Associated Press

Army

Men Women Men Women

Marines

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

2.9

8.5

2.8

9.2

more than 2 million American children have experienced a parent’s deployment to Iraq or Afghanistan.


Outsideofthemilitary,veteransarealsostrugglingwithdrug and alcohol dependence. At least 7,400 Iraq andAfghanistanveteranshavebeentreatedataVAhospitalfordrugaddiction,27,000newveteranshavebeendiagnosedwith “nondependent use of drugs,” meaning excessiveor improper drug use without a full diagnosis of drugdependence,and16,200havebeendiagnosedwithAlcoholDependence Syndrome.86 These numbers are only thetipof the iceberg;many veteransdonot turn to theVAforhelpcopingwithsubstanceabuse, insteadrelyingonprivateprogramsoravoidingtreatmentaltogether.

HomelessnessVeterans are far more likely to experience homelessnessthantheircivilianpeers,andratesofmentalillnessamongthehomelessareextremelyhigh.In2007,about154,000veteranswerehomelessonanygivennight.8745percentofhomelessveteranshaveapsychological illness,andmorethan 70 percent suffer from substance abuse.88 Already,thousands of Iraq and Afghanistan veterans are joiningveteransofothergenerationsonthestreetsandinshelters.Preliminary data from the VA suggests that Iraq andAfghanistanveteransalreadymakeup1.8percentof thehomeless veteran population,89 and 1,819 homeless IraqandAfghanistanveteranswereseenthroughVAhomelessoutreachprogramsbetweenFY2005andFY2007.90

Studieshavenotfound,however,thatPostTraumaticStressDisorder alone increases veterans’ risk of homelessness.91Rather, it is thepersonalandeconomicconsequencesofuntreated PTSD,92 including social isolation and violentbehavior,93thatincreasetheriskofhomelessness.Iftoday’sveteranscontinuetolackaccesstoqualitymentalhealthcare, the consequences of untreated PTSD will surelyresultinanincreaseinthenumberofIraqandAfghanistanveteransendinguphomeless.

SuicideUntreated psychological injuries have also pushed bothtroops and veterans to take their own lives. Since thestartofthewar,therehavebeenatotalof196confirmedmilitarysuicidesinIraqandAfghanistan,94andfarmoreamongthemilitaryandveteranpopulationasawhole.

Thesuiciderateforsoldiersonactive-dutyhasrisen,feedingconcerns about whether troops showing signs of mentalhealth injuries after their first deployment are being sentback to Iraq orAfghanistanwithout adequate treatment.Rates of suicides in the Army have been increasing everyyear since 2004, and Army suicides in 2008 are on trackto surpass theprior year’s record rate,with62confirmedsuicides and 31 apparent suicides under investigation bytheendofAugust.95 Ifcurrent trendscontinue, theArmysuicideratecouldsurpasstheequivalentcivilianrateof19.5per100,000.96Theincreaseisespeciallytroublinggiventhatmilitary recruits are screened formental healthproblemswhentheyjointhemilitary.

Army suicides have increased every year since 2004, reaching a 26 year high in 2007. As of August, the 2008 number was likely to be even higher. Source: Associated Press

2004

Confirmed Apparent Projected

2005 2006 2007 20080

20

40

60

80

100

120

140

Army Suicides Increasing

67

87

102

115

62

31about 154,000 veterans are homeless on any given night, 45 percent of homeless veterans have a psycho logical illness, and more than 70 percent suffer from substance abuse.

While the rate ofmilitary suicides is closelymonitored,thereisnoagencyorregistrykeepingtrackofsuicideratesamong veterans who have completed their service. As aresult,althoughanecdotalevidencesuggestsitisagrowingproblem, suicide among Iraq and Afghanistan veteransisverydifficult toestimate.AccordingtotheVArecordsfrom2002to2006,atleast254IraqandAfghanistan-eraveterans have killed themselves, but this number is farfromdefinitive.97

For veterans of all generations, data on suicide aretroubling.TheVAestimatesthateachyear,6,500veteranscommit suicide.98 Veterans make up only 13 percent oftheU.S.population,but theyaccount forapproximately20percentofthesuicides.99Maleveteransaremorethantwice as likely todieby suicide asmenwithnomilitaryservice100 and veterans with PTSD are more than threetimes as likely todie by suicide as their civilianpeers.101Younger veterans102 andwhite, college-educated veteranslivinginruralareas103areatthehighestrisk.

the response to the mental health crisis The mental health care systems in the Department ofDefenseand theDepartmentofVeteransAffairs includethousandsofdedicatedmentalhealthprofessionals, butthebureaucracieshavebeeninexcusablyslowtorespondtothegrowingmentalhealthcrisis.RecentinitiativeswithinDODandVAarebeginningtoaddresssomeoftheneedsofreturningtroopsandveterans,butfartoomanytroopsandveteransarestillfallingthroughthecracks.

According to the American Psychological Association,there are “significant barriers to receivingmental healthcare in theDepartmentofDefense (DOD)andVeteransAffairs(VA)system.”104First,boththeDODandtheVAarepassivesystems,leavingtheburdenontheservicememberor veteran to self-diagnose and seek out care. Second,there are gaps in the availability of services, both in themilitary and theVA system.Mentalhealthprofessionalsareoftenunavailabletotroops,especiallythoseincombattheatre,andtoveterans,particularlythoseinruralareas.Finally,evenfortroopswhohavesoughtoutcareandhave

IN PerSON: JOSHuA Lee OMVIG (1983-2005)

On December 22, 2005, just a few months after returning from an eleven-

month tour in Iraq, 22-year-old Army Reservist Joshua Omvig took his

own life. Omvig, who was suffering from Post Traumatic Stress Disorder,

experienced nightmares, depression, mood changes, and other symptoms

associated with combat stress. Omvig refused to seek help, however,

because he believed that receiving a mental health diagnosis would dam-

age his career in the military and his dream of becoming a police officer.

After his suicide, Joshua’s parents, Randy and Ellen Omvig, devoted

themselves to the passage of a new piece of suicide prevention legisla-

tion. The legislation included a mandate for a new campaign to de-stig-

matize mental health treatment, more training for VA workers in suicide

prevention, and a 24-hour suicide hotline for troops. In November 2007,

through the tireless work of the Omvig family and veterans groups includ-

ing IAVA, the Joshua Omvig Suicide Prevention Act was signed into law.

This legislation is a great first step to ensuring that all veterans of Iraq and

Afghanistan can get mental health treatment before it is too late.

| issue report 11


reachedamentalhealthprofessional, thequalityof carecanbeinconsistent.RAND’s Invisible Wounds of Warstudyhighlightedtheeffectsofthesegapsinserviceandsupportforreturningtroopsandveterans:105

• “OfthosereportingaprobableTBI,57percenthad not beenevaluatedbyaphysicianforbraininjury.”

• “Abouthalf(53percent)ofthosewhometthecriteriaforcurrentPTSDormajordepressionhadsoughthelpfromaphysicianormentalhealthproviderforamentalhealthprobleminthepastyear.”

• “Ofthosewhohaveamentaldisorderandalsosoughtmedical care for that problem, just over half receivedminimallyadequatetreatment.”

Until these systemic problems are resolved, troopsand veterans will continue to struggle with untreatedpsychologicalandneurologicalinjuries.

Department of Defense Still Leaves Troops at RiskThe military has made significant efforts to improvemental health treatment, including the launch of theDefenseCentersofExcellenceforPsychologicalHealthandTraumaticBrainInjury(DCoE),whichunifiedanumberofseparateDODmentalhealthandTBIinitiativesunderoneumbrella organization.106 The nonprofit Intrepid FallenHeroesFund is constructinganew$70million researchandeducationalcenterfortheDCoE,calledtheNationalIntrepid Center of Excellence for psychological healthand traumatic brain injury.107 This facility offers greatpotentialtoimprovetheunderstandingofandtreatmentforpsychologicalandneurologicalinjuries.

Nevertheless,manytroopsandveteransarestillstrugglingto access mental health services.108 The two primaryroadblocks to quality care are the shortages of trainedmental health care staff, and the inadequate screeningprocess used to recognize and treat troops at risk formentalhealthinjuries.

Staffing Shortages and Insufficient TrainingAccordingtothePentagon’sTaskForceonMentalHealth(MHTF), “the current complement of mental healthprofessionals is woefully inadequate” to providementalhealthcarefortoday’smilitary.109Thenumberoflicensedpsychologists in themilitary has dropped bymore than20percent in recent years.110TheArmy is attempting to

recruitmorementalhealthprofessionals,buthiringhasbeen slow.111Support available to troops in Iraq is alsodeclining;theratioofbehavioralhealthworkersdeployedtotroopsdeployeddroppedfrom1in387112in2004to1in734in2007.113

Unsurprisingly,almostoneinthreesoldiersinIraqsayitisdifficulttogettoamentalhealthspecialist.InAfghanistan,accesstotreatmentisalsolimited;ittakesanaverageof40hoursforapsychologisttovisitasoldierwhoneedsmentalhealth care.114 Predictably, the problemof access is evenmoreseverefortroopsstationedatremoteoutposts.115Asaresult,manytroopsneedingcaresimplydonotreceiveit.Onlyabout1 in3soldiersandMarineswhoscreenedpositiveforPTSDoncetheygothomereportedreceivingmentalhealthcareintheatre.116

Inaddition,qualityofmentalhealthcarevariesdramaticallybetween military bases.117 Unfortunately, “relatively fewhigh-qualityprogramsexist”anywhereintheDODsystem,according to the American Psychological Association.118There isalso“inexplicablevariation”betweenthemilitaryservicesintermsofwhatkindsofmentalhealthprofessionalstheyemploy,accordingtotheMHTF.119

Poor Evaluation of Combat TroopsAccording to a June 2007 Government AccountabilityOffice (GAO) report, the DOD cannot ensure thatservicemembersarementallyfittodeploy,noraccuratelyassesstroops’mentalhealthconditionwhentheyreturn.120Recently, the DOD has taken steps to expand pre- andpost-deploymentscreening,particularlyforTBI,buttherearestillsignificantgapsintroops’physical,psychologicalandneurologicalevaluations.

Concerns over DOD screening have been stoked by themountingevidencethatsometroopswhohavedeployedagainarestillcopingwiththeeffectsofanearliercombat

only about 1 in 3 soldiers and marines who screened positive for ptsd once they got home reported receiving mental health care in theatre.

13 | issue report 13

tour. In surveys of troops redeploying to Iraq, 20 to40 percent “still had symptoms of past concussions,including headaches, sleep problems, depression, andmemory difficulties.”121 In addition,many troops in thecombatzonearereliantonantidepressants.Amongtroopswhoexperiencehighlevelsofcombat,about12percentinIraqand17percentinAfghanistanaretakingprescriptionantidepressantsorsleepingmedication,andprescriptionsfor these medications are increasing, according to theArmy’sMental Health Advisory Team report.122 Currentmilitary regulationsdonotprevent troopsusing certainantidepressantsfromdeployingtoIraqorAfghanistan.123

ThesinglebiggestshortfallintheDODscreeningprocessis the lack of a mandatory in-person mental healthassessment of troops deploying to or returning fromcombat.Expertsagreethataface-to-faceinterviewwithamental health professional is the optimum approach toPTSDdiagnosis.124Buttheonlymandatorypsychologicalscreeningtroopscurrentlyreceive isapileofpaperwork,thepre-andpost-deploymenthealthforms.125

Thereareanumberofproblemswiththepre-deploymentscreening process, including inconsistencies in policiesgoverningthereviewofservicemembers’medicalrecords.BecauseofcontradictorylanguagewithinDODregulations,someservicemembersmaynothavetheirmedicalrecordsreviewedbeforebeingapprovedfordeployment.126

Therearealsosignificantquestionsaboutpre-deploymentTBI screening. In July 2008, the DOD initiated a newcomputer-basedpre-deploymentTBIscreeningtest,usedby 117,000 servicemembers as of December 2008.127 Itis unclear, however, if every deploying servicemember iscurrently receiving the TBI test.Moreover, a poor scoreontheTBItest,calledtheAutomatedNeuropsychologicalAssessment Metrics or ANAM, does not automaticallyprecludeaservicememberfromdeploying,128andalthoughpre-deploymenttestingisintendedtoidentifythebaselinementalfunctioningofeachdeployingservicemember,the

DODhasnotmandatedthatmilitaryunitskeeptheresultsofthesetestsavailableforcomparisonifaservicememberis injured.129 Although widespread TBI testing is clearlyastepintherightdirection,itdoesnotcurrentlyensurethattroopstestingpositiveforTBI,eitherbeforeorafterdeployment,aregettingthesupporttheyneed.

TheDODhasalsobeencriticizedfor“poordocumentationof blast exposures” in theatre. According to the Army’sMentalHealthAdvisoryTeam, “11.2 percent of Soldiersmetthescreeningcriteriaformildtraumaticbraininjuries.Lessthanhalfofthese(45.9%)reportedbeingevaluatedforaconcussion.”130Withoutadequateevaluationintheatre,thereisnowaytoassurethattroopswhohaveexperiencedaTBIareprotectedfromre-injury.

Evenaftertroopsreturnfromcombat,thescreeningtheyreceiveisinadequate.Immediatelyaftertheirtour,troopsmust fill out the Post Deployment Health Assessment(PDHA). Six months later, servicemembers complete asecondform,thePostDeploymentHealthRe-Assessment(PDHRA). The forms are later reviewed by health careproviderswhoaretypicallynotmentalhealthprofessionals.Theseproviders contact servicemembers inpersonor byphone, and are responsible for giving referrals to thosetroopstheydeemtobeatseriousmentalhealthrisk.131

The PDHA/PDHRA system was only universallyimplemented years after the current wars started —questions onTBIwere only added in January 2008132—and their effectiveness is questionable. A 2006 study133ledbyArmyCol.CharlesHoge,MD,at theWalterReedArmy InstituteofResearch, lookedat the resultsof IraqveteransPDHAs.Only19percentoftroopsreturningfromIraqself-reportedamentalhealthproblem.But35percentofthosetroopsactuallysoughtmentalhealthcareintheyearfollowingdeployment.134IfthePDHAisintendedtocorrectlyidentifytroopswhowillneedmentalhealthcare,itsimplydoesnotwork.

the dod has also been criticized for “poor documentation of blast exposures” in theatre.

in surveys of troops redeploying to iraq, 20 to 40 percent still had symptoms of past concussions.


A follow-up study in2007, alsopublished in the Journal of the American Medical Association, concluded: “Surveystakenimmediatelyonreturnfromdeploymentsubstantiallyunderestimatethementalhealthburden.”135

Although the PDHRA,which troops fill out sixmonthsafterdeployment,ismorelikelytoidentifymentalhealthinjuries,136itsoveralleffectivenessisalsodubious,becausethere are serious disincentives for returning troops todisclosetheirpsychologicalinjuries.

Again,amajorobstacle isthestigmaattachedtomentalhealth care. Admitting a psychological wound can alsoslowtroops’reunificationwiththeirfamilyafteracombattour,137 andmany troops are concerned about the effectofamentalhealthdiagnosisontheircareer.138Andwithgoodreason.AccordingtotheNationalAllianceonMentalIllness, “One in three individuals with severe mentalillness has been turned down for a job for which he orshewasqualifiedbecauseofapsychiatriclabel.”139Givensuchobviousdisincentives,itiscommonknowledgethattroopsdonotfill out their assessments accurately.Even

theVA’sownSpecialCommitteeonPostTraumaticStressDisorderadmits,“Nooneseemstoexpectthemtoanswertruthfully.”140

Moreover, those who do ask for help may not actuallyreceiveit.Foryears,thereferralprocessforpsychologicalcounselinghasbeenrifewithinconsistencies.141Particularlyin the case of National Guardsmen and Reservists, it isunclearwhethertroopswhoreceivereferralsthroughthePDHA/PDHRAactuallygetmentalhealthcare.142

Hundreds of Thousands of New Veterans Flood VA SystemThe Veterans Health Administration runs 153 veterans’hospitalsnationwide,aswellashundredsofcommunityclinicsandVetCenters,andserves5.5millionpatientsayear.143AsofAugust2008,42percentofeligibleIraqandAfghanistanveterans,ormore than400,000people,hadenrolledintheVAhealthcaresystem,whichisconsideredby experts to be “equivalent to, or better than, care inanyprivateorpublichealth-caresystem”144intheUnitedStates. Enrollment shouldbe expected to grow, andnotonlybecausetroopsarecontinuingtoreturnfromIraqandAfghanistan.Withthecurrentdownturnintheeconomy,new veterans coping with unemployment or lower-wagejobsmayturntotheVA,ratherthanacivilianemployers’health insurance. While the VA provides excellent care,increasing demandmay further limit veterans’ access tothesystem.

TheVAhasalreadybeenfloodedbynewveteransseekingcare for psychological injuries. More than 178,000 Iraqand Afghanistan veterans seen at the VA were given apreliminarydiagnosisofamentalhealthproblem,about45percentofthenewveteranswhovisitedtheVAforanyreason.Afteraseriesofdisastrousmisstepsintheirearlyresponse to the Iraq war, the VA has made significantprogress in responding to the needs of new veterans.AccordingtoRAND,theVA“providesapromisingmodelofqualityimprovementinmentalhealthcareforDOD.”145However,additionalactionmustbetakentopreparetheVA for the likely surge in IraqandAfghanistanveteransseekingcareinthecomingyears.

PDHA Fails to Detects Vets’ Mental Health Needs

About 42,000 troops self-reported a mental health injury on their PDHA mental health assessment, but more than 71,000 troops actually sought services in the following year. Source: Hoge 2006.

Mental Health Issue Reported on PDHA

Sought Mental Health Services Within One Year

16.1

0

10000

20000

30000

40000

50000

60000

70000

80000

42,506

71,036 71,036

VA MISTAKeS LeAVe VeTerANS WITHOuT ADeQuATe CAre

When veterans began returning home from Iraq and Afghanistan, the VA was caught unprepared, with a

serious shortage of staff and an exceedingly inadequate budget.

The workforce shortages at VA clinics and hospitals were apparent early. By October 2006, almost one-

third of Vet Centers, the VA’s walk-in counseling centers for combat veterans, admitted they needed more

staff.146 As a result of shortages of mental health professionals, veterans seeking mental health care in 2007

got about one-third fewer visits with VA specialists, compared to ten years earlier.147 Even a VA Deputy

Undersecretary admitted that waiting lists rendered mental health and substance abuse care “virtually inac-

cessible” at some clinics.148

Despite this overwhelming evidence, then-VA Secretary Jim Nicholson testified in 2007 that the VA is “ade-

quately staffed.”149 This kind of massive miscalculation typified the early top-level VA response to the mental

health needs of new veterans, and dramatically worsened the mental health crisis. In February 2006, the VA

claimed it was expecting only 2,900 new veteran PTSD cases in FY 2006. The actual number was roughly

six times that: 17,827.150 As a result, the VA failed to plan for the incoming veterans and failed to spend the

money it was allotted for mental health care. In 2005, the VA failed to allocate $12 million of a $100 million

earmark for mental health care. The VA also did not ensure that funds spent were actually used for mental

health initiatives. The following year, about $88 million of a $200 million earmark for mental health initia-

tives was not spent, and again the VA did not track the use of allocated funds.151

Recently, the VA also has come under fire for failing to release accurate information on rates of veterans’

suicides and downplaying the risk of suicide among veterans. Internal VA emails have shown that, although

the VA was publicly admitting only 790 veteran suicide attempts annually, their suicide coordinators were

seeing more than 1,000 suicide attempts a month.152

A primary responsibility of the new VA Secretary must be to ensure that the VA accurately predicts the needs

of returning veterans and that the Department prioritizes patient care, not public relations. These grievous

mistakes must be prevented in the future.

15 | issue report

15


Massive Budget Increases Help Fund New VA InitiativesIn thepast twoyears, theVAhasbecomemoreeffectiveincopingwiththeneedsofIraqandAfghanistanveterans—inlargepartbecausetheVAmentalhealthbudgethasdoubled.ThementalhealthbudgetoftheVAwasabout$2billion in2001.Thanks to the concertedadvocacyofveterans’ organizations, including IAVA, and dedicationofveterans’supportersinCongress,theVAmentalhealthbudgetreached$3.5billionin2008andisslatedat$3.9billionfor2009.TheVAmentalhealthbudgetnowmakesuptenpercentoftheentireVAhealthcarebudget,andtheDepartmentofVeteransAffairshasused the funding tointroduceawidearrayofmeasurestohelpmeettheneedsofveteransreturningfromIraqandAfghanistan.

TheVAisdevoting$37.7milliontoplacingpsychiatrists,psychologists, and social workers within primary careclinics,153whichwillallowveteranstoseekhelpinafamiliarsetting, without the stigma of visiting a mental healthclinic.154TheVAhasalsohirednewstaff.Psychologiststafflevelswerebelow 1995 levels until2006,155buttheVAhasrecruitedmorethan3,900newmentalhealthemployees,including800newpsychologists.156The totalVAmentalhealthstaffisnowabout17,000people.157TheVAisthesinglelargestemployerofpsychologistsinthecountry.158

TheVAhas also launched a national suicide preventionhotline, 1-800-273-TALK, which took 55,000 calls in itsfirstyear,including22,000callsdirectlyfromveteransand33,000callsfromconcernedfamilymembersorfriends.159TheVAclaimstohaveaverted1,221suicidesthroughthehotline.160 Other measures currently underway includethe addition of 61 new VA-run Vet Centers, which willbring the total to 268 centers nationwide,161 and thehiring ofmore suicide-prevention coordinators to allowforexpandedmentalhealthemergencyservices.162TheVAhasincreasedthebudgetoftheNationalCenterforPostTraumaticStressDisorderby$2million,163 andhasalsohired at least 100 Vet Center “Outreach Coordinators,”

IraqandAfghanistanveteranswhohelpguidetheirfellowservicemembersintocare.164

TBIisalsogettingmoreattentionwithintheVAsystem.Inspring2007,theVAput inplaceaTBIevaluationforallIraqandAfghanistanveteransseenatanyVAhospitalorclinic,165andbegandevelopmentofaTraumaticBrainInjuryVeteransHealthRegistry.166AlthoughlessthanhalfofeligibleIraqandAfghanistanveteransgototheVAforcare,167 andmany veterans are being screened only yearsaftertheirinjuries,thisisstillamajorsteptowardsproperlydiagnosingandtreatingTBI.TheVA’sTBIscreeningtoolissimilartothatoftheDefenseandVeteransBrainInjuryCenter,butitsreliabilityisnotyetcertain.168Infact,thereisnotcurrentlyadefinitivediagnostictestformildcasesofTBI.169Furtherresearchisneeded,andareliablescreeningtoolmustbedeveloped.

TheDODandVAhavealsocollaboratedonanexpandednationalprogramofPolytraumaRehabilitationCenters.170TheCenters,partoftheDefenseandVeteransBrainInjuryCenter network, use teams of physicians and specialiststhat administer individually tailored rehabilitationplans,171 including full-spectrum TBI care.172 TheCenters are supported by regional network sites acrossthe country,173 and the VA is also planning to add newPolytraumaSupportClinicstoprovidefollow-upservicesforthosewhonolongerrequireinpatientcarebutstillneedrehabilitation.174 A recent report from the VA InspectorGeneralhassuggestedthat,whilethepolytraumacentersprovideexcellentcare,therearestillextensivegapsinthecasemanagementandlong-termcareprovidedtoveteranswithTraumaticBrainInjury.175

ThemassiveexpansionofVAfacilitiesandservicespresentsserious challenges. Integrating the hundreds of newcentersandtrainingthethousandsofnewmentalhealthprofessionalswithintheVAmustbeatoppriorityofthenewSecretaryofVeteransAffairs.

since 2001, the va mental health budget has doubled.


Access to VA Care Still a ProblemDespite these steps, veterans requiring specializedtreatment toooftenfindcare is far fromhome.Only88percentofthoserelyingontheVA’sPolytraumanetworkhad“reasonable”accesstothesystem,accordingtoaVAstudy.Themediandistancefromaveteran’shometoeventhe most common, lowest level of polytrauma supportwas 64 miles.176 The study identified seven states withcounties that lacked reasonable access to rehabilitation:Alabama,Nevada,NorthDakota, Texas,Hawaii, Alaska,andMississippi.

Veterans in rural communities, who make up 38% ofveteransenrolledinVAhealthcare,177areespeciallyhard-hit.Asof2003,“morethan25percentofveteransenrolledinVAhealthcare—over1.7million—liveover60minutesdrivingtimefromaVAhospital.”178ThisproblemislikelytoworsenbecausethemissionsinIraqandAfghanistanhavereliedheavilyonrecruitsfromruralareas,whichareoftenunderservedbyVAhospitals and clinics.179 For instance,Montanaranksfourth insendingtroopstowar,butthestate’sVAfacilitiesprovidethelowestfrequencyofmentalhealth visits.180 IAVA will continue to monitor closelythe effect of newVAprograms on these gaps in service.

montana ranks fourth in sending troops to war, but the state’s va facilities provide the lowest frequency of mental health visits.

conclusion

Of the 1.7 million veterans who have served in Iraq orAfghanistan,abouthalfamillionaresufferingfromPostTraumaticStressDisorder,depressionorTraumaticBrainInjury.Leftuntreated,theramificationsareclear:increasesin family problems, drug abuse, and suicide.Over time,otherproblemslikeunemploymentandhomelessnessarelikelytoincreaseaswell.TheRANDCorporationestimatesthe costs of the psychological and neurological injuriessuffered by Iraq and Afghanistan veterans at between$4 and $6.2 billion, just in the first two years after combat.Providingpropercareforalloftheseveteranswouldlowerthat costby about27%.181TheDefenseDepartmentandtheDepartmentofVeteransAffairscanandmusttakeboldaction.Resolving just threeof themostpressingneeds—improvingmandatorymental health andTBI screening,increasing access to trainedmental healthprofessionals,andensuringmilitaryfamilieshaveaccesstomentalhealthcare—wouldbeatremendoussteptowardstemmingtheflood of veterans with untreatedmental health injuries,andwouldsavecountlesslives.Inaddition,newfundingtostudythecauses,effects,andtreatmentsofTraumaticBrain Injury would benefit hundreds of thousands ofcombat veterans now struggling with these invisiblewoundsofwar.Ournewestgenerationofheroesdeservesnothingless.

For IAVA’s recommendations on mental health, see our Legislative Agenda, available at www.iava.org/dc.


recommended reading and online resources

Tolearnmoreabouttheunemploymentandhousingissuesthatnewveteransarefacing,seethe2009IAVAIssueReports,“CareersAfterCombat:EmploymentandEducationChallengesforIraqandAfghanistanVeterans” and “ComingHome: TheHousingCrisis andHomelessness ThreatenNewVeterans.” Formoreontroops’andveterans’healthcareandcompensationissues,consultthe2008IAVAIssueReport:“BattlingRedTape:VeteransStruggleforCareandBenefits.”

YoucanalsolearnmoreaboutPTSDandTBIfromthefollowingsources:

• TerriTanielianandLisaH.Jaycox,Eds.,“InvisibleWoundsofWar:PsychologicalandCognitiveInjuries,TheirConsequences,andServicestoAssistRecovery,”RAND,2008:http://www.rand.org/pubs/monographs/MG720/.

• TheDefenseandVeteransBrainInjuryCenter:http://www.dvbic.org/.

• TheNationalInstituteofNeurologicalDisordersandStroke:http://www.ninds.nih.gov/disorders/tbi/tbi.htm.

• TheNationalCenterforPTSD:http://www.ncptsd.va.gov.

• InstituteofMedicine,“PosttraumaticStressDisorder:DiagnosisandAssessment,”TheNationalAcademiesPress,Washington,DC:2006.

• Miliken,Auchterlonie,andHoge,“LongitudinalAssessmentofMentalHealthProblemsAmongActiveandReserveComponentSoldiersReturningFromtheIraqWar,”Journal of the American Medical Association,November14,2007.

• MentalHealthAdvisoryTeam(MHAT)V,Report:OperationIraqiFreedom06-08,OperationEnduringFreedom8,February14,2008:http://www.armymedicine.army.mil/reports/mhat/mhat_v/Redacted1-MHATV-4-FEB-2008-Overview.pdf.

• AmericanPsychologicalAssociation,PresidentialTaskForceonMilitaryDeploymentServicesforYouth,FamiliesandServiceMembers,“ThePsychologicalNeedsofU.S.MilitaryServiceMembersandTheirFamilies:APreliminaryReport,”February2007:http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf.

• SusanOkie,“TraumaticBrainInjuryintheWarZone,”New England Journal of Medicine,May19,2005:http://content.nejm.org/cgi/reprint/352/20/2043.pdf.

• EmilySinger,“BrainTraumainIraq,”Technology Review,May/June2008.


endnotes1 1In1919and1920,scientistsSalmonandFentontrackedthelong-termadjustment of 758 veteranswhohadbeenhospitalized for “warneuroses” inFranceduringWorldWarI.RobertH.Stretch,“FollowUpStudiesofVeterans,”WarPsychiatry,Eds.FranklinJones,etal.,OfficeoftheSurgeonGeneral,1995,p.457-476:http://www.fas.org/irp/doddir/milmed/warpsychiatry.pdf#page=461.

2 Terri Tanielian and Lisa H. Jaycox, Eds., “Invisible Wounds of War:PsychologicalandCognitiveInjuries,TheirConsequences,andServicestoAssistRecovery,”RAND,2008:http:/www.rand.org/pubs/monographs/MG720/.

3 AmandaGardner,“TraumaticBrainInjuriesLinkedtoLong-TermHealthIssuesforVets,”The Washington Post,December4,2008:http://www.washing-tonpost.com/wp-dyn/content/article/2008/12/04/AR2008120402158.html

4 TanielianandJaycox,p.169.Seealso:LindaBilmes,“SoldiersReturningfrom Iraq and Afghanistan: The Long-term Costs of Providing VeteransMedicalCareandDisabilityBenefits,”Faculty Research Working Papers Series,January 2007: http://ksgnotes1.harvard.edu/Research/wpaper.nsf/rwp/RWP07-001/$File/rwp_07_001_bilmes.pdf.

5 For complete information about the symptoms of PTSD, visit theNationalCenterforPTSDathttp://www.ncptsd.va.gov/.

6 National Alliance on Mental Illness, “What Is Major Depression?”September 2006: http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement/ContentDisplay.cfm&ContentID=7725.

7 AsmanyashalfofPTSDpatientsreceivingpropertreatmentcanexpecta complete recovery, andmost can expect an improvement in symptoms.TanielianandJaycox,p.592.

8 Lucille Beck and Barbara Sigford, “Update onHealth Care: VA TBIScreeningProgram,”DepartmentofVeteransAffairs,September2008.

9 NationalInstituteofNeurologicalDisordersandStroke,“Traumaticbrain injury:hope through research,”Bethesda (MD):National InstitutesofHealth;2002Feb.NIHPublicationNo.:02-158.See:http://www.cdc.gov/ncipc/factsheets/tbi.htm.

10 MatthewJ.Friedman,MD,PhD,andPaulaP.Schnurr,PhD,“PTSDTreatment: Research and Dissemination,” National Center for PTSD, p.9.Theseverityofatraumaticbraininjuryisclassifiedbasedonthelengthof unconsciousness or amnesia. According to the New England Journal of Medicine,a“mild”TBIcauseslessthanonehourofunconsciousnessor24hoursofamnesia,a“moderate”TBIresultsinlessthanonedayofuncon-sciousnessorlessthan7daysofamnesia,anda“severe”TBIproducesmorethanadayofunconsciousnessormorethan7daysofamnesia.SusanOkie,“TraumaticBrainInjuryintheWarZone,”New England Journal of Medicine,May19,2005:http://content.nejm.org/cgi/reprint/352/20/2043.pdf.

11 Scott Huddleston, “Troops living with brain injury,” San Antonio Express-News, April 22, 2007: http://www.mysanantonio.com/specials/bat-tlefield/stories/MYSA042207.01A.brain_injury.358194b.html

12 KatherineH.Taber,etal.“Blast-RelatedTraumaticBrainInjury:Whatisknown?”Journal Neuropsychiatry and Clinical Neurosciences,Spring2006.

13 EmilySinger,“BrainTraumainIraq,”Technology Review,May/June2008.

14 GAO-08-276,“VAHealthCare:MildTraumaticBrainInjuryScreeningand Evaluation Implemented for OIF/OEF Veterans, But ChallengesRemain,”February2008,p. 7: http://www.gao.gov/new.items/d08276.pdf.Note:theDODistestingmultiplecommercialTBIscreeningprogramstofindthemostaccuratetestingsystemcurrentlyavailable.Formoreinforma-tion,see:http://deploymentlink.osd.mil/new.jsp?newsID=66.

15 “70%ofhiddenbraininjuriesshownosymptomsbythetimethey’rescreenedbyadoctor.”“TakeTBIseriously,” Army Timesopinion,August13,2007.However,thereisevidencethatrupturedeardrumsarecloselycorre-latedwithTBI.“Tympanic-MembranePerforationasaMarkerofConcussiveBrainInjuryinIraq,”New England Journal of MedicineLetterstotheEditor,August23,2007:http://content.nejm.org/cgi/content/short/357/8/830.

16 For more information, please see: http://www.cdc.gov/ncipc/tbi/Outcomes.htm

17 “MentalHealthAdvisoryTeam(MHAT) IV,FinalReport:OperationIraqiFreedom05-07,November17,2006:http://www.armymedicine.army.mil/reports/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf.”

18 Mental Health Advisory Team (MHAT) V, Report: Operation IraqiFreedom06-08,OperationEnduringFreedom8,February14,2008:http://www.armymedicine.army.mil/reports/mhat/mhat_v/Redacted1-MHATV-4-FEB-2008-Overview.pdf.

19 MentalHealth Advisory Team (MHAT) IV, Final Report: OperationIraqiFreedom05-07,November17,2006:http://www.armymedicine.army.mil/reports/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf.

20 Fred W. Baker III, “DoD Changes Security Clearance Question onMental Health,” Armed Forces Press Service, May 1, 2008: http://www.defenselink.mil/news/newsarticle.aspx?id=49735.

21 “Studies have linked traumatic stress exposures and PTSD to suchconditionsascardiovasculardisease,diabetes,gastrointestinaldisease,fibro-malgia, chronic fatigue syndrome, musculoskeletal disorders, and otherdiseases.” Joseph Boscarino, “Posttraumatic Stress Disorder and PhysicalIllness,” Annals of the New York Academy of Sciences,2004.SeealsoHogeetal.,“AssociationofPosttraumaticStressDisorderwithSomaticSymptoms,HealthCareVisits,andAbsenteeismAmongIraqWarVeterans,”American Journal of Psychiatry,January2007.

22 EmilySinger,“BrainTraumainIraq,”Technology Review,May/June2008.CharlesW.Hoge,M.D.,etal., “MildTraumaticBrainInjury inU.S.SoldiersReturningFromIraq,”The New England Journal of Medicine,Volume358:453-463,January31,2008:http://content.nejm.org/cgi/content/full/358/5/453.

23 “New Research on Combat Veteran Twins Unlocks BrainMysteriesofPTSD,”AmericanCollegeofNeuropsychopharmacologyPressRelease,December 9, 2008: http://www.acnp.org/asset.axd?id=4a282cc7-331b-4cff-9a40-c0d2834a8d5e.


25 “44%ofsoldierswhohadlostconsciousnessonthebattlefieldmetcri-teriaforPTSD,comparedwith16percentofthoseinthesamebrigadeswhosufferedotherinjuries.”Ibid.

26 Rapoport et al., “Cognitive Impairment Associated With MajorDepressionFollowingMildandModerateTraumaticBrainInjury,”Journal of Neuropsychiatry and Clinical Neuropsychiatry,Winter2005.

27 JenniferL.Price,Ph.D.,“FindingsfromtheNationalVietnamVeterans’ReadjustmentStudy,”NationalCenter forPTSDFactSheet:http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_nvvrs.html.

28 Forasummaryoftheresearchasofearly2008,pleasesee:TanielianandJaycox,p.35.

29 TanielianandJaycox,p.103.

30 DepartmentofVeterans’Affairs,Fifth Annual Report of the Department of Veterans Affairs Undersecretary for Health’s Special Committee on Post-Traumatic Stress Disorder,2005,p.12.

31 ThePresident’sCommissiononCareforAmerica’sReturningWoundedWarriors,“FinalReport,”July30,2007,p.15:http://www.pccww.gov/docs/Kit/Main_Book_CC%5BJULY26%5D.pdf.

32 MatthewFriedman,“AcknowledgingthePsychiatricCostofWar,”New England Journal of Medicine,July1,2004,351,75-77:http://content.nejm.org/cgi/content/short/351/1/75.

33 Miliken,Auchterlonie,andHoge,“LongitudinalAssessmentofMentalHealthProblemsAmongActiveandReserveComponentSoldiersReturningFromtheIraqWar,”Journal of the American Medical Association,November14,2007.p.2143-5.


34 Lawrence Korb et al., Center for American Progress, “Beyond theCall of Duty,” March 6, 2007, p. 10: http://www.americanprogress.org/issues/2007/03/readiness_report.html.

35 DepartmentofDefenseContingencyTrackingSystemDeploymentFileforOperationsEnduringFreedomandIraqiFreedom,asofJune30,2008.

36 WilliamH.McMichael, “15-monthwar tours start now for Army,”Army Times,April12,2007:http://www.armytimes.com/news/2007/04/army_15month_tours_070411/.

37 PresidentBushannouncedhisplantocutthelengthofArmycombattoursinApril2008,butthenewpolicyappliestosoldiersdeployingtoIraqandAfghanistanafterAugust1,2008.“Bushwon’tordernewIraqtroopdrawdowns,”AssociatedPress,April10,2008:http://www.msnbc.msn.com/id/24034202/.

38 MHATV,p.4.

39 SeeMHATIV,p.3andTanielianandJaycox,p.98.

40 GeneralJamesT.Conway,CommandantoftheMarineCorps,“MentalHealthAdvisoryTeam(MHAT)IVBrief,”April18,2007,p.9:http://www.militarytimes.com/static/projects/pages/mhativ18apr07.pdf.

41 ElisabethBumiller,“RedefiningtheRoleoftheU.S.MilitaryinIraq,”The New York Times,December21,2008:http://www.nytimes.com/2008/12/22/washington/22combat.html?bl&ex=1230181200&en=4637c51b4c895cd8&ei=5087%0A.

42 TanielianandJaycox,p.51.Seealso:KellyKennedy,“Study:PTSDrateshigherfortroopswhokill,”Military Times,November22,2008.

43 Althoughthoseunder25makeuponly36percentofthemilitaryasawhole,theyrepresentmorethanhalfofthefatalitiesinIraqandAfghanistan.See:http://www.militarytimes.com/news/2007/07/tns_4000_casualties_070709/.

44 Highercombatlevelsdramaticallyincreasetheriskofamentalhealthproblem.Whilesoldiersexposedto“lowcombat”havean11percentrateofmentalhealthproblems,thoseexposedto“highcombat”suffermentalhealthproblemsatarateofabout30percent.MHATIV,p.76.

45 Griegeretal.,“PosttraumaticStressDisorderandDepressioninBattle-InjuredSoldiers,” American Journal of Psychiatry,October2006.

46 “LandstuhlHopestoStartNewBrainTraumaCenter,”Stars and Stripes,November2,2007.EarlierdatashowedahigherrateofTBI–33%.See:SteveMroz,“Landstuhltriestogetaheadofbraininjuries,”Stars and Stripes,March25,2007:http://stripes.com/article.asp?section=104&article=51034&archive=true.

47 “Army testing soldiers’ brains before deployment,” Associated Press,September19,2007:http://www.msnbc.msn.com/id/20876109/.

48 RichardA.Bryant, “DisentanglingMildTraumaticBrain Injury andStressReactions,”New England Journal of Medicine,January31,2008.

49 Marilyn Elias, “National Guard feels own emotional tolls,” USA Today,August21,2007:http://www.airforcetimes.com/news/2007/08/gns_guardptsd_070821/.

50 “One-fifth of female airmen in combat get PTSD,” AirForce Times,August 21, 2007: http://www.airforcetimes.com/news/2007/08/airforce_womenstress_070820/.

51 Marilyn Elias, “National Guard feels own emotional tolls,” USA Today, August 21, 2007:http://www.airforcetimes.com/news/2007/08/gns_guardptsd_070821/.Seealso:TanielianandJaycox,p.101.


53 Donna St. George, “Women suffer stress disorder after combat,”The Washington Post, August 20, 2008: http://recall.uniontrib.com/union-trib/20060820/news_1n20ptsd.html.

54 Thedataonratesofsexualassaultandharassmentvarywidely.AccordingtoaVAstudy,“About15percentoffemaleveteransofthewars inIraqand

AfghanistanwhouseVAhealthcareexperiencedsexualassaultorharassment.”“VAscreeningsyielddataonmilitarysexualtrauma,”’VA Research Currents,Nov-Dec 2008. Veterans of previous generations experiencedmuch higher rates:“Nearlyathirdoffemaleveteranssaytheyweresexuallyassaultedorrapedwhileinthemilitary,and71percentto90percentsaytheyweresexuallyharrassedbythemenwithwhomtheyserved.”HelenBenedict,“ForWomenWarriors,DeepWounds,LittleCare,”New York Times,May26,2008.

55 “VA screenings yield data on military sexual trauma,”’ VA Research Currents,Nov-Dec2008.

56 Captain Bill Nash,MC, USN, COSC coordinator, presenting at theMarineCorpsCOSCConference,“ThePotentialRoleofStressandStressInjuriesinMisconduct,”June19,2007.

57 “MentalHealthAdvisoryTeam(MHAT)IVFinalReport,”November17,2006,p.4:http://www.armymedicine.army.mil/news/mhat/mhat_iv/MHAT_IV_Report_17NOV06.pdf.CaptainBillNash,MC,USN,COSCcoordinator,presenting at theMarineCorpsCOSCConference, “The PotentialRole ofStressandStressInjuriesinMisconduct,”June19,2007.

58 32percentofOEF/OIFveteranMarineswhoreceivedless-than-honor-abledischargesreceivedmentalhealthtreatmentpriortodischarge.Overall,onlyabout7percentofallMarinesreceiveanymentalhealthtreatmenteachyear(2-3percentforPTSD).CaptainBillNash,MC,USN,COSCcoordina-tor,presentingattheMarineCorpsCOSCConference,“ThePotentialRoleofStressandStressInjuriesinMisconduct,”June19,2007,p.3.SeealsoGreggZoroya,“Battlestressmayleadtomisconduct,”USA Today,July1,2007:http://www.usatoday.com/news/washington/2007-07-01-marine-stress_N.htm.

59 “Amid investigations, Marine Corps boosts ethics training,” AssociatedPress,July15,2007.ThomasE.RicksandAnnScottTyson,“TroopsatOddsWithEthicsStandards,”The Washington Post,May5,2007:http://www.washingtonpost.com/wp-dyn/content/article/2007/05/04/AR2007050402151_pf.html.

60 United States House of Representatives Committee on Veterans’Affairs,PressRelease,“PersonalityDisorder:ADeliberateMisdiagnosisToAvoid Veterans’Health Care Costs,” July 25, 2007: http://veterans.house.gov/news/PRArticle.aspx?NewsID=111.

61 DanielZwerdling, “ArmyDismissals forMentalHealth,MisconductRise,”NPR,November19,2007:http://www.npr.org/templates/story/story.php?storyId=16330374.

62 DepartmentofDefenseTaskForceonMentalHealth, “Anachievablevision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,”June2007,p.30:http://www.ha.osd.mil/dhb/mhtf/MHTF-Report-Final.pdf

63 United States House of Representatives Committee on Veterans’Affairs,PressRelease,“PersonalityDisorder:ADeliberateMisdiagnosisToAvoid Veterans’Health Care Costs,” July 25, 2007: http://veterans.house.gov/news/PRArticle.aspx?NewsID=111.

64 InstituteofMedicine,“GulfWarandHealth:Volume6.Physiologic,Psychologic, and Psychosocial Effects of Deployment-Related Stress,”(uncorrectedprepublicationproof)NationalAcademiesPress,Washington,DC,c.2007.


66 DepartmentofDefenseContingencyTrackingSystemDeploymentFileforOperationsEnduringFreedomandIraqiFreedom,asofFebruary2008.

67 MHATIV,p.30.

68 GreggZoroya,“Soldiers’divorceratedropsafter2004increase,” USA Today,January1,2006:http://www.usatoday.com/news/nation/2006-01-09-soldier-divorce-rate_x.htm.

69 Benjamin Karney and John S. Crown, “Families Under Stress: AnAssessment ofData, Theory, andResearch onMarriage andDivorce in theMilitary,”RAND,2007:http://www.Rand.org/pubs/monographs/MG599/.

70 Pauline Jelinek, “Divorce rate increases In Marine Corps, Army,”AssociatedPress,December2,2008:http://news.yahoo.com/s/ap/20081203/

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ap_on_go_ca_st_pe/military_divorces.

71 Ibid.

72 Benjamin Karney and John S. Crown, “Families Under Stress: AnAssessmentofData,Theory,andResearchonMarriageandDivorceintheMilitary,”RAND,2007:http://www.Rand.org/pubs/monographs/MG599/.PaulineJelinek,“DivorcerateincreasesInMarineCorps,Army,”AssociatedPress, December 2, 2008: http://news.yahoo.com/s/ap/20081203/ap_on_go_ca_st_pe/military_divorces.

73 VHAOfficeofPublicHealthandEnvironmentalHazards,“AnalysisofVAHealthCareUtilizationAmongUSGlobalWaronTerrorism(GWOT)VeteransOperationEnduringFreedomOperationIraqiFreedom,”January2009.


75 Chartrandetal.,“EffectofParents’WartimeDeploymentonBehaviorofYoungChildreninMilitaryFamilies,”Archives of Pediatric and Adolescent Medicine, November 2008: http://archpedi.ama-assn.org/cgi/content/abstract/162/11/1009.

76 AndreaStone, “Atcamp,militarykidsbear scarsof theirown,”USA Today, June 21, 2007: http://www.usatoday.com/news/nation/2007-06-20-camp-cover_N.htm?csp=34.

77 Chartrandetal.,“EffectofParents’WartimeDeploymentonBehaviorofYoungChildreninMilitaryFamilies.”

78 RobertDavis andGreggZoroya, “Study:Child abuse, troopdeploy-ment linked,” USA Today, May 7, 2007: http://www.usatoday.com/news/nation/2007-05-07-troops-child-abuse_N.htm.

79 Sayers, et al. “Family Problems Among Recently Returned MilitaryVeterans.”Unpublishedmanuscript.DepartmentofPsychiatry,UniversityofPennsylvaniaandVISN4MentalIllnessResearchEducation,andClinicalCenter,PhiladelphiaVAMedicalCenter.2007.

80 Sayers, et al. “Family Problems Among Recently Returned MilitaryVeterans.”Theseresultsareunsurprising,giventhehighratesofviolenceinfamiliesofVietnamveteranswithPTSD.SeeTanielianandJaycox,p.144.

81 Seealso:AmyMarshalletal.,“Intimatepartnerviolenceamongmilitaryvet-eransandactivedutyservicemen,”Clinical Psychology Review,May2005.

82 NationalGuardsmenandReservists,andyoungertroops,areatevenhigher risk of heavy drinking, binge drinking, and other alcohol-relatedproblems. Jacobson et al., “Alcohol Use and Alcohol-Related ProblemsBefore and After Military Combat Deployments,” Journal of the American Medical Association,August13,2008.

83 Millikenatal.,“LongitudinalAssessmentofMentalHealthProblemsAmongActiveandReserveComponentSoldiersReturningFromthe IraqWar,” Journal of the American Medical Association,January10,2008.

84 Ibid.

85 Department of Defense Task Force onMental Health, “An achievablevision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,”June2007,p.20:http://www.ha.osd.mil/dhb/mhtf/MHTF-Report-Final.pdf

86 Alcoholdependencesyndromeistechnicallydefinedas“amaladaptivepat-ternofalcoholuse,leadingtoclinicallysignificantimpairmentordistress.”(See:http://www.medicalcriteria.com/criteria/dsm_alcoholdep.htm) Data on usagefromtheVHAOfficeofPublicHealthandEnvironmentalHazards, “AnalysisofVAHealthCareUtilizationAmongUSGlobalWaronTerrorism(GWOT)VeteransOperationEnduringFreedomOperationIraqiFreedom,”January2009.

87 The150,000figurerepresentsa21percentdropinthenumberofhome-lessveteranssince the2006CHALENGreport.TheVAcites severalpossiblereasons for this, including altered methodology, the overall decline in theveteran population, and the effectiveness of VA programs. Department ofVeteransAffairs,“CommunityHomelessnessAssessment,LocalEducationandNetworking Group (CHALENG) for Veterans: Fourteenth Annual ProgressReport,” February 28, 2008, p. 16: http://www1.va.gov/homeless/docs/

CHALENG_14tH_annual_report_3-05-08.pdf. Because the homeless popula-tionsistransient,andbecausemanypeoplemayexperiencehomelessnessoff-and-onovermonthsorevenyears,correctlymeasuringthesizeofthehomelesspopulationisdifficult.Formoreinformationonthemethodsusedtocountthehomeless,seeLibbyPerl,“CountingHomelessPersons:HomelessManagementInformationSystem,”CongressionalResearchService,April3,2008.

88 DepartmentofVeteransAffairs,“OverviewofHomelessness,”March6,2008:http://www1.va.gov/homeless/page.cfm?pg=1

89 For now, Iraq and Afghanistan veterans remain underrepresentedin thehomeless veteranpopulation, as they account for 3percentof thetotal number of veterans nationwide. Department of Veterans Affairs,“CommunityHomelessnessAssessment,LocalEducationandNetworkingGroup(CHALENG)forVeterans:FourteenthAnnualProgressReport,”p.2.

90 MaryRooney,ProgramSpecialist,HomelessVeteransPrograms,andDeborahLee,VISN6NetworkHomelessCoordinator,U.S.DepartmentofVeteransAffairs,presentationattheNationalSummitonWomenVeteransAnnualConference,June20-22,2008:http://www1.va.gov/womenvet/page.cfm?pg=70.

91 Libby Perl, “Veterans and Homelessness,” Congressional ResearchService,March18,2008,p.11

92 ErinEdwardsandHallieMartin,“Willmorewomenvetsbehomeless?”MedillReports,March12,2008:http://news.medill.northwestern.edu/chi-cago/news.aspx?id=83199.

93 Perl,p.11.

94 Therewere169U.S.military suicides in Iraqand27 inAfghanistan.DatafromtheDefenseManpowerDataCenter,asofDecember6,2008.

95 Pauline Jelinek, “Army: soldier suicide rate may set record again,”Associated Press, Sept. 4, 2008: http://www.cleveland.com/nation/index.ssf/2008/09/army_soldier_suicide_rate_may.html.

96 Ibid.Theoverallcivilianrateofsuicideis11per100,000,butoncethatrateisadjustedtomatchthemuchyoungerandmoremalepopulationintheArmy, theequivalentcivilianrate is19.5percent.Rates intheMarineCorpswere16.5per100,000in2007.

97 Iraq andAfghanistan-era veterans are veteranswho left themilitaryafterSeptember11,2001.GreggZoroya,“VAreport:MaleU.S.veteransui-cidesathighestin2006,”USA Today,September8,2006:http://www.usato-day.com/news/military/2008-09-08-Vet-suicides_N.htm.

98 Katharine Euphrat, “22,000 vets called suicide hot line in a year,”AssociatedPress,July28,2008:http://www.msnbc.msn.com/id/25875340/.

99 George Bryson, “Returning vets could become part of ominousnationaltrend,”Anchorage Daily News,June24,2007:http://www.adn.com/news/military/story/9076628p-8992620c.html.KerryL.Knox,DepartmentofVeteransAffairs,“SuicideAmongVeterans:StrategiesforPrevention,”p.6.

100 MarkS.Kaplanetal.,“Suicideamongmaleveterans:aprospectivepopula-tion-basedstudy,” Journal of Epidemiology and Community Health,61,2007,p.620.

101 Kasprow and Rosenheck, 2000, cited in Fifth Annual Report of the Department of Veterans Affairs Undersecretary for Health’s Special Committee on Post-Traumatic Stress Disorder,2005,p.13.

102 BenedictCarey, “Study Looks at Suicide inVeterans,”The New York Times,October30,2007.

103 GeorgeBryson,“Returningvetscouldbecomepartofominousnationaltrend,”Anchorage Daily News,June24,2007:http://www.adn.com/news/mili-tary/story/9076628p-8992620c.html.

104 American Psychological Association Presidential Task Force onMilitary Deployment Services for Youth, Families and Service Members,“The Psychological Needs of U.S. Military Service Members and TheirFamilies:APreliminaryReport,”February2007,p.4:http://www.apa.org/releases/MilitaryDeploymentTaskForceReport.pdf.


105 TanielianandJaycox,p.xxi.

106 LearnmoreaboutDCoEat:http://www.dcoe.health.mil/About.aspx.

107 For more information, please see: http://www.fallenheroesfund.org/News/Articles/Officials-Break-Ground-for-Brain-Injury-Center-of-.aspx.


109 DepartmentofDefenseTaskForceonMentalHealth, “Anachievablevision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,”June2007,p.63:http://www.ha.osd.mil/dhb/mhtf/MHTF-Report-Final.pdf.

110 Dana Priest and Anne Hull, “The War Inside,” The Washington Post,June 17, 2007: http://www.washingtonpost.com/wp-dyn/content/arti-cle/2007/06/16/AR2007061600866.html.

111 Greg Zoroya, “Army counselors in short supply in war zones,”USAToday,April2,2008.

112 LisaChedekel, “MostStressCasesMissed:ArmyAdmitsDisorder IsUnder-Reported,”Hartford Courant,August6,2007.

113 MHATV,p.65.

114 Greg Zoroya, “Army counselors in short supply in war zones,” USA Today,April2,2008.

115 MHATV,p.173.

116 TanielianandJaycox,p.251

117 ErikSlavin,“AvailabilityofPTSDTreatmentDependsonBase,” Stars and Stripes,October30,2007:http://www.stripes.com/article.asp?section=104&article=57386&archive=true.


119 “For example, although clinical social workers represent the largestgroupofmentalhealthpractitioners in thenation,playingavital role inprovidingthefullarrayofapproachesforassessmentandtreatmentofpsy-chological problems, theNavy allows socialworkers toworkonlywithina small portion of their scope of services.” Department ofDefense TaskForceonMentalHealth,“Anachievablevision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,”June2007,p.63:http://www.ha.osd.mil/dhb/mhtf/MHTF-Report-Final.pdf.

120 GAO-07-831, “Comprehensive Oversight Framework Needed to HelpEnsureEffectiveImplementationofaDeploymentHealthQualityAssuranceProgram,”June2007,p.1:http://www.gao.gov/highlights/d07831high.pdf.


122 Mark Thompson, “America’sMedicated Army,” Time, June 5, 2008:http://www.time.com/time/nation/article/0,8599,1811858,00.html.

123 TroopstakingSSRIs,orselectiveserotoninreuptakeinhibitors,suchas Prozac or Zoloft, can be cleared to deploy to combat. “Itwasn’t untilNovember2006thatthePentagonsetauniformpolicyforalltheservices.Butthecuriousthingaboutitwasthatitdidn’tmentionthenewantidepressants.Instead,itsimplybarredtroopsfromtakingolderdrugs,including“lithium,anticonvulsantsandantipsychotics.”Thegoal,aparticipantincraftingthepolicysaid,wastogiveSSRIsa“greenlight”withoutsayingso.”Ibid.

124 Institute of Medicine, “Posttraumatic Stress Disorder: Diagnosis andAssessment,”TheNationalAcademiesPress,Washington,DC:2006,pg.16-17.See also theVeterans’DisabilityBenefitsCommission, “Honoring theCall to

Duty:VeteransDisabilityBenefitsinthe21stCentury,”October2007.

125 Beforedeployment, troopsfill outone form,DD2795.Afterdeploy-ment,troopsfillouttwoforms,DD2796(immediatelyafterdeployment),andDD2900(sixmonthsafterreturninghome).Copiesoftheseformsandinformationabouttheiruseareavailableathttp://www.dtic.mil/whs/direc-tives/infomgt/forms/eforms/dd2795.pdf and http://www.pdhealth.mil/dcs/post_deploy.asp.

126 AccordingtotheGAO,“DOD’sNovember2006policyimplementing…deployment standards requires a reviewof servicemembermedical records.However,DOD’sAugust2006InstructiononDeploymentHealth…issilentonwhethersuchareviewisrequired.”GAO-08-615,“DODHealthCare:MentalHealth and Traumatic Brain Injury Screening Efforts Implemented, butConsistent Pre-DeploymentMedical Record Review PoliciesNeeded,”May2008:http://www.gao.gov/new.items/d08615.pdf.

127 “DOD and VA Initiatives Addressing IOM Recommendations,”December18,2008:http://deploymentlink.osd.mil/new.jsp?newsID=66.

128 Lisa Chedekel, “U.S. Troops To Get Cognitive Screening,” Hartford Courant,June25,2008.

129 KellyKennedy,“ArmyissuesnewguidelinesforTBIcare,”Army Times,July17,2008.

130 MHATV,p.4.

131 GAO-08-615,p.2.

132 GAO-08-615,p.8.

133 Charles W. Hoge et al., “Mental Health Problems, Use of MentalHealth Services, and Attrition from Military Service After ReturningfromDeployment to Iraq orAfghanistan,” Journal of the American Medical Association,March1,2006,295,p.1023.

134 Ibid.

135 Miliken,Auchterlonie,andHoge,“LongitudinalAssessmentofMentalHealthProblemsAmongActiveandReserveComponentSoldiersReturningFromtheIraqWar,”Journal of the American Medical Association,November14,2007.p.2145.

136 Ibid.

137 NancyGoldstein,“MindGameIII-FullMetalLockout:TheMythofAccessibleHealthCare,”Raw Story,October30,2006:http://www.rawstory.com/news/2006/Mind_Game_III__Full_Metal_1030.html.

138 MHATIV,p.25.

139 “Stigma creates employment barriers,” USA Today (Society for theAdvancementofEducation)February1998:http://findarticles.com/p/arti-cles/mi_m1272/is_n2633_v126/ai_20305748.

140 DepartmentofVeteransAffairs,Fifth Annual Report of the Department of Veterans Affairs Undersecretary for Health’s Special Committee on Post-Traumatic Stress Disorder,2005,p.17.

141 In2006,theGovernmentAccountabilityOfficefoundthatonly22per-centofreturningtroopswhoseformsshowedthattheywereatriskformen-tal health problems were actually referred to amental health professional.GAO-06-397, “Post-Traumatic StressDisorder:DODNeeds to Identify theFactors Its Providers Use toMakeMental Health Evaluation Referrals forServicemembers,”May2006,p.5:http://www.gao.gov/new.items/d06397.pdf.Seealso:Miliken,Auchterlonie,andHoge,“LongitudinalAssessmentofMentalHealthProblemsAmongActiveandReserveComponentSoldiersReturningFromtheIraqWar,”JournaloftheAmericanMedicalAssociation,November14,2007,p2145.Therearealsoquestionsaboutpre-deploymentscreeningandreferrals;in2006,referralswereonlygivento6.5percentofdeployingservicememberswhoindicateamentalhealthproblem.LisaChedekelandMatthewKauffman,“MentallyUnfit,ForcedtoFight,” Hartford Courant,May14,2006.Inshort,theDODcouldnot“providereasonableassurancethat…servicemem-berswhoneed referrals receive them.”GAO-06-397, “Post-Traumatic Stress

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Disorder:DODNeedstoIdentifytheFactorsItsProvidersUsetoMakeMentalHealthEvaluationReferralsforServicemembers,”May2006,p.5.

142 GAO-08-615,p.19.

143 Department of Veterans Affairs, “VA Benefits and Health CareUtilization,” October 27, 2008: http://www1.va.gov/vetdata/docs/4X6_fall08_sharepoint.pdf.Seealso:FY2008 Independent Budget,pg.35:www.inde-pendentbudget.org.

144 FY2008 Independent Budget,pg.35:www.independentbudget.org.

145 TanielianandJaycox,p.xxv.

146 United States House of Representatives Committee on Veterans’Affairs–DemocraticStaff,“ReviewofCapacityofDepartmentofVeteransAffairsReadjustmentCounselingServiceVetCenters,”October2006,p.2:http://www.veterans.house.gov/democratic/officialcorr/pdf/vetcenters.pdf.

147 ChrisAdams,“VAsystemill-equippedtotreatmentalanguishofwar,”McClatchy Newspapers, February 5, 2007: http://www.mcclatchydc.com/reports/veterans/story/15554.html.

148 Rich Daly, “New Freedom Commission Members Assess Report’sImpact,” Psychiatric News,May5,2006.

149 Hope Yen, “Nicholson pledges to improve veterans care, defendsbonuses,”AssociatedPress,May9,2007.

150 Rep.MichaelMichaud,LettertoVASecretaryJimNicholson,Dec.1,2006.

151 GAO-07-66, “VAHealthCare: Spending forMentalHealthStrategicPlanInitiativesWasSubstantiallyLessThanPlanned,”November21,2006,p.6:http://www.gao.gov/cgi-bin/getrpt?GAO-07-66.

152 Armen Keteyian, “VA Hid Suicide Risk, Internal E-mails Show,”CBS News, April 21, 2008: http://www.cbsnews.com/stories/2008/04/21/cbsnews_investigates/main4032921.shtml.

153 Hope Yen, “US to expand veterans mental health services,”AssociatedPress, July17,2007:http://www.boston.com/news/nation/arti-cles/2007/07/17/us_to_expand_veterans_mental_health_services/.

154 Thispolicyshouldalsoimprovethedetectionofmentalhealthproblems.Beforethewidespreadinstitutionofmentalhealthcareinaprimarycaresetting,“only18percentofprimarycarepatientsnotreceivingspecialtymentalhealthcare butmeeting research criteria for PTSDwere recognized to have PTSD.”CharlesEngel,“Improvingprimarycareformilitarypersonnelandveteranswithposttraumaticstressdisorder–theroadahead,”General Hospital Psychiatry,2005.

155 Randy Phelps, PhD. Deputy Executive Director for ProfessionalPractice, American Psychological Association, Testimony before the USSenateCommitteeonVeteransAffairs,“MakingtheVAtheWorkplaceofChoiceforHealthCareProviders,”April9,2008.

156 Ibid.

157 IraKatz,2008presentation,“MentalHealthServices IntheVeteransHealthAdministration.”

158 Randy Phelps, PhD. Deputy Executive Director for ProfessionalPractice, American Psychological Association, Testimony before the USSenateCommitteeonVeteransAffairs,“MakingtheVAtheWorkplaceofChoiceforHealthCareProviders,”April9,2008.

159 SAMHSANewsRelease, “VeteransSuicidePreventionHotline (1-800-273-TALK)ProvidesVitalHelptoMoreThan55,000InItsFirstYear,”July28,2008.

160 Katharine Euphrat, “22,000 vets called suicide hot line in a year,”AssociatedPress,July28,2008.

161 “VASuicidePreventionInitiatives,”VAFactSheet,September2008.

162 HopeYen,“UStoexpandveteransmentalhealthservices,”AssociatedPress,July 17, 2007:http://www.boston.com/news/nation/articles/2007/07/17/us_to_expand_veterans_mental_health_services/.

163 UnitedStatesSenateCommitteeonVeteransAffairs,PressRelease,“SenatorsAnnounceAdditionalFundingforNationalCenteronPTSD,”May2,2008.

164 HonorableR.JamesNicholson,Secretary,U.S.DepartmentofVeteransAffairs, Testimony before the United States House of RepresentativesCommitteeonVeterans’Affairs,September18,2007:http://veterans.house.gov/hearings/Testimony.aspx?TID=4446.

165 DepartmentofVeteransAffairs,PressRelease,“VALeadingtheWayinCareforTraumaticBrainInjuries,”February27,2007:http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1302.

166 TheInstituteofMedicinehasmaderecommendationsregardingtheexpansion of the TBI Registry. See theNational Academies press release,“MilitaryPersonnelWithTraumaticBrainInjuryatRiskforSeriousLong-TermHealth Problems;More StudiesNeeded onHealth Effects of BlastInjuries,” December 4, 2008. http://www8.nationalacademies.org/onpin-ews/newsitem.aspx?RecordID=12436

167 VHAOfficeofPublicHealthandEnvironmentalHazards,“AnalysisofVAHealthCareUtilizationAmongUSGlobalWaronTerrorism(GWOT)VeteransOperationEnduringFreedomOperationIraqiFreedom,”January2009.

168 NumbersfromOctober2007suggestthatnearly20%oftroopsarescreeningpositiveforTBIsymptoms.GAO-08-276,p.8.Only6%areactuallyreceivingaTBIdiagnosis.Thisnumberisfarlowerthanthatpredictedbybraininjuryexperts.RickMaze,“VAsays6%ofcombatvetshaveTBIs,”Army Times,November4,2007.

169 GAO-08-276,p.7.

170 Over350IraqandAfghanistanveteranshaverequiredin-patient,round-the-clockcareatoneofthemilitaryandVApolytraumacenters.Departmentof Veterans’ Affairs, “VA Polytrauma System of Care: Frequently AskedQuestions,”April19,2007:http://www.polytrauma.va.gov/faq.asp#FAQ2.

171 Department of Veterans’ Affairs, “VA Polytrauma System of Care,”April19,2007:http://www.polytrauma.va.gov/index.asp.

172 VAOfficeofInspectorGeneral,“HealthcareInspection:HealthStatusofandServicesforOperationEnduringFreedom/OperationIraqiFreedomVeteransAfterTraumaticBrainInjuryRehabilitation,”June12,2006,p.3:http://www.pdhealth.mil/admin/nlAttachments/DHCCUploads/Healthcare_Inspection_OEF-OIF_TBI.pdf.

173 For the locations of the Polytrauma Rehabilitation Centers andNetworkSites,seehttp://www.polytrauma.va.gov/.

174 DepartmentofVeterans’Affairs,“VAPolytraumaSystemofCare,”April19,2007:http://www.polytrauma.va.gov/facility_locations.asp?isFlash=1.

175 DepartmentofVeteransAffairs,OfficeofInspectorGeneral,“Follow-upHealthcare Inspection,” VA’s Role in Ensuring Services for OperationEnduring Freedom/Operation Iraqi Freedom Veterans after TraumaticBrainInjuryRehabilitation.”May1,2008.

176 “PuttingPolytraumaCare‘ontheMap’”VA Research Currents,October2008.

177 Lucille Beck and Barbara Sigford, “Update onHealth Care: VA TBIScreeningProgram,”DepartmentofVeteransAffairs,September2008.

178 GAO-03-756T, “Department of Veterans Affairs: Key ManagementChallenges inHealthandDisabilityPrograms,”May8,2003,p.6:http://www.gao.gov/new.items/d03756t.pdf.

179 AnnScottTyson,“Youths inRuralU.S.AreDrawntoMilitary,”The Washington Post, November 4, 2005: http://www.washingtonpost.com/wp-dyn/content/article/2005/11/03/AR2005110302528.html.

180 ChrisAdams,“VAsystemill-equippedtotreatmentalanguishofwar,”McClatchy Newspapers, February 5, 2007: http://www.mcclatchydc.com/reports/veterans/story/15554.html.


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Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans

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