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Center for Military Health Policy Research A JOINT ENDEAVOR OF RAND HEALTH AND THE RAND NATIONAL SECURITY RESEARCH DIVISION THE ARTS This PDF document was made available from www.rand.org as CHILD POLICY a public service of the RAND Corporation. CIVIL JUSTICE EDUCATION Jump down to document6 ENERGY AND ENVIRONMENT HEALTH AND HEALTH CARE INTERNATIONAL AFFAIRS The RAND Corporation is a nonprofit research NATIONAL SECURITY organization providing objective analysis and POPULATION AND AGING PUBLIC SAFETY effective solutions that address the challenges facing SCIENCE AND TECHNOLOGY the public and private sectors around the world. 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RAND monographs present major research findings that address the challenges facing the public and private sectors. All RAND monographs undergo rigorous peer review to ensure high standards for research quality and objectivity. Invisible Wounds of War Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery TERRI TANIELIAN AND LISA H. JAYCOX, EDITORS Sponsored by the California Community Foundation Center for Military Health Policy Research A JOINT ENDEAVOR OF RAND HEALTH AND THE RAND NATIONAL SECURITY RESEARCH DIVISION This work was funded by a grant from the Iraq Afghanistan Deployment Impact Fund, which is administered by the California Community Foundation. The study was conducted jointly under the auspices of the Center for Military Health Policy Research, a RAND Health center, and the Forces and Resources Policy Center of the National Security Research Division (NSRD). Library of Congress Cataloging-in-Publication Data Tanielian, Terri L. Invisible wounds of war : psychological and cognitive injuries, their consequences, and services to assist recovery / Terri Tanielian, Lisa H. Jaycox. p. ; cm. Includes bibliographical references. ISBN 978-0-8330-4454-9 (pbk. : alk. paper) 1. Post-traumatic stress disorder—United States. 2. Brain—Wounds and injuries— United States. 3. Depression—United States. 4. Veterans—Mental health— United States. 5. Iraq war, 2003–—Psychological aspects. 6. Afghan war, 2001– —Psychological aspects. 7. War on terrorism, 2001–—Psychological aspects. 8. War—Psychological aspects. I. Jaycox, Lisa. II. Rand Corporation. III. Title. [DNLM: 1. Combat Disorders. 2. Brain Injuries. 3. Depressive Disorder. 4. Iraq War, 2003– . 5. Stress Disorders, Post-Traumatic. 6. Veterans—psychology. WM 184 T164i 2008] RC552.P67T34 2008 362.196'85212—dc22 2008008840 The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. Cover design by Eileen Delson La Russo Cover photo: U.S. Army photo by SPC Eric Jungels © Copyright 2008 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2008 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665 RAND URL: http://www.rand.org To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: [email protected] Preface Since October 2001, approximately 1.64 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Early evidence suggests that the psychological toll of these deployments—many involving prolonged exposure to combat-related stress over multiple rotations—may be disproportionately high compared with the physical injuries of combat. In the face of mounting public concern over post-deployment health care issues confronting OEF/ OIF veterans, several task forces, independent review groups, and a President’s Com- mission have been convened to examine the care of the war wounded and make rec- ommendations. Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder and traumatic brain injury. Many recent reports have referred to these as the signature wounds of the Afghanistan and Iraq conflicts. With the increasing incidence of suicide and suicide attempts among returning veterans, concern about depression is also on the rise. The study discussed in this monograph focuses on post-traumatic stress disorder, major depression, and traumatic brain injury, not only because of current high-level policy interest but also because, unlike the physical wounds of war, these conditions are often invisible to the eye, remaining invisible to other servicemembers, family members, and society in general. All three conditions affect mood, thoughts, and behavior; yet these wounds often go unrecognized and unacknowledged. The effect of traumatic brain injury is still poorly understood, leaving a large gap in knowledge related to how extensive the problem is or how to address it. RAND conducted a comprehensive study of the post-deployment health-related needs associated with post-traumatic stress disorder, major depression, and traumatic brain injury among OEF/OIF veterans, the health care system in place to meet those needs, gaps in the care system, and the costs associated with these conditions and with providing quality health care to all those in need. This monograph presents the results of that study. These results should be of interest to mental health treatment providers; health policymakers, particularly those charged with caring for our nation’s veterans; and U.S. service men and women, their families, and the concerned public. All the research products from this study are available at http://veterans.rand.org. iii iv Invisible Wounds of War Data collection for this study began in April 2007 and concluded in January 2008. Specific activities included a critical review of the extant literature on the prevalence of post-traumatic stress disorder, major depression, and traumatic brain injury and their short- and long-term consequences; a population-based survey of servicemembers and veterans who served in Afghanistan or Iraq to assess health status and symptoms, as well as utilization of and barriers to care; a review of existing programs to treat servicemembers and veterans with post-traumatic stress disorder, major depression, and traumatic brain injury; focus groups with military servicemembers and their spouses; and the development of a microsimulation model to forecast the economic costs of these conditions over time. Interviews with senior Office of the Secretary of Defense (OSD) and Service (Army, Navy, Air Force, Marine Corps) staff within the Department of Defense and within the Veterans Health Administration informed our efforts to document the treatment and support programs available to this population. Note, however, that the views expressed in this monograph do not reflect official policy or the position of the U.S. government or any of the institutions we included in our interviews. This work was funded by a grant from the Iraq Afghanistan Deployment Impact Fund, which is administered by the California Community Foundation. The fund had no role in the design and conduct of this study; collection, management, analysis, or interpretation of data; or in the preparation of this document. The study was conducted jointly under the auspices of the Center for Military Health Policy Research, a RAND Health center, and the Forces and Resources Policy Center of the National Security Research Division (NSRD). The principal investigators are Terri Tanielian and Lisa H. Jaycox. More information about RAND is available at www.rand.org. Preface v Study Directors Terri Tanielian Lisa H. Jaycox Management Team Terri Tanielian Lisa S. Meredith Lisa H. Jaycox Christine Eibner M. Audrey Burnam Jeanne S. Ringel Terry L. Schell Karen N. Metscher Grant N. Marshall Gail Fisher Benjamin R. Karney Survey Team Systems of Care Terry L. Schella M. Audrey Burnama Grant N. Marshalla Lisa S. Mereditha Jeremy N. V. Miles Elizabeth D’Amico Gail Fisher Todd C. Helmus Karen N. Metscher Robert A. Cox Lisa H. Jaycox Laurie T. Martin Terri Tanielian Diane C. Schoeff Rachel M. Burns Economics/Costs Kayla M. Williams Christine Eibnera Michael R. Yochelson Jeanne S. Ringela Ellen Burke Beckjord Beau Kilmer Andrew M. Parker Rosalie Liccardo Pacula Manan M. Trivedi Claudia Diaz Sarah Gaillot Regina A. Shih Communications Support Literature Review of Consequences Mary E. Vaianaa Benjamin R. Karneya David M. Adamson Rajeev Ramchand Jerry M. Sollinger Karen Chan Osilla Leah Barnes Caldarone Administrative Support Rachel M. Burns Samantha Abernethy Catherine Chao Taria Francois Stacy Fitzsimmons Michael Woodward a Denotes team leader. Contents Preface ................................................................................................. iii Figures ................................................................................................xiii Tables ..................................................................................................xv Summary ............................................................................................. xix Acknowledgments ................................................................................ xxxv Abbreviations .................................................................................... xxxvii Part I: Introduction, Current Policy Context, and Historical Perspective ................ 1 CHAPTER ONE Introduction ........................................................................................... 3 Signature Wounds ..................................................................................... 3 Unique Features of the Current Deployments ..................................................... 5 Changes in Military Operations, Including Extended Deployments ......................... 5 Higher Rates of Survivability from Wounds ..................................................... 6 Traumatic Brain Injuries ........................................................................... 6 Caring for Invisible Wounds .......................................................................... 7 The Current Policy Context .......................................................................... 9 The Purpose of the RAND Study ...................................................................11 Scope of the Monograph ............................................................................12 Organization of This Monograph ...................................................................14 References ..............................................................................................15 CHAPTER TWO The Wars in Afghanistan and Iraq—An Overview ............................................19 What the Current Fighting Force Looks Like .....................................................19 Troops Deployed to OEF/OIF ....................................................................21 The Conflicts in Perspective .........................................................................21 What Makes the Conflicts in Afghanistan and Iraq Different? .............................. 22 Operation Enduring Freedom .................................................................... 23 Operation Iraqi Freedom .......................................................................... 24 vii viii Invisible Wounds of War Casualties and Improvised Explosive Devices .....................................................25 The Military and Veterans Health Systems ....................................................... 27 Concluding Comments ..............................................................................29 References ............................................................................................. 30 Part II: The Nature and Scope of the Problem .................................................33 CHAPTER THREE Prevalence of PTSD, Depression, and TBI Among Returning Servicemembers ........35 Methods ................................................................................................35 Results ................................................................................................. 36 Screening for PTSD, Depression, and TBI in Epidemiological Surveys .................... 36 Defining a Case .....................................................................................37 Mental and Cognitive Conditions Pre-Deployment ........................................... 42 Mental and Cognitive Conditions in Theater .................................................. 42 Mental and Cognitive Conditions Post-Deployment .......................................... 43 Emergent Themes .....................................................................................47 Discussion ............................................................................................. 54 Consistencies and Inconsistencies Across Studies .............................................. 54 Strengths and Limitations of the Existing Studies ..............................................55 Future Research Directions ..........................................................................57 Conclusion .............................................................................................58 References ..............................................................................................82 CHAPTER FOUR Survey of Individuals Previously Deployed for OEF/OIF .................................. 87 Introduction .......................................................................................... 87 Methods ............................................................................................... 88 Eligibility and Sampling .......................................................................... 88 Informed Consent ..................................................................................91 Interviews ............................................................................................91 Measures ............................................................................................91 Statistical Analysis ................................................................................. 94 Results ................................................................................................. 96 Discussion ............................................................................................ 103 Strengths and Limitations ....................................................................... 110 Conclusions ......................................................................................... 112 References ............................................................................................ 113