Addressing the Invisible Wounds of War

RAND Solution

Sailors aboard the USS San Jacinto pray for suicide victims during a suicide prevention and awareness event called Walk Out of Darkness

Challenge

By 2007, concerns had been voiced over the high instance of post-traumatic stress disorder (PTSD) and exposure to traumatic brain injury (TBI) among U.S. troops returning from Iraq and Afghanistan. However, little was known about how the availability of behavioral health services compared with the need among returning troops—or about the consequences to the nation if these needs were not met.

Context

Depressed man on bench

Exposure to traumatic stress has always been a part of combat. In Iraq and Afghanistan, however, advances in combat medicine and body armor meant that the lives of wounded soldiers that would likely have been lost in previous conflicts were instead being saved—though with significant physical, emotional, and cognitive impairments. In 2007, concerns about PTSD and TBI were sparking media attention and additional health assessments of service members. As the news over living conditions at the Walter Reed Army Medical Center broke, there were growing concerns about how returning service members were being treated. Several working groups and commissions identified the signature wounds of these conflicts as PTSD and TBI, but they did not examine the capacity of the system to meet treatment needs. By and large, the invisible nature of these conditions rendered them unrecognized and unacknowledged among service members, resulting in unmet need and suffering. As of 2007, there was no systematic quantification of the prevalence and treatment of behavioral health problems and injuries among returning service members, nor of the costs involved.

“The research project . . . is the first and only large-scale, nongovernmental assessment of the psychological needs of Iraq and Afghanistan veterans”

Lisa Simpson, president and CEO of AcademyHealth

Project Description

The California Community Foundation sponsored a study by RAND to fill these information gaps for PTSD, major depression, and TBI. RAND assembled a team of over 30 experts in psychology, economics, public health, and related fields to review scientific research, survey service members and veterans, assess systems of care, and develop an econometric model to estimate costs. The study was the first of its kind to take a comprehensive view from a societal perspective.

Research Questions

  1. What is the scope of mental health and cognitive conditions that troops face when returning from deployment to Afghanistan and Iraq?
  2. What are the costs of these conditions, including the costs of treatment and of lost productivity? What are the costs and potential savings associated with different levels of medical care?
  3. What existing programs meet the health-related needs of service members with PTSD, major depression, or TBI? What are the gaps in these programs and what steps can be taken to close them?

Key Findings & Recommendations

  • In 2007, 18.5 percent of U.S. service members who had returned from Iraq or Afghanistan had PTSD or depression, and 19 percent had reported experiencing a TBI while deployed.
  • There are significant short- and long-term cascading consequences associated with these disorders. The two-year post-deployment costs of PTSD and depression are significant, as high as $6.2 billion; however, providing high quality, evidence-based treatment to everyone with these conditions would save money or pay for itself within the same time frame.
  • Roughly half of those who needed treatment for those conditions sought it, but only slightly more than half of those receiving it were getting even minimally adequate care. Service members reported barriers to seeking care including concerns about negative career repercussions.

Recommendations

  • Increase the cadre of providers who are certified to deliver evidence-based care, so that capacity is adequate for needs.
  • Change policies to encourage more active-duty personnel and veterans to seek needed care.
  • Deliver proven, evidence-based care to service members and veterans.
An Army psychiatrist speaks with a soldier

Impact

  • The RAND study raised the profile of behavioral and cognitive health problems among returning veterans. In the days and weeks following release of the report, these problems were discussed by congressional committees, and in newspaper editorials and stories across the country.
  • The RAND work was the only research cited in the White House’s Joining Forces Initiative, established in January 2011 to guide federal agency efforts to support military families.
  • Within weeks of the release, DoD announced changes to its applications for security clearance to exempt service members from reporting that they had received combat- or family-related counseling from a mental health professional. RAND had reported that acknowledging such treatment had been perceived by service members as having negative career consequences.
  • The Chairman of the Joint Chiefs of Staff called for screening for all returning military personnel, including face-to-face evaluations for PTSD.
  • The findings galvanized citizens and policy makers, and led to large psychological and cognitive health projects funded by the DoD both at RAND and elsewhere. Ongoing projects consider Pentagon programs addressing suicide, family resilience, quality of care, program effectiveness, and other issues related to behavioral health.

“Congress relies upon this kind of rigorous analysis and objective assessment to help frame our policy choices.”

Senator Edward M. Kennedy and U.S. Congresswoman Gwen Moore, letter to AcademyHealth, July 16, 2009

“Invisible Wounds of War provided the nation with a much needed 'wakeup call' on PTSD, TBI, and depression among combat veterans.”

Excerpt from Why We Help, Caring for Military Families, Elizabeth Dole Foundation, 2013