American service members have sacrificed a great deal in the battles in Afghanistan and Iraq, and many of those who have returned are still battling. Only now they are not fighting the enemy around them. They are, at times, fighting an even more elusive foe within—the psychological effects of war. This foe is often not recognized or acknowledged. Moreover, the system that provides treatment for psychological trauma for veterans is not always well implemented.

More than 1.6 million American service members have deployed to Iraq and Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), and over 565,000 have deployed more than once (Veterans for Common Sense, 2008). As of December 2008, more than 4,200 troops have been killed and over 30,800 have returned from a combat zone with visible wounds and a range of permanent disabilities (O’Hanlon and Campbell 2008). In addition, an estimated 25-40 percent have less visible wounds—psychological and neurological injuries associated with Post Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI) (Tanielian and Jaycox 2008; Hoge, et al. 2008).

It is common to make a distinction between visible injuries such as orthopedic injuries, burns, and shrapnel wounds and less visible injuries such as PTSD. The distinction often is characterized as “physical” versus “mental” injuries. These terms imply that PTSD somehow is not physical. However, this is an artificial distinction. PTSD and other “mental illnesses” are characterized by measurable changes in the brain and in the hormonal and immune systems. In this report, we use the terms “visible” and “not visible” to make the distinction.

Although PTSD and TBI have different origins—PTSD is caused by exposure to extreme stress, whereas TBI is caused by blast exposure or other head injury—they are closely related. People with TBI are more prone to PTSD, and many people with PTSD may have co-morbid undiagnosed mild TBI. Substance abuse, often associated with both injuries, complicates the situation for many people. Although this report focuses on PTSD and TBI, these injuries account for only a portion of the mental health issues affecting our service members including depression, generalized anxiety disorders, substance abuse, and interpersonal conflicts.

War is inherently a traumatic experience, but PTSD can be mitigated through prevention and training programs prior to deployment, effective stress reduction techniques during operations, and treatment programs after combat exposure. DoD, VA, and civilian researchers have developed many strategies to diminish the onset of PTSD and treat both the direct symptoms of PTSD and its impact on the individual’s ability to function.

Despite these strategies, a plethora of evidence points to gaps in the current health care system for service members and veterans. Media reports, Congressional inquiries, commissions, and lawsuits have revealed deficiencies in outreach, access, care coordination, and treatment. The evidence points to wide variations in access to mental health services; an inadequate supply of mental health providers; resistance on the part of some military leaders to adopt new attitudes; and resistance on the part of the service member or veteran to seek service because of the stigma associated with psychological disorders.

In the past several years, DoD and VA have developed a number of new programs, policies, and strategies to address the mental health needs of service members and veterans of OEF/OIF. For example, Congress extended the automatic eligibility for services through the Veterans Health Administration from two years to five; DoD instituted mandatory PTSD screening upon service members’ return from combat as well as a reassessment 3-6 months later; VA has developed treatment protocols that incorporate evidence-based practices; the Vet Centers have hired additional staff to provide outreach; and DoD and VA are working toward integrating their systems to be more effective.

Although DoD and VA have dedicated unprecedented attention and resources to address PTSD and TBI in recent years (eg. Defense Centers of Excellence), and some evidence suggests that these policies and strategies have had a positive impact, work still needs to be done. In 2007, the Department of Defense Task Force on Mental Health concluded that “Despite the progressive recognition of the burden of mental illnesses and substance abuse and the development of many new and promising programs for their prevention and treatment, current efforts are inadequate to ensure the psychological health of our fighting forces. Repeated deployments of mental health providers to support operations have revealed and exacerbated pre-existing staffing inadequacies for providing services to military members and their families. New strategies to effectively provide services to members of the Reserve Components are required. Insufficient attention has been paid to the vital task of prevention” (US DoD Task Force on Mental Health 2007).

The situation requires an urgent response. While the intensity of combat and the number of enemy initiated attacks has fallen since mid 2007, service members continue to struggle with the wounds of PTSD that they acquired earlier in the war and that others continue to acquire. Early intervention and timely rehabilitation is critical to maximizing the long-term health outcomes of the men and women who served in Iraq and Afghanistan.

NCD's study examines evidence based approaches for prevention, diagnosis, and treatment of PTSD, reviews preliminary indications of many new strategies being implemented by VA and DoD, and concludes that the extra attention being devoted to this disability is not only warranted, but has the potential to greatly reduce financial and human costs for all concerned.

NCD recognizes that these issues have been studied by other governmental and professional organizations. This report attempts to augment the recommendations of these previous studies with a focus on barriers to access to care for citizens with disabilities; the importance of early intervention and comprehensive rehabilitation to minimize the long term effects of disability; and the need for continuing consumer involvement both in the rehabilitation of individuals and the oversight of the implementation of the many policy and service delivery changes needed to effectively address the rehabilitative needs of service members and veterans.

This report is structured as follows in the succeeding sections:

• Section 2 provides a brief description of the demographic composition of the fighting forces and their experiences in the combat theater. Many of these characteristics are associated with an increased risk of PTSD.
• Section 3 describes the symptoms, prevalence and risk factors for PTSD and TBI.
• Section 4 reviews the evidence-based approaches for preventing and treating PTSD and TBI.
• Section 5 reviews the systems that are in place and discusses how they differ from the evidence based approaches described in Section 4.
• Section 6 addresses the issue of service members not availing themselves of all services.
• Section 7 describes special issues affecting the families of service members and the availability of services to address these issues.
• Section 8 presents NCD’s recommendations.

In preparing this report, NCD gathered information from scientific journals, professional conferences, commission reports, VA and DoD protocols and regulations, Congressional testimony, newspaper reports, advocacy websites and papers, blogs, on-line support groups, and interviews. These sources represent a range of perspectives including those of DoD and VA leaders, mental health providers, veterans, advocates, parents, and spouses.

Some of the information and recommendations were drawn from the reports of recent task forces and commissions, including the President's Commission on Care for America's Returning Wounded Warriors (the Dole/Shalala Commission); the Task Force on Returning Global War on Terror Heroes (the Nicholson Task Force); the Veterans Disability Benefits Commission; the Department of Defense Task Force on Mental Health; the American Psychological Association’s Presidential Task Force on Military Deployment Services for Youth, Families and Service Members; and, the US Army Surgeon General’s Mental Health Advisory Team’s annual assessment of needs and survey of deployed troops. A complete list of sources is provided at the end of the report.