Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery

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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. 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 servicemenbers, family members, and society in general.
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Product Details

  • ISBN-13: 9780833044549
  • Publisher: Rand Publishing
  • Publication date: 6/15/2008
  • Edition description: New Edition
  • Pages: 424
  • Product dimensions: 7.00 (w) x 9.90 (h) x 1.20 (d)

Table of Contents

Preface iii Figures xiii Tables xv Summary xix Acknowledgments xxxv Abbreviations xxxvii Part I Introduction, Current Policy Context, and Historical Perspective 1 Chapter 1 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 2 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 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 3 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 4 Survey of Individuals Previously Deployed for OEF/OIF 87 Introduction 87 Methods 88 Eligibility and Sampling 88 Informed Consent 91 Interviews 91Measures 91 Statistical Analysis 94 Results 96 Discussion 103 Strengths and Limitations 110 Conclusions 112 References 113 Part III Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury 117 Chapter 5 Predicting the Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury in Veterans of Operation Enduring Freedom and Operation Iraqi Freedom 119 The Challenge of Predicting the Future 119 Goals and Scope of Our Discussion 120 Theoretical Perspectives on the Consequences of Mental Health and Cognitive Conditions 120 The Stress-Diathesis Model 121 Life-Span Developmental Perspectives 122 An Integrated Model of the Consequences of Post-Combat Mental Health and Cognitive Conditions 123 Empirical Research on the Consequences of Post-Combat Mental Health and Cognitive Conditions 124 Co-Morbidity and Other Mental Health Problems 125 Suicide 128 Physical Health and Mortality 131 Substance Abuse 134 Labor-Market Outcomes: Employment and Productivity 136 Homelessness 140 Marriage and Intimate Relationships 141 Parenting and Child Outcomes 146 Summary and Recommendations 149 Recommendations for Future Research 150 Conclusions 152 References 153 Part IV Economic Consequences 167 Chapter 6 The Cost of Post-Deployment Mental Health and Cognitive Conditions 169 Introduction 169 Prior Cost Estimates 172 The Cost of PTSD and Major Depression and the Benefits of Evidence-Based Care 175 Background 175 Motivation for the Microsimulation Approach 176 Overview of the Microsimulation Framework 177 Model Limitations 186 Model Results 189 Discussion 199 The Cost of Deployment-Related Traumatic Brain Injury in 2005 201 Previous Estimates of the Cost of TBI 202 Data and Assumptions Regarding Deployment-Related TBI and Costs 203 Estimates of the Cost of Deployment-Related TBI in 2005 210 Limitations 213 Discussion 214 Conclusion 214 Appendix 6.A Model Map 217 Appendix 6.B Model Architecture, Assumptions, and Parameters 221 References 234 Part V Caring for the Invisible Wounds 243 Chapter 7 Systems of Care: Challenges and Opportunities to Improve Access to High-Quality Care 245 Introduction 245 Access and Quality Challenges 247 Study Approach 248 Access to Mental Health Care for PTSD and Major Depression 250 What Is the Gap in Access to Care? 250 Overview of Health Service Systems 253 What Structural Factors Impede or Facilitate Access to DoD Mental Health Services? 255 What Structural Factors Impede or Facilitate Access to Mental Health Services Within the VA? 263 Transitions and Coordination Across Systems Pose Challenges to Access and Continuity of Care 270 State and Local Community Initiatives Aim to Fill Gaps in Access 274 What Social, Cultural, and Personal Factors Impede or Facilitate Servicemembers' and Veterans' Access to Mental Health Care? 275 Quality of Mental Health Care 282 What Is High-Quality Evidence-Based Treatment for PTSD and Major Depression? 283 What Organizational Models Support High-Quality Mental Health Care? 284 To What Extent Are Quality Standards and Processes for Mental Health Care Supported in Systems of Care for Veterans and Military Servicemembers? 288 Summary of Critical Gaps 296 Gaps in Access to Care and Care Quality for Active Duty Military Servicemembers 296 Gaps in Access to Care and Care Quality for OEF/OIF Veterans 301 Special Issues for Traumatic Brain Injury 304 Mild TBI 306 Moderate and Severe TBI 310 What Is High-Quality Care for TBI? 320 Summary of Gaps and Recommendations for TBI Services 323 Appendix 7.A Approach to Interviews with Administrators and Providers 327 Appendix 7.B Summary of Focus Groups with Military Servicemembers and Spouses 329 Appendix 7.C Evidence-Based Practices 335 Appendix 7.D Studies of Mental Health Services Utilization Among Servicemembers 391 Appendix 7.E State and Local Mental Health Resources 398 References 404 Part VI Conclusions and Recommendations 429 Chapter 8 Treating the Invisible Wounds of War: Conclusions and Recommendations 431 Key Findings 433 Prevalence of Mental Health Conditions and TBI 433 Long-Term Consequences of Mental Health and Cognitive Conditions 436 Costs 438 Systems of Care 440 Strengths and Limitations 445 Recommendations 446 Treating the Invisible Wounds of War 452 References 453
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