Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families
The wars in Iraq and Afghanistan have been the longest sustained U.S.
military operations since the Vietnam era, sending more than 2.2 million
troops into battle, and resulting in more than 6,600 deaths and 48,000 injuries.
Many service members returning from the conflicts in Iraq and Afghanistan
are relatively unscathed. Upon return, the vast majority report that their
experiences were rewarding, and they readjust to life off the battlefield with
few difficulties. Others, however, return with varied complex health conditions
and find that readjusting to life at home, reconnecting with family, finding
work, or returning to school is an ongoing struggle.
In response to the surge of Iraq and Afghanistan veterans returning with
lingering problems, Congress required the Department of Defense (DoD) and
the Department of Veterans Affairs (VA) to study their physical and mental
health, and other readjustment needs. The Institute of Medicine (IOM) committee
conducted this congressionally mandated assessment in two phases.
The result of the second phase, Returning Home from Iraq and Afghanistan:
Assessment of Readjustment Needs of Veterans, Service Members, and Their
Families, presents the IOM committee’s comprehensive assessment of the
physical, psychological, social, and economic effects of deployment on service
members, their families, and communities.
Multiple, Overlapping Stressors from Deployment
The all-volunteer troops engaged in these extended military operations in Iraq
and Afghanistan have included more women, parents of young children, and
reserve and National Guard troops than those in previous conflicts. Military personnel often have served longer deployments
with shorter intervals at home between missions.
Although the majority of returning troops
have readjusted well to post-deployment life,
44 percent have reported difficulties after they
returned. Significant numbers of personnel
deployed to Iraq and Afghanistan have suffered
traumatic brain injuries (TBI) and many have
shown symptoms of posttraumatic stress disorder
(PTSD), depression, and substance misuse or
abuse. In the scientific literature, the estimates of
the prevalence of those conditions among service
members who served in these two conflicts range
from 19.5 to 22.8 percent for mild TBI (commonly
known as concussion), 4 to 20 percent for PTSD, 5
to 37 percent for depression, and 4.7 to 39 percent
for problematic alcohol use.
These military and veteran personnel often
have more than one health condition. The most
common overlapping health disorders are PTSD,
substance use disorders, depression, and symptoms
attributed to mild TBI. In 2010, nearly 300
service members committed suicide, and about
half of those suicides involved service members
who had deployed to Iraq or Afghanistan.
On top of contending with lingering health
problems, returning service members had other
difficulties readjusting to civilian life. In 2011, the
unemployment rate among all post-9/11 veterans
aged 18 to 24 was 30.2 percent, compared with
16.1 percent for similarly aged nonveterans.
Further, military sexual trauma has been
occurring in high rates throughout the U.S. armed
forces, including the Iraq and Afghanistan theaters.
Sexual harassment and assaults disproportionately
affect women; they have both mental
and physical ramifications, and in many cases
these victims have a difficult time readjusting.
The depth and breadth of challenges faced
by returning military service members varies
and are the result of a complex interplay of factors.
And today’s challenges are just a prelude
to future problems. Previous wars have demonstrated
that veterans’ needs peak several decades
after their war service, highlighting the necessity of managing current problems and planning for
future needs. Moreover, if their readjustment is
to be successful, the IOM committee concludes,
the difficulties that service members and veterans
face must be addressed by primary prevention,
diagnostics, treatment, rehabilitation, education,
outreach, and community support programs.
Focusing on Evidence-Based
In many ways, the DoD and the VA are at the forefront
of providing evidence-based care for service
members with TBI and psychological health problems.
But challenges exist in both systems. Not all
service members and veterans who need treatment
receive it. Recent increases in hiring may
help to alleviate a shortage of clinicians; however,
unrealized opportunities remain in improving clinician
training and evaluation. When care departs
from the scientific evidence base and varies significantly
from clinician to clinician, patients may
receive poor quality care.
While the DoD and the VA have assembled an
array of programs and interventions to meet the
needs of Iraq and Afghanistan service members,
veterans, and their families, more needs to be
done to evaluate their effectiveness. For example,
when the DoD assesses cognitive function after a
head injury, it uses a tool whose effectiveness has
no clear scientific evidence base. Also, research
shows that restricting access to lethal means to
carry out a suicide, such as a gun, prevents suicides.
Even if a service member is at risk for suicide,
however, a DoD policy prohibits restricting
access to privately owned weapons. The VA has
included Acceptance and Commitment Therapy
for depression in its national rollout of preferred
mental health treatments, but the therapy lacks
sufficient scientific evidence to support its use as
a first-line intervention.
What’s more, the committee has serious misgivings
about inadequate and untimely clinical
follow-up and low rates of delivery of evidence-based treatments, especially therapies to treat
PTSD, depression, and substance use disorder.
There are scant data documenting which treatments
patients receive or whether those treatments
were appropriate and timely.
The committee recommends that the DoD
and the VA systematically and periodically evaluate
clinicians after training to ensure they administer
therapeutic interventions in ways that are
supported by scientific evidence. Further, the two
departments should align treatments with the
evidence base, especially before any treatment is