Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military: Oversight Issues for Congress
Congressional research reportAug 8, 2013
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Post-Traumatic Stress Disorder and Other
Mental Health Problems in the Military:
Oversight Issues for Congress
(name redacted)
Analyst in Foreign Affairs
(name redacted)
Analyst in Defense Health Care Policy
August 8, 2013
Congressional Research Service
7-....
www.crs.gov
R43175
CRS Report for Congress
Prepared for Members and Committees of Congress
Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Summary
Military servicemembers suffering from post-traumatic stress disorder (PTSD), traumatic brain
injury (TBI), and depression, as well as military suicides, continue to be a major concern of
Congress. Numerous legislative provisions have been enacted over the past years to address these
issues. Members will likely seek to offer legislation in the 113th Congress to address this complex
set of issues. This report is intended to provide assistance in understanding the issues associated
with psychological health in the active duty forces, potential congressional responses, and what
questions may remain unanswered.
Key points in this report include the following:
•
mental disorders such as PTSD are poorly understood and in most cases cannot be
physically identified but, rather, must be diagnosed using symptoms reported by the
servicemember;
•
estimates of the prevalence of mental health conditions in any given population may
be greatly affected by the methodology used;
•
diagnoses of mental health conditions among active duty servicemembers have
increased substantially relative to non-deployed servicemembers. This increase may
be due to the psychological toll of exposure to conflict, but may also be due in part to
increased and improved screening methods as well as Department of Defense (DOD)
efforts to reduce the stigma associated with seeking mental health treatment that
might dissuade some servicemembers from reporting mental health concerns or
accessing care; and
•
reliable evidence is lacking as to the quality of mental health care and counseling
offered in DOD facilities. A 2012 Institute of Medicine (IOM) study recommended
that DOD undertake efforts to measure the effectiveness of efforts to improve quality,
such as training providers in evidence-based practice, that are not integrated into the
system of mental health care offered in DOD treatment facilities.
Significant areas for potential congressional oversight activities regarding psychological health in
the active duty forces include the following:
•
research into the causes and physical manifestations of psychological health
conditions, screening tools, and treatments;
•
the effectiveness of screening and treatment efforts;
•
servicemembers’ access to mental health care, including efforts to reduce the stigma
of seeking mental health care, waiting times for care, staffing levels of mental health
treatment professionals, mental health care available in remote or deployed settings,
and care available to de-activated Reserve and Guard members;
•
the quality of mental health care available to servicemembers, including the use of
appropriate and effective treatments by qualified mental health treatment
professionals;
•
oversight of ongoing program evaluation efforts, including evaluation of the variety
of suicide-prevention, stigma-reduction, and transition assistance programs within the
services and DOD; and
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
•
the costs of mental health care for active duty servicemembers, including present
costs through the Defense Health Program, as well as the future costs of mental
health care once servicemembers are no longer part of the active duty forces.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Contents
Introduction...................................................................................................................................... 1
Psychological Health in the Military ......................................................................................... 1
Mental Health Disorders, Including PTSD, Anxiety, and Depression ................................ 1
Traumatic Brain Injury (TBI) .............................................................................................. 7
Suicide ................................................................................................................................. 8
Screening and Treatment Programs ................................................................................................. 9
Screening ................................................................................................................................... 9
Accession Screening ........................................................................................................... 9
Periodic Health Assessment—Annual Physical ................................................................ 10
Pre-Deployment and Post-Deployment Mental Health Assessments and
Reassessments ................................................................................................................ 10
Deployment Limiting Conditions...................................................................................... 10
Treatment Programs ................................................................................................................ 11
Mental Health Providers.................................................................................................... 11
Clinical Practice Guidelines .............................................................................................. 12
Stigma Reduction Efforts .................................................................................................. 13
Costs of Mental Disorder Treatment ................................................................................. 13
Other Responses ...................................................................................................................... 15
Prevention Programs ......................................................................................................... 15
Defense Centers of Excellence for Psychological Health and Traumatic Brain
Injury .............................................................................................................................. 16
Past Recommendations and Actions .............................................................................................. 16
Reports, Studies, and Recommendations................................................................................. 16
Institute of Medicine ......................................................................................................... 17
RAND National Defense Research Institute ..................................................................... 18
DOD Task Force on the Prevention of Suicide ................................................................. 18
Army Health Promotion, Risk Reduction, and Suicide Prevention .................................. 18
Mental Health Advisory Team Reports ............................................................................. 19
Executive Order 13625 ............................................................................................................ 19
Previous Congressional Actions .................................................................................................... 20
Previous Congressional Funding ............................................................................................. 20
Issues for Congress ........................................................................................................................ 22
Research .................................................................................................................................. 22
Treatment ................................................................................................................................. 22
Access to Care ......................................................................................................................... 23
Suicide Prevention ................................................................................................................... 23
Oversight ................................................................................................................................. 23
Costs of Mental Health Care Treatment .................................................................................. 24
Psychological Health in the Active Duty Forces ........................................................................... 24
Data Caveats ............................................................................................................................ 24
PTSD ................................................................................................................................. 26
Alcohol and Drug-Use Disorders ...................................................................................... 31
Depressive Disorders......................................................................................................... 36
Adjustment Disorder ......................................................................................................... 38
Other Conditions ............................................................................................................... 39
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Traumatic Brain Injury (TBI) .................................................................................................. 41
Overview ........................................................................................................................... 41
Prevalence in the Military ................................................................................................. 42
Causes ............................................................................................................................... 45
Associated Illnesses........................................................................................................... 47
Suicide ..................................................................................................................................... 48
Overview ........................................................................................................................... 48
Prevalence in the Military ................................................................................................. 48
Suicide and Suicide Attempt Methods .............................................................................. 51
Contextual Factors............................................................................................................. 53
Deployments, Combat Exposure, and Psychological Health Disorders ........................................ 54
Repeated Deployments ............................................................................................................ 54
Dwell Time .............................................................................................................................. 55
Combat-Specific and Health Care Occupations ...................................................................... 57
Figures
Figure 1. Number of Mental Disorder Diagnoses, 2000-2011......................................................... 2
Figure 2. Diagnoses of Mental Disorders in the Active Duty Forces, 2000-2011 ........................... 3
Figure 3. Incidence Rate of Mental Disorder Diagnoses, 2001-2011 .............................................. 4
Figure 4. Incidence Rate of Selected Mental Health Conditions by Service, 2010 ......................... 5
Figure 5. Hospitalizations for Mental Disorders.............................................................................. 6
Figure 6. Other Mental Health Problems in the Active Duty Forces, 2011 ..................................... 7
Figure 7. TBI Incidence by Severity, 2001-2012 ............................................................................. 8
Figure 8. Costs of Military Mental Disorder Treatment for Active Duty and Activated
Guard/Reserve ............................................................................................................................ 14
Figure 9. Active Duty and Activated Guard/Reserve Mental Disorder Treatment Costs,
FY2012 ....................................................................................................................................... 15
Figure 10. Incidence of PTSD by Service, Active Component ..................................................... 28
Figure 11. PTSD Diagnoses Among Deployed and Non-Deployed Active Duty
Servicemembers, Calendar Years 2000-2012 ............................................................................. 30
Figure 12. Rates of Alcohol-Related Diagnoses Among the Active Duty Component,
2000-2009 ................................................................................................................................... 33
Figure 13. Incidence Rate of Substance Abuse Disorder Diagnoses ............................................. 34
Figure 14. Incidence Rate of Substance Abuse Disorder Diagnoses ............................................. 35
Figure 15. Illicit Drug Misuse by Servicemembers, 2002-2008 .................................................... 36
Figure 16. Incidence Rates of Major Depressive Disorder Among the Active Component
Services, 2007-2010 ................................................................................................................... 38
Figure 17. Incidence of Other Mental Health Problems ................................................................ 40
Figure 18. TBI Injuries by Severity, 2001-2012 ............................................................................ 43
Figure 19. TBI Incidence by Severity, 2001-2012 ......................................................................... 44
Figure 20. TBIs by Severity and Service, 2001-2011 .................................................................... 46
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Figure 21. Suicides Among the Active Duty Forces, by Service ................................................... 48
Figure 22. Suicide in the Active Duty Forces, 1998-2011 ............................................................. 49
Figure 23. Suicides by Service, 1998-2011 ................................................................................... 50
Figure 24. Suicide Rates by Method of Suicide ............................................................................ 52
Figure 25. Percentage of Deployed Servicemembers Diagnosed with Selected Mental
Disorders, by “Dwell Times,” by Gender, 2003-2010 ................................................................ 57
Figure 26. Percentage of Deployed Servicemembers Diagnosed with Selected Mental
Disorders, by Number of Deployments and Military Occupational Group, 2003-2010............. 59
Figure A-1. Codes Used by the Medical Surveillance Monthly Report and the Armed
Forces Medical Examiners to Track Mental Health Diagnoses and Other Behavioral
Health Concerns ......................................................................................................................... 60
Tables
Table 1. Reported Changes in Incidence Rates of Mental Disorder Diagnoses Between
2000-2011 ..................................................................................................................................... 3
Table 2. Changes in Incidence Rates of DSM-IV “V Codes” Between 2000-2011......................... 6
Table 3. Funding for Psychological Health (including PTSD and TBI) ........................................ 20
Table 4. Funds Allocated for Psychological Health, FY2007-FY2013 ......................................... 21
Table 5. Symptoms and Severity of Non-Penetrating Traumatic Brain Injuries............................ 41
Appendixes
Appendix A. Diagnostic Codes...................................................................................................... 60
Appendix B. Legislation ................................................................................................................ 61
Contacts
Author Contact Information........................................................................................................... 68
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Introduction
The psychological health of active duty servicemembers has been an issue of significant concern
for Congress in recent years, with particular attention to the links between deployments and
psychological health concerns, such as post-traumatic stress disorder (PTSD). News stories have
emphasized the challenges faced by some servicemembers returning from deployments, but
psychological health is a salient issue for the entire active duty force. It should also be pointed out
that mental health issues are not unique to servicemembers or military service. Research suggests
that an estimated 26.2% of Americans ages 18 and older experience a diagnosable mental
disorder in any given year.1
Within the Department of Defense (DOD), the Office of the Assistant Secretary of Defense
(Health Affairs) is primarily responsible for the medical aspects of mental health issues. The
individual military services (Army, Navy, Marine Corps, and Air Force) also conduct a variety of
mental health programs and suicide prevention efforts. In 2012, a Defense Suicide Prevention
Office was opened to provide suicide prevention services across all the services.
This report will discuss the prevalence of different psychological health concerns within the
Armed Forces, current mental health screening and treatments, and DOD responses. It will also
provide an overview of the recommendations of key reports and studies, past congressional
actions and funding, and current issues for Congress. Finally, the report discusses specific mental
health issues, including PTSD, alcohol and drug use disorders, depressive disorders, traumatic
brain injury, and suicide in more detail.
This report does not address veterans. Veteran’s mental health issues are addressed in CRS
Reports CRS Report R41921, Mental Disorders Among OEF/OIF Veterans Using VA Health
Care: Facts and Figures, by (name redacted), CRS Report R40941,Traumatic Brain Injury
Among Veterans, by (name redacted),and CRS Report R42340, Suicide Prevention Efforts of the
Veterans Health Administration, by (name redacted).
Psychological Health in the Military
Mental Health Disorders, Including PTSD, Anxiety, and Depression
Overall, mental health disorders have significant impacts on servicemember health care
utilization, disability, and attrition from service. In 2011, mental disorders accounted for more
hospitalizations of servicemembers than any other illness and more outpatient care than all
illnesses except musculoskeletal injuries and routine medical care.2
Between 2001 and 2011, the rate of mental health diagnoses among active duty servicemembers
increased approximately 65%. A total of 936,283 servicemembers, or former servicemembers
during their period of service, have been diagnosed with at least one mental disorder over this
1
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV
disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005
Jun;62(6):617-27.
2
“Mental Disorders and Mental Health Problems, Active Component, U.S. Armed Forces, 2000-2011,” Medical
Surveillance Monthly Report, vol. 19, no. 6 (June 2012), pp. 11-17.
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time period (see Figure 1). Nearly 49% of these servicemembers were diagnosed with more than
one mental disorder.3
Figure 1. Number of Mental Disorder Diagnoses, 2000-2011
Source: Data provided by the Armed Forces Health Surveillance Center, and expended from the data
presented in “Mental disorders and mental health problems, active component, U.S. Armed Forces, 2000-2011,”
Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: An individual may be a case within a category only once per lifetime. This figure presents the number of
diagnoses, not the incidence (rate of new diagnoses in a population) or prevalence (total number of cases in a
population). As such, the number of diagnoses can be expected to change in relation to changes in the
population size.
Between 2000 and 2011, diagnoses of adjustment disorders, depression, and anxiety disorders
(excluding PTSD) made up 26%, 17%, and 10% of all diagnoses of mental disorder diagnoses.
Alcohol abuse and dependence disorders, and substance abuse and dependence disorders made up
13% and 4%, respectively. PTSD represented approximately 6% of mental disorder diagnoses
over this time period.4 (See Figure 2.)
3
Mental Disorders and Mental Health Problems, Active Component, U.S. Armed Forces, 2000-2011,” Medical
Surveillance Monthly Report, vol. 19, no. 6 (June 2012), pp. 11-17.
4
“Mental Disorders and Mental Health Problems, Active Component, U.S. Armed Forces, 2000-2011,” Medical
Surveillance Monthly Report, vol. 19, no. 6 (June 2012), pp. 11-17.
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Figure 2. Diagnoses of Mental Disorders in the Active Duty Forces, 2000-2011
Source: Data provided by the Armed Forces Health Surveillance Center, extended from the data presented in
“Mental disorders and mental health problems, active component, U.S. Armed Forces, 2000-2011,” Medical
Surveillance Monthly Report, 19(6), June 2012.
The rates of specific mental disorders have also changed dramatically between 2000 and 2011.
The reported incidence of PTSD has increased approximately 650%, from about 170 diagnoses
per 100,000 person years in 2000, to approximately 1,110 diagnoses per 100,000 person years in
2011. The incidence of anxiety, adjustment disorders, and depression diagnoses has also
increased. By contrast, the incidence of alcohol abuse/dependence, schizophrenia, and personality
disorders fell. (See Table 1, Figure 3.)
Table 1. Reported Changes in Incidence Rates of Mental Disorder Diagnoses
Between 2000-2011
Category of Mental Disorder Diagnosis
Change in Incidence Rate per 100,000
Person-Years
PTSD
656.5%
Anxiety
225.8%
Other MH
125.8%
Adjustment disorders
97.7%
Other psychoses
36.5%
Depression
62.4%
Substance abuse and dependence
28.5%
Alcohol abuse and dependence
-20.2%
Schizophrenia
-22.0%
Personality disorders
-50.0%
Any MH diagnosis
61.9%
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Category of Mental Disorder Diagnosis
More than one MH diagnosis
Change in Incidence Rate per 100,000
Person-Years
84.9%
Source: Analysis by CRS. Data provided by the Armed Forces Health Surveillance Center, expanded from the
data presented in “Mental disorders and mental health problems, active component, U.S. Armed Forces, 20002011.” Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: Incidence rate is number of diagnoses per 100,000 person-years. For example, for an incidence rate of
7,000, out of a population of 100,000 observed for one year, 7,000 new diagnoses would be expected. For a
population of 50,000 observed for one year (50,000 person years), or a population of 100,000 observed for 6
months (also 50,000 person-years), 3,500 new diagnoses would be expected.
Figure 3. Incidence Rate of Mental Disorder Diagnoses, 2001-2011
Source: Data provided by the Armed Forces Health Surveillance Center, and expanded form of the data
presented in “Mental disorders and mental health problems, active component, U.S. Armed Forces, 2000-2011,”
Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: Incidence rate is number of diagnoses per 100,000 person-years. For example, for an incidence rate of
7,000, out of a population of 100,000 observed for one year, 7,000 new diagnoses would be expected. For a
population of 50,000 observed for one year (50,000 person years), 3,500 new diagnoses would be expected.
Among the services, the Army, followed by the Marine Corps, has consistently had the highest
incidence rates for PTSD, major depression, alcohol dependence, and substance dependence
between 2007 and 2010, followed by the Navy and the Air Force. (See Figure 4.)
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Figure 4. Incidence Rate of Selected Mental Health Conditions by Service, 2010
Source: Analysis by CRS. Data from “Selected mental disorders among active component members, U.S. Armed
Forces, 2007-2010.” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center, Vol. 17, No
11. Supplemental Report, p. 3.
Notes: Incident rates are cases per 1,000 persons per year. In each year from 2007 to 2010, the Army had the
highest incidence rates of PTSD, major depression, substance dependence, and of mental health diagnoses in
general. The Army was also the service with the highest incidence rate of alcohol dependence diagnoses in 2009
and 2010. In 2007 and 2008 the Marine Corps had the highest incidence rate of alcohol dependence.
Hospitalizations for mental health mental disorders were steady between 2000 and 2006, before
increasing more than 50% from 2006 through 2009, from 10,262 to 15,328. This increase in
hospitalizations was driven by sharp increases in hospitalization for PTSD, depression, and
substance abuse. Calculated by lost duty time, the Army has been the service most affected by
hospitalizations of active duty servicemembers for mental disorders, followed by the Marine
Corps. (See Figure 5.)
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Figure 5. Hospitalizations for Mental Disorders
Active Duty Forces, 2000-2009
Source: From “Hospitalizations for mental disorders, active components, U.S. Armed Forces, January 2000December 2009.” Medical Surveillance Monthly Report, Vol. 17, No 11, November 2010, p. 10.
Table 2. Changes in Incidence Rates of DSM-IV “V Codes” Between 2000-2011
Category of Other Mental Health Problem
Change in Incidence Rate per 100,000 Person-Years
Mental, behavioral and substance abuse
117.8%
Family circumstance
-1.1%
Any V code
-19.2%
Life circumstance problem
-31.2%
Partner relationship
-31.2%
More than 1 type of V code
-38.4%
Maltreatment related
-79.1%
Source: Analysis by CRS. Data provided by the Armed Forces Health Surveillance Center, expanded from the
data presented in “Mental disorders and mental health problems, active component, U.S. Armed Forces, 20002011.” Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: Incidence rate is number of diagnoses per 100,000 person-years, for example, for an incidence rate of
7,000, out of a population of 100,000 observed for one year, 7,000 new diagnoses would be expected. For a
population of 50,000 observed for one year (50,000 person years), or a population of 100,000 observed for 6
months (also 50,000 person-years), 3,500 new diagnoses would be expected.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Figure 6. Other Mental Health Problems in the Active Duty Forces, 2011
Source: Analysis by CRS. Data provided by the Armed Forces Health Surveillance Center, expanded from of
the data presented in “Mental disorders and mental health problems, active component, U.S. Armed Forces,
2000-2011.” Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: The number of active duty members who sought treatment for other mental health problems in 2011
totaled nearly 32,000. These numbers do not include servicemembers who received a diagnosis for a specific
mental disorder.
Traumatic Brain Injury (TBI)
TBI has been considered a “signature injury” of the conflicts in Iraq and Afghanistan. However,
approximately 80% of servicemember TBIs occur in a non-deployed setting. Common causes of
TBI include vehicle crashes, falls, sports and recreation activities, and military training.5
Since 2001, it is reported that servicemembers have experienced about 255,852 TBIs, including
approximately 212,741 incidences of mild TBI, approximately 20,168 incidences of moderate
TBI, approximately 6,472 incidences of severe TBI/penetrating head injuries, and 16,471
unclassifiable TBIs. Incidents of mild TBI rose sharply between 2005 and 2007, due in part to
more aggressive screening measures for mild TBI instituted in 2006.6 (See Figure 7.) Diagnoses
of TBI in deployed settings nearly doubled between 2010 and 2011, due in part to a greater focus
on identifying and treating TBIs among deployed servicemembers.7
5
Defense and Veterans Brain Injury Center, “DOD Worldwide Numbers for TBI.” http://www.dvbic.org/dodworldwide-numbers-tbi
6
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, Vol. 177, No. 8:67, August 2012 Supplement, p. 67.
7
“External Causes of Traumatic Brain Injury, 2000-2011.” Monthly Surveillance Medical Report, Armed Forces
Health Surveillance Center. Vol 20, No 3. p. 13.
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Figure 7. TBI Incidence by Severity, 2001-2012
Source: Data provided by the Armed Forces Health Surveillance Center (AFHSC), April 2013.
Notes: The diagnosis and severity of injury were determined using ICD-9 codes. The ICD-9 codes are the
International Statistical Classification of Diseases and Related Health Problems standard codes published by the
World Health Organization to classify diseases and injuries, 9th Revision. Each data set is based on garrison
medical encounters in the Defense Medical Surveillance System, Standard Ambulatory Data Records, Health
Care Service Record and TRICARE Encounter Data feeds, and theater medical encounters in the Theater
Medical Data Store. Servicemembers may be counted only once, at the most severe level of injury. Therefore,
these data cannot track multiple TBIs experienced by the same servicemember.
These data include TBIs for active duty and activated Guard and Reserve members.
Suicide
Beginning in 2010, suicide has been the second-leading cause of death for active duty
servicemembers, behind only war injuries.8 Researchers have suggested that, similar to suicides
among civilians, suicides by servicemembers are often impulsive acts triggered by various
stressors, including relationship problems and financial or legal problems.9
Suicides among the active duty forces have increased between 1998 and 2012, rising from
approximately 200 deaths by suicide in 1998 to 349 in 2012. Between 1998 and 2011, the
8
“Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011,”
Medical Surveillance Monthly Report, vol. 19, no. 6 (June 2012), pp. 11-17.
9
“Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011,”
Medical Surveillance Monthly Report, vol. 19, no. 6 (June 2012), pp. 11-17.
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incidence rate of deaths by suicide for active duty servicemembers overall was approximately 14
per 100,000 person years. Most of the increase in suicide rates between 2000 and 2011 has been
concentrated in the Army and Marine Corps. Between 2005 and 2009, the incidence of suicide
has nearly doubled for Army and Marine personnel, while remaining approximately level for
Navy and Air Force personnel.10 In 2011, the suicide rate for Army personnel was approximately
23 per 100,000, while the rates for the Navy and Marine Corps were approximately 15 per
100,000 and the rate for the Air Force was approximately 13 per 100,000.
While the rates of suicide in the Armed Forces overall have increased between 1998 and 2011, the
rates for active duty servicemembers overall remain lower than for comparable civilian
populations. Lower suicide rates among the Armed Forces have been attributed to a variety of
factors, including the servicemember’s full-time employment; “healthy-worker” effects, including
a sense of belonging and purpose among active duty servicemembers; and universal access to
health care among the military population.11
Screening and Treatment Programs
Screening
Accession Screening
Accession into the uniformed services provides an opportunity to screen potential
servicemembers for potential behavioral health issues. Certain learning, behavioral, and
psychological conditions are considered disqualifying for military service.12 However, there is no
required battery of psychological tests for accessions into the military other than the learning and
behavioral questions on the Armed Services Vocational Aptitude Battery (ASVAB). During the
course of the history and physical that every recruit is required to complete, specific questions
and other methods are utilized to evoke potential markers of psychological and behavioral
dysfunction potentially incompatible with military service.
Since 2009, the Supplemental Health Screening Questionnaire has augmented the standard Report
of Medical History (DD 2807-2). This form includes 12 queries regarding past history of
psychiatric, psychological, or behavioral issues as well as questions regarding substance abuse.
Any condition reported or elucidated during the examination that does not meet the Department
of Defense Instruction (DODI) 6130.03: Accession Medical Standard is considered disqualifying.
Each service has the authority to waive the standard on a case by case basis. According to data
provided by DOD from the U.S. Military Entrance Processing Command’s database, out of
10
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in US Service Members and Veterans: Concerns After a
Decade of War,” Journal of the American Medical Association, Vol. 308, no. 7 (August 15, 2012), p. 671.
11
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in US Service Members and Veterans: Concerns After a
Decade of War,” Journal of the American Medical Association, Vol. 308, no. 7 (August 15, 2012), p. 671; Eaton KM,
Messer SC, Garvey Wilson AL, Hoge CW, “Strengthening the validity of population-based suicide rate comparisons:
an illustration using U.S. military and civilian data.” Suicide and Life-Threatening Behavior. April 2006, 36(2), pp.
182-91.
12
Department of Defense Instruction (DODI) 6130.03: Accession Medical Standard.
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296,000 accessions in fiscal year 2009, a total of 11,845 accessions with medical waivers were
granted. Of these, 1,178 were accessions with mental health conditions, of which 127 were for
anxiety, 32 for depression, 182 for personality disorder, and 19 for PTSD.13
In addition, during the physical examination portion of accession medical evaluation, evidence of
self-harm, mutilation, or excessive or otherwise inappropriate tattooing or piercings, among other
physical findings, would lead the examiner to evaluate the recruit further for psychological
problems or maladaptive behavior.
In any of the above situations, reasonable suspicion on the part of the examiner that the recruit
may manifest psychological or behavior health conditions incompatible with service would be
referred for further psychological evaluation and if found unfit, would be subjected to the
decision of the individual service to exercise its waiver authority.
The study of the effects of prior psychological and behavioral health issues on successful military
service is ongoing. Multiple forms of additional screening tools have and are being piloted,
however, to date, the requisite data to determine if these tools have any predictive value in
determining the ability of a recruit to complete a successful tour of duty are still outstanding.
Periodic Health Assessment—Annual Physical
Servicemembers are required to receive an annual physical examination known as a periodic
health assessment (PHA). The PHA is intended to identify changes in health status, including
mental health changes, especially those that could impact a member’s ability to perform military
duties.14
Pre-Deployment and Post-Deployment Mental Health Assessments and
Reassessments
Servicemembers who are deployed in connection with a contingency operation are required to
receive face-to-face mental health assessments conducted by mental health professionals.
Separate assessments are required at four separate times: within 120 days before the estimated
date of deployment, between 90 and 180 days after return from deployment, between 181 days
and 18 months after return from deployment, and between 18 and 30 months after return from
deployment. Assessments must be administered at least 90 days apart.15
Deployment Limiting Conditions
The following conditions are cited as limiting deployability, meaning an individual diagnosed
with these conditions may not deploy:
(1) Psychotic and/or bipolar disorders;
13
Communication from DOD official dated 9/1/2010.
Department of Defense Instruction 6025.19: Individual Medical Readiness (IMR http://www.dtic.mil/whs/directives/
corres/pdf/602519p.pdf).
15
10 U.S.C. §1074m.
14
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(2) Psychiatric disorders under treatment with fewer than 3 months of demonstrated stability;
(3) Clinical psychiatric disorders with residual symptoms that impair duty performance;
(4) Mental health conditions that pose a substantial risk for deterioration and/or recurrence of
impairing symptoms in the deployed environment; and
(5) Chronic medical conditions that require ongoing treatment with antipsychotics, lithium,
or anticonvulsants.16
Treatment Programs
Servicemembers on active duty are covered by DOD’s TRICARE Prime health insurance
program. Under this program servicemembers receive free health care without any copayments,
deductibles, or premiums. Servicemembers typically receive most of their health care in a
military treatment facility but may be referred to private providers for specialty care or if
insufficient providers are available on base.
Prior authorization is not required for services received through a military treatment facility but is
required for all nonemergency inpatient behavioral health care services. Psychiatric emergencies
do not require prior authorization, but authorization is required for continued stay in the facility
beyond the initial emergency.
The Telemental Health program is available to all U.S. TRICARE beneficiaries. At Telemental
Health-participating TRICARE facilities, secure audio-visual conferencing is available to connect
with off-site mental health care providers.
TRICARE covers medical treatments that DOD has deemed to be proven safe and effective by
reliable evidence as defined in regulation.17 TRICARE excludes from coverage services and
supplies that are not medically or psychologically necessary for the diagnosis or treatment of a
covered illness (including mental disorder) or injury. It also excludes treatments that are not
proven medically. All services related to a non-covered condition or treatment, or provided by an
unauthorized provider, are also excluded from coverage. Authorized providers of mental health
care include psychiatrists, clinical psychologists, certified marriage and family therapists,
certified nurse practitioners, and certified clinical social workers. Certain services otherwise not
covered by TRICARE may, in certain circumstances, be provided through the DOD Supplemental
Health Care Program.18 This program is not subject to the statutory TRICARE coverage
limitations and has been used, for example, to provide cognitive therapy to TBI patients.
Mental Health Providers
Active duty servicemembers may receive treatment from military mental health providers as well
as federal civilian and contractor mental health providers. In some circumstances active duty
16
Assistant Secretary of Defense for Health Affairs Memorandum, “Policy Guidance for Deployment-Limiting
Psychiatric Conditions and Medications,” November 7, 2006, (http://tricare.mil/tma/congressionalinformation/
downloads/200803/MedicalReadinessPlanJointMedicalReadinessOversightCommittee.pdf).
17
32 CFR §199.2.
18
Program regulations are at 32 C.F.R. §199.16.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
servicemembers also may be referred outside of military treatment facilities to private providers.
Mental health providers include psychiatrists, psychologists, social workers, licensed mental
health counselors, and psychiatric nurse practitioners. Concerns about the potential for
servicemembers to lack appropriate access to mental health care due to insufficient numbers of
mental health providers led to legislation mandating that DOD develop and implement a plan to
significantly increase the number of DOD military and civilian mental health personnel by
September 30, 2013.19 Overall, Defense Health Program personnel has increased, with officer end
strength growing from 31,244 in fiscal year 2012 to a projected 31,852 for fiscal year 2014 and
from 64,236 civilian personnel to 67,577 over the same period.
The 2014 budget request specifically includes an increase of $21 million to fund expansion of
embedded behavioral health (EBH) teams in the Army to 19 Army installations world-wide. EBH
teams are composed of 13 civilian behavioral health personnel and provide behavioral health care
to servicemembers in close proximity to their unit areas. The intent is to optimize care and
maximize behavioral health resources through early identification of servicemembers with
behavioral health problems.20
Clinical Practice Guidelines
Treatment of servicemembers is generally provided by either civilian or military mental health
care providers working in a military treatment facility. Their treatment decisions typically are
made following clinical practice guidelines. DOD and the Department of Veterans Affairs (VA)
have worked together to develop joint clinical practice guidelines, including, among others,
guidelines for PTSD,21 TBI,22 depression,23 and substance abuse disorder.24
The VA/DOD Evidence-Based Practice Guideline Work Group (EBPWG) was established to
advise the VA/DOD Health Executive Council on the use of clinical and epidemiological
evidence to improve the health of the population across the Veterans Health Administration
(VHA) and Military Health System. The EBPWG has two co-chairpersons (one from VA and one
from DOD) and includes representatives for each military branch and the VHA Veterans
Integrated Service Networks (VISN). The workgroup was first chartered in 2004. It continues to
refine existing guidelines as circumstances require and develop new clinical practice guidelines.
19
Subsection 714(b)(2) of the National Defense Authorization Act for Fiscal Year 2010 (P.L. 111-84).
Defense Health Program Fiscal Year (FY) 2014 Budget Estimates, p. 14. Available at http://comptroller.defense.gov/
defbudget/fy2014/budget_justification/pdfs/09_Defense_Health_Program/
FY2014_DHP_Budget_Estimates_Vol_1.pdf.
21
Department of Defense and Department of Veterans Affairs, VA/DOD Clinical Practice Guideline For Management
of Post-Traumatic Stress, available at http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp.
22
Department of Defense and Department of Veterans Affairs, Management of Concussion-mild TBI available at
http://www.healthquality.va.gov/management_of_concussion_mtbi.asp.
23
Department of Defense and Department of Veterans Affairs, Management of Major Depressive Disorder, available at
http://www.healthquality.va.gov/Major_Depressive_Disorder_MDD_Clinical_Practice_Guideline.asp.
24
Department of Defense and Department of Veterans Affairs, Management of Substance Abuse Disorder, available at
http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp.
20
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Stigma Reduction Efforts
Concern has been expressed that servicemembers may underreport mental health conditions as a
result of stigma attached to seeking treatment for those conditions. DOD has issued instructions
to all heads of DOD components stating:
It is DOD policy that:
a. The DOD shall foster a culture of support in the provision of mental health care and
voluntarily sought substance abuse education to military personnel in order to dispel the
stigma of seeking mental health care and/or substance misuse education services.
b. Healthcare providers shall follow a presumption that they are not to notify a Service
member’s commander when the Service member obtains mental health care or substance
abuse education services. 25
This policy further requires that “Commanders must also reduce stigma through positive regard
for those who seek mental health assistance to restore and maintain their mission readiness, just
as they would view someone seeking treatment for any other medical issue.”
Efforts to address the stigma issue may be, at least in part, responsible for greater rates of mental
health diagnoses. The Armed Forces Health Surveillance Center stated that:
The Department of Defense has made significant efforts to reduce stigmas associated with
care seeking for, and treatment of, mental illnesses and to remove barriers to receiving timely
and appropriate diagnostic and treatment services. Undoubtedly, such changes have resulted
in increases in the detection and treatment of previously undiagnosed mental disorders and
more complete documentation of mental disorders in electronic medical records.26
Nevertheless, the Mental Health Advisory Teams report a stable response pattern over the years
among junior enlisted servicemembers to questions regarding factors that affect an individual’s
decision to receive mental health services, with over 30% of individuals screening positive for
mental disorders reporting fear of harm to career.27
Costs of Mental Disorder Treatment
Many active duty servicemembers and activated Guard and Reserve members seek mental
disorder treatment through the military health care system. Between FY2007 and FY2012, the
costs to the military health system of providing mental disorder treatments to active duty
servicemembers and activated Guard and Reserve members has nearly doubled, increasing from
about $468 million in FY2007 to about $994 million in FY2012. (See Figure 8.) These numbers
include mental disorder treatment costs for all active duty and activated Guard and Reserve
25
Department of Defense Instruction number 6490.08 “Command Notification Requirements to Dispel Stigma in
Providing Mental Health Care to Service Members,” available at http://www.dtic.mil/whs/directives/corres/pdf/
649008p.pdf.
26
“Selected Mental Health Disorders Among Active Component Members, U.S. Armed Forces, 2007-2010.” Monthly
Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol 17, No 11. Supplemental Report. p. 11.
27
Report of the Joint Mental Health Advisory Team 7 (J-MHAT 7) Operation Enduring Freedom 2010 Afghanistan,
February 22, 2011, p. 33.
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members. Costs for mental disorder treatments for servicemembers while deployed are not
available.
Figure 8. Costs of Military Mental Disorder Treatment for Active Duty and Activated
Guard/Reserve
FY2007-FY2012, in millions of $
Source: Data provided by the Office of the Assistant Secretary of Defense (Health Affairs), January 30, 2012.
Notes: Includes total cost of inpatient, outpatient, and pharmacy records as of January 22, 2013. FY2012 data
are estimated to completion. Not all of the records for FY2012 have been received, therefore an estimate, with
a high level of confidence, is provided.
Not all costs of active duty and activated Reserve and Guard mental health treatment will appear in this chart, as
not all servicemembers seek mental disorder treatment through the military health system. Deactivated Guard
and Reserve members are covered by the Transitional Assistance Management Program for 180 days. Following
this 180 days, deactivated Guard and Reserve members may be eligible to purchase TRICARE Reserve Select
coverage. Those ineligible to purchase TRICARE Reserve Select may be eligible to purchase the Continued
Health Care Benefit Program, which can provide benefits for up to 18 or 36 months, depending on eligibility.
In FY2012, the military medical system spent nearly $1 billion on mental disorder treatment costs
for active duty and activated Guard and Reserve members. Over half of these costs, about $567
million, were for outpatient active duty mental health treatments. Overall, approximately 63% of
mental disorder treatment costs were for outpatient treatment, 31% for in-patient treatment, and
7% for pharmacy costs.
Mental disorder treatment for active duty servicemembers accounted for 89% of military health
care spending on mental disorder treatment between FY2007 and FY2012, approximately $4
billion. Over the same time frame, the military health system spent about $461 million on mental
health care treatment for activated Guard and Reserve members. (See Figure 9.)
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Figure 9. Active Duty and Activated Guard/Reserve Mental Disorder Treatment
Costs, FY2012
Active Duty
Inpatient 26%
Active Duty
Outpatient 58%
Activated
Guard/Reserve
Inpatient 3%
Active Duty
Pharmacy 5%
Activated
Guard/Reserves
11%
Activated
Guard/Reserve
Outpatient 7%
Activated
Guard/Reserve
Pharmacy 1%
Source: Data provided by the Office of the Assistant Secretary of Defense (Health Affairs), January 30, 2012.
Notes: Includes total cost of inpatient, outpatient, and pharmacy records as of January 22, 2013. FY2012 data
are estimated to completion. Not all of the records for FY2012 have been received, therefore an estimate, with
a high level of confidence, is provided.
Not all costs of active duty and activated Reserve and Guard mental health treatment will appear
in this chart, as not all servicemembers seek mental disorder treatment through the military health
system. Deactivated Guard and Reserve members are covered by the Transitional Assistance
Management Program for 180 days. Following this 180 days, deactivated Guard and Reserve
members may be eligible to purchase TRICARE Reserve Select coverage. Those ineligible to
purchase TRICARE Reserve Select may be eligible to purchase the Continued Health Care
Benefit Program, which can provide benefits for up to 18 or 36 months, depending on eligibility.
Other Responses
Prevention Programs
DOD and the services have implemented a number of programs and strategies to promote
psychological resilience among servicemembers.28 “Psychological resilience” is understood to be
the ability to bounce back from negative experiences. It is thought to be related to an individual’s
ability to avoid experiencing diagnosable mental health conditions. However, a RAND study
28
A 2011 RAND study identified 77 such programs. For the full list, see Meredith, Lisa et al, “Promoting
Psychological Resilience in the U.S. Military,” 2011, appendix C. The RAND Corporation, 2011. Available at
http://www.rand.org/content/dam/rand/pubs/monographs/2011/RAND_MG996.pdf.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
reported that “there is very little empirical evidence that these programs effectively build
resilience.”29
With respect to suicide, “DOD and each service have a myriad of activities currently in place to
prevent suicides.”30 To better coordinate these efforts, DOD has created a Defense Suicide
Prevention Office to oversee cross-service programs. These programs include (1) a DOD Suicide
Prevention and Risk Reduction Committee that meets monthly, (2) the Real Warriors Campaign, a
public education initiative to address the stigma of seeking psychological care and treatment, (3)
the Department of Defense Suicide Event Report (DoDSER), and (4) annual suicide-prevention
conferences. In addition, the services each have a suicide prevention program manager to oversee
service-specific programs. However, here too empirical evidence for the efficacy of these
programs is limited. One recent study stated that the “quality of mental health care and counseling
offered in DOD is unknown, and efforts to improve quality, such as training providers in
evidence-based practice, are not integrated into the system of mental health care offered in DOD
treatment facilities.”31
Defense Centers of Excellence for Psychological Health and Traumatic Brain
Injury
The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCOE)
was established in 2007 to focus on prevention, outreach, and care for servicemembers with
psychological health conditions, including TBI. The DCOE for Psychological Health and
Traumatic Brain Injury are intended to be principal integrators and authorities on psychological
health and traumatic brain injury knowledge and standards for DOD. There are three centers
under the DCOE: the Defense and Veterans Brain Injury Center, the Deployment Health Clinical
Center, and the National Center for Telehealth and Technology. Support responsibility for DCOE
is currently shifting from the TRICARE Management Activity office to the Army’s Medical
Research and Materiel Command. A key project of the DCOE centers in 2013 will be
“determining the impact of mental health programs across the military.”32
Past Recommendations and Actions
Reports, Studies, and Recommendations
A number of reports have made recommendations that Congress could build upon in fashioning
legislation or conducting oversight. These reports include in reverse chronological order:
29
Meredith, Lisa et al, Promoting Psychological Resilience in the U.S. Military, 2011, appendix C. The RAND
Corporation, 2011, p. 75. Available at http://www.rand.org/content/dam/rand/pubs/monographs/2011/
RAND_MG996.pdf.
30
Ramchand, Rajeev, Joie Acosta, Rachel M. Burns, Lisa H. Jaycox and Christopher G. Pernin. The War Within:
Preventing Suicide in the U.S. Military, The RAND Corporation, 2011, p. 83. Available at http://www.rand.org/pubs/
monographs/MG953.
31
Ibid, p. 118.
32
Nick Simeone, “DOD Health Official Updates Status of PTSD, TBI Care,” American Forces Press Service, January
13, 2013, http://www.defense.gov/news/newsarticle.aspx?id=119020.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Institute of Medicine
The Institute of Medicine (IOM) published the results of the first phase of a two-part study titled
“Treatment for Posttraumatic Stress Disorder (PTSD) in Military and Veteran Populations” in
July 2012.33 The IOM report concluded with seven general recommendations, in five major areas,
for further areas of research and service. The report findings were summarized by the DOD as:
•
History, Diagnostic Criteria, and Epidemiology—Servicemembers that served in
OEF/OIF/OND appear to have a 13%-20% lifetime prevalence of PTSD. In contrast,
the unadjusted general population lifetime prevalence of PTSD in adults appears to
be 8%;
•
Neurobiology—Further research is needed to identify biomarkers of PTSD, brain
imaging diagnostic models, and effective pharmacologic agents to enhance therapyrelated learning;
•
Programs and Services for PTSD in the DOD and VA—Both the DOD and VA
have a played an active and pivotal role in the prevention, screening, diagnosis, and
treatment of PTSD; however, further evaluation is needed to identify the
effectiveness of these efforts;
•
Prevention—DOD supports several PTSD prevention programs that build resiliency
and teach servicemembers to anticipate some of the traumatic events commonly
experienced in combat zones;
•
Screening and Diagnosis—Screening measures for PTSD are essential to the
identification of servicemembers and veterans that need treatment. DOD currently
utilizes screening tools, but needs to ensure that every servicemember identified
through such screening methods is referred to trained professionals that can provide
comprehensive assessments, diagnosis, and treatment;
•
Treatment—The VA/DOD clinical practice guidelines for the management of PTSD
make specific suggestions concerning treatment of PTSD symptoms. IOM recognizes
that DOD offers numerous treatments for PTSD, and continues to develop additional
treatment methods; and
•
Co-occurring Psychiatric and Medical Conditions and Psychosocial
Complexities—Given the presence of co-occurring conditions in more than 50% of
OEF/OIF/OND veterans, IOM recommends evidence-based PTSD models to ensure
the success of PTSD treatment for comorbid conditions.34
33
Institute of Medicine, “Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial
Assessment.” July 13, 2012. http://www.iom.edu/Reports/2012/Treatment-for-Posttraumatic-Stress-Disorder-inMilitary-and-Veteran-Populations-Initial-Assessment.aspx.
34
Department of Defense, “Report to Congress on the Institute of Medicine Report “Treatment for Posttraumatic Stress
Disorder in Military and Veteran Populations: Initial Assessment” In Accordance with Section 726 of the National
Defense Authorization Act For Fiscal Year 2010, pp. 5-6, January 2013. Available at http://www.tricare.mil/tma/
congressionalinformation/downloads/Independent%20Study%20on%20PostTraumatic%20Stress%20Disorder%20%28PTSD%29%20Efforts.pdf.
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DOD generally concurred with the IOM report recommendations and findings. In Phase 2 of its
study, the IOM will analyze barriers to care and ways to improve access to high-quality care for
servicemembers and veterans.
RAND National Defense Research Institute
The RAND National Defense Research Institute released a study entitled “The War Within,
Preventing Suicide in the U.S. Military” in February 2011. The War Within report made 14
recommendations in 6 categories:
1. Raise Awareness and Promote Self-Care;
2. Identify Those at High Risk;
3. Facilitate Access to High-Quality Care;
4. Provide High-Quality Care;
5. Restrict Access to Lethal Means; and
6. Respond Appropriately.35
DOD Task Force on the Prevention of Suicide
Section 733 of the Duncan Hunter National Defense Authorization Act for Fiscal Year 2009 (P.L.
110-417) required the Secretary of Defense to establish a Task Force “to examine matters relating
to prevention of suicide by members of the Armed Forces.” The DOD Task Force on the
Prevention of Suicide by Members of the Armed Forces was established in August 2009, and was
composed of seven DOD and seven non-DOD members. In August 2010, the Task Force issued a
document entitled “The Challenge and the Promise: Strengthening the Force, Preventing Suicide
and Saving Lives” that listed 49 findings and 76 associated recommendations. The Task Force’s
report did not address the earlier Army report described below. The findings fall into four areas:
Organization and Leadership; Wellness Enhancement and Training; Access to, and Delivery of,
Quality Care; and Surveillance, Investigations, and Research.36
Army Health Promotion, Risk Reduction, and Suicide Prevention
In July 2010, the Department of the Army issued a document entitled “Health Promotion, Risk
Reduction, and Suicide Prevention (HP/RR/SP) Report” (hereinafter referred to as “the Army
Report”) that listed 67 specific conclusions and recommendations. Among the Army Report’s
major findings was discovering gaps in the identification and mitigation of high-risk behavior
among soldiers. The report attributed these gaps to an operational tempo that required leadership
35
Ramchand, Rajeev, Joie Acosta, Rachel M. Burns, Lisa H. Jaycox and Christopher G. Pernin, The War Within:
Preventing Suicide in the U.S. Military. Santa Monica, CA: RAND Corporation, 2011. Available at
http://www.rand.org/pubs/monographs/MG953.
36
DOD Task Force on the Prevention of Suicide by Members of the Armed Forces, “The Challenge and the Promise:
Strengthening the Force, Preventing Suicide and Saving Lives,” August 2010. Available at http://www.health.mil/dhb/
downloads/Suicide%20Prevention%20Task%20Force%20final%20report%208-23-10.pdf.
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focus on deployment rather than the enforcement of policies designed to ensure good order and
discipline. The Army Report’s recommendations were addressed to specific audiences, including
Army Headquarters (HQDA), the Medical Command (MEDCOM), and Unit Commanders and
are organized by themes. Recommendations addressed to HQDA appear most amenable to
congressional action.
Mental Health Advisory Team Reports
Since 2003, DOD has deployed a series of teams to Iraq and Afghanistan to evaluate soldiers’
psychological health in theater, the results of which are published as publicly available reports.37
The sixth, and most recent, of these Mental Health Advisory Teams (MHAT VI) to report worked
in Iraq from February to March 2009 and in Afghanistan from April to June 2009. The teams
included research psychologists, a social worker, a psychiatric nurse, and enlisted behavioralhealth specialists. The reports have made numerous recommendations, including to continue the
“funding of basic-research models of concussive and traumatic brain injury work to advance the
development of novel evidence-based interventions” that would require continuing congressional
action in the form of appropriations.38
Executive Order 13625
Executive Order 13625, “Improving Access to Mental Health Services for Veterans, Service
Members, and Military Families,” issued on August 31, 2012, contained a number of provisions
designed to increase access to and the quality of mental health care for active duty
servicemembers, including establishing an interagency task force with an annual reporting
requirement as well as providing for increased mental health care staffing within the Department
of Veterans Affairs. With respect to broadly applicable issues, Executive Order 13625 provides
for a National Research Action Plan, stating:
Sec. 5. Improved Research and Development. (a) The lack of full understanding of the
underlying mechanisms of PostTraumatic Stress Disorder (PTSD), other mental health
conditions, and Traumatic Brain Injury (TBI) has hampered progress in prevention,
diagnosis, and treatment. In order to improve the coordination of agency research into these
conditions and reduce the number of affected men and women through better prevention,
diagnosis, and treatment, the Departments of Defense, Veterans Affairs, Health and Human
Services, and Education, in coordination with the Office of Science and Technology Policy,
shall establish a National Research Action Plan within 8 months of the date of this order.
(b) The National Research Action Plan shall include strategies to establish surrogate and
clinically actionable biomarkers for early diagnosis and treatment effectiveness; develop
improved diagnostic criteria for TBI; enhance our understanding of the mechanisms
responsible for PTSD, related injuries, and neurological disorders following TBI; foster
development of new treatments for these conditions based on a better understanding of the
underlying mechanisms; improve data sharing between agencies and academic and industry
researchers to accelerate progress and reduce redundant efforts without compromising
privacy; and make better use of electronic health records to gain insight into the risk and
37
Military Health Advisory Team reports are available at http://www.armymedicine.army.mil/reports/mhat/mhat.html.
See Joint Mental Health Advisory Team 7 (J-MHAT 7) Operation Enduring Freedom 2010 Afghanistan, February 22
2011, p. 95. Available at http://www.armymedicine.army.mil/reports/mhat/mhat_vii/J_MHAT_7.pdf.
38
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mitigation of PTSD, TBI, and related injuries. In addition, the National Research Action Plan
shall include strategies to support collaborative research to address suicide prevention.
(c) The Departments of Defense and Health and Human Services shall engage in a
comprehensive longitudinal mental health study with an emphasis on PTSD, TBI, and related
injuries to develop better prevention, diagnosis, and treatment options. Agencies shall
continue ongoing collaborative research efforts, with an aim to enroll at least 100,000 service
members by December 31, 2012, and include a plan for long term follow up with enrollees
through a coordinated effort with the Department of Veterans Affairs.39
Previous Congressional Actions
Previous Congressional Funding
In addition to funding via the Defense Health Program, Congress has also allocated significant
funding to research in these issues through the Congressionally-Directed Research Program.
There are no specific line items in the DOD budget request for suicide prevention or PTSD.
Generally PTSD treatment and research costs are included in the Defense Health Program
operations and maintenance (O&M) appropriation. Suicide prevention funds are included in the
services’ management accounts. Therefore, it is not possible to provide complete totals for all
funding that may be directed to these purposes.
Table 3. Funding for Psychological Health (including PTSD and TBI)
in millions
FY2007/2008
FY2009
FY2010
FY2011
FY2012
O&M Funding
$454.5
$575.0
$655.9
$669.2
RDT&E Funding
$506.1
$163.1
$230.3
$112.6
Procurement Funding
$18.9
$20.0
$0
$0
Defense
and
Veterans’
Brain
Injury
Center
(DVBIC)
O&M
unknown
$34.25
$36.62
$38.38
$32.59
Procurement
unknown
$1.7
$0
$0
$0
The Congressionally Directed Medical Research Programs’ Psychological Health and Traumatic
Brain Injury (PH/TBI) Research Program (formerly called Post Traumatic Stress Disorder and
Traumatic Brain Injury Research Program) was established in 2007 in response to U.S. Troop
Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act, P.L.
39
Executive Order 13625 “Improving Access to Mental Health Services for Veterans, Service Members, and Military
Families,” August 31, 2012.
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110-28, which provided $150 million (M) for research on PTSD and $150M for research on TBI.
An additional $1M was provided for research on PTSD in P.L. 109-289.
Table 4. Funds Allocated for Psychological Health, FY2007-FY2013
Fiscal Year
Amount
Topic
Funding Language
Law
2013 (proposed)
$125 m
(House)
TBI and psychological health
(proposed—CDMR)
H.Rept. 112-493
Department of Defense
Appropriations Act, 2013
(P.L. 113-6, 3/26/13)
S.Rept. 112-196
$60 m
(Senate)
2012
$10m
suicide prevention
H.Rept. 112-331
accompanying H.R. 2055
Consolidated
Appropriations Act, 2012
(P.L. 112-74, 12/23/11)
2012
$135.5 m
TBI and psychological health
(CDMR)
H.Rept. 112-331
Consolidated
Appropriations Act, 2012
(P.L. 112-74, 12/23/11)
2011
$100 m
TBI and psychological health
(CDMR)
House Rules Committee’s
tables accompanying H.R.
1473
An Act To extend the
Generalized System of
Preferences, and for
other purposes. (P.L.
112-40, 10/21/11)
2010
$120 m
TBI and psychological health
(CDMR)
Joint Explanatory Statement
to the Defense
Appropriations Act , See
Congressional Record,
December 16, 2009, pp.
H15319-H15320.
Department of Defense
Appropriations Act, 2010
(P.L. 111-118, 12/19/09)
2009
$75 m
TBI and psychological health
peer-reviewed research
H.Rept. 111-151. Allocates
this funding per
recommendations in H.Rept.
111-105 H.Rept. 111-105
Supplemental
Appropriations Act, 2009
(P.L. 111-32, 6/24/09)
2009
$165 m
TBI and psychological health
peer-reviewed research
(CDMR)
See Congressional Record,
September 24, 2008, pp.
H9725 – H9726.
Consolidated Security,
Disaster Assistance, and
Continuing
Appropriations Act, 2009
- Division C, Department
of Defense
Appropriations Act, 2009
(P.L. 110-329, 9/30/08)
2009
$190m
TBI and psychological health
H. Appropriations Committee
Print, H.R. 2638
Consolidated Security,
Disaster Assistance, and
Continuing
Appropriations Act, 2009
- Division C, Department
of Defense
Appropriations Act, 2009
(P.L. 110-329, 9/30/08)
($60m in Consolidated
Health Care, $36m in
Information Management/IT,
$1m in Management
Headquarters, $3m in Base
Operation and
Communication, $90m
under Research and
development)
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Fiscal Year
Amount
Topic
Funding Language
Law
2008
n/a
TBI and psychological health
P.L. 110-116 permits the
$600m appropriated by P.L.
110-28 to be used for
psychological health in
addition to PTSD
Department of Defense
Appropriations Act, 2008
(P.L. 110-116,
11/13/2007)
2007
$150m
TBI and psychological health
(CDMR)
H.Rept. 109-676
Department of Defense
Appropriations Act, 2007
(P.L. 109-289, 9/29/06)
2007
$151
PTSD (CDMR)
H.Rept. 109-676
Department of Defense
Appropriations Act, 2007
(P.L. 109-289, 9/29/06).
2007
$600m
Treatment of TBI and PTSD
P.L. 110-28 pp. 134-135
U.S. Troop Readiness,
Veterans’ Care, Katrina
Recovery, and Iraq
Accountability
Appropriations Act, 2007
(P.L. 110-28, 5/25/2007)
($118m for procurement,
and $331.7m for RDT&E)
Issues for Congress
As discussed elsewhere in the report and as listed in Appendix B, numerous laws have been
enacted with provisions intended to address military mental health issues. These efforts include
provisions to improve screening for mental health conditions and TBI, and providing for
additional mental health providers, improved reporting, and continued research. While Congress
has taken significant interest in issues related to the psychological health of the active duty forces,
including PTSD, alcohol and substance abuse, depression, traumatic brain injury, and other
mental health concerns, significant areas for potential congressional oversight remain. These
include:
Research
The physical manifestations in the brain of mental health conditions, including PTSD, are poorly
understood. Further research is needed to identify biomarkers, brain imaging, diagnostic models,
and effective pharmacologic agents to enhance therapy-related learning. In conducting its
oversight activities, Congress may wish to monitor ongoing research efforts for significant
findings with implications for current mental health strategies, as well as consider whether there
are gaps in research being conducted into the causes, biomarkers, and translational research for
improved treatments.
Treatment
Screening measures for mental health conditions and TBI are essential to the identification of
servicemembers and veterans that need treatment. DOD uses screening tools, but many observers
recommend greater involvement of primary care providers in this process. Once servicemembers
are identified as having potential diagnoses, oversight may be needed to assure they will be
referred to trained professionals that can provide comprehensive assessments, diagnosis, and
evidence-based treatment. Given the presence of co-occurring conditions in more than 50% of
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OEF/OIF/OND veterans, the IOM has recommended evidence-based models to ensure the
success of treatments for comorbid conditions.40 In conducting its oversight activities, Congress
may wish to consider how the efficacy of treatment is monitored and evaluated.
Access to Care
Although Congress has provided resources allowing DOD to expand its pool of military mental
health providers, Congress may wish to determine how DOD is responding to Institute of
Medicine (IOM) findings expressing “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.”41 Congress
may also wish to examine the question of whether DOD is ensuring optimal means of access to
and assignment of mental health care providers. Congress may also wish to examine the
effectiveness of DOD initiatives to encourage servicemembers to seek care, and reduce the stigma
of seeking mental health care.
Suicide Prevention
Congress may wish to examine the appropriateness of DOD’s response to RAND study findings
that the two most evidence-supported suicide prevention strategies are (1) training primary care
physicians to assess servicemembers for depression or other risk factors for suicide, and (2)
restricting servicemembers’ access to lethal means, primarily private firearms.
Oversight
As discussed above, Executive Order 16325 requires a special interagency task force to evaluate:
•
agency efforts to improve care quality and ensure that DOD and VA providers
and community based mental health providers are trained in the most current
evidence based methodologies for treating PTSD, TBI, depression, related mental
health conditions, and substance abuse;
•
agency efforts to improve awareness and reduce stigma for those needing to seek
care; and
•
agency research efforts to improve the prevention, diagnosis, and treatment of
TBI, PTSD, and related injuries, and explore the need for an external research
portfolio review.
Congress may wish to be apprised of these evaluation efforts.
40
Institute of Medicine, “Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial
Assessment.” July 13, 2012, p. 375 http://www.iom.edu/Reports/2012/Treatment-for-Posttraumatic-Stress-Disorder-inMilitary-and-Veteran-Populations-Initial-Assessment.aspx.
41
Institute of Medicine “Report Brief,” March 26, 2013, p. 1. Available at http://www.iom.edu/Reports/2013/
Returning-Home-from-Iraq-and-Afghanistan/Report-Brief032613.aspx.
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In addition, Congress may consider whether additional oversight is necessary in areas such as:
•
The allocation of resources between research, treatment, oversight, types of
providers, provider to program staffing; and
•
The efficacy of entities such as the DCOE for Psychological Health and
Traumatic Brain Injury.
Costs of Mental Health Care Treatment
DOD’s spending on mental health care treatment has increased, as the number of active duty
servicemembers receiving diagnoses of mental health conditions and seeking treatment for these
conditions has increased. Congress may wish to examine the role of supplying larger amounts of
mental health care in the context of the Defense Health Program (DHP) appropriation since
growth in the unified medical budget relative to the overall Defense budget has been identified by
some senior leaders as unsustainable. Although this report has addressed only the issues of active
duty mental health, Congress may well be interested in examining the implications of DOD’s
programs as they relate to the long-term costs experienced in the various programs administered
by the VA.
Psychological Health in the Active Duty Forces
Within the active duty forces, psychological health issues include diagnosed mental disorders,
such as depression or PTSD, as well as other mental health problems, such as problems with
personal relationships or family circumstances. Other mental health issues facing the Armed
Forces include traumatic brain injuries (TBI) and the suicides of servicemembers. Mental health
issues in the active duty force have an impact not only on the individual servicemembers and their
families, but also on the services as a whole.
Data Caveats
In this report, much of the data comes from past issues of the Medical Surveillance Monthly
Report, a publication of DOD’s Armed Forces Health Surveillance Center. The Armed Forces
Health Surveillance Center (AFHSC) data include diagnoses received by servicemembers though
the military medical system while on active duty service. The AFHSC data are the most complete
and reliable data on servicemember diagnoses of mental health conditions, however, they likely
represent the lower bound of actual servicemember incidences of diagnosable mental health
disorders.
These data do not include servicemembers who may experience mental health problems but who
do not seek treatment for them at a fixed military medical or reimbursable civilian location.
Accordingly, these data likely underestimate the true incidence and prevalence numbers and rates
among active duty servicemembers of the U.S. Armed Forces. Additionally, these data will likely
not capture Reserve and Guard servicemembers who seek mental health treatment after they are
deactivated.42
42
For more information the Armed Forces Health Surveillance Center’s standard methodologies used for routine
(continued...)
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The underlying database used by the Armed Forces Health Surveillance Center is the Defense
Medical Surveillance System. This database includes ambulatory visits and hospitalizations at
fixed military medical and reimbursed civilian locations by servicemembers while on active duty,
but does not include medical encounters at non-fixed locations. Medical encounters outside of
fixed locations, such as care received in deployed settings or shipboard, are not routinely entered
into the Defense Medical Surveillance System, and are thus not available for analysis.
These Armed Forces Health Surveillance Center data are of diagnoses of selected mental
disorders, rather than continued care for diagnosed mental disorders. Incidence cases were
generally defined as one hospitalization, two outpatient visits for the same diagnostic coding
within 180 days, or a single outpatient visit in a psychiatric or mental health care specialty setting
where the mental disorder was the primary or second diagnosis. Diagnostic codes of the selected
mental disorders used to assemble the data are included in Appendix A. A servicemember was
counted only once for each mental disorder during the surveillance period, although they may
have been counted as a unique case for more than one of the mental disorders. Since many
individuals have more than one diagnosis, the total of the number of diagnoses does not reflect
the actual number of individual servicemembers who have been diagnosed.43
In considering relative numbers of diagnoses over time, it may also be useful to keep in mind that
although there were 1,425,113 active duty servicemembers as of September 31, 201144 (at the end
date of most of the time series data presented), over fiscal years 2001 through 2011, the total
number of individuals who left military service since September 11, 2001, is estimated to be
1,790,290.
The methodology used by the Armed Forces Health Surveillance Center is different from that
used in other studies frequently reported in the news media and elsewhere, therefore the results
are not directly comparable. Data caveats may apply to other studies as well and in many
instances may be discussed in the article or study itself. (Please see text box below for an
explanation.)
Methodological Differences Between Monthly Medical Surveillance Report
prevalence figures and other reported rates
“The news media have extensively covered the subject of mental health among military service members. Journalists
have cited published numerical estimates of the frequency of mental health disorders in service members, especially
among those who have deployed in support of current operations. The sources of such estimates have used differing
methods and assumptions in collecting and analyzing their data. Accordingly, the rates of mental health disorders
reported here are likely not directly comparable to other published rates. For example, the 2009 post-traumatic
stress disorder (PTSD) incidence rate of 9.2 per 1,000 person-years and the prevalence rate of 1.9% among all service
members of the active component contrast sharply with figures in media reports and the scientific literature. By way
of illustration, news media have cited published medical articles that suggest PTSD prevalence of 12% or higher among
service members following deployment.
Several important factors distinguish the results in this report from those in others. First, the results presented here
(...continued)
surveillance and reporting of medical cases, please see their methodological guide, located at http://www.afhsc.mil/
viewDocument?file=CaseDefs/Web_Introduction_Final_9Mar11.pdf. The descriptions of the criteria for inclusion of
mental health cases are found at http://www.afhsc.mil/viewDocument?file=CaseDefs/
Web_12_MENTAL%20HEALTH_SEPT12.pdf.
43
Department of Veterans Affairs, VetPop11 projection model. https://www.va.gov/vetdata/Veteran_Population.asp.
44
Department of Defense report, see http://siadapp.dmdc.osd.mil/personnel/MILITARY/history/hst1109.pdf
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reflect healthcare provider-assigned clinical diagnostic codes entered into the electronic medical records of service
members, i.e., the providers rendered formal diagnoses of the conditions enumerated in this report. In contrast,
other published studies have relied upon self-reported data from deployment health assessments, anonymous
questionnaires, or retrospective interviews in which service members affirm or deny the presence of symptoms that
are often associated with the mental health disorders of interest. ...”
From the Armed Forces Health Surveillance Center’s Monthly Medical Surveillance Report, November, 2010, page 4.
PTSD
Overview
According to current diagnostic criteria45 for PTSD (see text box, below), a person must
experience a traumatic event involving death or serious injury, or a threat to the physical integrity
of self or others, and react to the trauma with intense horror, fear, or helplessness. Sometime after
that trauma, the person must also develop symptoms that cause clinically significant distress or
impairment lasting for more than one month. Those symptoms must include symptoms from each
of the following three symptom clusters:
•
Reexperiencing the traumatic event, such as having recurring and distressing
recollections or nightmares;
•
Avoidance of stimuli associated with the trauma, such as thoughts, feelings, and
conversations, along with diminished responsiveness and loss of interest in activities;
and
•
Hyperarousal, such as irritability, anger, hypervigilance, insomnia, or difficulty with
concentration.
The formal DSM-IV-TR diagnostic criteria are below:
DSM-IV-TR Diagnostic Criteria for 309.81 Post-traumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following were present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integrity of self or others.
(2) the person’s response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions.
(2) recurrent distressing dreams of the event.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions,
hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated).
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the
traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present
45
DOD uses the Diagnostic and Statistical Manual of Mental Disorders (DSM) – IV text revision published by the
American Psychiatric Association in 2000 and frequently referred to as “DSM-IV-TR.” The 5th edition, the DSM-V ,
was published on May 18, 2013, superseding the DSM-IV-TR.
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before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the
following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hyper vigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B,C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or ther important areas
of functioning.
Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text
Revision DSM-IV-TR, 2000, pp. 467-468, notes regarding children not included.
Acute PTSD occurs when the duration of symptoms is between one and three months. Patients
with symptoms extending for more than three months are considered to have chronic PTSD.
Delayed-onset PTSD occurs when symptoms begin at least six months after the trauma.46 These
criteria may change with the impending issuance of a DSM-V expected sometime in 2013.
Prevalence of PTSD in the Military
In 2010, 5,959 cases of PTSD were diagnosed in active duty servicemembers, a rate of
approximately 8.4 new cases per 1,000 servicemembers. Overall, 2% of active duty
servicemembers had ever received a PTSD diagnosis. However, the rates of PTSD diagnoses in
the Army and Marine Corps were much higher than for servicemembers in the Air Force and the
Navy. In 2010, the incidence rates of new diagnoses of PTSD in the active duty Army and Marine
Corps were 14.3 per 1,000 and 9.7 per 1,000, respectively, compared to incidence rates of 3.7 per
1,000 for the Navy and 3.4 per 1,000 for the Air Force.47 (See Figure 10.)
46
Adapted from Congressional Budget Office, “The Veterans Health Administration’s Treatment of PTSD and
Traumatic Brain Injury Among Recent Combat Veterans.” February 2012, p. 23. http://www.cbo.gov/publication/
42969
47
Analysis by CRS. Data from “Selected Mental Health Disorders Among Active Component Members, U.S. Armed
Forces, 2007-2010,” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol. 17, No. 11,
Supplemental Report. p. 3
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Figure 10. Incidence of PTSD by Service, Active Component
January 1, 2007-June 30, 2010
Source: Analysis by CRS. Data from “Selected Mental disorders Among Active Component Members, U.S.
Armed Forces, 2007-2010.” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol
17, No 11. Supplemental Report. p. 3.
Notes: Incidence rate refers to the number of new diagnoses per 1,000 person/years. Individuals are counted
only once per condition. The incidence rate is distinct from the prevalence rate, or the number of individuals
with a condition at any given time.
Estimates of PTSD prevalence vary depending on the methodologies used in developing them,
including the means of assessment and the characteristics of the applicable population (e.g.,
deployment history), among other factors. Additionally, prevalence estimates based on screening
tools and reported symptoms, including the pre- and post-deployment health assessments required
of all deployed servicemembers, will tend to be higher than those based on the numbers of
clinical diagnoses of PTSD.48 However, rates of PTSD incidence relying solely on PTSD
diagnoses will likely underestimate the true prevalence of PTSD among the Armed Forces, given
the variety of barriers to mental health treatment that exist.
According to the Veterans’ Administration, studies have shown that approximately 10%-18% of
combat troops serving in Iraq or Afghanistan have probable PTSD after deployment.49 One study,
estimating PTSD prevalence based on post-deployment health assessments and reassessments
(conducted 90 and 180 days after return from deployment, between 181 days and 18 months after
return from deployment, and between 18 and 30 months after return from deployment), found that
48
The incidence figures presented above are of PTSD among deployed and non-deployed servicemembers diagnosed
with PTSD in the military medical system. Therefore, these incidence numbers are likely to be lower than the true
incidence rate, as they will not capture servicemembers who either do not seek psychological health treatment or who
do not seek it within the military medical system. Service members who are deployed in connection with a contingency
operation are required to receive periodic person-to-person mental health assessments. While these screenings may
capture symptoms of PTSD, they are not in themselves sufficient to establish a diagnosis of PTSD.
49
Brett T. Litz and William E. Schlenger, “PTSD in Service Members and New Veterans of the Iraq and Afghanistan
Wars: A Bibliography and Critique,” PTSD Research Quarterly, Vol. 20 No. 1 (Winter 2009). p. 3.
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that probable PTSD prevalence based on reported symptoms among active duty servicemembers
increased from 11.8% to 16.7% between assessments. For reservists and National Guard
members, this study found that probable PTSD rates rose from 12.7% to 24.5% by the second
assessment.50 A telephone-based survey of personnel previously deployed to Iraq or Afghanistan
found that approximately 14% reported symptoms indicative of probable PTSD. This study found
that risk factors for PTSD included Guard or Reserve status, being of the female gender, Hispanic
ethnicity, more lengthy deployments, and more extensive exposure to combat.51 However, as
discussed above, these studies relied on reported symptoms to estimate the probable prevalence of
PTSD, rather than actual diagnoses of PTSD. By comparison, in the U.S. population as a whole,
the proportion of those who have ever experienced PTSD was estimated at 6.8%.52 The
proportion of the U.S. population currently experiencing PTSD was estimated at 3.5%.53
Between January 1, 2001, and December 3, 2012, a total of 103,792 PTSD cases have been
diagnosed in servicemembers who have been deployed for at least 30 days in support of OEF,
OIF, or OND, according to DOD data.54 As Figure 11 indicates, the number of diagnoses is
higher among deployed servicemembers than non-deployed servicemembers. As of July 31, 2012,
approximately 2,453,036 servicemembers from the active duty, National Guard, and Reserve
components have ever deployed to OEF, OIF, and/or OND.
50
Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. Longitudinal assessment of mental health problems among active
and reserve component soldiers returning from the Iraq War. Journal of the American Medical Association, 298, 20078,
pp. 2141-2148.
51
Schell, T. L., and Marshall, G. N. (2008), “Survey of individuals previously deployed for OEF/OIF,” in T. Tanielian
and L. H. Jaycox (Eds.), Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and
Services to Assist Recovery, pp. 87-115, Santa Monica, CA: RAND Center for Military Health Policy Research.
52
Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., and Walters, E.E. (2005), “Lifetime Prevalence
and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication,” Archives of
General Psychiatry, 62(6): 593-602. Data from the the National Comorbidity Survey Replication (NCS-R), conducted
between February 2001 and April 2003, based upon interviews of a nationally representative sample of Americans aged
18 years and older. The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%.
53
Kessler, R.C., Chiu, W.T., Demler, O., Merikangas, K.R., and Walters, E.E. (2005), “Prevalence, Severity, and
Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” Archives of General
Psychiatry, 62(6): 617-627. The twelve-month prevalence was 1.8% among men and 5.2% among women. National
Comorbidity Survey (2005), NCS-R Appendix Tables: Table 1. Lifetime Prevalence of DSM-IV/WMH-CIDI
Disorders by Sex and Cohort. Table 2. Twelve-Month Prevalence of DSM-IV/WMH-CIDI Disorders by Sex and
Cohort. Available at http://www.hcp.med.harvard.edu/ncs/publications.php.
54
CRS communication with Dr. Michael Carino, Army Office of the Surgeon General, December 13, 2012. Data
source is the Defense Medical Surveillance System (DMSS).
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Figure 11. PTSD Diagnoses Among Deployed and Non-Deployed Active Duty
Servicemembers, Calendar Years 2000-2012
Source: Data from the Armed Forces Health Surveillance Center, Defense Medical Surveillance System and
Theatre Data Store, April 2013.
Several studies have linked diagnoses of PTSD with factors common in the deployment
experience. Specifically, greater combat exposure, length and/or number of deployments,
perceived threat of personal danger, and deployment-related physical injuries have been
associated with greater PTSD risk among servicemembers deployed to Operation Enduring
Freedom, Operation Iraqi Freedom, and/or Operation New Dawn.55 Other factors, such as
perceived preparedness for combat, have also been found to mitigate the link between combat and
perceived threat. Additionally, a sense of unit cohesion has been associated with a lower risk of
PTSD in OEF/OIF/OND servicemembers.56 Greater exposure of deployed Army and Marine
Corps servicemembers to these aspects of combat, such as greater perceived threat of personal
danger or deployment-related physical injuries, could be a factor in the higher rates of PTSD
among the Army and Marine Corps, as compared to the Navy and Air Force.
55
Phillips, C.J., Leardman, C.A., Gumbs, G.R., and Smith, B., “Risk Factors For Posttraumatic Stress Disorder Among
Deployed US Male Marines,” BMC Psychiatry, 2010; 10: 52, and Sandweiss, D.A., Slymen, D.J., Leardman, C.A., et
al., “Preinjury Psychiatric Status, Injury Severity, and Postdeployment Posttraumatic Stress Disorder,” Archives of
General Psychiatry, 2011, 68: pp. 496-504. Cited in Herman, Barbara A., Brian Shiner, Matthew J. Friedman,
“Epidemiology and Prevention of Combat-Related Post-Traumatic Stress in OEF/OIF/OND Service Members.”
Military Medicine, 177, 8:1, p. 3.
56
Pietrzak, R.H., Johnson, D.C., Goldstein, M.B., et al., “Psychosocial Buffers of Traumatic Stress, Depressive
Symptoms, and Psychosocial Difficulties in Veterans of Operations Enduring Freedom and Iraqi Freedom: The Role of
Resilience, Unit Support, and Postdeployment Social Support,” Journal of Affective Disorders, 2010; 120, pp. 188-192.
Cited in Herman, Barbara A., Brian Shiner, Matthew J. Friedman, “Epidemiology and Prevention of Combat-Related
Post-Traumatic Stress in OEF/OIF/OND Service Members.” Military Medicine, 177, 8:1, p. 3.
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Between 2001 and 2012, approximately 80% of PTSD cases among previously deployed
servicemembers were diagnosed in active component servicemembers. Approximately 13% of
PTSD diagnoses among previously deployed servicemembers were given to National Guard
members, while 7% were given to Reserve component members. Two studies of National Guard
and Reserve troops found that post-deployment stressors, including economic and relationship
difficulties, also appear to be PTSD risk factors for OIF-deployed servicemembers.57
Alcohol and Drug-Use Disorders
Overview
The Diagnostic and Statistical Manual IV Trial Revision (DSM-IV-TR) uses specific terminology
to refer to various categories of diagnoses related to alcohol and substance use. The broadest
category is “substance-related disorders,” which includes both “substance use disorders” (e.g.,
alcohol abuse or nicotine dependence) and “substance-induced disorders” (e.g., intoxication or
withdrawal). Within the category of “substance use disorders,” the DSM-IV-TR distinguishes
between “abuse” and “dependence.” (See text box below.) Substance-related disorders include
dependence on and abuse of drugs, alcohol, or other substances (e.g., nicotine). A diagnosis of
dependence requires at least three of seven diagnostic symptoms (e.g., tolerance or withdrawal).
Substance use that does not meet criteria for dependence, but leads to clinically significant
distress or impairment, is called abuse.58 Each diagnosis is specific to the substance, so an
individual may have multiple diagnoses of abuse or dependence—one for each substance (e.g.,
marijuana dependence and cocaine abuse).59
DSM-IV-TR Criteria for Substance Abuse
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one
(or more) of the following, occurring at any time in the same 12 month period:
(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home
(2) recurrent substance use in situations where it is physically hazardous
(3) recurrent substance-related legal problems
(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance
DSM-IV-TR Criteria for Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three
57
Polusny, M.A., Erbes, C.R., and Murdoch, M., et al., “Prospective Risk Factors for New-Onset Post-Traumatic Stress
Disorder in National Guard Soldiers Deployed to Iraq,” Psychological Medicine 2011, (41), pp. 687-698; and Riviere,
L.A., Kendall-Robbins, A., and McGurk, D., et al., “Coming Home May Hurt: Risk Factors for Mental Ill Health in US
Reservists After Deployment in Iraq,” British Journal of Psychiatry 2011 (198), pp. 136-142. Cited in Herman, Barbara
A., Brian Shiner, and Matthew J. Friedman, “Epidemiology and Prevention of Combat-Related Post-Traumatic Stress
in OEF/OIF/OND Service Members,” Military Medicine, 177, 8:1, p. 3.
58
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Washington, DC: American Psychiatric Association, 2000), pp. 191-199.
59
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Washington, DC: American Psychiatric Association, 2000), p. 197.
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(or more) of the following, occurring at any time in the same 12-month period:
(1) tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the substance
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving
long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological
problem that is likely to have been caused or exacerbated by the substance (e.g., current cocain use despite
recognition of cocaine-induced depression, or continued drinking despite recognition than an ulcer was made worse
by alcohol consumption)
Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text
Revision DSM-IV-TR, 2000, p. 197, notes not included.
Alcohol Use Disorder Prevalence in the Military
Alcohol-related diagnoses and medical encounters in the active duty forces have increased since
2001, with the sharpest increases since 2007. (See Figure 12.) Between 2001 and 2010, 190,302
servicemembers had at least one medical encounter where they received an acute alcohol
diagnosis, such as drunkenness, excessive blood alcohol content, or alcohol poisoning.
Approximately 21% of these were considered recurrent acute cases, with at least three medical
encounters with acute alcohol diagnoses.60 However, over 90% of these recurrent acute cases
likely represent treatment encounters, rather than recurrent acute cases. Approximately 4% of all
coded acute alcohol diagnoses represent actual recurrent cases.61 Over the same time period
(2001–2010), over 141,000 active duty servicemembers had a medical encounter in which they
received a diagnosis connected to alcohol abuse or dependence, such as alcohol abuse or
alcoholic liver disease.62
60
“Alcohol-related Diagnoses, Active Component, U.S. Armed Forces, 2001-2011.” Medical Surveillance Monthly
Report, 18(10), October 2011. pp. 9-11.
61
“Surveillance Snapshot: Recurrent Medical Encounters Associated with Alcohol Abuse-Related Diagnostic Codes,
Active Compontent, U.S. Armed Forces, 2001-2010,” Medical Surveillance Monthly Report, 19(2), February 2012, p.
23.
62
“Alcohol-Related Diagnoses, Active Component, U.S. Armed Forces, 2001-2011,” Medical Surveillance Monthly
Report, 18(10), October 2011. p. 10.
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In a 2008 survey of servicemembers, 47% self-reported as binge drinkers and 5% reported
possible dependence.63
Figure 12. Rates of Alcohol-Related Diagnoses Among the Active Duty Component,
2000-2009
Source: Institute of Medicine, “Substance Use Disorders in the U.S. Armed Forces,” 2012, p. 2-22. Citing
Department of Defense, Office of the Undersecretary of Defense, “Comprehensive Plan on Prevention,
Diagnosis, and Treatment of Substance Use Disorders and Disposition of Substance Use Offenders in the Armed
Forces,” 2011.
Notes: Incidence rates per 100,000.
Drug-Use Disorder Prevalence in the Military
Between 2000 and 2011, drug abuse disorders accounted for 4% of mental disorders diagnosed
among the active duty forces, with a total of 73,623 diagnoses. Though rates dipped in 2011, the
rate of drug disorder diagnoses had risen between 2000 and 2009.64 (See Figure 13.) The increase
in substance abuse disorders is often connected to deployment. Incidence rates of cannabis and
cocaine use declined, while rates of opioid and “mixed/other” substance abuse increased sharply.
(See Figure 14.) This rise potentially reflects an increase in the misuse of prescription drugs.
While overall drug use is lower in the military than civilian populations, prescription drug abuse
has recently been increasing at a greater rate in the military than among the civilian population.65
Substance abuse disorder diagnoses declined with increasing age, time in service, rank, and
number of combat deployments. Rates of substance abuse diagnoses were 1.8 times greater
among the youngest servicemembers than older servicemembers, while junior enlisted
servicemembers had diagnoses of substance abuse disorders at a rate 17.6 times higher than
officers. Substance abuse rates were consistently highest in the Army, followed by the Marine
Corps.
63
“Alcohol-Related Diagnoses, Active Component, U.S. Armed Forces, 2001-2011,” Medical Surveillance Monthly
Report, 18(10), October 2011. p. 9.
64
Servies, Tammy, Zheng Hu, and Angelia Eick-Cost, et al., “Substance Use Disorders in the U.S. Armed Forces,
2000-2011,” Medical Surveillance Monthly Report, 19(11) November 2012, p. 11.
65
Servies, Tammy, Zheng Hu, and Angelia Eick-Cost, et al., “Substance Use Disorders in the U.S. Armed Forces,
2000-2011,” Medical Surveillance Monthly Report, 19(11) November 2012, p. 15.
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Figure 13. Incidence Rate of Substance Abuse Disorder Diagnoses
By service, 2000-2011
Source: Servies, Tammy, Zheng Hu, and Angelia Eick-Cost, et al., “Substance Use Disorders in the U.S. Armed
Forces, 2000-2011,” Medical Surveillance Monthly Report, 19(11) November 2012, p. 11.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Figure 14. Incidence Rate of Substance Abuse Disorder Diagnoses
By drug type, 2000-2011
Source: Servies, Tammy, Zheng Hu, and Angelia Eick-Cost, et al., “Substance Use Disorders in the U.S. Armed
Forces, 2000-2011,” Medical Surveillance Monthly Report, 19(11) November 2012, p. 11.
A 2008 health survey of servicemembers found a decrease in illegal drug use since the 2005
survey, but an increase in prescription drug misuse, predominantly prescription pain medication.
(See Figure 15.) Researchers have suggested that these increases in self-reported drug misuse can
be partially attributed to improve survey design, as well as to increased deployments and
associated diagnoses of pain disorders, PTSD, and other mental disorders.66
66
Sirratt, Deborah, Alfred Ozanian, and Barbara Traenkner, “Epidemiology and Prevention of Substance Abuse
Disorders in the Military,” Military Medicine, 177, August Supplement 2012, p. 23.
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Figure 15. Illicit Drug Misuse by Servicemembers, 2002-2008
Source: Sirratt, Deborah, Alfred Ozanian, and Barbara Traenkner, “Epidemiology and Prevention of Substance
Abuse Disorders in the Military,” Military Medicine, 177, August Supplement 2012, p. 23.
Notes: Data from the 2002, 2005, and 2008 Health Related Behaviors Surveys. Accordingly, these figures
represent self-reported rates of illicit drug use, rather than diagnosed incidences of substance abuse disorders.
Depressive Disorders
Overview
Depression, formally diagnosed as major depressive disorder (see text box) is a mental disorder
characterized by episodes of all-encompassing low mood accompanied by low self-esteem and
loss of interest or pleasure in normally enjoyable activities.
Major depressive disorder is a very common mental disorder in the United States, affecting
approximately 16% of adults across their lifetimes, and approximately 6.6% of adults in any 12month period. In a subset of the overall U.S. population with the same socio-demographic
characteristics of the U.S. Army, the estimated prevalence of major depression was 1.3%.67
DSM-IV-TR Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a
change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or
pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions
67
Ronald C. Kessler, Patricia Berglund, and Olga Demler, et al., “The Epidemology of Major Depressive Disorder:
Results from the National Comorbidity Survey Replication (NCS-R),” Journal of the American Medical Association,
vol. 289, no. 23 (June 18, 2003), pp. 3095-3105.
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or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or
empty) or observation made by others (e.g., appears tearful).
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as
indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month),
or decrease or increase in appetite nearly every day.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of
restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not
merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as
observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas
of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or
a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms
persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Source: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text
Revision DSM-IV-TR, 2000, p. 356, notes not included.
Prevalence in the Military
Among active duty troops, the prevalence of major depressive disorder for never-deployed troops
was estimated at 5.7%, based on a meta-analysis of previous studies. The prevalence of major
depressive disorder among currently deployed servicemembers was estimated at 12%, and at
approximately 13% for previously deployed servicemembers.68 One limitation of this analysis
was that it was not able to control for those servicemembers who did not respond to surveys or
screenings, potentially underrepresenting servicemembers with high risk of mental disorders in
the survey data. A second limitation is that the sampling within some of the individual studies
over-represented combat units in the Armed Forces, and over-represented the months just before
deployment and just after redeployment.
According to analysis by the Armed Forces Health Surveillance center using the number of
diagnoses of major depressive disorder among the active duty forces, the percentage of the active
duty forces ever diagnosed with major depressive disorder rose from 4.4% in 2007 to 5.1% in
68
Gaderman, et. al., “Prevalence of DSM-IV Major Depression Among U.S. Military Personnel,” Military Medicine,
Vol. 177, August Supplement 2012.
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2010, while the incidence rate of new diagnoses rose to 19.2 per 1,000 per year in 2009 from 17.3
per 1,000 per person per year in 2007 before declining to 15.1 per 1,000 per year in 2010.69 (See
Figure 16.)
Figure 16. Incidence Rates of Major Depressive Disorder Among the Active
Component Services, 2007-2010
Source: Data from “Selected Mental Disorders Among Active Component Members, U.S. Armed Forces, 20072010,” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol. 17, No 11.
Supplemental Report, p. 3.
Notes: Incidence rates include new cases per 1,000 persons per year. Individuals are counted only once per
condition, in the year during which the first medical encounter for the mental health condition occurred.
Limited data are available about the rates of major depressive disorder among the individual
services. However, data on diagnoses of major depressive disorder among the services allow for
limited comparison of the incidence rates between the services. The incidence rate of diagnoses of
major depressive disorder is highest among the Army over this four-year period, peaking at 28.8
per 1,000 per year in 2009.70
Adjustment Disorder
Overview
Adjustment disorder is a psychological response to one or more stressors, including life events
such as divorce or a period of unemployment. The diagnosis includes four components: the
69
Data from “Selected Mental Health Disorders Among Active Component Members, U.S. Armed Forces, 20072010,” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol 17, No 11. Supplemental
Report. p. 3.
70
Data from “Selected Mental Health Disorders Among Active Component Members, U.S. Armed Forces, 20072010,” Monthly Surveillance Medical Report, Armed Forces Health Surveillance Center. Vol 17, No 11. Supplemental
Report. p. 3.
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stressor(s), symptoms, the lack of an alternative explanation for the symptoms, and the timing of
the symptoms. Stressors may occur once, multiple times, or be chronic.
A diagnosis of adjustment disorder does not require specific symptoms. Rather, it requires
clinically significant distress, such as anxiety or depressed mood, or impairment in functioning,
such as social or occupational problems. A diagnosis of adjustment disorder is a residual category
for cases that do not meet the criteria for another mental disorder. Finally, a diagnosis of
adjustment disorder must take the timing of the symptoms relative to the stressor(s) into account.
In order for a diagnosis of adjustment disorder to be appropriate, symptoms must appear within
three months of the onset of the stressor(s) and resolve within six months of the termination of the
stressor(s).71 Adjustment disorder is acute if symptoms resolve within six months in total, and
chronic if symptoms persist for longer than six months.
Prevalence in the Military
Between 2000 and 2011, adjustment disorders accounted for 26% of mental disorders diagnosed
among the active duty forces, for a total of 471,833 diagnoses. The rates of adjustment disorder
diagnoses increased by 98% between 2000 and 2011.72
Other Conditions
Overview
The Diagnostic and Statistical Manual also provides a means of recording other circumstances of
concern that are clinically significant, but that are not diagnosable mental disorders. These are
called “V codes” (not to be confused with the DSM-V issued by the APA in May 2013, the
successor edition to the DSM-IV-TR) and identify conditions other than a disease or injury. These
codes are also used to report significant factors that may influence present or future care or may
be a focus of clinical attention. V codes are not necessarily a primary diagnosis.
V codes in the DSM-IV-TR include codes for problems in partner relationships; other family
relationships; maltreatment, such as physical abuse or sexual abuse; and life circumstances,
including bereavement and occupational, religious, academic, identity, or acculturation problems.
For details on the use of V codes for mental health issues in the military, please see Appendix A.
Prevalence in the Military
Active duty servicemembers have been provided assistance for other mental issues, such as
difficulties related to life circumstances (including pending, current, or recent deployments),
difficulty in a partner relationship, or mental, behavioral, or substance use difficulties. Between
2000 and 2011, over 425,000 active duty servicemembers sought help for these mental health
71
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (Washington, DC: American Psychiatric Association, 2000), pp. 679-683.
72
Analysis by CRS. Data provided by the Armed Forces Health Surveillance Center, expanded from the data presented
in “Mental Disorders And Mental Health Problems, Active Component, U.S. Armed Forces, 2000-2011,” Medical
Surveillance Monthly Report, 19(6), June 2012.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
problems. This number does not include servicemembers who received diagnoses for specific
mental disorders.
Overall, incidence rates of DSM “V codes” related to mental health issues have declined overall
from 2000 through 2011 by approximately 30%, but with a sharp increase between 2004 and
2005. Incidence rates and numbers of DSM “V codes” connected to mental, behavioral, and
substance abuse issues are the only category of mental health problems to have increased between
2000 and 2011, increasing by approximately 120%. (See Figure 17.)
Figure 17. Incidence of Other Mental Health Problems
Active Duty Forces, 2000-2011
Source: Analysis by CRS. Data provided by the Armed Forces Health Surveillance Center, expanded from the
data presented in “Mental Disorders And Mental Health Problems, Active Component, U.S. Armed Forces,
2000-2011,” Medical Surveillance Monthly Report, 19(6), June 2012.
Notes: The number of active duty members who sought treatment for other mental health problems between
2000 and 2011 totaled approximately 425,000. These numbers do not include servicemembers who received a
diagnosis for a specific mental disorder.
Incidence rate is number of diagnoses per 100,000 person-years, for example, for an incidence rate of 7,000 out
of a population of 100,000 observed for one year, 7,000 new diagnoses would be expected. For a population of
50,000 observed for one year (50,000 person years), or a population of 100,000 observed for six months (also
50,000 person-years), 3,500 new diagnoses would be expected.
While these other mental health issues are not themselves mental health diagnoses, they play an
important role in the psychological health of the active duty force. For example, one study of
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
servicemembers who have received mental health care for “V code” conditions related to family
or partner problems found they were at increased risk of death by suicide.73
Traumatic Brain Injury (TBI)
Overview
The Centers for Disease Control and Prevention defines TBI as an injury to the head arising from
blunt or penetrating trauma, or from acceleration-deceleration forces that result in one or more of
the following:
•
decreased level of consciousness;
•
amnesia regarding the event itself or events preceding or following the injury;
•
skull fracture;
•
a neurological or neuropsychological abnormality such as disorientation,
agitation, or confusion; or
•
an intracranial lesion such as a traumatic intracranial hematoma, cerebral
contusion, or penetrating injury.74
Neurologists classify the severity of the TBI as mild, moderate, severe, or penetrating. (See Table
5.) Penetrating TBIs are open head injuries in which the dura mater, the outer layer of the
meninges (the membranes that surround the brain), is penetrated. Because TBI has a readily
observable physical cause, it is much different than psychological health conditions.
Nevertheless, as discussed below, there may be associations between TBI and other mental health
diagnoses.
Table 5. Symptoms and Severity of Non-Penetrating Traumatic Brain Injuries
Confusion or
Disorientation
Loss of
Consciousness
Memory Loss
MRI or CT results
Mild (Concussion)
< 24 hrs
< 30 minutes
< 24 hrs
normal
Moderate
> 24 hrs
> 30 minutes
> 24 hrs, < 7 days
normal or abnormal
> 7 days
normal or abnormal
< 24 hrs
Severe
> 24 hrs
> 24 hrs
Source: Defense and Veterans’ Brain Injury Center (DVBIC), “DOD Numbers for Traumatic Brain Injury
Worldwide—Totals,” http://www.dvbic.org/sites/default/files/uploads/dod-tbi-2000-2012.pdf, accessed 7/26/2013.
TBI is a common injury from the wars in Iraq and Afghanistan,75 and is a signature injury of
improvised explosive device (IED) blasts. However, according to the Defense and Veteran’s
73
Skopp, N., Trofimovich, L., Grimes, J., et al, “Relations between suicide and traumatic brain injury, psychiatric
diagnoses, and relationship problems, active component, U.S. Armed Forces, 2001-2009, Military Medical
Surveillance Report, 19(2), 2012, pp. 473-481.
74
Adapted from Congressional Budget Office, “The Veterans Health Administration’s Treatment of PTSD and
Traumatic Brain Injury Among Recent Combat Veterans.” February 2012. p. 24.
75
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
(continued...)
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Brain Injury Center, 84% of TBIs occur in a non-deployed setting. Common causes of TBI
include crashes in privately owned and military vehicles, falls, sports and recreation activities,
and military training.76
Symptoms of mild TBI often include headache; dizziness; weakness; sensitivity to light or sound;
cognitive symptoms, including difficulty with attention, memory, or language; and psychological
symptoms, including irritability, depression, anxiety, or personality changes.77 Symptoms of mild
TBI often overlap with symptoms of other psychological issues, and therefore require concurrent
treatment. Approximately 85%-90% of servicemembers who have sustained a combat-related,
mild TBI recover with no lasting clinical difficulties.78
Symptoms of moderate or severe TBI often include longer periods of confusion or disorientation,
loss of consciousness, and memory loss. MRI or CT results may be normal or abnormal.
Moderate or severe TBI sustained in combat requires early recognition of the injury and speedy
evacuation to a combat support hospital or trauma center where specialized neurological care is
available. Effective treatment and decisions during the period immediately after brain injury are
essential for optimal outcomes.79
Prevalence in the Military
Since 2001, servicemembers have experienced about 255,852 TBIs, including approximately
212,741 incidences of mild TBI, approximately 20,168 incidences of moderate TBI,
approximately 6,472 incidences of severe TBI/penetrating head injuries, and 16,471
unclassifiable TBIs. (See Figure 18.)
(...continued)
Diagnosis, and Treatment,” Military Medicine, Vol. 177, No. 8, August 2012 Supplement, p. 67.
76
Defense and Veterans Brain Injury Center, “DoD Worldwide Numbers for TBI.” Available at http://www.dvbic.org/
dod-worldwide-numbers-tbi.
77
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, Vol. 177, No. 8, August 2012 Supplement, p. 70.
78
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, Vol. 177, No. 8:67, August 2012 Supplement, p. 70.
79
Maj. Scot A. Marshall and Ronald G. Riechters II, “Diagnosis and Management of Moderate and Severe Traumatic
Brain Injury Sustained in Combat,” Military Medicine Vol. 177, No. 8, August 2012 Supplement, p. 76.
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Figure 18. TBI Injuries by Severity, 2001-2012
Source: Data from the Armed Forces Medical Surveillance Center, Defense Medical Surveillance System
(DMSS), and the Theater Medical Data Store (TMDS), April 2013.
Notes: The diagnosis and severity of injury were determined using ICD-9 codes. Each data set is based on
garrison medical encounters in the Defense Medical Surveillance System, Standard Ambulatory Data Records,
Health Care Service Record and TRICARE Encounter Data feeds, and theater medical encounters in the Theater
Medical Data Store. Servicemembers may be counted only once, at the most severe level of injury. Therefore,
these data cannot track multiple TBIs experienced by the same servicemember.
These data include TBIs for active duty and activated Guard and Reserve members.
Incidents of mild TBI rose sharply between 2005 and 2007, due in part to more aggressive
screening measures for mild TBI instituted in 2006.80 (See Figure 19.) Since March 2006, all
servicemembers returning from theatre and all servicemembers arriving at Landsruhe Medical
Center receive a TBI screen regardless of other medical conditions. Diagnoses of TBI in deployed
settings nearly doubled between 2010 and 2011, due in part to a greater focus on identifying and
treating TBIs among deployed servicemembers,81 as reflected in the July 2010 “Policy Guidance
for the Management of Concussion/Mild Traumatic Brain Injury in the Deployed Setting.”82
These policies require TBI screening for those exposed to potentially concussive events, and
medical evaluation for all servicemembers who sustained physical injury, exhibited TBI
symptoms such as headache or ear ringing, or were within 50 meters of a blast.83
80
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, Vol. 177, No. 8, August 2012 Supplement, p. 67.
81
“External Causes of Traumatic Brain Injury, 2000-2011,” Monthly Surveillance Medical Report, Armed Forces
Health Surveillance Center, Vol. 20, No. 3, p. 13.
82
DTM 09-033 and DODI 6490.1.
83
“External Causes of Traumatic Brain Injury, 2000-2011,” Monthly Surveillance Medical Report, Armed Forces
Health Surveillance Center, Vol. 20, No. 3, p. 13.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Figure 19. TBI Incidence by Severity, 2001-2012
Source: Data provided by the Armed Forces Health Surveillance Center (AFHSC) April 2013.
Notes: The diagnosis and severity of injury were determined using ICD-9 codes. Each data set is based on
garrison medical encounters in the Defense Medical Surveillance System, Standard Ambulatory Data Records,
Health Care Service Record and TRICARE Encounter Data feeds, and theater medical encounters in the Theater
Medical Data Store. Servicemembers may be counted only once, at the most severe level of injury. Therefore,
these data cannot track multiple TBIs experienced by the same servicemember.
These data include TBIs for active duty and activated Guard and Reserve members.
Screening for TBI is indicated if the servicemember has been exposed to any mechanism of
injury that could potentially cause TBI, for example, blast exposures, falls, or vehicle crashes.84
According to researchers, reliance on servicemember self-reports and co-occurring conditions can
make TBI screening challenging. The deployed acute screening tool for concussion, the
Concussion Management Algorithm, was updated in early 2012.85 Screening for concussion is
required for any servicemember who is in a vehicle with a blast event, collision, or rollover; is
within 50 meters of a blast; sustains a direct blow to the head; or at the direction of their
commander, for example, with repeated exposures to injury mechanisms. All exposed
servicemembers, including those who test negative for concussion, are mandated to rest for 24
hours before returning to duty.86
84
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, vol. Vol. 177, No. 8:67, August 2012 Supplement, p. 67.
85
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
Diagnosis, and Treatment,” Military Medicine, vol. Vol. 177, No. 8:67, August 2012 Supplement, p. 68.
86
Kathryn R. Marshall, Sherray L. Holland, and Kimberly S. Meyer, et al., “Mild Traumatic Brain Injury Screening,
(continued...)
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Causes
All services have experienced a rise in the number of TBIs, although the rate of increase has been
much greater for the Army and Marines Corps than for the Navy and Air Force. When broken out
by type of TBI (mild, moderate, severe/penetrating, or unclassifiable), Army servicemembers
have experienced the greatest number of TBIs of each type. (See Figure 20.)
Over the 12 years between 2000 and 2011, approximately 175,290 active component
servicemembers had at least one TBI diagnosis. Records of the cause of injury were not available
for over 60% of these diagnoses. Between 2008 and 2011, for the 24,115 servicemembers where
the cause of the TBI was recorded, approximately 74% were the result of accidents, including
motor vehicle accidents (20%), falls (20%), or striking or being struck by an object (15%).
Assaults and battle injuries were each the reported cause of 11% of TBIs where the cause was
recorded. In combat theatres, 6,950 TBIs were diagnosed between 2008 and 2011. While only
15% of these diagnoses had cause-of-injury codes, nearly all of these TBIs were attributed to
combat injuries (88%) or gun/explosive accidents (7%).87
(...continued)
Diagnosis, and Treatment,” Military Medicine, vol. Vol. 177, No. 8:67, August 2012 Supplement, p. 68.
87
“External Causes of Traumatic Brain Injury, 2000-2011,” Monthly Surveillance Medical Report, Armed Forces
Health Surveillance Center. Vol. 20, No. 3, pp. 9-13.
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Figure 20. TBIs by Severity and Service, 2001-2011
Mild
Moderate
Severe/Penetrating
Not Classifiable
Source: Data provided by the Armed Forces Health Surveillance Center (AFHSC).
Notes: The diagnosis and severity of injury were determined using ICD-9 codes. Each data set is based on garrison medical encounters in the Defense Medical
Surveillance System, Standard Ambulatory Data Records, Health Care Service Record and TRICARE Encounter Data feeds, and theater medical encounters in the
Theater Medical Data Store. Servicemembers may be counted only once, at the most severe level of injury. Therefore, these data cannot track multiple TBIs experienced
by the same servicemember. These data include TBIs for active duty and activated Guard and Reserve members.
CRS-46
Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Associated Illnesses
A 2008 Institute of Medicine report conducted a meta-analysis and review of research on the
long-term consequences of TBI. Studies have found TBI and brain injury survivors are at elevated
risk for depression, generalized anxiety disorder, and PTSD.88 One study of TBI and associated
psychiatric illnesses found that 49% of those with moderate or severe TBI had evidence of
psychiatric illness, compared to 34% in the mild TBI group and 18% of those without TBI. The
risk generally scales with the increased severity of a TBI.89 There is also limited evidence that
suggests an association between TBI and completed suicide, although there is insufficient
evidence to determine whether there is an association between TBI and attempted suicide.90
Among Gulf War veterans, there is limited/suggestive evidence of an association between mild
TBI and PTSD.91 The 2008 Institute of Medicine report also concluded that TBI is associated
with aggression, irritability, emotional reactivity, sleep disorders, drug and alcohol abuse and
dependence, and personality disorders, among other personality and behavioral outcomes related
to poor psychosocial functioning.92
Several studies have shown a connection between TBI and a greater risk of developing dementia.
A 2010 study of 280,000 veterans at the San Francisco VA Medical Center found that 15% of
veterans diagnosed with TBI developed dementia, compared to 7% of those without a diagnosis.93
The 2008 Institute of Medicine meta-analysis and review of research on the long-term
consequences of TBI concluded that that there is evidence of an association between moderate or
severe TBI and dementia of the Alzheimer type and Parkinson’s disease. It also found that there is
limited or suggestive evidence between mild TBI and some types of dementia.94
88
Rogers and Read (2007), “Psychiatric Comorbidity Following Traumatic Brain Injury,” Brain Injury 21(13): 13211333, cited in Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain
Injury, 2008, pp. 237-263, http://www.nap.edu/catalog/12436.html.
89
Fane et al. 2004, “Psychiatric Illness Following Traumatic Brain Injury in an Adult Health Maintenance Organization
Population,” Archives of General Psychiatry, 61(1): 53-61, cited in Institute of Medicine, Gulf War and Health:
Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008, pp. 237-263, http://www.nap.edu/catalog/
12436.html.
90
Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008,
pp. 277-278, http://www.nap.edu/catalog/12436.html.
91
Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008,
p. 284, http://www.nap.edu/catalog/12436.html.
92
Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008,
pp. 289-293, http://www.nap.edu/catalog/12436.html.
93
Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008,
pp. 237-263, http://www.nap.edu/catalog/12436.html.
94
Institute of Medicine, Gulf War and Health: Volume 7: Long-Term Consequences of Traumatic Brain Injury, 2008,
pp. 237-263, http://www.nap.edu/catalog/12436.html.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Suicide
Overview
Beginning in 2010, suicide has been the second-leading cause of death for active duty
servicemembers, behind only war injuries.95 Researchers have suggested that, similar to suicides
among civilians, suicides by servicemembers are often impulsive acts triggered by various
stressors, including relationship problems, financial or legal problems, or financial problems.96
Prevalence in the Military
Suicides among the active duty forces have increased between 1998 and 2012, rising from
approximately 200 deaths by suicide in 1998 to 349 in 2012. (See Figure 21.)
Figure 21. Suicides Among the Active Duty Forces, by Service
2008-2012
Source: Data from the 2008-2011 DOD Suicide Event Reports, available at https://dodser.t2.health.mil/
welcome, 2012 Data from the Armed Forces Health Surveillance Center, March 2013.
Notes: These figures include some probable suicides that have not been definitively determined to be suicides
by April 1 each year, when data for each report are compiled.
Between 1998 and 2011, 2,990 servicemembers on active duty have died by suicide, with an
incidence rate of approximately 14 per 100,000 person years. However, the suicide rate among
active duty servicemembers has sharply increased since 2005, reaching a peak of 18.5 per
100,000 in 2009 and declining slightly to 17.5 per 100,000 in 2010 and 18 per 100,000 in 2011.97
95
“Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011,”
Medical Surveillance Monthly Report, Vol. 19, No. 6 (June 2012), pp. 11-17.
96
“Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011,”
Medical Surveillance Monthly Report, Vol. 19, No. 6 (June 2012), pp. 11-17.
97
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
(continued...)
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
(See Figure 22.) While the rates of suicide in the Armed Forces overall have increased between
1998 and 2011, the rates remain lower than for comparable civilian populations. Lower suicide
rates among the Armed Forces have been attributed to a variety of factors, including the
servicemember’s full-time employment; “healthy-worker” effects, including a sense of belonging
and purpose among active duty servicemembers; and universal access to health care among the
military population.98
Figure 22. Suicide in the Active Duty Forces, 1998-2011
Source: “Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 19982011,” Medical Surveillance Monthly Report, vol. 19, no. 6 (June 2012), p. 8.
From 1990 to 2000, before the wars in Iraq and Afghanistan, the incidence of suicide in active
duty forces was approximately 25% lower than in comparable civilian populations, approximately
8.31 per 100,000 people per year among the active duty forces, as compared to 12.31 per person
per year in the civilian population.99 Between 1998 and 2011, researchers have estimated that if
the active duty Armed Forces had the same rates of death by suicide as a comparable civilian
population, the number of deaths by suicide among male active duty servicemembers would have
(...continued)
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012.
“Table 2.2 CY 2011 and 2009-2010 AFMES and DMDC Demographic Data for Suicides,” p. 12.
98
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in U.S. Service Members and Veterans: Concerns After a
Decade of War,” Journal of the American Medical Association, Vol. 308, No. 7 (August 15, 2012), p. 671; Eaton,
K.M., Messer, S.C., Garvey Wilson, A.L., and Hoge, C.W., “Strengthening the Validity of Population-Based Suicide
Rate Comparisons: An Illustration Using U.S. Military and Civilian Data,” Suicide and Life-Threatening Behaviour,
April 2006, 36(2), pp. 182-91.
99
Eaton, K.M., Messer, S.C., Garvey Wilson, A.L., and Hoge, C.W., “Strengthening the Validity of Population-Based
Suicide Rate Comparisons: An Illustration Using U.S. Military and Civilian Data,” Suicide and Life-Threatening
Behaviour, April 2006, 36(2), pp. 182-91.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
been approximately 23% higher, resulting in an additional 598 deaths by suicide among male
servicemembers.100
Rates of death by suicide also differ across the services. Between 1998 and 2011, the Army has
experienced the greatest number of servicemember deaths by suicide, 1,370, or 46% of all
servicemember deaths by suicide. (See Figure 23.) Most of the increase in suicide rates between
2000 and 2011 has been concentrated in the Army and Marine Corps. Between 2005 and 2009 the
incidence of suicide has nearly doubled for Army and Marine personnel, while remaining
approximately level for Navy and Air Force personnel.101 In 2011, the suicide rate for Army
personnel was approximately 23 per 100,000, while the rates for the Navy and Marine Corps
were approximately 15 per 100,000 and the rate for the Air Force was approximately 13 per
100,000.
Figure 23. Suicides by Service, 1998-2011
Source: Analysis by CRS. Data from “Deaths by Suicide While on Active Duty, Active and Reserve
Components, U.S. Armed Forces, 1998-2011,” Medical Surveillance Monthly Report, vol. 19, no. 6 (June 2012), p. 9.
According to the 2011 DOD Suicide Event Report, servicemembers who died by suicide in 2011
were more likely than the rest of the general military population to be male, junior enlisted (E1E4) or high school educated, under the age of 25, and non-Hispanic white. These trends among
attempted suicides and death by suicide among the active duty forces for 2011 were similar to
those in 2010 and 2009, the two other calendar years for which detailed information is available.
100
“Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011,”
Medical Surveillance Monthly Report, Vol. 19, No. 6 (June 2012), p. 10. According to the Centers for Disease Control,
in 2009, the latest year for which data are available, the suicide rate for males between 10 and 24 years of age was 11.5
per 100,000, while the suicide rate for males between 25 and 64 years of age was 25 per 100,000.100 However, because
young males make up a much greater proportion of the military population than the civilian population, active duty and
civilian suicide rates are not directly comparable. Suicide rates from National Suicide Statistics at a Glance. “Trends in
Suicide Rates Among Males, by Age Group, United States, 1991-2009,” http://www.cdc.gov/ViolencePrevention/
suicide/statistics/trends03.html.
101
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in U.S. Service Members and Veterans: Concerns After
a Decade of War,” Journal of the American Medical Association, Vol. 308, No. 7 (August 15, 2012), p. 671.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Additionally, the suicide rate for divorced servicemembers was 55% greater than the suicide rate
for married servicemembers in 2011.102
In general, these data regarding deaths by suicide among the active duty forces must be regarded
with caution. The deaths by suicide, as captured by the Armed Forces Medical Examiner system,
include only suicides that occurred during active duty military service. Therefore, these suicide
figures for the active duty forces do not include deaths by suicide or suicide attempts by
inactivated National Guard and Reserve members, or individuals who die by suicide after their
military service has ended. In addition, suicides by various methods may be difficult to
authoritatively ascertain as suicides. For example, suicides by drug overdoses or automobile
accidents may be misclassified as accidents, leading to the undercounting of both deaths by
suicide and suicide attempts.
Suicide and Suicide Attempt Methods
Between 1998 and 2011, firearms were the most frequently used method of suicide by active duty
servicemembers, accounting for 62% of suicides among males and 42% among females. The
proportion of suicides due to firearms was highest in the Reserve component, at 70%. Firearms
were the most commonly used method of suicide among males of all age groups and females age
20 and over. Nearly 60% of all active duty deaths by suicide in 2011 used firearms. Non-military
issue firearms were used in 49% of deaths by suicide in 2011. Hanging was the second most
common cause of death by suicide, accounting for 20% of all deaths by suicide.103
In 2011, drug overdoses were the most common method of suicide attempts, accounting for
nearly 60% of non-fatal attempted suicides. Of all suicide attempts that involved drug use, 64%
involved the use of prescription drugs. 41% of all deaths by suicide or attempts at suicide
involved prescription drug use. Alcohol use was involved in 31% of suicide attempts. Firearms
were used in 4% of suicide attempts.104
Between 1998 and 2011, nearly half of active duty deaths by suicide involved personal weapons,
while about 6% of suicide attempts involved firearms. (See Figure 24.) Firearms were present in
the homes of 50% of servicemembers who died by suicide, as compared to 11% of
servicemembers who attempted suicide. DOD officials are developing a suicide prevention
campaign that will encourage friends and families of potentially suicidal servicemembers to
safely store or voluntarily remove personal firearms from their homes.105
102
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012. p. 1.
103
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012. p. 2.
104
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012. p. 2.
105
James Dao, “As Military Suicides Rise, Focus Is on Private Weapons,” New York Times, October 7, 2012,
http://www.nytimes.com/2012/10/08/us/with-military-suicides-rising-new-policies-take-shape.html?pagewanted=all.
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Figure 24. Suicide Rates by Method of Suicide
1998-2011, Males and Females
Source: “Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 19982011,” Medical Surveillance Monthly Report, vol. 19, no. 6 (June 2012), p. 9.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Contextual Factors
Most servicemembers who attempted suicide (76%) or died by suicide (74%) were not known to
have communicated their potential for self-harm. Those who did most often communicated with
spouses, friends, and other family members.106
Of the 301 servicemembers who died by suicide in 2011:
•
55% had no known behavioral health disorder;
•
20% had mood disorders. 11% had depression, the most common diagnosed mood
disorder;
•
16% had an anxiety disorder. The most common anxiety disorder, at 6% of deaths by
suicide, was PTSD;
•
25% had a known history of substance abuse, while 16% received substance abuse
treatment services;
•
40% received outpatient behavioral health care, while 17% had received outpatient
behavioral health services within the month prior to suicide;
•
15% had received inpatient behavioral health treatment;
•
26% had a known history of psychotropic medication use, most frequently
antidepressants (22%);
•
47% had experienced a failure of a spousal or intimate relationship, 27.5% within the
30 days prior to suicide;
•
18% had experienced Article 15 proceedings/non-judicial punishment, while 13%
had experienced civil legal problems;
•
21% had a known history of job loss or instability, e.g., demotions; and,
•
47% had been deployed, while 8% had been deployed multiple times. 15% had direct
combat experience.
In 2011, 915 active duty servicemembers attempted, but did not complete, suicide. 896
servicemembers attempted suicide once, 18 attempted suicide twice, and 1 servicemember
attempted suicide three times.107 Of the 915 active duty servicemembers who attempted suicide in
2011:
•
64% had a known history of a behavioral health disorder;
•
34% had a mood disorder, most frequently major depression (21%);
•
25% had diagnoses of anxiety disorders, most frequently PTSD (12%);
•
27% had a known history of substance abuse;
106
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012, p. 2.
107
National Center for Telehealth & Technology, Defense Centers of Excellence for Psychological Health & Traumatic
Brain Injury, Department of Defense Suicide Event Report, Calendar Year 2011 Annual Report, November 2012, pp.23.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
•
43% had a known history of psychotropic medication use, most frequently
antidepressants (36.5%);
•
61% had received outpatient behavioral health services within the month prior to
suicide;
•
52% had experienced a failure of a spousal or intimate relationship, 33% within the
month prior to suicide;
•
19% had experienced Article 15 proceedings/non-judicial punishment, while 7% had
experienced civil legal problems;
•
31% had a known history of job loss or instability, e.g., demotions; and
•
40% had been deployed, 4% had been deployed multiple times, and 17% had direct
combat experience.
Deployments, Combat Exposure, and Psychological
Health Disorders
The reasons for the higher rates in mental health diagnoses and suicide rates among Army and
Marine personnel are not clear. While repeated ground combat tours would be a possible answer,
according to U.S. military medical researchers, “to date no study has definitively confirmed an
independent variation” of ground combat tours with servicemember suicides.108 Researchers
suggest that “the cumulative strain from the protracted war effort, across both deployed and
garrison environments” may be “causing higher population prevalence of mental disorders,”
leading to higher suicide rates.109
Many Members of Congress, military leaders, and health providers have expressed concern that
increased numbers of deployments and shorter “dwell” times between deployments have
increased the stress and mental health toll on U.S. servicemembers. However, studies of deployed
servicemembers have reached varying conclusions regarding the links between deployment(s)
and various psychological health concerns, including PTSD, depression, anxiety, and stress.
Repeated Deployments
While several studies have found higher rates of mental health problems among repeat deployers
than among first-time deployers, other studies have found little evidence of a causal link between
repeated deployments and various mental health problems. One possible explanation is that
servicemembers who are more negatively affected by deployments are less likely to deploy again,
and may leave the Armed Forces. Therefore, the servicemembers who deploy repeatedly may be
more resilient. Additionally, servicemembers with repeated deployments may gain additional
108
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in US Service Members and Veterans: Concerns After a
Decade of War,” Journal of the American Medical Association, Vol. 308, No. 7 (August 15, 2012), pp. 671-672.
109
Charles W. Hoge and Carl A. Castro, “Preventing Suicides in US Service Members and Veterans: Concerns After a
Decade of War,” Journal of the American Medical Association, Vol. 308, No. 7 (August 15, 2012), pp. 671-672.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
knowledge, skills, and confidence in combat environments, also increasing their psychological
resilience.110
According to an analysis of diagnoses received by previously deployed active component
servicemembers, rates of diagnoses of anxiety disorders and adjustment reactions (including
PTSD) rose after the first, second, and third deployments, before falling sharply for the fourth and
fifth deployments.111 A follow-up study, focusing specifically on mental health diagnoses received
in the year after a servicemember returns from combat, found that among male servicemembers,
diagnoses of PTSD, adjustment reactions, anxiety-related disorders, and depressive disorders
were more common after second, third, and fourth deployments than first deployments. Among
male servicemembers, a greater proportion was diagnosed with alcohol or drug disorders, suicidal
ideation/self-inflicted injuries, and psychosocial problems after the first deployment than all
following deployments.112
The results among female servicemembers were somewhat different. Like among male
servicemembers, PTSD diagnoses increased following the second, third, and fourth deployments.
However, the percentage of female servicemembers diagnosed with other mental disorders,
including depressive disorders, alcohol/drug disorders, suicidal ideation/self-inflicted injury,
adjustment reactions, anxiety disorders, and psychosocial problems all declined after repeated
deployments.113 (See Figure 25.)
Overall, for all deployed active component servicemembers, larger percentages received
diagnoses of PTSD and anxiety-related disorders after the second and/or third deployment than
after the first deployment. The rates of PTSD diagnoses fall sharply after the fourth and fifth
deployments.114 However, for other mental disorders than anxiety disorders and PTSD, a greater
proportion of deployed servicemembers receive diagnoses after their first deployment than
subsequent deployments.
Dwell Time
Quickened deployment cycles and the shorter “dwell” time between deployments are often cited
as a risk factor leading to greater stress and higher rates of mental disorders among deployed
servicemembers.
110
Armed Forces Health Surveillance Center, “Associations between Repeated Deployments to OEF/OIF/OND,
October 2001-December 2010, and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces.”
Medical Surveillance Monthly Report, 18(7), July 2011, pp. 2-11.
111
Armed Forces Health Surveillance Center, “Associations between Repeated Deployments to OEF/OIF/OND,
October 2001-December 2010, and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces.”
Medical Surveillance Monthly Report, 18(7), July 2011, p. 6.
112
Armed Forces Health Surveillance Center, “Associations between Repeated Deployments to OEF/OIF/OND,
October 2001-December 2010, and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces.”
Medical Surveillance Monthly Report, 18(7), July 2011, p.3.
113
Armed Forces Health Surveillance Center, “Associations between Repeated Deployments to OEF/OIF/OND,
October 2001-December 2010, and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces.”
Medical Surveillance Monthly Report, 18(7), July 2011, p.3.
114
Armed Forces Health Surveillance Center, “Associations between Repeated Deployments to OEF/OIF/OND,
October 2001-December 2010, and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces.”
Medical Surveillance Monthly Report, 18(7), July 2011, p.3.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
However, a recent analysis by the Armed Forces Health Surveillance Center found that the
percentages of deployed servicemembers diagnosed with a mental disorder were greater among
servicemembers with longer dwell times between deployments. However, the study cautions that
personal circumstances can greatly influence the nature, magnitude, duration, and effects of
stresses related to transition and readjustment periods, such as preparing for or following a
deployment. The Armed Forces Health Surveillance Center study also speculates that the double
transition from “warrior” to being fully adjusted as non-deployed back to “warrior” status may
play a role. They also note that servicemembers with medical conditions associated with recent
deployments may have very long dwell times and be at a higher risk of recurrent or related
conditions following their deployment.115
115
Armed Forces Health Surveillance Center, “Associations Between Repeated Deployments to Iraq (OIF/OND) and
Afghanistan (OEF) and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed Forces, 2003-2010,”
Monthly Medical Surveillance Report, 18(9), September 2011, p. 9.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Figure 25. Percentage of Deployed Servicemembers Diagnosed with Selected
Mental Disorders, by “Dwell Times,” by Gender, 2003-2010
Source: From Armed Forces Health Surveillance Center, “Associations Between Repeated Deployments to Iraq
(OIF/OND) and Afghanistan (OEF) and Post-deployment Illnesses and Injuries, Active Component, U.S. Armed
Forces, 2003-2010,” Monthly Medical Surveillance Report, 18(9), September 2011, p. 8.
Notes: These figures include deployed active component servicemembers diagnosed at non-deployed medical
treatment facilities within one year of OEF/OIF/OND deployment.
Combat-Specific and Health Care Occupations
Deployed servicemembers in health care occupations consistently had the highest rates of PTSD
diagnoses, as well as diagnoses of other anxiety disorders, adjustment reactions, and depressive
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
disorder than servicemembers in other occupations, including combat-specific occupations. (See
Figure 26.) One possible explanation is that the consistent exposure of servicemembers in health
care occupations to traumatic injuries suffered by others leads to higher rates of PTSD, as
compared to the more intermittent, but more intense and personal exposures to life-threatening
experiences among combat-specific occupations. Additionally, servicemembers in health care
occupations likely have a higher utilization of health care, including mental health care, than
servicemembers in combat-specific occupations.116
116
Armed Forces Health Surveillance Center, “Associations Between Repeated Deployments to Iraq (OIF/OND) and
Afghanistan (OEF) and Post-Deployment Illnesses and Injuries, Active Component, U.S. Armed Forces, 2003-2010,”
Monthly Medical Surveillance Report, 18(9), September 2011, p. 9.
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Post-Traumatic Stress Disorder and Other Mental Health Problems in the Military
Figure 26. Percentage of Deployed Servicemembers Diagnosed with Selected
Mental Disorders, by Number of Deployments and Military Occupational Group,
2003-2010
Source: From Armed Forces Health Surveillance Center, “Associations Between Repeated Deployments to Iraq
(OIF/OND) and Afghanistan (OEF) and Post-Deplo
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