Institute of Medicine Reports

Provision of Mental Health Counseling Services Under TRICARE (2010)The mental health care needs of this population are large and diverse, requiring a skilled group of professionals to diagnose and treat a variety of disorders. These professionals include mental health counselors, who—like clinical social workers, marriage and family therapists, and psychiatric nurse specialists—typically hold masters degrees and are obligated by state licensure and other requirements to have demonstrated clinical experience in order to practice. Under current TRICARE rules, mental health counselors are required to practice under a physician’s supervision, and their patients must be referred to them by a physician in order for their services to be eligible for reimbursement. At the request of Congress, the IOM examined the credentials, preparation, and training of licensed mental health counselors. In this report, the IOM makes recommendations for permitting counselors to practice independently under the TRICARE program and instituting a comprehensive quality management system for all mental health professionals.

Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families (2010)Nearly 1.9 million U.S. troops have been deployed to Afghanistan and Iraq since October 2001. Most return successfully to their normal lives, but many have encountered serious challenges readjusting after their return home. These wars are unlike past conflicts, and the demographics of the all-volunteer military population have changed drastically since the previous war. Many service members deploy multiple times; reservists and National Guard members are called to active duty at an unprecedented rate; more service members are returning home with severe injuries; and more women and parents of young children serve on active duty. These unique circumstances cause unique problems for service members, veterans, and their families, both during and after deployment to Iraq and Afghanistan. In 2009, Congress asked the IOM to conduct a two-phase study to examine the physical, mental, and other needs of military personnel returning from the conflicts in Iraq and Afghanistan, and of veterans and their family members. This preliminary report presents findings on the scope and magnitude of the problems facing these populations, and lays out a plan for the detailed assessment in the second phase. In the interim, this initial report makes several recommendations that the Department of Defense (DoD) and Department of Veterans Affairs (VA) can act on now...

Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel (2011)Military personnel, especially those in combat zones, face a distinct risk of traumatic brain injury (TBI). The injuries can range from mild to severe, and their effects can appear within minutes or hours—or sometimes weeks or even years later. Although estimates of incidence and prevalence are elusive, some estimates suggest that TBI has accounted for up to one-third of combat-related injuries. TBI also is a major problem among civilians, especially those who engage in certain sports, with an estimated 1.6 to 3.8 million sports-related TBIs occurring annually. Despite such health tolls, the mechanisms and damaging effects of TBI on the brain are not fully understood. While some research has explained these mechanisms of injury, new information suggests that nutritional interventions could help in treating or even providing resilience against TBI. In this light, the Department of Defense (DoD) asked the IOM to review the potential role of nutrition in the treatment of and resilience against TBI. Given the complexity of TBI and the current gaps in scientific knowledge, the IOM could identify only one action that can immediately improve treatment efforts: early feeding to patients with severe TBI. Research has shown that feeding the severely injured soon after an injury is known to help in decreasing mortality. In addition, new information suggests that nutritional interventions could help in treating or even providing resilience against TBI. The IOM identified a number of other possible benefits for specific nutritional interventions and recommends that the DoD and other collaborates conduct more research.

Cognitive Rehabilitation Therapy for Traumatic Brain Injury: Evaluating the Evidence (2011)The Department of Defense asked the IOM to conduct a study to determine the effectiveness of CRT for treatment of TBI. The IOM was asked to consider whether existing research on CRT provides a conclusive evidence base to support using specific CRT interventions and to guide the use of CRT for members of the military and veterans. The committee recommends an investment in research to further define, standardize, and assess the outcomes of CRT interventions. CRT interventions are promising approaches, but further development of this therapy is required.

Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment (2012)Prior to the military conflicts in Iraq and Afghanistan, wars and conflicts have been characterized by such injuries as infectious diseases and catastrophic gunshot wounds. However, the signature injuries sustained by United States military personnel in these most recent conflicts are blast wounds and the psychiatric consequences to combat, particularly posttraumatic stress disorder (PTSD), which affects an estimated 13 to 20 percent of U.S. service members who have fought in Iraq or Afghanistan since 2001. PTSD is triggered by a specific traumatic event – including combat – which leads to symptoms such as persistent re-experiencing of the event; emotional numbing or avoidance of thoughts, feelings, conversations, or places associated with the trauma; and hyperarousal, such as exaggerated startle responses or difficulty concentrating. As the U.S. reduces its military involvement in the Middle East, the Departments of Defense (DoD) and Veterans Affairs (VA) anticipate that increasing numbers of returning veterans will need PTSD services. As a result, Congress asked the DoD, in consultation with the VA, to sponsor an IOM study to assess both departments’ PTSD treatment programs and services. This first of two mandated reports examines some of the available programs to prevent, diagnose, treat, and rehabilitate those who have PTSD and encourages further research that can help to improve PTSD care.

Substance Use Disorders in the U.S. Armed Forces (2012)Like many sectors of society, the U.S. military has a long history of alcohol and other drug misuse and abuse. In recent years, the face of the issue has been transformed by increasing rates of prescription drug abuse among service members. Heavy alcohol use and binge drinking continues to be a concern within the military. To better understand the current substance use problems within the U.S. military, the Department of Defense (DoD) asked the IOM to analyze policies and programs that pertain to prevention, screening, diagnosis, and treatment of substance use disorders for active duty service members in all branches, members of the National Guard and Reserve, and military families. The IOM concludes that to deal with this public health crisis, the DoD will need to consistently implement evidence-based prevention, screening, diagnosis, and treatment services and take leadership for ensuring that these services expand and improve.

Gulf War and Health: Volume 6. Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress (2008)The sixth in a series of congressionally mandated reports on Gulf War veterans' health, this volume evaluates the health effects associated with stress. Since the launch of Operation Desert Storm in 1991, there has been growing concern about the physical and psychological health of Gulf War and other veterans. In the late 1990s, Congress responded by asking the National Academy of Sciences (NAS) to review and evaluate the scientific and medical literature regarding associations between illness and exposure to toxic agents, environmental or wartime hazards, and preventive medicines or vaccines in members of the armed forces who were exposed to such agents. Deployment to a war zone has a profound impact on the lives of troops and on their family members. There are a plethora of stressors associated with deployment, including constant vigilance against unexpected attack, difficulty distinguishing enemy combatants from civilians, concerns about survival, caring for the badly injured, and witnessing the death of a person. Less traumatic but more pervasive stressors include anxiety about home life, such as loss of a job and income, impacts on relationships, and absence from family. The focus of this report, by the Institute of Medicine (IOM) Committee on Gulf War and Health: Physiologic, and Psychosocial Effects of Deployment-Related Stress, is the long-term effects of deployment-related stress. Gulf War and Health: Volume 6. Physiologic, and Psychosocial Effects of Development Related Stress evaluates the scientific literature regarding association between deployment-related stressors and health effects, and provides meaningful recommendations to remedy this problem.

Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their FamiliesAs of December 2012, Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq have resulted in the deployment of about 2.2 million troops; there have been 2,222 US fatalities in OEF and Operation New Dawn (OND)1 and 4,422 in OIF. The numbers of wounded US troops exceed 16,000 in Afghanistan and 32,000 in Iraq. In addition to deaths and morbidity, the operations have unforeseen consequences that are yet to be fully understood. In contrast with previous conflicts, the all-volunteer military has experienced numerous deployments of individual service members; has seen increased deployments of women, parents of young children, and reserve and National Guard troops; and in some cases has been subject to longer deployments and shorter times at home between deployments. Numerous reports in the popular press have made the public aware of issues that have pointed to the difficulty of military personnel in readjusting after returning from Iraq and Afghanistan. Many of those who have served in OEF and OIF readjust with few difficulties, but others have problems in readjusting to home, reconnecting with family members, finding employment, and returning to school. In response to the return of large numbers of veterans from Iraq and Afghanistan with physical-health and mental-health problems and to the growing readjustment needs of active duty service members, veterans, and their family members, Congress included Section 1661 of the National Defense Authorization Act for fiscal year 2008. That section required the secretary of defense, in consultation with the secretary of veterans affairs, to enter into an agreement with the National Academies for a study of the physical-health, mental-health, and other readjustment needs of members and former members of the armed forces who were deployed in OIF or OEF, their families, and their communities as a result of such deployment. The study consisted of two phases. The Phase 1 task was to conduct a preliminary assessment. The Phase 2 task was to provide a comprehensive assessment of the physical, psychologic, social, and economic effects of deployment on and identification of gaps in care for members and former members, their families, and their communities. The Phase 1 report was completed in March 2010 and delivered to the Department of Defense (DOD), the Department of Veterans Affairs (VA), and the relevant committees of the House of Representatives and the Senate. The secretaries of DOD and VA responded to the Phase 1 report in September 2010. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families fulfills the requirement for Phase 2.