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

This book is a compilation of papers coedited by Terri Tanielian, who has a master's in psychology, and Lisa H. Jaycox, who has a doctorate in clinical psychology. Both are now with RAND; Tanielian is currently the codirector for the Center for Military Health Policy Research, and Jaycox is a senior behavioral scientist and clinical psychologist.

This book begins by explaining what makes the conflicts in Afghanistan and Iraq different from other wars. It continues by determining the prevalence, correlates, and consequences of posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) among returning service members of Operation Enduring Freedom and Operation Iraqi Freedom. The book concludes with a discussion of the cost of mental health care as well as the challenges and opportunities to improve access to high-quality health care for this population.

The key findings on prevalence of mental health conditions and TBI are that current rates of exposure to combat trauma and mental health conditions among returning veterans are relatively high. Groups at higher risk for these conditions include Army soldiers and Marines, those serving in military reserve forces, discharged soldiers, retired military, enlisted personnel, women, and Hispanics. Also at risk are personnel serving 12- to 15-month deployments and those with more extensive exposure to combat trauma. There is a gap in care for PTSD and TBI. The need for treatment is high, but few receive adequate services because of concerns that care would not be kept confidential and would preclude recipients from future job assignments.

A key finding is that PTSD, major depression, and TBI can have long-term, cascading consequences. These consequences include substance abuse, suicide attempts, unhealthy behaviors, physical health problems, mortality, diminished productivity, and unemployment.

The costs associated with treating the mental health conditions resulting from combat service are also examined. Estimates of the cost of treating major depression or PTSD for two years postdeployment range from $5,904 to $25,757 per case. Provision of evidence-based care will save money or pay for itself. In 2005, estimates of the cost of TBI ranged from $25,572 to $30,730 per mild case and from $252,251 to $383,221 per moderate or severe case. Another main finding is that lost productivity is a key driver of the costs associated with major depression, PTSD, and mild TBI.

The contributors offer several observations about systems of care. For example, many mental health services are available for active duty personnel, but gaps and barriers are substantial. Quality of mental health treatment needs increased attention from the Department of Defense, and the Veterans Administration (VA) offers a promising model to this end. However, because of fixed-budget constraints, the VA faces challenges in providing access to mental health care for veterans and deactivated reservists and National Guard personnel. The VA is a leader in assessment of health care quality and improvement, but VA medical centers and community providers, including those within the TRICARE military health plan, still need evaluation. Also, the book points out that the science of treating TBI is young. The difficulty of identifying those with lasting effects from mild TBI hampers care. The complex health care needs of military service members with more severe injuries require careful coordination of services.

This book has very adequately met its stated objectives, and it is a must for those working in the psychiatric field who want to learn more to understand and treat veterans of the conflicts in Afghanistan and Iraq.