Transformation of Mental Health Care for U.S. Soldiers and Families During the Iraq and Afghanistan Wars: Where Science and Politics Intersect
Abstract
Key Research Investments
Historical Highlights, 2002–2009
Year(s) Initiated | Identified Problem | Response to Problem |
---|---|---|
2003 or before | Incomplete understanding of mental health effects of wartime service | Uniformed research psychologists |
Millennium Cohort Study | ||
Land Combat Study | ||
Serial mental health advisory team assessments in Iraq and Afghanistan | ||
2003–2005 | Inadequate postdeployment mental health screening | Postdeployment health assessment: expansion of mental health screening items |
Postdeployment health reassessment | ||
Validation of screening measures | ||
2005–2006 | Deficiencies in in-theater mental health services | Revision of combat-operational stress control field manuals for soldiers and leaders |
Publication of mental health standards for deployment | ||
Guidelines for use of psychotropic medications | ||
Increase in number of deployed mental health personnel | ||
Improved distribution of mental health personnel | ||
2007–2009 | Critical gaps in addressing postdeployment mental health needs (including stigma and other barriers to care) | Expanded funding for research and clinical programs |
Establishment of large clinical trial consortiums | ||
Establishment of Defense Center of Excellence for Psychological Health and Traumatic Brain Injury | ||
Publication of DOD/VA clinical practice guidelines for PTSD and mild TBI | ||
Revision of administrative separation policies | ||
Initiation of Comprehensive Soldier and Family Fitness program | ||
Since 2009 | Stovepiped, variable, poorly integrated, and/or redundant clinical services | Reorganization and consolidation of all mental health services under the Behavioral Health Service Line |
Increased mental health personnel Army-wide | ||
Embedded behavioral health | ||
Behavioral health in primary care | ||
Child and family behavioral health system | ||
Behavioral Health Data Portal | ||
Additional refinements in screening for PTSD and mild TBI | ||
PTSD assessment and treatment policy | ||
Revision of disability evaluation system |
2002–2003
2004–2005
2005–2006
2007
2008–2009
Transformation of Army Mental Health Care: 2010–Today
Centralized Management and Reorganization of Services
Novel Behavioral Health Programs
Embedded behavioral health.
Behavioral health in primary care.
Child and family behavioral health system.
Behavioral Health Data Portal.
Additional Core Program Components
Screening initiatives across a soldier’s career.
Health care policies to facilitate standards of care.
Revision of disability evaluations.
Program Evaluation
2010 | 2011 | 2012 | 2013 | 2014 | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Measure | N | % | N | % | N | % | N | % | N | % |
Total population | 571,379 | 579,938 | 568,102 | 549,515 | 530,552 | |||||
Receiving outpatient mental health care (direct care) | 193,494 | 33.9 | 223,385 | 38.5 | 198,257 | 34.9 | 174,785 | 31.8 | 157,854 | 29.7 |
Receiving outpatient mental health care (direct and purchased care) | 198,656 | 34.8 | 229,052 | 39.5 | 205,110 | 36.1 | 182,489 | 33.2 | 164,203 | 30.9 |
Outpatient mental health encounters (direct care) | 1,100,183 | 1,126,708 | 1,083,312 | 1,049,715 | 1,029,137 | |||||
Outpatient mental health encounters (direct and purchased care) | 1,244,285 | 1,305,192 | 1,348,766 | 1,277,517 | 1,222,988 | |||||
Inpatient mental health admissions (direct care) | 4,243 | 4,836 | 4,816 | 4,599 | 4,769 | |||||
Inpatient mental health admissions (direct and purchased care) | 10,857 | 12,298 | 12,558 | 10,646 | 9,655 | |||||
Inpatient bed days (direct care) | 29,328 | 33,920 | 37,546 | 38,136 | 39,569 | |||||
Inpatient bed days (direct and purchased care)b | 128,186 | 144,539 | 162,629 | 135,093 | 114,774 | |||||
Outpatient mental health encounter within 7 days of hospital discharge (%)c | NA | NA | 92 | 92 | 95 | |||||
Outpatient mental health encounter within 30 days of hospital discharge (%)c | NA | NA | 97 | 97 | 98 |
Challenges and Critical Gaps
Summary
Category | Considerations and Recommendations |
---|---|
Ensure optimal clinical research infrastructure | Sustain research funding for military-related mental health concerns |
Ensure that research is incorporated into operational planning | |
Establish equitable processes for research grant applications that focus as much on novel treatments/interventions as on established approaches | |
Foster grant applications from individual investigators. Establish research consortiums only when multicenter trials are clearly indicated | |
Prioritize randomized clinical trials to ensure that they meet the highest priority needs | Establish clear priorities that address most critical clinical gaps focused both on the deployment mission and postdeployment care |
Current top priorities include: | |
Interventions to improve treatment engagement and retention | |
Primary care interventions for postdeployment health conditions | |
Novel treatment approaches for PTSD and other mental health concerns | |
Educate mental health providers | Incorporate lessons learned from recent wars into graduate medical education programs |
Maintain experienced military providers and educators who can ensure retention and evolution of knowledge | |
Ensure that mental health clinicians are trained in and gain direct experience in recognizing the immediate and long-term consequences of war and are skilled in providing evidence-based treatment | |
Evolve medical practice in-theater and in garrison | Ensure that clinical practice guidelines and military doctrine and training incorporate lessons from recent wars |
Enhance ability to detect and understand long-term impact of mental disorders to refine screening, deployability criteria, and treatment | |
Ensure that screening efforts are partnered with care coordination | |
Ensure optimal structure of clinical services, both in-theater and postdeployment, and continually re-evaluate the structure of care | |
Ensure continued synchronization and coordination of mental health care | |
Optimize care for generalized health concerns (e.g., collaborative primary care interventions that address persistent postconcussion and/or postdeployment symptoms, chronic pain, and polypharmacy) | |
Ensure availability of evidence-based treatments for substance use disorders, with confidentiality equivalent to that for other mental disorders | |
Sustain routine collection of clinically meaningful outcome measures | |
Address larger population needs | Address unique needs of reserve component members and ensure that they have services equivalent to those of active component members |
Ensure that the needs of families are fully addressed | |
Validate prevention initiatives | Validate mental health prevention and/or resilience training prior to large-scale rollout |
Build program evaluation into new programs and ensure that evaluations have sufficient scientific rigor |
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