Skip to Main Content
Have library access? Log in through your library
Invisible Wounds of War

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

Copyright Date: 2008
Published by: RAND Corporation
Pages: 498
  • Book Info
    Invisible Wounds of War
    Book Description:

    Since October 2001, approximately 1.64 million U.S. troops have been deployed for Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) in Afghanistan and Iraq. Early evidence suggests that the psychological toll of these deployments many involving prolonged exposure to combat-related stress over multiple rotations--may be disproportionately high compared with the physical injuries of combat. In the face of mounting public concern over post-deployment health care issues confronting OEF/OIF veterans, several task forces, independent review groups, and a Presidential Commission have been convened to examine the care of the war wounded and make recommendations. Concerns have been most recently centered on two combat-related injuries in particular: post-traumatic stress disorder and traumatic brain injury. With the increasing incidence of suicide and suicide attempts among returning veterans, concern about depression is also on the rise. The study discussed in this monograph focuses on post-traumatic stress disorder, major depression, and traumatic brain injury, not only because of current high-level policy interest but also because, unlike the physical wounds of war, these conditions are often invisible to the eye, remaining invisible to other servicemembers, family members, and society in general. All three conditions affect mood, thoughts, and behavior; yet these wounds often go unrecognized and unacknowledged. The effect of traumatic brain injury is still poorly understood, leaving a large gap in knowledge related to how extensive the problem is or how to address it. RAND conducted a comprehensive study of the post-deployment health-related needs associated with these three conditions among OEF/OIF veterans, the health care system in place to meet those needs, gaps in the care system, and the costs associated with these conditions and with providing quality health care to all those in need. This monograph presents the results of our study, which should be of interest to mental health treatment providers; health policymakers, particularly those charged with caring for our nation's veterans; and U.S. service men and women, their families, and the concerned public. All the research products from this study are available at Data collection for this study began in April 2007 and concluded in January 2008. Specific activities included a critical review of the extant literature on the prevalence of post-traumatic stress disorder, major depression, and traumatic brain injury and their short- and long-term consequences; a population-based survey of servicemembers and veterans who served in Afghanistan or Iraq to assess health status and symptoms, as well as utilization of and barriers to care; a review of existing programs to treat servicemembers and veterans with the three conditions; focus groups with military servicemembers and their spouses; and the development of a microsimulation model to forecast the economic costs of these conditions over time. Among our recommendations is that effective treatments documented in the scientific literature, evidence-based care--are available for PTSD and major depression. Delivery of such care to all veterans with PTSD or major depression would pay for itself within two years, or even save money, by improving productivity and reducing medical and mortality costs. Such care may also be a cost-effective way to retain a ready and healthy military force for the future. However, to ensure that this care is delivered requires system-level changes across the Department of Defense, the Department of Veterans Affairs, and the U.S. health care system.

    eISBN: 978-0-8330-4529-4
    Subjects: Health Sciences, Management & Organizational Behavior

Table of Contents

Export Selected Citations Export to NoodleTools Export to RefWorks Export to EasyBib Export a RIS file (For EndNote, ProCite, Reference Manager, Zotero, Mendeley...) Export a Text file (For BibTex)
  1. Front Matter
    (pp. i-ii)
  2. Preface
    (pp. iii-vi)
  3. Table of Contents
    (pp. vii-xii)
  4. Figures
    (pp. xiii-xiv)
  5. Tables
    (pp. xv-xviii)
  6. Summary
    (pp. xix-xxxiv)
  7. Acknowledgments
    (pp. xxxv-xxxvi)
  8. Abbreviations
    (pp. xxxvii-xliv)
  9. Part I: Introduction, Current Policy Context, and Historical Perspective

    • CHAPTER ONE Introduction
      (pp. 3-18)
      Terri Tanielian, Lisa H. Jaycox, David M. Adamson and Karen N. Metscher

      Since October 2001, approximately 1.64 million U.S. troops have deployed as part of Operation Enduring Freedom (OEF, Afghanistan) and Operation Iraqi Freedom (OIF, Iraq). These operations have employed smaller forces and (notwithstanding episodes of intense combat) have produced casualty rates of killed or wounded that are historically lower than in earlier prolonged conflicts, such as Vietnam and Korea. However, casualties of a different kind—invisible wounds, such as mental health conditions and cognitive impairments resulting from deployment experiences—are just beginning to emerge. Recent reports and increasing media attention have prompted intense scrutiny and examination of these injuries. As a...

    • CHAPTER TWO The Wars in Afghanistan and Iraq—An Overview
      (pp. 19-32)
      Jerry M. Sollinger, Gail Fisher and Karen N. Metscher

      This chapter provides a thumbnail sketch of the conflicts in Afghanistan and Iraq. The first section describes the composition of the U.S. forces by demographic components and organizational affiliations in the Active and Reserve Components. The second section places the conflicts in perspective, comparing them with other wars the United States has fought. The third section shows the history of troop deployments in the war on terrorism and arrays those deployments against significant events that have occurred in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). The third section also discusses the casualties for ground forces sustained in Iraq...

  10. Part II: The Nature and Scope of the Problem

    • CHAPTER THREE Prevalence of PTSD, Depression, and TBI Among Returning Servicemembers
      (pp. 35-86)
      Rajeev Ramchand, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns and Leah Barnes Caldarone

      As Kessler (2000) has noted: “Any assessment of the societal impact of a disorder must begin with a consideration of prevalence” (p. 4). By critically reviewing the current epidemiological studies on post-traumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) following deployment to Afghanistan and Iraq, we aim specifically to address several questions of both scientific and political importance, including: How widespread are mental health and cognitive conditions in the military currently? How do rates of mental health and cognitive conditions differ among troops deployed to Afghanistan, those deployed to Iraq, and nondeployed troops? How long do conditions and...

    • CHAPTER FOUR Survey of Individuals Previously Deployed for OEF/OIF
      (pp. 87-116)
      Terry L. Schell and Grant N. Marshall

      RAND conducted a large population-based survey on individuals previously deployed as part of Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) to address several gaps in the existing literature concerning the prevalence and correlates of mental health conditions and traumatic brain injury (TBI) stemming from service in OEF/OIF. As reported in Chapter Three, research on the prevalence of post-traumatic stress disorder (PTSD) and major depression has typically focused on active duty Army personnel and has largely neglected several types of servicemembers deployed in OEF/OIF. For example, although Air Force and Navy personnel account for 38 percent of the deployed force...

  11. Part III: Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury

    • CHAPTER FIVE Predicting the Immediate and Long-Term Consequences of Post-Traumatic Stress Disorder, Depression, and Traumatic Brain Injury in Veterans of Operation Enduring Freedom and Operation Iraqi Freedom
      (pp. 119-166)
      Benjamin R. Karney, Rajeev Ramchand, Karen Chan Osilla, Leah Barnes Caldarone and Rachel M. Burns

      Although there is an emerging consensus that mental health and cognitive conditions stemming from service in Afghanistan and Iraq are likely to have severe and broad consequences if left untreated, allocating resources toward particular treatments and interventions requires a detailed understanding of what the consequences of these problems are likely to be. For example, if it can be reasonably assumed that servicemembers will manifest any mental health or cognitive conditions immediately upon return from deployment, then initial assessments will be sufficient to identify those who may require extra support. In contrast, if there are reasons to expect delayed reactions to...

  12. Part IV: Economic Consequences

    • CHAPTER SIX The Cost of Post-Deployment Mental Health and Cognitive Conditions
      (pp. 169-242)
      Christine Eibner, Jeanne S. Ringel, Beau Kilmer, Rosalie Liccardo Pacula and Claudia Diaz

      The previous part of this monograph (see Part III) described the consequences associated with deployment-related post-traumatic stress disorder (PTSD), major depression, and traumatic brain injury (TBI). In this chapter, we evaluate the costs associated with these conditions. Prior analyses of the costs associated with the conflicts in Afghanistan and Iraq have typically used standard accounting methodologies to project the costs that accrue to the government (Bilmes, 2007; Bilmes and Stiglitz, 2006; Goldberg, 2007), typically taking a per-person cost figure from existing data, multiplying by the projected population, and inflating over time with trend factors. These studies have focused on the...

  13. Part V: Caring for the Invisible Wounds

    • CHAPTER SEVEN Systems of Care: Challenges and Opportunities to Improve Access to High-Quality Care
      (pp. 245-428)
      M. Audrey Burnam, Lisa S. Meredith, Todd C. Helmus, Rachel M. Burns, Robert A. Cox, Elizabeth D’Amico, Laurie T. Martin, Mary E. Vaiana, Kayla M. Williams and Michael R. Yochelson

      How can we best provide services for military personnel who are suffering from mental health and cognitive problems? The answer to that question is the focus of Chapter Seven.

      We examine the health care services available to military servicemembers who have returned from Afghanistan and Iraq with post-traumatic stress disorder or depression, or who have suffered a traumatic brain injury during their deployment.

      We also examine gaps in these services, with the goal of supporting efforts to meet the mental health and cognitive needs of returning OEF/OIF servicemembers and veterans. We consider two kinds of service gaps:gaps in access...

  14. Part VI: Conclusions and Recommendations

    • CHAPTER EIGHT Treating the Invisible Wounds of War: Conclusions and Recommendations
      (pp. 431-454)
      Terri Tanielian, Lisa H. Jaycox, Terry L. Schell, Grant N. Marshall and Mary E. Vaiana

      Throughout its history, the United States has striven to recruit, prepare, and sustain an armed force with the capacity and capability to defend the nation. The Department of Defense (DoD), through the Secretary of Defense and the Services, bears the responsibility for ensuring that the force is ready and deployable to conduct and support military operations.

      The nation has committed not only to compensating military servicemembers for their duty but also to addressing and providing compensation, benefits, and medical care for any Service-connected injuries and disabilities. For those who suffer injuries but remain on active duty, benefits and medical care...