Stop Loss

A Nation Weighs the Tangible Consequences of Invisible Combat Wounds

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Traumatic Brain Injury

TBI is a head trauma that either temporarily or permanently disrupts the brain’s functions. In combat situations, TBI can be caused by improvised explosive devices, mortars, vehicle accidents, grenades, bullets, mines, and falls. As such, TBI can be difficult to diagnose. Its symptoms can range from headaches, irritability, and sleep disorders to memory problems and depression.

Figure 7 —

The Cost Per Case of TBI Can Vary Substantially According to the Severity of Injury

The Cost Per Case of TBI Can Vary Substantially According to the Severity of Injury
SOURCE: Invisible Wounds of War, 2008.
NOTES: The diagnostic criteria for mild TBI include loss of consciousness for less than 30 minutes, memory loss for less than 24 hours, and no persistent neurological deficits. Moderate to severe TBI is any head injury resulting in loss of consciousness for more than 30 minutes, memory loss for more than 24 hours, and persistent neurological deficits.
  

Figure 8 —

Mortality Is the Largest Cost Component for Moderate to Severe Cases of TBI

Mortality Is the Largest Cost Component for Moderate to Severe Cases of TBI
SOURCE: Invisible Wounds of War, 2008.
NOTES: The cost components are based on the one-year losses in 2005 from 609 TBI cases, including 279 new mild cases, 139 new moderate or severe cases, and 191 moderate or severe cases preexisting from 2003 and 2004. The four scenarios incorporate different assumptions about the costs associated with treatment, mortality, suicide, and productivity.

TBI varies in magnitude from mild to severe. Mild TBI, commonly known as a concussion, is associated with full functional recovery in 85 to 95 percent of cases. The vast majority of individuals who screen positive for having experienced a probable TBI are likely to have experienced a mild TBI and to regain full cognitive functioning within one year.

But mild as well as moderate and severe TBI can all result in long-term impairment, including difficulty in returning to work. The most common cognitive consequences following moderate to severe TBI are problems with attention and concentration and deficits in new learning and memory. Moderate to severe TBI can also involve skull fractures and intracranial lesions, and it can lead to death.

We estimated TBI costs for a single year because there are insufficient data to project two-year costs. The cost varies substantially according to the severity of injury. The estimated one-year cost per case of mild TBI ranges from $27,260 to $32,760. The estimated one-year cost per case of moderate to severe TBI ranges from $268,900 to $408,520 (see Figure 7). Many of the costs of TBI, particularly for those with moderate to severe injuries, will continue in the long term. Therefore, our cost estimates are likely conservative.

There is great uncertainty surrounding the societal cost of TBI, because serious questions remain regarding the total number of TBI cases, the severity of the cases, and the extent of comorbidity with PTSD and major depression. Based on just the 2,726 cases of post-deployment TBI that have been documented through mid-2007, we estimate that the total one-year societal cost of TBI ranges from $591 million to $910 million, depending on different assumptions about treatment levels, wage reductions, suicides, and other deaths. These figures account for only the diagnosed TBI cases that have led to contact with the health care system; the figures do not include costs for individuals with probable TBI who have not sought treatment or who have not been formally diagnosed.

Hence, the TBI prevalence rate implied in our cost estimate is much lower than the TBI prevalence rate of 19.5 percent detected in our survey. However, since individuals who have screened positively for probable TBI but who have fully recovered from it do not enter the health care system to treat this ailment, it would be inappropriate for us to apply the cost per documented TBI case to the larger prevalence rate found in our survey.

We cannot estimate the effect of improving the quality of care for TBI, because not enough is known about effective treatment or about recovery rates. However, to the extent that additional troops deploy and more TBI cases occur, total costs will rise.

Productivity losses may account for 47 to 57 percent of costs associated with mild TBI cases. For moderate to severe TBI cases, which can lead to death, mortality is the largest cost component, accounting for 70 to 80 percent of costs (see Figure 8).

Health System Limitations

In recent years, the defense department and the U.S. Department of Veterans Affairs (VA) have been expanding their health services, especially in the areas of mental health and TBI. But several gaps remain, both within and beyond the U.S. military health care systems.

There is a wide disparity between the need for mental health services and the use of those services. This disparity stems from structural factors, such as a shortage of providers, as well as from personal, institutional, and cultural factors. Servicemembers often cite concerns about the negative career consequences of using mental health services. Many servicemembers feel that seeking mental health care could damage their career prospects, deprive them of a security clearance, and diminish the trust of coworkers (see Figure 9).

Figure 9 —

Servicemembers Often Cite Concerns About the Dire Career Consequences of Using Mental Health Services

Servicemembers Often Cite Concerns About the Dire Career Consequences of Using Mental Health Services
SOURCE: Invisible Wounds of War, 2008.
NOTE: The response rates are based on a nationally representative survey of 1,965 recently returned servicemembers.

There is a vast unmet need for care. In our survey, only 53 percent of the returning servicemembers who met criteria for PTSD or major depression had sought help for these conditions in the previous year. For those who experienced a probable TBI during deployment, only 43 percent had been evaluated by a physician for a brain injury.

For PTSD and major depression, there are shortfalls in the delivery of quality care as well. Of the servicemembers who had these conditions and did seek treatment, just over half received minimally adequate treatment (at least eight sessions of psychotherapy or a minimal course of medication). The number who received high-quality, evidence-based treatment would be even fewer.

Many servicemembers feel that seeking mental health care could damage their career prospects, deprive them of a security clearance, and diminish the trust of coworkers.

There are also holes in monitoring the quality of care provided to the nation’s veterans. The VA has been a leader in promoting quality, and the documented improvements in the quality of VA care for depression in particular are impressive. But studies evaluating the quality of VA care for PTSD have not been published to date. Moreover, the VA’s quality improvement efforts have not been extended to the hundreds of community-based Vet Centers that typically operate out of storefront settings around the country. At the same time, similar efforts have not been implemented within the defense department’s military health system.

With respect to treating TBI, limitations in medical knowledge need to be addressed. More research is needed to determine what quality treatment for TBI entails. Moderate to severe forms of TBI may require both traditional medical treatment and mental health care. TBI symptoms include those of other mental health conditions, thus requiring the coordination of different professionals from physical medicine and rehabilitation to mental health care. Moderate and severe TBI also present unique needs for close coordination across the VA and defense department with other community agencies.

Finally, the VA faces a challenge in providing access to younger veterans, particularly in facilities now serving mostly older veterans. The VA needs better projections of the treatment demand among newer veterans to ensure that proper resources can be allocated for them as well.

Nadia McCaffrey, president of the Patrick McCaffrey Foundation, sits in front of a proposed housing site for veterans in Guerneville, California.
AP IMAGES/ERIC RISBERG 
Nadia McCaffrey, president of the Patrick McCaffrey Foundation, sits in front of a proposed housing site for veterans in Guerneville, California, on March 13, 2008. Her dream is to house veterans scarred by post-traumatic stress disorder and to ease their returns from combat zones. Her son, Army Specialist Patrick McCaffrey, was killed in Iraq in 2004.

Systemic Solutions

Lessons from the health services field suggest that a sustained systems approach will be required to make meaningful advances in care. Attempts to fill the current gaps in care will not be successful unless they take into account the other components of the system.

For instance, expanding the number of mental health providers will not make mental health care more accessible if the concerns about negative career consequences associated with mental health care are not alleviated. Evidence-based care cannot be implemented effectively unless there is a way to continuously measure and improve it. And although the VA has been a leader in promoting quality care in the United States, not all veterans receive their care through the VA. Many veterans seek care through private employer–sponsored health plans and through the public sector, such as Medicaid.

Therefore, a major national effort is needed to expand and to improve the capacity of the U.S. mental health system to deliver effective care for servicemembers and veterans. This effort must incorporate the military, veteran, and civilian health care systems. It should focus on training more providers to use high-quality, evidence-based treatment methods, and it should encourage servicemembers and veterans to seek needed care. The scale of the effort presents the country with an enormous challenge, but also an opportunity.

We offer recommendations that apply to the entire national health care system — military and civilian, public and private. Efforts to implement these recommendations should be standardized to the greatest extent possible within the defense department, within the VA, across these systems, and throughout the community-based civilian health care sector.

Increase and improve the capacity of the mental health care system to deliver evidence-based care. The defense department, the VA, and civilian health care systems need to recruit and to train more providers to meet the mental health care needs of returning servicemembers and veterans. Although the precise number of newly trained providers required is not yet known, it is likely to be in the thousands. Additional training in evidence-based treatment for trauma will also be required for tens of thousands of existing professionals. Because the dramatic increase in need for services already exists, the required expansion in the number of trained providers is several years overdue.

Change policies to encourage more servicemembers and veterans to seek needed care. Servicemembers need ways to obtain confidential services without the fear of negative career repercussions. There should be no perceived or real adverse career consequences for individuals who seek treatment, except when functional impairment — such as poor job performance or being a hazard to oneself or others — compromises fitness for duty. Providing options for confidential treatment can enhance force readiness by encouraging individuals to seek needed care before problems rise to a critical level. In this way, mental health treatment would be appropriately used by the military as a tool to avoid or to mitigate functional impairment, rather than as evidence of functional impairment.

The systems of care for treating these conditions have been improved, but not enough.

Deliver evidence-based care in all settings. Providers in all settings should be trained and required to deliver evidence-based care. This change will require the implementation of new procedures to ensure sustained quality, to coordinate care, and to enable quality monitoring and improvement across all settings in which servicemembers and veterans are served. Providing evidence-based care is not only the humane course of action; it is also a cost-effective way to retain a ready and healthy military force for the future.

Invest in research to close the knowledge gaps and to help plan effectively. Medical science would benefit from a deeper understanding of how PTSD, major depression, and TBI evolve and how treatment can affect outcomes. The United States needs a national strategy to support an aggressive research agenda across all medical service sectors on behalf of returning servicemembers and veterans.

As the conflicts in Afghanistan and Iraq continue, the prevalence of mental health and cognitive conditions could grow higher. Without effective treatment, these conditions will carry significant long-term costs and negative consequences. The systems of care for treating these conditions have been improved, but not enough.

Ultimately, this issue reaches beyond the defense department and the VA and into the broader U.S. health care system and society at large. The entire system must adapt to the needs of returning servicemembers if the nation is to meet its obligations to military veterans now and in the future. Safeguarding the mental health of servicemembers is an important part not only of ensuring the future readiness of U.S. military forces but, even more important, of compensating and honoring those who have served the nation. square

Related Reading

Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, Terri Tanielian, Lisa H. Jaycox, eds., RAND/MG-720-CCF, 2008, 498 pp., ISBN 978-0-8330-4454-9.
Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries, Terri Tanielian, Lisa H. Jaycox, Terry L. Schell, Grant N. Marshall, M. Audrey Burnam, Christine Eibner, Benjamin R. Karney, Lisa S. Meredith, Jeanne S. Ringel, Mary E. Vaiana, RAND/MG-720/1-CCF, 2008, 64 pp., ISBN 978-0-8330-4453-2.
Post-Deployment Stress: What Families Should Know, What Families Can Do, RAND/CP-535 (3/08), 16 pp.
Post-Deployment Stress: What You Should Know, What You Can Do, RAND/CP-534 (3/08), 16 pp.

Multimedia

In a RAND-hosted conference call, RAND experts fielded questions from the media on the report Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, April 17, 2008.
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