Congressional Newsletter
Monthly updates to Congress on RAND's work in health policy

Caring for the Invisible Wounds of War

soldiers in shadow

Since October 2001, approximately 1.6 million U.S. troops have deployed in support of operations in Afghanistan and Iraq. Many have been exposed to combat-related stress or traumatic events. These exposures can contribute to later mental health disorders, such as post-traumatic stress disorder (PTSD) and depression, or cognitive problems associated with traumatic brain injury (TBI), the result of head wounds or exposure to blasts. Safeguarding the health of these servicemembers is important to ensuring future military readiness and to compensating and honoring those who have served the United States.

However, despite concern and a clear commitment on the part of the federal government to address these issues, the impetus for policy change has outrun the knowledge needed to inform solutions. Fundamental gaps remain in the understanding of the mental health and cognitive needs of U.S. servicemembers returning from Afghanistan and Iraq, the care systems available to deliver treatment, and the costs of mental health and cognitive conditions. To begin closing these knowledge gaps, RAND undertook the first comprehensive study of psychological and cognitive injuries among servicemembers deployed to Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom. The study focused on three major conditions: PTSD, major depression, and TBI.

A RAND survey of nearly 2,000 recently returned servicemembers found that 18.5% meet criteria for PTSD, depression, or both; about 19% reported experiencing probable TBI during deployment; and about 7% meet criteria for a mental health problem and also report possible TBI. Thus, about 30 percent of all deployed servicemembers have experienced at least one of these three problems. Based on these results, analysts estimate that about 300,000 returning servicemembers currently have PTSD, depression, or both and that about 320,000 may have experienced TBI.

The study found gaps between the need for mental health services and their use. Only 53 percent of returning troops who met criteria for PTSD or major depression sought help for their condition within the past year. When asked why they do not get care, many servicemembers cited concerns that their career prospects might suffer or their coworkers' trust would decline if they sought mental health services. Others were concerned about the quality of the care that is available to them or the side effects of drugs used to treat these conditions. Only 43 percent of those reporting probable TBI during deployment had been evaluated by a physician for a brain injury.

soldier and wife

The study also found gaps in the ability to provide and monitor quality care. Slightly more than half of returning servicemembers who had sought care for PTSD or depression received even minimally adequate treatment. The Department of Defense (DoD) and the Department of Veterans Affairs (VA) have begun training mental health care providers in proven practices; however, these efforts have not yet been integrated into a larger system redesign that provides incentives to improve quality of care. Significant improvements in the quality of depression care delivered by the VA have been documented. Efforts to evaluate PTSD care in the VA, however, remain under way.

Unless treated, PTSD, depression, and TBI can have far-reaching, negative consequences, including higher risks of other psychological problems; higher rates of attempted suicide, unhealthy behaviors, physical health problems, and mortality; and lower productivity. These longer-term problems might be reduced if more servicemembers had access to effective care.

RAND created a model to estimate the societal costs (measured in terms of medical costs, lost productivity associated with ineffective treatment, and the cost of lives lost to suicide). RAND estimates that the cost of PTSD and major depression for two years after deployment ranges from $5,900 to $25,760 per case. Based on the estimates of those afflicted by these conditions, the total two year societal cost is an estimated $4.0 billion to $6.2 billion. The cost of TBI is substantially higher—between $27,260 and $408,520 per case in the first year, depending on severity. Uncertainty is high because data are lacking, but the total one-year cost associated with diagnosed cases of TBI (approximately 2,700 cases through the middle of 2007) ranges from $591 million to $910 million.

Fortunately, evidence-based treatments are available, particularly for PTSD and depression, though not yet in all settings. The model estimates that delivering evidence-based care to 100 percent of those needing it would substantially reduce the cost per case. For example, the per case cost of depression could be reduced by more than $9,000 over two years. Overall, RAND researchers predict that the total costs associated with PTSD and depression could be reduced by as much as $1.7 billion over two years by providing evidence-based treatment. While providing treatment to more individuals would increase costs, these higher costs would be more than offset by savings from productivity gains and a lowered risk of suicide. At the rate of saving noted here, evidence-based treatment would pay for itself within two years

To improve treatment and outcomes for servicemembers faced with these conditions, the RAND team offered four main recommendations:

  • Increase and improve the capacity of the mental health care system to deliver evidence-based care.
  • Change policies to encourage more servicemembers and veterans to seek needed care.
  • Deliver evidence-based care in all settings.
  • Invest in research to close knowledge gaps and plan effectively.

Adequately addressing these issues reaches beyond the DoD and the VA. Many veterans seek care through private employer-sponsored health plans and in the public sector. The broader health care system must also adapt to the needs of this population if the United States is to meet its obligations to military veterans.

Read the Research Brief »

Read More on the Invisible Wounds Project »

Members of the Invisible Wounds Team

Project Leaders

Terri Tanielian • Lisa Jaycox

  • Management Team
    • Audrey Burnam
    • Terry L. Schell
    • Grant N. Marshall
    • Benjamin R. Karney
    • Lisa S. Meredith
    • Christine Eibner
    • Jeanne S. Ringel
    • Karen N. Metscher
    • Gail Fisher
  • Survey Team
    • Terry L. Schell
    • Grant N. Marshall
    • Jeremy N.V. Miles
    • Gail Fisher
    • Karen N. Metscher
  • Economics/Costs
    • Christine Eibner
    • Jeanne S. Ringel
    • Beau Kilmer
    • Rosalie Liccardo Pacula
    • Claudia Diaz
    • Regina A. Shih
  • Literature Review of Consequences
    • Benjamin R. Karney
    • Rajeev Ramchand
    • Karen Chan Osilla
    • Leah Barnes Calderone
    • Rachel Burns
  • Systems of Care
    • Audrey Burnam
    • Lisa S. Meredith
    • Elizabeth D'Amico
    • Todd C. Helmus
    • Robert A. Cox
    • Laurie T. Martin
    • Dianne C. Schoeff
    • Rachel Burns
    • Kayla M. Williams
    • Michael R. Yochelson
    • Ellen Burke Beckjord
    • Andrew M. Parker
    • Manan M. Trivedi
    • Sarah Gaillot
  • Communications Support
    • Mary E. Vaiana
    • David M. Adamson
    • Jerry M. Sollinger
  • Administrative Support
    • Samantha Abernethy
    • Catherine Chao
    • Taria Francois
    • Stacy Fitzsimmons
    • Michael Woodward


Project Leaders of the Invisible Wounds Research

Terri Tanielian

Terri Tanielian

Terri Tanielian MA, is a senior social research analyst and serves as the Co-Director of RAND's Center for Military Health Policy Research. In this capacity, she oversees the diverse military health research portfolio with RAND and maintains relationships with senior military health leaders. Tanielian has studied the mental health aspects of disasters and public health emergencies, including a study examining health decision making following the 2001 anthrax attacks as well as assessing the uptake of mental health services for children within schools affected by the Hurricane Katrina. She also recently co-led a Congressionally mandated evaluation of a demonstration to expand access to mental health counselors under TRICARE.

Read more work by Terri Tanieliean »

Lisa Jaycox

Lisa Jaycox

Lisa Jaycox PhD, is a Senior Behavioral Scientist at RAND and a clinical psychologist. Dr. Jaycox has wide-ranging clinical and research expertise in the areas of child, adolescent, and adult mental health problems with a special emphasis on reactions to trauma exposure. Prior to joining RAND, Dr. Jaycox conducted clinical trials of psychotherapy treatment and prevention programs for PTSD in assault survivors. She has studied post-injury PTSD among survivors of community violence and other traumatic injuries, as well as developing and evaluating intervention programs related to depression prevention for school children, adolescent substance-abuse treatment programs, and trauma-focused interventions for children exposed to community violence and natural disaster.

Read more work by Lisa Jaycox »


Lindsey Kozberg
Vice President, Office of External Affairs

Shirley Ruhe
Director, Office of Congressional Relations

Kristy Anderson
Health Legislative Analyst

RAND Office of Congressional Relations
(703) 413-1100 x5395


RAND researchers Terri Tanielian and Lisa Jaycox will present a Congressional briefing on Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. The briefing will be on April 28, 2008 at 1:00 pm. Location TBA. For more information, please contact Kristy Anderson at or 703-413-1100 ext. 5196.


More Congressional Resources on Health

Health Research Area

RAND Health

Center for Military Health Policy Research

Invisible Wounds of War Study

RAND Congressional Web Site

RAND Web Site



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