The United States has been fighting wars in Iraq and then Afghanistan for well over a decade. Those conflicts have exacted a toll, not only in treasure and blood but also on servicemembers who have returned from the battlefield with physical and mental injuries and illnesses. Some remain on active duty, some move into the reserves, and others leave the service and seek civilian employment. However, all face a range of challenges, from reestablishing patterns of everyday interactions with their families to finding a job. Many must also cope with injuries and the treatment for those wounds. They must seek mental health services in some cases or navigate the complex array of the programs and systems of care available to veterans. The military services and the Department of Veterans Affairs have aggressively developed programs to help servicemembers reintegrate, with particular interest in mitigating the difficulties of reintegration for servicemembers with mental wounds. The U.S. Air Force wanted to gain greater insight into the well-being of its members who have sustained mental or physical injuries in combat or combat-related situations, with an eye toward improving services provided and enabling wounded airmen to become fully functioning members of society, and taking advantage of ongoing research into how best to do so. Areas of interest include their quality of life and the challenges that will impede their reintegration following separation or retirement. To begin the process of gaining this insight, the Air Force asked RAND's Project AIR FORCE for assistance in gauging the current status of the Air Force's wounded warriors, including their use of and satisfaction with Air Force programs designed to serve them. This article presents the baseline findings from the longitudinal analysis undertaken to understand these ongoing issues.
How We Went About the Analysis
Understanding the quality of life and challenges facing wounded warriors is a multifaceted task. We reviewed the history of physical, psychological, personal, and social adjustment difficulties experienced by veterans of previous wars, which emphasized the need to examine reintegration from a holistic perspective. Within the broad categories of difficulties discussed in the literature, we focused on four primary domains: mental health, unemployment, homelessness, and interpersonal relationships. Each domain is a potential target of interventions and policies that the Air Force could implement. By focusing on these domains, we present a relatively comprehensive picture of the reintegration of returning wounded warriors and help answer the Institute of Medicine's (2010) call for a more complex and holistic examination of reintegration.
To assess these domains throughout the process of reintegration, we fielded a survey to serve as the baseline assessment in a longitudinal analysis of the lives of airmen who sustained mental or physical wounds in combat or combat-related situations. According to the Air Force's administrative data, the majority of airmen in the sampling frame (74 percent) had received a diagnosis of post-traumatic stress disorder (PTSD). Thus, mental health was identified as a key reintegration challenge for the airmen in our sample before the survey's development. Guided by the literature, we included validated measures for assessing the presence of various psychological disorders, barriers to employment and job satisfaction, indicators of housing instability, and some established measures of other domains. The survey also asked respondents to evaluate the care and service they have received from the Air Force, specifically the Air Force Wounded Warrior (AFW2) program and the Air Force Recovery Care Coordinator (AFRCC) program. The AFW2 program coordinates services other than medical care for airmen injured in combat or activities related to combat (this may include deployment-related training). The AFRCC program employs Recovery Care Coordinators whose purpose is to ensure recovering airmen and families understand the likely recovery path, oversee the development and implementation of airmen's Comprehensive Recovery Plans, work with Medical Care Case Managers, and advocate for airmen. We fielded this survey in the fall of 2011 to the enrollees in the Air Force Wounded Warriors Program who were receiving benefits or undergoing evaluation to receive benefits. This approach enabled us to reach our target population: Airmen who have typically suffered injuries in combat or related situations that had either caused them to retire or were considered likely to cause them to retire or separate from the military.* Thus, our holistic approach is applied to a highly selected and unique population of airmen who have been identified as having injuries and illnesses that are related to combat and who are particularly vulnerable to suffering long-term effects from their wounds.
Using the AFW2 enrollee census enabled us to identify reliable locations of retirees, whose current contact information would otherwise not be contained in Air Force personnel files. This approach enabled us to incorporate former airmen who otherwise might be difficult to contact. Of the 872 airmen who were invited to participate, 493 started the survey; the majority of these, 459 (for an overall response rate of 53 percent), completed it either over the web or by phone. These airmen largely resembled the broader population of wounded retirees and active-duty airmen enrolled in AFW2, with some minor differences in that they were slightly more likely to have a college degree, were about a year older, and had spent about a year longer on active duty. The majority of respondents, like the population itself, were retired, male, and white; and most were former enlisted servicemembers.
Results in Brief
Our results show that airmen in our sample are indeed experiencing challenges in a number of different domains. Our results, which parallel those of the Air Force, show a high proportion of airmen screening positive for current PTSD (roughly 78 percent) and current major depressive disorder (MDD) (roughly 75 percent), with 69 percent screening positive for both. We also find somewhat elevated rates of reported substance use over the past year relative to the U.S. adult general population and low levels of current self-rated physical heath relative to a civilian sample of adults with physical and mental chronic illnesses. Although the current sample reported very high rates of mental health treatment within the past year for those who screened positive for current PTSD or current MDD (90 percent), within that same time frame about half indicated there was at least one instance when they desired mental health treatment but did not receive it. A one-year time frame is broad. However, given the identified need for mental health services among this population and the efforts that have been undertaken to better address servicemembers' mental health needs, failure to receive treatment when desired remains a pertinent issue.
Reported barriers to receiving mental health care reveal ongoing concerns regarding confidentiality and stigma, though the current data do not link these concerns to a particular treatment setting (i.e., civilian, medical treatment facility, or Veterans Affairs). Other concerns regarding the quality of available treatment are also evident and included the belief that available mental health treatments are not very good and concerns about the side effects of psychotropic medication. A reported preference for civilian providers is potentially troubling because of findings that civilian mental health care is not likely to be driven by an evidence base (e.g., Institute of Medicine, 2006; President's New Freedom Commission on Mental Health, 2003).
Survey responses also suggested potential deficits in social support among airmen. Airmen were asked to identify the nature of their relationship to the one individual “who most often helps you deal with problems that come up,” i.e., their “primary supporter.” Nearly one-half of respondents selected their spouse or domestic partner as their primary supporter. Minorities of respondents (i.e., less than 10 percent) named a friend, parent or parent-in-law, other relative, or boyfriend or girlfriend as their primary supporter. Just over one-quarter of respondents indicated that they did not have a primary supporter, i.e., they did not share their problems with anyone. Not having an identified primary supporter may be because of a dearth of social support resources or personal choice not to share problems. Hence, the proportion reporting this status may or may not consider it a problem that they do not have someone with whom to share. Nonetheless, it may be considered an indicator of potential risk in terms of availability of social support resources.
Findings in other domains also reveal vulnerabilities. Although a comparatively low proportion of airmen reported falling below the U.S. Department of Health and Human Services' poverty guidelines, about 10 percent could be considered as living in poverty. Similarly, close to 15 percent would be considered unemployed based on the U.S. Bureau of Labor Statistics' oft-reported U3 measure of unemployment. High unemployment rates are common in the current economic situation, but these rates may represent a particular concern for our population. Moreover, some of the perceived barriers to employment suggest interventions in the form of skills training and provision of jobs information would be beneficial. For example, some respondents felt concern regarding their qualifications, in particular that their deployments put them behind their civilian counterparts (42 percent) or a general lack of confidence (42 percent).
Housing instability represents another potential area of concern, with almost 10 percent of the entire sample indicating that their first experience with potential homelessness occurred after their return from their most recent deployment. Further analysis showed that relatively few airmen were homeless; that said, given the well-known troubles of past generations of veterans, this domain warrants continued attention.
Across the domains examined, Reserve and Guard members evidenced heightened challenges. They indicated more severe symptoms of mental health disorders and subsequently met screening criteria for mental health diagnoses at a higher rate than active component airmen still on active duty. Within the domain of employment, Reserve and Guard personnel who indicated that they were employed at least part time also indicated that their productivity was lower than did our other duty status groups.
Finally, we also asked questions regarding use of and satisfaction with two Air Force programs available to help these airmen. High numbers of respondents indicated that they were receiving services, particularly from the AFW2 program. This is a positive finding because our population consisted of enrollees in that program. Respondents also reported overall satisfaction with the program. Although eligibility requirements dictated that a smaller proportion of our population would be covered by the AFRCC program, airmen who reported receipt of AFRCC services received a variety of them and were very satisfied with the program. For both programs, the nature of services provided can be characterized as a form of social support.
Policy Recommendations and Conclusions
We focus our recommendations on two domains: mental health and employment. We do so because the problems in these domains were notably elevated and amenable to intervention. We also focus on areas where Air Force case managers could take action. Finally, concerns in these areas, if mitigated, would be expected to have a positive influence on problems in other domains.**
Mental Health Recommendations
Our recommendations in the mental health domain are designed to deal with the reported barriers to accessing mental health services. To overcome these barriers to treatment, we recommend that the Air Force (and other related systems of care) take the following actions to increase airmen's receipt of high-quality mental health treatment:
- Inform airmen about the quality of care available to them.
- Collect and publicize data on the quality of care that is implemented.
- Educate airmen on the questions to ask prospective mental health care providers to improve their chances of getting high-quality treatment.
- Inform airmen on the options for psychotropic medications and alternatives to them.
- Emphasize and enhance confidential treatment options.
- Promote available confidential nonmedical counseling options for airmen who would otherwise forgo mental health treatment.
- Place mental health care providers in primary care clinics.
The employment literature suggests that attention to individual skill sets and their presentation on resumes and in interviews, as well as individual preferences, pay dividends in the forms of employment, lasting employment, and satisfaction (Drake, Bond, and Becker, 2012; Resnick, Rosenheck, and Drebing, 2006; Wanberg, 2012). Our recommendations capitalize on both this finding and the existence of the many employment aid offerings already provided for wounded, ill, and injured warriors (GAO, 2012, noted 19 different programs in FY 2010). We do not recommend additional programs but rather suggest that the employment assistance to airmen should focus on individual skill sets and their translation to new contexts.
To help those who are unemployed, we recommend the following actions:
- Offer employment assistance that focuses on individual skill sets and their transition to new contexts; continue existing programs that have this individual focus.
- Identify and continue to treat mental health disorders.
Our findings regarding the multidomain challenges experienced by Reserve and Guard servicemembers in our sample in tandem with the larger literature indicate the Reserve and Guard may be more vulnerable to various issues. These include experiencing heightened PTSD symptoms postdeployment (e.g., Schell and Marshall, 2008; Wells et al., 2011) and suggest continued attention to the needs of the reserve components will be necessary to make sure the care they receive meets their needs. The process of recovery and reintegration is likely to be lengthy, particularly for those with injuries and illnesses. A long-term approach is needed to parse the effectiveness of the many interventions and conditions that affect it. Thus, we suggest ongoing program evaluation. Many studies have examined various aspects of the reintegration problem, but much remains to be done. Moreover, because no one study can encompass the complexities of real life, it is appropriate to take advantage of quality research from multiple avenues. The Air Force, by means of this research project and others, is starting to compile the information it needs to understand the process of recovery and reintegration. Our data are cross-sectional. We therefore present a snapshot of wounded airmen's well-being on a holistic set of indicators. Our findings reveal that enrollees in the AFW2 program are facing a variety of reintegration challenges. These are likely to remain pressing. The Air Force and society at large must continue to provide support through this process. In a time of declining resources, research can help determine the most effective means to do so.
Drake, Robert E., Gary R. Bond, and Deborah R. Becker, Individual Placement and Support: An Evidence Support Based Approach to Supported Employment, New York: Oxford University Press, 2012.
GAO—See United States Government Accountability Office.
Institute of Medicine of the National Academies, Committee on Quality of Health in America: Improving the Quality of Health Care for Mental and Substance Use Conditions, Washington, D.C.: The National Academies Press, 2006, pp. 77–139.
Institute of Medicine of the National Academies, “Returning Home from Iraq and Afghanistan Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families,” 2010. As of April 9, 2013:
President's New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America, Rockville, Md.: National Alliance on Mental Illness, 2003.
Resnick, Sandra G., Robert A. Rosenheck, and Charles E. Drebing, “What Makes Vocational Rehabilitation Effective? Program Characteristics Versus Employment Outcomes Nationally in VA,” Psychological Services, Vol. 3, No. 4, 2006, pp. 239–248.
Schell, Terry L., and Grant N. Marshall, “Survey of Individuals Previously Deployed for OEF/OIF,” in Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, Santa Monica, Calif.: RAND Corporation, MG-720-CCF, 2008, pp. 87–115. As of January 14, 2014:
United States Government Accountability Office, Employment for People with Disabilities: Little is Known about the Effectiveness of Fragmented and Overlapping Programs, Washington, D.C., GAO-12-677, June 29, 2012. As of January 14, 2014:
Wanberg, Connie R., “The Individual Experience of Unemployment,” Annual Review of Psychology, Vol. 63, 2012, pp. 369–396.
Wells, Timothy S., Shannon C. Miller, Amy B. Adler, Charles C. Engel, Tyler C. Smith, and John A. Fairbank, Mental Health Impact of the Iraq and Afghanistan Conflicts: A Review of U.S. Research, Service Provision, and Programmatic Responses, San Diego, Calif.: Naval Health Research Center, Report No. 11-10, 2011.
* Note that some do in fact remain in service rather than separating or retiring.
** For example, improving employment outcomes would likely promote housing stability.
The research reported here was commissioned by the Assistant Secretary of the Air Force for Manpower and Reserve Affairs (SAF/MR); the Director, Air Force Directorate of Services (AF/A1S); and the Air Force Surgeon General (AF/SG). The analysis was conducted within the Manpower, Personnel, and Training Program of RAND Project AIR FORCE.