Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families
Nov 9, 2011
Over the past decade, U.S. military forces have engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well under these difficult circumstances, many have experienced and will continue to experience difficulties related to post-traumatic stress disorder (PTSD, an anxiety disorder that can develop after direct or indirect exposure to an event or ordeal in which grave physical harm occurred or was threatened) or major depression. Others live with the short- and long-term psychological and cognitive consequences of traumatic brain injury (TBI), an injury that has become increasingly common with the growing use of improvised explosive devices on the battlefield. Deployment may also have consequences for military families, particularly for marriage and intimate relationships, the well-being of spouses and partners, parenting practices, and children's well-being.
Over the past several years, the Department of Defense (DoD) has implemented numerous programs to support servicemembers and their families in these areas. These programs focus on a variety of clinical and nonclinical concerns and address various components of biological, psychological, social, spiritual, and holistic influences on psychological health. Despite the proliferation of programs and related efforts, an ongoing challenge for DoD is to identify and characterize the scope, nature, and effectiveness of these various and ever-evolving activities. To address this need, the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to develop a comprehensive catalog of existing programs currently sponsored or funded by DoD to address psychological health and TBI.
The result is a new RAND report that provides a "snapshot" of all programs currently sponsored or funded by DoD that address psychological health and TBI. RAND researchers identified and characterized more than 200 programs and described a number of barriers to maximizing the effectiveness of these programs, including the decentralized nature of the programs and the lack of a process to systematically develop, track, and evaluate programs. RAND provided recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, reducing barriers faced by programs, and building the evidence base regarding program effectiveness.
In the study, the term program is used to describe entities that provide active services, interventions, or other interactive efforts to address psychological health, as well as care for servicemembers (and their families) who are experiencing such problems as PTSD, anxiety, depression, and TBI. Programs are distinct from clinical care services (e.g., mental health clinics, medical services for physical health problems), non–clinical care services (e.g., other services unrelated to psychological health and/or TBI), and resources (e.g., a directory that lists services available at an installation).
To identify, classify, and examine the range of relevant programs, researchers first sought to identify the full range of potential programs that were active in the period from December 2009 to August 2010 (e.g., through web and media searches, review of program materials and public domain documents, consultations with key personnel) and subsequently applied a set of inclusion and exclusion criteria to determine which entities were programs according to the study criteria. When possible, program personnel were interviewed to obtain relevant information about the nature of services provided, methods of implementation, populations served, and so on. Researchers identified a total of 211 programs.
To better understand the types of services provided by the programs, researchers grouped programs based on their mission, goals, and activities. They identified three broad areas of focus (see the table), each of which is further categorized by two or more specific themes. Together, these themes encompass 23 key activities in which programs engage (activities not shown). Activities range from improving resilience to preventing domestic violence, operating a telephone hotline, conducting screening for mental health problems, and training servicemembers to provide peer-to-peer support for improving psychological health.
|Preventing problems||Reducing the incidence of psychological health problems and TBI|
|Employing public health approaches|
|Identifying individuals in need and connecting them to care||Providing information, connecting individuals to care, and encouraging help-seeking|
|Identifying individuals with mental health concerns or TBI|
|Caring for servicemembers and families in need||Providing or improving clinical services|
|Offering mental health services in nontraditional locations to expand access to care|
|Nonclinical activities that provide support|
|Responding to incidents of concern|
The study found duplication of effort across programs, both within and across branches of service. For example, large numbers of programs in each service and DoD-wide focus on providing training or education and/or on improving resilience and the ability to handle stress among members of the military community. Most programs focus their efforts on uniformed servicemembers, with some programs offering services to family members and civilian employees. In general, fewer programs focus on TBI than on issues associated with psychological health, which include depression, PTSD, substance use, suicide prevention, and general psychological health. Many programs focus on nonclinical issues related to families and/or children, resilience, stress reduction, deployment, or postdeployment and reintegration.
RAND's analysis identified a number of potential barriers that should be addressed in order to maximize program effectiveness:
Based on the interviews with program representatives and the process of identifying these programs, researchers identified several high-level priorities for DoD.
Take advantage of programs' unique capacity for supporting prevention, resilience, early identification of symptoms, and help-seeking to meet the psychological health and TBI needs of servicemembers and their families. The strength of existing programs could be better leveraged in many ways. For example, programs can potentially play a unique role in training and education to support early identification of concerns and symptoms. Programs also offer opportunities to build skills in prevention and resilience among servicemembers and their families and can also serve as testbeds for piloting new and innovative approaches to psychological health and TBI care.
The figure presents an overview of the ideal characteristics of services provided by programs and by the existing delivery system, including clinical care and supportive counseling services. Under this framework, the majority of care provided in existing delivery systems should consist of treatment approaches that are supported by an empirical evidence base. Ideally, novel or unproven treatment approaches would be mostly avoided in this setting. Programs, in comparison, offer opportunities to test new and innovative approaches to psychological health and TBI care and can provide a mechanism for building the evidence base for both clinical care and for nonclinical approaches. With appropriate research and evaluation to demonstrate program effectiveness, a subset of programs may be scaled up for widespread implementation, or program approaches might become part of routine care, when appropriate.
Establish clear and strategic relationships between programs and existing mental health and TBI care delivery systems. Programs should complement or supplement existing services. Programs may do so by focusing on subclinical psychological health issues, which can reduce some of the burden on the clinical care system and supportive counseling services; by focusing on prevention, resilience, and early identification of problems; by embedding mental health providers in nontraditional locations, such as within military units or in primary care settings; or by providing services in coordination with the clinical care system.
Ensuring appropriate referrals and transitions between providers and care settings is essential for ensuring that servicemembers' and family members' needs for care are met, that their care is continuous and coordinated, and that they transition safely between care providers. Referrals to existing clinical care systems should be tracked on a continual basis.
Examine existing gaps in routine service delivery that could be filled by programs. A formal, comprehensive needs assessment conducted throughout DoD is key to understanding what services are necessary for addressing psychological health and TBI. This assessment should establish the magnitude of demand for different types of services, the characteristics of individuals in need, and their geographic locations. This analysis should identify the full range of services needed, as well as the magnitude of existing need.
A formal gap analysis would provide an in-depth understanding of the extent to which existing programs meet the needs identified and where gaps exist that warrant the development of new programs. Further, adoption of a single departmentwide conceptual framework for psychological health across DoD would help reduce the current confusion and ambiguity when attempting to examine psychological health services and programs across the branches of service and would allow programs to be categorized and evaluated consistently.
Reduce barriers faced by programs. DoD should continue efforts to reduce stigma and institutional barriers associated with seeking treatment for mental health problems and TBI. It may be helpful for training messages within DoD to focus on mental health problems as part of a range of reactions to combat and operational stress, to emphasize help-seeking as an appropriate response, and to avoid setting unrealistically high expectations for resilience.
For servicemembers or family members participating in a program, continuity of care is important throughout the deployment cycle and across permanent change of station, and programs need a method to ensure such continuity. One model may be transitional coordination and coaching for servicemembers who are participating in programs or receiving clinical or supportive counseling services. The sharing of information also should be improved across programs.
Evaluate and track new and existing programs, and use evidence-based interventions to support program efforts. The evidence base regarding program effectiveness needs to be developed. Existing programs and those under consideration for future development should be required to embed an ongoing evaluation that addresses at least four key questions: (1) What works well? (2) What are the unanticipated consequences of the program? (3) What are the opportunities for improvement? (4) What lessons were learned during program implementation that can affect the successful transfer of the program to new organizations or locations?
The evidence base regarding program effectiveness also needs to be centralized and made accessible across DoD. New programs should be built on the existing evidence base wherever possible and should focus on one of three approaches: (1) replicating programs that have been evaluated and shown to be effective; (2) using evidence-based components of existing programs or other evidence-based approaches to care provision to develop new programs; or (3) using new treatments, techniques, or materials that are developed explicitly as pilot programs with appropriate plans for evaluation.
Programs that are shown to be ineffective should be discontinued and should not be replicated. To avoid the proliferation of programs without adequate evidence and the duplication of effort across services to identify best practices, DoD should identify a central authority charged with the coordination of programs between branches of service and within the Office of the Secretary of Defense, centralization of the evidence base regarding program effectiveness, and ongoing tracking of programs. Both new and existing programs should be tracked on an ongoing basis by a single entity, preferably the same organization that is charged with developing guidance regarding program proliferation.
While the attention given to programs to address psychological health and TBI is both necessary and laudable, the proliferation of programs creates a high risk of a poor investment of DoD resources. Given the financial investment that the nation is making in caring for servicemembers with mental health problems and TBI, servicemembers and their families deserve to know what these investments are buying. Strategic planning, centralized coordination, and the sharing of information across branches of service, combined with rigorous evaluation, are imperative for ensuring that these investments will result in better outcomes and will reduce the burden faced by servicemembers and their families.