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Summer 2013 Vol. 13 Number 1

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War's Aftermath

Easing the Return to Civilian Life

New Jersey National Guard Family Assistance Center in Bordentown, N.J., which provides a variety of services including financial, medical and legal aid, U.S. Air Force photo by Master Sgt. Mark Olsen

More than 2.2 million U.S. troops have served in the wars in Iraq and Afghanistan, which have claimed 6,600 American lives and resulted in more than 48,000 injuries. War's consequences also reach beyond the immediate and physical, reverberating through the lives of soldiers, families, and communities long after those who have served return home.

Although many veterans of the recent wars have transitioned back to civilian life with few difficulties, a large minority have struggled. Forty-four percent of veterans of the Iraq and Afghanistan wars report difficulty readjusting to civilian life, 48 percent have experienced strains in family life, and 47 percent report outbursts of anger. Such difficulties are sometimes exacerbated by lingering war-related health problems, such as traumatic brain injuries and post-traumatic stress disorder (PTSD).

How can the departments of Defense and Veterans Affairs help these soldiers readjust, along with their families and communities? At the request of Congress, the Institute of Medicine conducted a study to advise these agencies on how to meet the needs of this growing group of veterans.

Currently, the approaches DOD and VA use to screen and treat veterans for brain injuries and psychological health problems are not always solidly supported by evidence, IOM's report concludes. The tool DOD uses to assess cognitive function after a head injury, for example, lacks clear evidence of effectiveness. On the other hand, research shows that restricting access to lethal means effectively reduces suicides, but DOD policy prohibits restricting access to privately owned weapons for those at risk. The IOM study committee also expressed concern at the low rates of delivery of certain evidence-based treatments, such as psychotherapies to treat PTSD and depression and approved medications for substance use disorder.

While most health consequences of service are linked to the inherently dangerous nature of war, many female service members face lingering emotional and physical effects from traumas unrelated to combat: sexual assaults and harassment, which studies show are occurring at high rates in the military, including during the wars in Iraq and Afghanistan. DOD should intensify its efforts to eliminate assault and harassment, and should add criteria to commanding officers' performance reviews that assess how well they deal with these problems, the report says.

DOD has many programs and policies to support veterans' families, who often face hardships during and after deployments, ranging from economic and health burdens to domestic violence. But these programs typically do not consider all types of families, focusing almost exclusively on married, heterosexual couples and their children. The agency should ensure that its policies, programs, and practices aim to support a full range of military families, which increasingly include unmarried partners, same-sex couples, single parents, and stepfamilies.

Unemployment and underemployment, problems currently faced by many American citizens, are even more acute for veterans, especially young ones, the report says. Among post 9/11 veterans ages 18 to 24, the unemployment rate was almost twice as high as among their civilian peers -- 30.2 percent compared with 16.1 percent. DOD should evaluate its programs to assist veterans in transitioning to the civilian work force. Identifying those that are most effective will allow scarce resources to be targeted appropriately.

DOD and VA should also conduct forecasts of the amount and types of resources that will be needed to support Iraq and Afghanistan veterans over the next 30 years or more, the report says. Previous wars have shown that veterans' needs peak several decades after the war in which they served. -- Sara Frueh & Christine Stencel

Returning Home From Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Committee on the Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families; Board on the Health of Select Populations; Institute of Medicine (2013, 794 pp.; ISBN 978-0-309-26427-3; available from National Academies Press, tel. 1-800-624-6242; $72.00 plus $5.00 shipping for single copies).

The study committee was chaired by George W. Rutherford, Salvatore Pablo Lucia Professor and vice chair, department of epidemiology and biostatistics, and director, prevention and public health group, Global Health Sciences, University of California, San Francisco. The study was funded by the U.S. Department of Defense.

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Copyright 2013 by the National Academy of Sciences