The Road to Reintegration: Status and Continuing Support of the U.S. Air Force's Wounded, Ill, and Injured

The U.S. Air Force asked RAND Project AIR FORCE (PAF) to help assess the well-being of its wounded members and the quality of services provided to facilitate their recovery and reintegration. RAND PAF fielded a survey in the fall of 2016 to assess wounded airmen's functioning in the domains of physical health, mental health, interpersonal relationships, unemployment, and financial status, as well as their utilization and perceptions of Air Force nonmedical programs for wounded airmen. The authors of this study invited all 713 wounded airmen enrolled in the Air Force Wounded Warrior program to complete the survey, and 270 airmen (38 percent) completed it. One-third of airmen reported difficulty obtaining care for physical or mental health conditions, and one-quarter expressed dissatisfaction with coordination of care. Similar proportions of airmen reported barriers to care for physical and mental health conditions. Difficulty scheduling appointments was the most commonly endorsed barrier for both types of conditions. Small but notable proportions of airmen reported potential social support deficits, unemployment, and financial problems. For many of the Air Force's programs for wounded airmen, over 80 percent of program users reported overall program satisfaction. The authors recommend that the Air Force consider focusing on improving care coordination, increasing health care system capacity, continuing employment assistance, and improving marketing of programs with low uptake.

Online peer support groups for family caregivers: are they reaching the caregivers with the greatest needs?

Background

Online peer support groups are an increasingly common venue for caregivers supporting disabled family members to exchange informational, emotional, and instrumental support. We know very little, however, about who uses these groups and whether they are reaching those with the greatest needs.

Objective

To examine whether caregiving factors (ie, caregiving demands and strain, competing demands, access to support and services, and other caregiving characteristics) are related to online community support use and intensity of use.

Method

This study used data from a new survey of family caregivers who provide care to disabled military veterans. We used logistic regression models to examine the likelihood of online community support group usage and intensity of use as a function of a variety of caregiving factors.

Results

Those with greater caregiving demands were more likely to use online peer support. Specifically, helping the care recipient with more activities was associated with a statistically significantly greater likelihood of visiting an online community support group. Caring for a veteran with a neurological or psychological condition, which, in prior work, suggests more complex care needs, was also positively and significantly related to visiting an online community support group. Hours of care and several other caregiving factors were related to intensity of use.

Conclusions

We show that family caregivers with the most caregiving demands are most engaged with online support communities. This suggests that online communities could be used to support the most vulnerable family caregivers. The implications of this work for online support systems are discussed.

The Deployment Life Study: Longitudinal Analysis of Military Families Across the Deployment Cycle

In 2009, RAND launched the Deployment Life Study, a longitudinal study of military families across a deployment cycle in order to assess family readiness. Family readiness refers to the state of being prepared to effectively navigate the challenges of daily living experienced in the unique context of military service. The study surveyed families at frequent intervals throughout a complete deployment cycle---before a service member deploys (sometimes months before), during the actual deployment, and after the service member returns (possibly a year or more after she or he redeployed). It assessed a number of outcomes over time, including: the quality of marital and parental relationshipsthe psychological, behavioral, and physical health of family memberschild and teen well-being (e.g., emotional, behavioral, social, and academic)military integration (e.g., attitudes toward military service, retention intentions).This culminating paper briefly reviews the study design and data collection procedures, presents results from analyses of the longitudinal data collected from some 2,700 military families, and offers recommendations for programs and future research related to military families. The research was jointly sponsored by the Office of the Surgeon General, U.S. Army, and by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.

Acupuncture for Major Depressive Disorder: A Systematic Review

Major depressive disorder (MDD) is a prevalent condition associated with significant burden in terms of reduced quality of life, lower productivity, increased prevalence of other conditions and increased health care costs. We conducted a systematic review and qualitative summary of randomized controlled trials (RCTs) that assessed the effectiveness and safety of acupuncture for the treatment of MDD. We searched the databases PubMed, CINAHL, PsycINFO, Web of Science, Embase, CDSR, CENTRAL, clinicaltrials.gov, DARE, and PILOTS for English-language RCTs published through January 2015. Two independent reviewers screened the identified literature against inclusion and exclusion criteria, abstracted study level data, and assessed the risk of bias and methodological quality of included studies. The quality of the evidence was assessed using GRADE. Eighteen studies met inclusion criteria. Eleven assessed acupuncture as monotherapy, seven as adjunct depression treatment. Intervention approaches and comparators varied. Evidence on the effectiveness and comparative effectiveness of acupuncture to treat MDD for the outcomes depression improvement, measured as scale score differences and the number of responders, is very weak. Acupuncture may be superior to waitlist (low quality of evidence) but findings for effect estimates compared to other comparators are inconclusive. Few studies reported on patients achieving remission. The effect of acupuncture on relapse rates could not be determined. Too few studies assessed quality of life to estimate treatment effects. Reported adverse events were typically mild in nature, but the assessment lacked rigor and studies were not designed to detect rare events.

Navigating the Road to Reintegration: Status and Continuing Support of the U.S. Air Force's Wounded Warriors

The U.S. Air Force, wanting to gain greater insight into the well-being of its members who have sustained mental or physical injuries in combat or combat-related situations, including their quality of life and the challenges they will confront in their reintegration following separation or retirement, asked the RAND Corporation 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 a longitudinal analysis of enrollees in the Air Force Wounded Warrior (AFW2) program who were receiving benefits or undergoing evaluation to receive benefits, the majority of whom had a primary administrative diagnosis of post-traumatic stress disorder (PTSD). A high proportion of the Airmen in the sample screened positive for PTSD (roughly 78 percent) and major depressive disorder (MDD) (roughly 75 percent); 69 percent screened positive for both. Although more than 90 percent of those in the sample who screened positive for PTSD or MDD were receiving treatment, about half indicated that there was at least one instance during the past year in which they desired mental health treatment but did not receive it. Participants reported concerns about stigma, confidentiality, and the quality of available treatment as barriers to receiving mental health care, though the current data do not link these concerns to a particular treatment setting. About 10 percent of Airmen reported a financial situation that could be considered as living in poverty based on U.S. Department of Health and Human Services' poverty guidelines. Similarly, close to 15 percent of those in the labor force could be considered unemployed. Reserve and National Guard Airmen evidenced heightened challenges across examined domains. Respondents were overall satisfied with the services they received from the AFW2 and Air Force Recovery Care Coordinator programs.

Evaluation of the Operational Stress Control and Readiness (OSCAR) Program

The Marine Corps Operational Stress Control and Readiness (OSCAR) program embeds mental health personnel within Marine Corps units and extends their reach by training officers and noncommissioned officers to recognize Marines showing signs of stress and intervene early. RAND Corporation researchers conducted an outcome evaluation of the OSCAR program that included four components: (1) a quasi-experimental study that compared Marines in OSCAR-trained and non-OSCAR-trained battalions on a wide array of stress-related outcomes before and after deployment, (2) a longitudinal pre- and postdeployment survey of perceptions of OSCAR among Marines who attended OSCAR training, (3) focus groups with Marines, and (4) semistructured interviews with commanding officers of battalions that had received OSCAR training. Results indicated that, after the authors adjust for a wide array of baseline characteristics and deployment experiences, Marines in OSCAR-trained battalions were more likely than those in non-OSCAR-trained battalions to report having sought help with stress problems from a peer, leader, or corpsman-behavior that is consistent with OSCAR goals. In addition, Marines considered OSCAR a valuable tool for enhancing combat and operational stress response and recovery efforts in the Marine Corps. However, this evaluation did not find evidence that OSCAR affected the key mental health outcomes it was designed to address. Thus, the results of this evaluation do not support the continuation of OSCAR in its current form. Based on lessons learned about OSCAR from this evaluation, other research, and best practices for program improvement and implementation, recommendations for improving combat and operational stress training in the Marine Corps are offered.

Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Hidden Heroes: America's Military Caregivers - Executive Summary

While much has been written about the role of caregiving for the elderly and chronically ill and for children with special needs, little is known about "military caregivers"-the population of those who care for wounded, ill, and injured military personnel and veterans. These caregivers play an essential role in caring for injured or wounded service members and veterans. This enables those for whom they are caring to live better quality lives, and can result in faster and improved rehabilitation and recovery. Yet playing this role can impose a substantial physical, emotional, and financial toll on caregivers. This article distills a longer report, Hidden Heroes: America's Military Caregivers, which describes the results of a study designed to describe the magnitude of military caregiving in the United States today, as well as to identify gaps in the array of programs, policies, and initiatives designed to support military caregivers. Improving military caregivers' well-being and ensuring their continued ability to provide care will require multifaceted approaches to reducing the current burdens caregiving may impose, and bolstering their ability to serve as caregivers more effectively. Given the systematic differences among military caregiver groups, it is also important that tailored approaches meet the unique needs and characteristics of post-9/11 caregivers.

A Needs Assessment of New York State Veterans: Final Report to the New York State Health Foundation

Mental health disorders and other types of impairments resulting from deployment experiences are beginning to emerge, but fundamental gaps remain in our knowledge about the needs of veterans returning from Iraq and Afghanistan, the services available to meet those needs, and the experiences of veterans who have tried to use these services. This article highlights the findings of a study focused directly on the veterans living in New York state. The study included veterans who currently use U.S. Department of Veterans Affairs (VA) services as well as those who do not; and it looked at needs across a broad range of domains. The authors collected information and advice from a series of qualitative interviews with veterans of Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) residing in New York, as well as their family members. In addition, they conducted a quantitative assessment of the needs of veterans and their spouses from a sample that is broadly representative of OEF/OIF veterans in New York state. Finally, they conducted a review the services currently available in New York state for veterans. The study found substantially elevated rates of post-traumatic stress disorder (PTSD) and major depression among veterans. It also found that both VA and non-VA services are critically important for addressing veterans' needs, and that the health care systems that serve veterans are extremely complicated. Addressing veterans' mental health needs will require a multipronged approach: reducing barriers to seeking treatment; improving the sustainment of, or adherence to, treatment; and improving the quality of the services being delivered. Finally, veterans have other serious needs besides mental health care and would benefit from a broad range of services.

Maturation of cGMP response to ANP by isolated glomeruli

Experiments were done to determine whether there is a maturational increase in production of guanosine 3',5'-cyclic monophosphate (cGMP) by glomeruli or in eggression of cGMP out of glomerular cells. Both preweaned and adult isolated rat glomeruli responded with an acute rise in intracellular cGMP after 0.5-min exposure to 0.1 microM ANP. However, at 4 h extracellular cGMP was significantly greater in ANP-treated adult compared with preweaned glomeruli (P less than 0.005). In the absence of 3-isobutyl-1-methylxanthine (IBMX) intracellular cGMP was significantly higher in preweaned glomeruli (P less than 0.05). Moreover, the specific activity of phosphodiesterases for cGMP hydrolysis was twofold less in preweaned glomerular membranes (P less than 0.004). Finally, probenecid decreased export of adult glomerular cGMP by 60 +/- 4%, whereas preweaned glomerular cGMP export decreased by only 27 +/- 4% (P less than 0.05). In conclusion, compared with adult, ANP-treated preweaned glomeruli export less cGMP out of glomerular cells, have a higher concentration of intracellular cGMP, and have lower cGMP-specific phosphodiesterase activity, and the organic ion transporter in preweaned glomerular cells exports cGMP less effectively. The limited transport of cGMP out of preweaned glomeruli may account for the blunted natriuretic and diuretic response following ANP stimulation of young rats.