As the U.S. Department of Defense advances its efforts to evaluate and improve psychological health services for military members and their families, it should develop, track and evaluate programs based on scientific evidence to ensure their effectiveness, says a new report from the Institute of Medicine. DOD has implemented numerous resilience and prevention programs -- mostly focused on individual-level interventions -- that address various aspects of psychological health. While some of these programs have demonstrated effectiveness, many are not evidence-based and are evaluated infrequently. 

“Increasing rates of mental health problems among service members and the related psychological toll on families point to an urgent need to prevent and mitigate these conditions,” said Kenneth Warner, chair of the committee that wrote the report and Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan. “DOD should rigorously evaluate any new programs that are developed to do so, because we remain uncertain about which approaches work and which ones are ineffective.”

Also contributing to the report was committee member Hortensia Amaro, USC’s associate vice provost, community research initiatives and dean’s professor of social work and preventative medicine at the USC School of Social Work and Keck School of Medicine, as well as five other social work faculty members whose work was cited, including Ron Astor, Carl Castro, Julie Cederbaum, Tamika Gilreath and Hazel Atuel.

From 2000 to 2011, 936,283 current or former service members were diagnosed with a psychological condition; such diagnoses increased by about 62 percent among active-duty service members during approximately the same time frame. Adjustment disorders, such as feeling stressed or hopeless, made up 26 percent of the diagnoses; depression 17 percent; and anxiety disorders (excluding post-traumatic stress disorder) 10 percent. PTSD accounted for 6 percent, while alcohol and substance abuse and dependence made up 17 percent.

In response to the surge of veterans returning from Iraq and Afghanistan with various problems, Congress required DOD to study their physical and mental health and other readjustment needs. The IOM conducted such an assessment, which resulted in the 2013 report Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. This new report is a follow-up to examine the quality and evidence base of programs in DOD designed to prevent negative psychological health outcomes among service members and their families and to identify appropriate performance measures for such programs.

DOD screens at multiple points throughout the military life cycle to provide early recognition and interventions for psychological health needs of service members and their families who are at high risk. It also implements structural interventions that support improved mental health assessment and care -- such as embedded mental health providers, the "patient-centered medical home," and Re-engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil). While DOD has adopted these numerous resilience and prevention programs, gaps exist in the evidence supporting their effectiveness. For example, based on internal research data that show only very small effects, DOD concluded that Comprehensive Soldier and Family Fitness -- a broadly implemented program intended to foster resilience and enhance performance -- is effective, despite external evaluations that dispute that conclusion.

In addition, the committee was unable to identify any evidence-based programs to prevent domestic abuse across DOD services. Though the services use a number of interventions to prevent sexual assaults, a DOD review found that components needed to measure their effectiveness are missing. Furthermore, DOD does not systematically consider cost-effectiveness to ensure that resources are directed to programs that see the greatest results per dollar spent.

Certain strategies with strong evidence of effectiveness are underused, the committee said, such as restricting access to personal firearms to prevent suicide or homicide in domestic violence cases or placing restrictions on the sale of alcohol to reduce substance misuse. In place of these proven approaches, the committee typically found unsubstantiated interventions such as campaigns, Internet tools, or in-person events, which may be effective but are seldom evaluated.

DOD has many family-focused prevention programs, but here, too, there are gaps in the evidence supporting their effectiveness, the report says. It recommends that DOD implement comprehensive, well-supported programs to prevent psychological health problems in the families of service members, targeting risks and vulnerabilities such as family violence, substance abuse, and stress reaction.

The report was sponsored by the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

Copies of Preventing Psychological Disorders in Service Members and Their Families: An Assessment of Programs are available from the National Academies Press on the Internet at http://www.nap.edu or by calling 202.334.3313 or 1.800.624.6242.

INSTITUTE OF MEDICINE
Board on the Health of Select Populations
Committee on the Assessment of Resiliency and Prevention Programs for Mental and Behavioral Health in Service Members and Their Families

Kenneth E. Warner, Ph.D. (chair)
Avedis Donabedian Distinguished University Professor of Public Health
Department of Health Management and Policy
School of Public Health
University of Michigan
Ann Arbor

Hortensia de los Angeles Amaro, Ph.D.
Associate Vice Provost for Community Research Initiatives and
Dean's Professor of Social Work and Prevention Medicine
Keck School of Medicine
School of Social Work
University of Southern California
Los Angeles

Frederic Blow, Ph.D.
Professor of Psychiatry
Department of Psychiatry
University of Michigan Medical School; and
Director, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) 
Ann Arbor VA Center for Clinical Management Research
U.S. Department of Veteran Affairs
Ann Arbor

Raul Caetano, M.D.
Regional Dean and Professor
School of Public Health
University of Texas, and
Dean and Professor
School of Health Professionals
University of Texas Southwestern Medical Center
Dallas

Jacquelyn C. Campbell, Ph.D., R.N.
Anna D. Wolf Chair and Professor
School of Nursing
Johns Hopkins University
Baltimore

Joyce D. Essien, M.D., M.B.A.
Retired Captain
U.S. Public Health Service; and
Retired Director
Center for Public Health Practice
Rollins School of Public Health
Emory University
Atlanta

Lisa Jaycox, Ph.D.
Senior Behavioral Scientist
RAND Corp.
Arlington, Va.

Mary Jo Larson, Ph.D.
Senior Scientist
Heller School of Social Policy and Management
Brandeis University
Waltham, Mass.

Patricia Lester, M.D.
Jane and Marc Nathanson Family Professor of Psychiatry, and
Director, Nathanson Family Resilience Center
University of California
Los Angeles

Donald L. Patrick, Ph.D., M.S.P.H.
Professor
SeaQoL Group
Department of Health Services
School of Public Health
University of Washington
Seattle

Rhonda J. Robinson Beale, M.D.
Chief Medical Officer
OptumHealth Behavioral Solutions
Glendale, Calif.

M. David Rudd, Ph.D.
Provost
University of Memphis
Memphis, Tenn.

Naomi M. Simon, M.D.
Associate Professor
Department of Psychiatry
Harvard Medical School;
Director, Center for Anxiety and Traumatic Stress Disorders, and
Director, Complicated Grief Program
Massachusetts General Hospital; and
Chief Medical Officer
Red Sox Foundation and Massachusetts General Hospital Home Base Program
Boston