The Challenges of Co-Occurrence of Post-Deployment Health Problems

Over 2.2 million U.S. service members have participated in Operation Iraqi Freedom and Operation Enduring Freedom (OEF/OIF), about half of whom have left active duty and become eligible for VA services. Since 2002, the proportion of OEF/OIF Veterans using VA has been increasing such that by September 2010, 625,384 (approximately 50 percent) OEF/OIF Veterans had obtained health care through VA. OEF/OIF Veterans now comprise approximately 7 percent of VA users.

OEF/OIF VA users are demographically distinct from other Veteran cohorts. For example, approximately 70 percent are 31 years old or younger; 12 percent are female; and 46 percent deployed to OEF/OIF from Reserve/National Guard components of the military. Most have access to the Internet and use it daily. As Dr. Jesse points out in his commentary, OEF/OIF Veterans may also have deployment-related health problems, many of which are not visible, but which VA is uniquely equipped to diagnose and treat. These problems include the sequelae of psychological and physical trauma in the war zone. Furthermore, even in the absence of diagnosable disorders, OEF/OIF Veterans may have difficulty adjusting to civilian life after combat experiences and these reintegration difficulties may have implications for health, health behaviors, and outcomes.

VA has implemented significant innovations to help ensure that the visible and invisible problems of these returning Veterans are identified and treated. Dr. Jesse referred to national screening for a range of post-deployment health concerns, new patient registries, and suicide prevention. Additional innovations include a system of care for Veterans with Traumatic Brain Injury (TBI)/polytrauma and, more recently, a separate system of care for Veterans with amputation, primary care clinics specializing in OEF/OIF Veterans' issues, improved collaboration with the DoD to facilitate Veterans' transition across health care systems and to share information, and expanded programs for family caregivers, particularly but not exclusively for the family caregivers of those with severe war-related injuries. These initiatives have also created new opportunities for researchers to expand the evidence-base for practice and to partner with clinicians, VA, and DoD leaders to improve post-deployment health care.

It has been almost ten years since 9/11. Research on post-deployment health in U.S. Veterans conducted over the past decade spans numerous medical and social science domains. One finding across studies stands out as warranting particular attention because of its implications for health care delivery—the co-occurrence of post-deployment health concerns in OEF/OIF Veterans. That is, VA researchers are not only shedding light on the prevalence of specific post-deployment health disorders but also on the fact that deployment- related health problems do not occur in isolation. In fact, co-morbidity of conditions that cut across specialty medical areas is the rule rather than the exception. This finding is illustrated in the case of Veterans who have a history of combat-related TBI. VA researchers are showing that Veterans with probable mild TBI usually have Post Traumatic Stress Disorder (PTSD) or another mental health disorder and pain-related diagnoses.1, 2 We also know that dual (auditory and visual) sensory impairment is common in Veterans with deployment-related mild TBI.3

The finding of co-occurrence of post-deployment health problems creates challenges for health care systems and interventional strategies organized around specific conditions or diseases. How is care for these Veterans with multiple deployment-related problems best coordinated or sequenced? How should clinicians prioritize these Veterans' multi-system problems and conceptualize their ongoing symptoms and functional difficulties? Research protocols and clinical practice guidelines typically focus on single disorders and therefore may offer less guidance than needed (e.g., there are separate clinical practice guidelines for PTSD, mild TBI, and pain). How should they be altered to ensure that VA garners the evidence it needs and Veterans with multi-system comorbidities receive evidence-based care? Dr. Jesse's commentary brings our attention to the PACT care model. How should PACT and specialty care teams interact to meet the needs of complex OEF/OIF patients who may require a range of behavioral as well as medical interventions?

I was pleased that Dr. Jesse ended his commentary by noting the importance of collaboration with researchers. Addressing questions about the models of care and treatment protocols for OEF/OIF Veterans with multiple deployment-related morbidities will require partnership among clinicians, policymakers, and researchers. In addition, it will be important for researchers and policymakers to work together to determine whether VA can extend its reach to OEF/OIF Veterans who do not yet use VA but could benefit from its expertise in post-deployment health. Indeed, VA researchers have an important role to play in helping VA achieve its goal of providing this new cohort of Veterans with data-driven, patient-centered care.

  1. Lew HL, Otis JD, Tun C, et al. Prevalence of Chronic Pain, Posttraumatic Stress Disorder, and Persistent Postconcussive Symptoms in OIF/OEF Veterans: Polytrauma Clinical Triad. Journal of Rehabilitation Research and Development 2009; 46:697-702.
  2. Carlson KF, Nelson D, Orazem R, et al. Psychiatric Diagnoses among Iraq and Afghanistan Veterans Screened for Deployment-Related Traumatic Brain Injury. Journal of Traumatic Stress 2010; 23:17-24.
  3. Lew HL, Pogoda TK, Baker E, et al. Prevalence of Dual Sensory Impairment and Its Association with Traumatic Brain Injury and Blast Exposure in OEF/OIF Veterans. Journal of Head Trauma Rehabilitation 2011 (e-Published ahead of print March 7).