EXECUTIVE SUMMARY

This paper analyzes the cost/benefit of long-term care of Soldiers returning from Iraq and Afghanistan and the constraints the Department of Veterans Affairs faces in trying to meet the needs of these Soldiers. This paper uses data collected from government sources like the Department of Veterans Affairs and the Veterans Benefit Administration. The conclusions of the analysis are that: (a) The Veterans Health Administration (VHA) is already overwhelmed by the number of patients it currently sees and the addition of these new Veteran’s seeking care will put a severe strain on the resources that are currently available; (b) The Veterans Benefit Association (VBA) is in need of restructuring to be able to handle the influx on claims it is currently experiencing. As it stands now the current wait time is up to 90 days before a Veteran will receive their disability rating and that time can increase with these additional claims; and (c) Providing medical care and disability compensation benefits to the Soldiers returning from the conflicts in Iraq and Afghanistan can cost anywhere from $400 - $900 billion depending on the type of care required, how quickly they file their claims, and the growth rate of those benefits.
The recommendations that need to be considered include: increasing the staff as well as the budget for Veterans Medical Centers especially those that specialize in mental health treatment; restructure the claims process and increase staffing to help speed the process to get Veterans claims to them more expeditiously.

Cost/ Benefit Analysis of Providing Medical Care to Soldiers Returning from Iraq and Afghanistan-PTSD and TBI

MSA 685 Project Report

Submitted in Partial Fulfillment of Requirements
For the Degree of
Master of Science in Administration
(Concentration in General Administration)

By
Ronnie E. Heare
Student ID# 284890

Project Instructor
Dr. Robert Weltzer

April 17, 2009

CHAPTER I
DEFINITION OF THE PROBLEM
Introduction

Post Traumatic Stress Disorder, PTSD, and Traumatic Brain Injury, TBI have become an ever increasing problem in the military since the inception of the Global War on Terrorism. All too often Soldiers are misdiagnosed, given medication for depression and sent back for multiple tours to Iraq and Afghanistan. According to VA statistics, 505,366 troops from Iraq and Afghanistan have left the military as of February 2008. Of that number, 144,424 (29 percent) have sought VA health care, and 20,638, more than 14 percent of those, have been diagnosed with PTSD (Vlahos, 2006).
This paper will focus on the following aspects of the needs of returning veteran’s. 1. Disability Compensation -Projected Costs -Backlog of pending claims
2. Medical Care -Capacity Issues -Projected costs -Veteran’s Centers
3. Overall assessment of U.S. readiness to meet its obligations to veteran’s
4. Recommendations

Background
Post Traumatic Stress Disorder is not something new within the military but, until recently, was not something the military considered a problem. During the Vietnam era PTSD was known as “combat fatigue” and Soldiers were given a few days of Rest and Relaxation, (R and R) and then sent back to duty. Despite all the exposure given to PTSD since the inception of the War on Terror, Soldiers and their families are either not getting the treatment they need or the treatment they are receiving is not helping.
While there are many factors that help contribute to PTSD, every patient has one thing in common; they experienced a traumatic event while deployed in a combat zone. These events, not only put the individual at risk, but their family as well. While many soldiers are receiving help with their disorder, for some, the help comes too late and they are unable to cope or continue with their life. Since combat operations began in March 2003, 45 soldiers have killed themselves in Iraq, and an additional two dozen have committed suicide after returning home, the Army has confirmed. (Mclemore, 2005).
While these numbers are staggering some experts feel that the worst is yet to come. The problem for some is that they either do not know there is a problem or do not want anyone to know that they have a problem. The Army has recently begun screening of personnel that have recently returned from a deployment but that still does not help the thousands who have returned in previous years. According to Veterans Affairs (VA) data, 9,600 of the 360,000 soldiers discharged after fighting in Iraq and Afghanistan have received a provisional diagnosis of PTSD. (Mclemore, 2005).
Problem Statement
Many soldiers are returning to Iraq and Afghanistan with mental illness and given anti-depressants to help with their problems. A 2004 Army report found that up to 17 percent of combat-seasoned infantrymen experienced major depression, anxiety or post-traumatic stress disorder after one combat tour to Iraq. Less than 40 percent of them had sought mental-health care. (Rogers, 2006).
One problem lies in that many soldiers want to return to combat with their units and as long as they are medically cleared to go then they are permitted to go. The second problem is the medical professional basically being able to predict the future and how the deployment will affect the soldier returning to combat.
Purpose of the Project
The purpose of this project is to analyze the effects PTSD and TBI on the Soldier and their families and the effectiveness of the treatments they are given by medical personnel. We will also look at the projected cost of disability compensation, the backlog of pending claims as well as the projected cost of medical care of these veterans.
Research Questions
This research paper will answer the following questions about PTSD and TBI in the military and how Soldiers and their families are being treated. 1. Should Soldiers be redeployed after being diagnosed with PTSD or TBI? 2. Are the treatments currently available helping? 3. What is done to help family members whose loved one is diagnosed with PTSD? 4. Are family members continued to be cared for by the military after the death/suicide of a loved one? 5. What are the long-term effects of Soldiers who are/are not treated for PTSD and TBI?
Assumptions
The assumptions to be incorporated into this research project were:
1) All known cases of PTSD and TBI have been reported.
2) All current treatments have been listed and information associated with those treatments is correct and up to date.
3) VA information on the amount of backlogged claims is current.
4) Reporting of information does not vary between different VA Centers and Hospitals.
5) Monetary costs for each type of treatment are consistent in all VA Centers.

Limitations
The possible limitations are having to rely on statistical data for most of my research. In doing this some of the information may not be correct because all cases, for whatever reason, may not have been reported. Also, being able to ensure that all the data is updated regularly to reflect the most current information available may not be possible.
Definitions
Combat Zone - An area designated as a war zone during a specified period.
Post Traumatic Stress Disorder (PTSD) - A common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Rest and Relaxation (R& R) - Military slang for rest and relaxation (or rest and recreation), is a term used for the free time of personnel in the US military or UN Volunteers (UNV). Traumatic Brain Injury (TBI) - occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Veteran’s Affairs (VA) - Established in 1989, the Department of Veterans Affairs (VA) provides federal benefits to US veterans and their families. The agency is the second largest of the 15 Cabinet departments and offers health-care, financial assistance, and burial benefits programs. More than 60 million people - veterans, their family members, and survivors of veterans - are eligible for the VA's benefits (a few of children of Civil War veteran’s still draw benefits). Selected benefits include education assistance, home loans, life insurance, and vocational rehabilitation.

CHAPTER II
LITERATURE REVIEW
Introduction
Posttraumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) are becoming ever increasing problems in today’s military. These disorders are nothing new and have affected veterans from World War I, World War II, the Korean War, the Vietnam War and Desert Shield/Desert Storm. There are particularly good descriptions of posttraumatic stress symptoms in the medical literature on combat veterans of World War II and on Holocaust survivors. (Veterans Affairs Fact Sheet, 2006). But with the many deployments in the past several years to Iraq and Afghanistan, with many soldiers going over for the third or fourth deployments, the pressures mounting on today’s military has become too much for some to handle.
The main difference between past and present wars is the ever increasing number of women who are seeing combat on the front lines. Women are being tasked to fill more and more lethal combat roles as the war on terror continues and women appear to be more susceptible to PTSD than their male counterparts. Studies indicate that many of these women suffer from more pronounced and debilitating forms of PTSD than men, a worrisome finding in a nation that remembers how many traumatized troops got back from Vietnam and turned to drugs and violence, alcohol and suicide. (Scharnberg, 2005).
The rate of suicides among-active duty soldiers is on pace to surpass both last year’s numbers and the rate of suicide in the general U.S. population for the first time since the Vietnam war, according to U.S. Army officials. As of August, 62 Army soldiers have committed suicide, and 31 cases of possible suicide remain under investigation, according to Army statistics. Last year, the Army recorded 115 suicides among its ranks, which was also higher than the previous year. (Mount, 2008). According to the National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), nearly 7.7 million Americans have PTSD at any given time and about 30 percent of men and women who have spent time in war zones experience PTSD. (University of Virginia Health System, 2007).
Symptoms and Characteristics of PTSD
There are many symptoms for PTSD and not every individual who has PTSD reacts in the same way. Some of these symptoms can include, but are not limited to, irritability, violent outbursts, trouble working or socializing, losing touch with reality and reenacting the event for a period of seconds or hours or, vary rarely, days. (University of Virginia Health System, 2007). Persons with PTSD experience extreme emotional, mental, and physical distress when exposed to situations that remind them of the traumatic event. Some may repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day, along with these symptoms persons who suffer from PTSD also exhibit many characteristics such as, sleep problems, depression, loss of interest of things that used to make them happy and avoidance of certain places or situations that bring back memories. (National Center for PTSD, 2008).
Diagnosing PTSD
Not every person who experiences a trauma develops PTSD, or experiences symptoms at all. PTSD is diagnosed only if symptoms last more than one month. In those who do have PTSD, symptoms usually begin within three months of the trauma, but can also start months or years later. PTSD can also occur at any age, to include childhood, and can last just a few months to several years.
The difficulty lies in the fact that PTSD is hard to diagnose and therefore often goes unrecognized for many years. PTSD is unique among psychiatric disorders in that it is identified not only by symptoms, but also by the precursor of the illness (the traumatic event). Since talking about trauma may evoke painful emotions, people often refrain from discussing past traumatic events. (Cohen, 2006). This is where the problem comes in because many people refrain from talking about the trauma to avoid reliving the painful memories.
When a person is unable or unwilling to discuss a traumatic event, accurate diagnosis is difficult. For example, domestic violence and sexual abuse are subjects that many persons feel uncomfortable in raising, even with professionals. For others, feelings of shame and guilt related to the event and social pressures to “deal with” the symptoms that come afterward make talking about it difficult. Additionally, persons with PTSD often have other disorders, such as substance abuse or depression. These other disorders share some of the symptoms of PTSD and can also make diagnosis more difficult. (Cohen, 2006).
Treatment
Once a person has been diagnosed with PTSD they can begin a treatment regimen based on how severe their illness may be. PTSD is a complex condition that can impair life functions. There is a growing body of evidence about effective treatment of PTSD. In response to the traumatic incidents of September 11, 2001 New York State has looked to these treatments as it expands its role in public mental health to meet the trauma-related needs of people who have not traditionally been served in the public mental health system. (New York State Department of Mental Health, 2006). Treatment for PTSD typically begins with a detailed evaluation and development of a treatment plan that meets the unique needs of the survivor. Research has shown that the most effective interventions for PTSD are based on cognitive therapy approaches. Cognitive therapy involves working with the affected individual to change her/his emotions, thoughts, and behaviors regarding the traumatic event. (New York State Department of Mental Health, 2006).
One treatment that is being used is called “Virtual Iraq.” Researchers at Weill Cornell Medical College are using this to try and help understand how symptoms of PTSD are developed. The Weill Cornell researchers are testing whether physiological arousal (heart rate, stress hormones) and anxiety while viewing the simulation — as well as suppressing memories after viewing the simulation — affect the ability to remember the scenario and suppress intrusive scenario memories. (Science Blog, 2006).
Another major factor in the treatment of PTSD is getting the Soldiers family members involved and helping them understand what is going on with their loved one. Education is a key component of care for the veteran and the veteran’s family when returning from a war experience and is intended to improve understanding and recognition of symptoms, reduce fear and shame about symptoms, and, generally, “normalize” his or her experience. (National Center for PTSD, 2007). It should also provide the veteran and their family with a clear understanding of how recovery is thought to take place, what will happen in treatment, and, as appropriate, the role of medication. (National Center for PTSD, 2007).
While in the process of getting help, if family members feel comfortable, they should let their loved one know that they are willing to listen if the survivor would like to talk about his or her trauma. But the family should stop if anyone gets too upset or overwhelmed. If everyone is able, it is also important to talk about how the trauma is affecting the family and what can be done about it. (Department of Veterans Affairs Fact Sheet, 2008).
Symptoms and Characteristics of TBI
The symptoms of TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. Some symptoms are evident immediately, while others do not surface until several days or weeks after the injury. There has been an increase in these types of injuries in Iraq and Afghanistan because of the use of Improvised Explosive Devices (IED) and the use of Vehicle Born Improvised Explosive Devices (VBIED). These devices are exploded as a convoy is approaching or has started to pass the point where the device is placed.
Diagnosing TBI
Diagnosing TBI can be very difficult at times and often will go unnoticed without proper treatment when Soldiers return from deployment. Methods of diagnosis are: * A detailed neurological examination is important and will bring out evidence of brain injury. * Brain imaging with CAT scan, MRI, SPECT and PET scan may be useful. * Cognitive evaluation by a Neuropsychologist with formal neuropsychological testing. * Evaluations by physical, occupational and speech therapists help clarify the specific deficits of an individual.
Two scales widely-used to evaluate a person's level of consciousness are the Glasgow Coma Scale and the Rancho Los Amigos Scale. The Glasgow Coma Scale (Figure 1) is a simple, 15-point scale that evaluates the level of consciousness and chances for recovery. The Rancho Los Amigos Scale is a much more complex tool that categorizes a patient into eight separate levels of consciousness. Glasgow Coma Scale | | 1 | 2 | 3 | 4 | 5 | 6 | Eyes | Does not open eyes | Opens eyes in response to painful stimuli | Opens eyes in response to voice | Opens eyes spontaneously | N/A | N/A | Verbal | Makes no sounds | Incomprehensible sounds | Utters inappropriate words | Confused, disoriented | Oriented, converses normally | N/A | Motor | Makes no movements | Extension to painful stimuli | Abnormal flexion to painful stimuli | Flexion / Withdrawal to painful stimuli | Localizes painful stimuli | Obeys commands | Figure 1 *Wikipedia
The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).
Best eye response (E)
There are 4 grades starting with the most severe: 1. No eye opening 2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously Best verbal response (V)
There are 5 grades starting with the most severe: 1. No verbal response 2. Incomprehensible sounds. (Moaning but no words.) 3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)
Best motor response (M)
There are 6 grades starting with the most severe: 1. No motor response 2. Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) 3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6. Obeys commands. (The patient does simple things as asked.)
Rancho Los Amigos Scale
The Ranchos Los Amigos (Revised) Cognitive Scale is used by many health care teams to can begin treatment that will develop skills and promote appropriate behavior. Health care professionals often suggest the following simple measures to family and friends while the patient is still in coma: * Always talk as if the patient hears when you are nearby. * Speak directly to the patient about simple things and frequently reassure them. * Explain events and noises in the surrounding area. Tell the patient what has happened and where they are. * Touch and stroke the patient gently. Tell the patient who you are each time you approach the bedside. Hold their hand. * Play the patient's favorite music for them. * For parents of young children, tape yourself singing or reading your child's favorite stories.
Levels of Cognitive Functioning
Level I - No Response: Total Assistance * Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.
Level II - Generalized Response: Total Assistance * Demonstrates generalized reflex response to painful stimuli. * Responds to repeated auditory stimuli with increased or decreased activity. * Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization. * Responses noted above may be same regardless of type and location of stimulation. * Responses may be significantly delayed.
Level III - Localized Response: Total Assistance * Demonstrates withdrawal or vocalization to painful stimuli. * Turns toward or away from auditory stimuli. * Blinks when strong light crosses visual field. * Follows moving object passed within visual field. * Responds to discomfort by pulling tubes or restraints. * Responds inconsistently to simple commands. * Responses directly related to type of stimulus. * May respond to some persons (especially family and friends) but not to others.
Level IV - Confused/Agitated: Maximal Assistance * Alert and in heightened state of activity. * Purposeful attempts to remove restraints or tubes or crawl out of bed. * May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's request. * Very brief and usually non-purposeful moments of sustained alternatives and divided attention. * Absent short-term memory. * May cry out or scream out of proportion to stimulus even after its removal. * May exhibit aggressive or flight behavior. * Mood may swing from euphoric to hostile with no apparent relationship to environmental events. * Unable to cooperate with treatment efforts. * Verbalizations are frequently incoherent and/or inappropriate to activity or environment.
Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance * Alert, not agitated but may wander randomly or with a vague intention of going home. * May become agitated in reponse to external stimulation, and/or lack of environmental structure. * Not oriented to person, place or time. * Frequent brief periods, non-purposeful sustained attention. * Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity. * Absent goal directed, problem solving, self-monitoring behavior. * Often demonstrates inappropriate use of objects without external direction. * May be able to perform previously learned tasks when structured and cues provided. * Unable to learn new information. * Able to respond appropriately to simple commands fairly consistently with external structures and cues. * Responses to simple commands without external structure are random and non-purposeful in relation to command. * Able to converse on a social, automatic level for brief periods of time when provided external structure and cues. * Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.
Level VI - Confused, Appropriate: Moderate Assistance * Inconsistently oriented to person, time and place. * Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection. * Remote memory has more depth and detail than recent memory. * Vague recognition of some staff. * Able to use assistive memory aide with maximum assistance. * Emerging awareness of appropriate response to self, family and basic needs. * Moderate assist to problem solve barriers to task completion. * Supervised for old learning (e.g. self care). * Shows carry over for relearned familiar tasks (e.g. self care). * Maximum assistance for new learning with little or no carry over. * Unaware of impairments, disabilities and safety risks. * Consistently follows simple directions. * Verbal expressions are appropriate in highly familiar and structured situations.
Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills * Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time. * Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks. * Minimal supervision for new learning. * Demonstrates carry over of new learning. * Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing. * Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance. * Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs. * Minimal supervision for safety in routine home and community activities. * Unrealistic planning for the future. * Unable to think about consequences of a decision or action. * Overestimates abilities. * Unaware of others' needs and feelings. * Oppositional/uncooperative. * Unable to recognize inappropriate social interaction behavior.
Level VIII - Purposeful, Appropriate: Stand-By Assistance * Consistently oriented to person, place and time. * Independently attends to and completes familiar tasks for 1 hour in distracting environments. * Able to recall and integrate past and recent events. * Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance. * Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance. * Requires no assistance once new tasks/activities are learned. * Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action. * Thinks about consequences of a decision or action with minimal assistance. * Overestimates or underestimates abilities. * Acknowledges others' needs and feelings and responds appropriately with minimal assistance. * Depressed. * Irritable. * Low frustration tolerance/easily angered. * Argumentative. * Self-centered. * Uncharacteristically dependent/independent. * Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.
Level IX - Purposeful, Appropriate: Stand-By Assistance on Request * Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours. * Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested. * Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested. * Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist to anticipate a problem before it occurs and take action to avoid it. * Able to think about consequences of decisions or actions with assistance when requested. * Accurately estimates abilities but requires stand-by assistance to adjust to task demands. * Acknowledges others' needs and feelings and responds appropriately with stand-by assistance. * Depression may continue. * May be easily irritable. * May have low frustration tolerance. * Able to self monitor appropriateness of social interaction with stand-by assistance.
Level X - Purposeful, Appropriate: Modified Independent * Able to handle multiple tasks simultaneously in all environments but may require periodic breaks. * Able to independently procure, create and maintain own assistive memory devices. * Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them. * Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies. * Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or comepensatory strategies to select the appropriate decision or action. * Accurately estimates abilities and independently adjusts to task demands. * Able to recognize the needs and feelings of others and automatically respond in appropriate manner. * Periodic periods of depression may occur. * Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress. * Social interaction behavior is consistently appropriate.
Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R. Revised scale 1997 by Chris Hagen.

Summary
Post Traumatic Stress Disorder, as well as Traumatic Brain Injury continues to be a very misunderstood and often, misdiagnosed, mental illness. Studies have shown that almost 30% of the veterans returning from Iraq and Afghanistan suffer from some sort of mental disorder. Many of these people have not been able to cope with the trauma and, unfortunately, have taken their own lives. This only compounds the problems for their loved ones left behind and often leaves them wondering why this all had to happen.
At this time there is no single treatment available to help these individuals cope with the trauma they have faced. One study, that is ongoing, is the “Virtual Iraq”, at Weill Cornell Medical College where the researchers there are using a virtual reality simulator to reenact the possible events of the trauma to help them better understand how the symptoms of PTSD and TBI are developed.
The one constant that remains in the treatment of PTSD and TBI is the early diagnosis and getting the Soldiers the proper care that they need. Ensuring that the family gets involved and has everything explained to them about what is going on with their loved one is also very important. Getting the proper medication along with the proper treatment can go a long way in helping not only the Soldier recover, but the Soldiers family as well.

CHAPTER III
METHODOLOGY
Purpose
The purpose of this research project was to analyze the effects of Post Traumatic Stress Disorder and Traumatic Brain Injury on members of the military and their family members, as well as the costs associated with their treatments. As the researcher I will provide information about the target population as well as how the data was collected and finally the limitations incurred during this study.
Target Population
This project looked at the overall population of the Active Duty military as well as those in the National Guard, Reserve and Veteran’s that have been diagnosed with Post Traumatic Stress Disorder and Traumatic Brain Injury. The amount of personnel in these populations has increased since the inception of the Global War on Terror in 2001 and the cost of care and treatment has risen at an astronomical rate.
Data Collection Process
Secondary data was used to look at these populations. Data (gathered by the United States Military and the Department of Veterans Affairs) from the patients that were diagnosed with PTSD and TBI. The numbers reported are based on the servicemen and women involved in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF, Afghanistan) unless otherwise noted. With the ever increasing role of women in combat there has been a significant rise in the number of PTSD and TBI among women in the military. (Appendix A).
There were no focus groups of any kind nor was there a review of any of the processes or procedures used on how the data was collected from the different organizations supplying the information. The information will, however, be broken down, not only by the war it was collected in but also divided into male and female statistics where possible.
Reliability and Validity
This study was conducted to show the effects of PTSD and TBI, not only on the Soldier, but also how it affects the family as well. With the ever increasing deployments and the length of these deployments the statistics used in this study will continually change long after these deployments end. At the time of this study the data used is the most up to date and accurate data available.
Limitations
As the researcher in this study all of the data that I collected and used was from secondary source to include The Department of Veterans Affairs as well as other Veterans Organizations and the Military. Additional studies may be needed long after the Global War on Terror, to not only review the statistics, but to see if there has been a rise, or hopefully a decline, in the number of Veterans suffering from Post Traumatic Stress Disorder.

APPENDIX A
Post-Traumatic Stress Disorder (PTSD) - Women
Vietnam-era veterans developing PTSD: 1/4
Gulf War-era veterans w/PTSD, 2 years after deployment: 16%
Rate of female-to-male combat PTSD: 2-to-1
VA-treated females noting rape/attempted rape while in service: 1/4
...raped multiple times: 37%
...gang-raped: 14%
Military sexual assaults reported, 2005: 2,374
Military sexual assault investigations, 2004-2005: 3,038
...of above, resulting in court-martial of perpetrator: 329 (10%)
OEF/OIF vets diagnosed with possible PTSD: ~3,800
Inpatient PTSD programs serving women exclusively: 2

References
Armstrong, Keith; Best, Suzanne, & Domenici, Paula. (2006). Courage After Fire. Berkeley, CA: Ulysses Press.
Cantrell, Bridget C and Dean, Chuck. (2005) Down Range to Iraq and Back. Seattle, WA: Wordsmith Publishing.
Donn, Jeff and Hefling, Kimberly. (September 29, 2007).Coming Home Wounded-The Price. Associated Press
Henderson, Kristin. (2006). While They’re At War: The True Story of American Families. New York, NY: Houghton Mifflin Company
National Center for PTSD. How Common is PTSD? www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_how_common_is_ptsd.html?printable-template=factsheet retrieved September 30, 2008
Seal, Karen; Bertenthal, Daniel; Miner, Christian; Sen, Saunak; & Marmar, Charles. (2007, March 12). Bringing the War Back Home: Mental Health Disorders Among 103,788 US Veterans
Returning from Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities. Archives of Internal Medicine, 167, 476-482.
Street, Amy and Stafford, Jane (2005). Military sexual trauma: Issues in caring for veterans. National Center for PTSD. Retrieved November 2, 2007 from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_clinician_guide_ch_9.pdf?opm=1&rr=rr1519&srt=d&echorr=true http://www.traumaticbraininjury.com/content/symptoms/diagnosisoftbi.html

References
Department of Veterans Affairs Homepage. What is Posttraumatic Stress Disorder? [online]. Available: http://www.ncptsd.va.gov/topics/war.html (2006, February 22).
Mclemore, David. (2005, Dec 8). For troops, stress a lingering hazard. The Dallas Morning News.
Nadelson, Theodore. Damage: War's Awful Aftermath. In Trained to Kill: Soldiers at War, 89-103. Baltimore: Johns Hopkins University Press, 2005. 191pp. (U21.5 .N33 2005)
Rogers, Rick. (2006, March 19). Some troops headed back to Iraq are mentally ill. The San Diego Union Tribune.
Scharnberg, Kirsten. (2005, March 28). Women GIs and Post-Traumatic Stress Disorder. The Chicago Tribune.
U.S. Government Accountability Office. VA Health: VA Should Expedite the Implementation of Recommendations Needed to Improve Post-Traumatic Stress Disorder Services. Washington, D.C.: U.S. Government Accountability Office, February 2005. 58pp. Available from http://www.gao.gov/new.items/d05287.pdf. Internet. http://www.scienceblog.com/cms/virtual-iraq-used-treat-returning-soldiers-ptsd-13223.html http://www.omh.state.ny.us/omhweb/EBP/adult_ptsd.htm#Why http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/treatment_ret_iraq.html?opm=1&rr=rr124&srt=d&echorr=true http://www.braininjurydisorders.org/tbi_2.html

Casualties in Iraq
The Human Cost of Occupation
Edited by Margaret Griffis: Contact American Military Casualties in Iraq | Date | Total | In Combat | | American Deaths | | | Since war began (3/19/03): | 4278 | 3436 | Since "Mission Accomplished" (5/1/03) (the list) | 4139 | 3328 | Since Capture of Saddam (12/13/03): | 3817 | 3130 | Since Handover (6/29/04): | 3419 | 2803 | Since Obama Inauguration (1/20/09): | 50 | 31 | American Wounded | Official | Estimated | Total Wounded: | 31215 | Over 100000 | Latest Fatality Apr. 25, 2009 |