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Director’s Blog: Healing Invisible Wounds: An Action Plan

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Since September 11, 2001, more than 2.5 million service members have deployed to Iraq and Afghanistan. In contrast to previous wars, these recent wars have been fought by an all-volunteer force that has experienced multiple deployments. Many of the service members are in reserve or National Guard units. Many women and parents of young children have served. And many have survived severe injuries that would have almost certainly been fatal in previous wars. Invisible brain injuries like traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have been the signature wounds of these wars. The Armed Forces Health Surveillance Center reports more than a quarter million cases of TBI occurring in the military between 2000 and 2012. The prevalence of PTSD and depression in the military has been estimated to surpass 20 percent. The rate of suicide in the military, which traditionally is lower than the civilian rate, has doubled in the Army since 2003 and now exceeds the rate of suicide in civilians matched for age, sex, and race. Since 2009, more soldiers have died from suicide than combat.

Recognizing these facts, President Obama issued an Executive Order  last August requesting “all hands on deck” to ensure better outcomes for those who have sacrificed for all of us. In a speech to wounded veterans in Orlando over this past weekend, the President announced one of the results of this Executive Order: the National Research Action Plan  or NRAP. The NRAP was the result of months of planning between the Department of Defense, the Department of Veterans Affairs, the National Institutes of Health, and the Department of Education. These agencies together reviewed the state of the science, the current research portfolios, and the opportunities for progress. Together they have committed to transforming the research landscape to accelerate progress.

Each of the agencies already has a large investment in research on TBI and PTSD. The NRAP calls for a new culture of standardization, integration, and sharing of data across all funding agencies. We recognize TBI and PTSD as brain injuries, but the brain tissue we need to study to understand them is in short supply. The NRAP calls for an increased inventory of tissue, blood, and cerebrospinal fluid samples with creation of virtual repositories in the interest of increasing access to these resources for scientific purposes. In contrast to most other neuropsychiatric disorders, TBI and PTSD are the result of injury. Yet, we have no way of knowing after an injury who will recover completely and who will be disabled; even mild symptoms may lead to significant impairment. The NRAP calls for the identification of predictive or diagnostic biomarkers for PTSD and TBI which can be evaluated in clinical trials for their potential to help us better understand treatment response and more effectively match individuals to treatments. Many service members and veterans who develop PTSD respond well to treatment, but too many do not recover. The NRAP will help focus research efforts to improve our understanding of the impact of trauma and ultimately provide better treatments to improve the lives of those who have served as well as the tens of thousands of civilians who are exposed to traumatic events.

We know that service members and veterans with neuropsychiatric disorders are at increased risk for suicide, but we do not have useful tools with which to predict the individuals at highest risk. The Executive Order called for recruitment by the end of 2012 of 100,000 soldiers to assess risk for suicide. NIMH and the Department of the Army, collaborating on the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS), completed recruitment of more than 100,000 soldiers last December and is already defining the major predictors of risk for suicide. The NRAP calls for expanding Army STARRS into a long-term longitudinal study, similar to the Framingham study of heart disease, encompassing not just suicide, but PTSD, TBI, and other comorbid conditions.

This is the third time the President has talked about mental health in recent months. In April he announced the BRAIN initiative, in June the National Conversation on Mental Health, and now the NRAP. Taken together, these three announcements define not only the dimensions of a major national health challenge but a potential solution based on (a) better tools for studying brain disorders, (b) better public awareness and broader access to mental health care, and (c) better coordination of research between agencies. The NRAP will serve as a strategic plan for reducing the morbidity and mortality of PTSD and TBI.

The President in Orlando told of the remarkable journey of an Army Ranger, Sergeant First Class Cory Remsburg who was nearly killed by an improvised explosive device in Afghanistan. After months in a coma, dozens of surgeries, and years of rehab, Sergeant Remsburg is now planning for a 42-mile bike race. As the President said in Orlando on Saturday, “The war in Afghanistan may be ending, but for Cory and our disabled vets, the work has only just begun. Cory is 30 years old. His recovery -- like so many of yours -- will last a lifetime. But he won’t give up, because you haven't given up. And when it comes to our work, to making sure that our nation is fulfilling its promises to the men and women who served and sacrificed, America cannot give up either.”

NIMH was founded in 1948, charged by President Truman to address the problems of soldiers and veterans with “combat neurosis.” Now, 65 years later, we have the same charge, to address the same illnesses from a very different war. Fortunately, we have better tools and a better understanding of the problem. But it is important to acknowledge that there is still much we do not know. We can provide better access to current diagnostics and current treatments, but for too many people this will not be enough. As the NRAP makes clear, we will need better science if we are to repay the debt owed to the more than 2 million men and women who have sacrificed for us all.