Traumatic brain injury (TBI) is the signature injury of recent wars in Afghanistan and Iraq. Technology such as improved body armor has ensured that soldiers stay alive through injuries that may once have been lethal. Instead of death, then, US soldiers have had an increase in injury, specifically the head injuries associated with exposure to explosive blasts.
In recognition of the surge in head injuries suffered by service members, Congress in 2008 requested that the military screen troops before going to war and after returning. The military responded with a screening tool known as Automated Neuropsychological Assessment Metrics (ANAM). This is a computerized cognitive assessment that takes about 20 minutes.
This screening program now appears steeped in controversy. A recent investigation by NPR and ProPublica describes multiple problems with the program. For one, ANAM was never actually proven to detect TBI. A diagnosis of TBI requires a skilled physician, who often works in conjuction with neuropsychologists, psychiatrists, and others to establish the diagnosis and provide necessary treatment. While a 20-minute computerized test cannot replace such specialized analysis, the military hoped that the screen would help alert experts to someone who might require extra attention.
Another problem seems to be the selection of the ANAM test. Other screening tests are available, such as a program called ImPact, used by the US Hockey team. According to the investigation by NPR and ProPublica, military sources state that ANAM was selected without serious comparisons between tests, despite concerns of medical advisers. Some have stated concerns about conflicts of interest around the selection of ANAM, as some who could gain money by the selection served on the selection board. Officials are now looking more closely with an in-depth study, the results of which are expected in 2015, years after most troops are scheduled to return home.
As a whole, the test seems too sensitive, meaning that someone who didn't sleep well might require further screening for brain injuries. On the one hand, this is the safer of two evils. It would theoretically be better to accidentally get more people without brain injury to be evaluated than to miss people who actually have TBI.
However, many officials are refusing to administer the test. The over-sensitivity of the test has made officials, especially in the Army, mistrust the results. Those who score low may not be referred for a follow-up medical evaluation. Perhaps due to a shortage of appropriately trained staff in the face of too many potential TBI sufferers, follow-up evaluations based on ANAM were discouraged. The military has done a much better job giving the ANAM to troops before deployment, but very few have been given on return, which is when TBI would be most likely to be detected.
Even if these tests are done, more hurdles remain. Because the ANAM data do not reside on any one computer network, a physician who wants to review their patient's information needs to call a hotline and request the information by fax or e-mail. A few thousand such requests have been made over the last three years, but nowhere near the more than 90,000 diagnoses of TBI being made over that time.
The program has cost 42 million dollars to date. In August 2011, in the face of growing concerns about the program, a Senate committee reviewed the use of ANAM, but decided the program should continue. How this can be accomplished if the military commanders fail to follow through on any data collected is an open question.
Many programs to help patients with TBI are available through the military, such as the newly established National Intrepid Center of Excellence, a center for brain-injured soldiers with a $65 million dollar budget. But unless the problem is adequately recognized, many soldiers will never get access to these resources.