C O R P O R A T I O N

Improving the Quality of Mental Health Care for VeteransLessons from RAND Research

Veterans, especially those who deployed overseas, face elevated risks of mental health conditions. Veterans who have served since the September 11, 2001, attacks are especially vulnerable (see Figure 1). Roughly one

in five veterans experiences mental health problems, including posttraumatic stress disorder (PTSD), major depression, and anxiety. Deployment can also increase the risk of unhealthy alcohol and drug use, substance use disorders, and suicidal behavior. If

left untreated, these conditions can have long-lasting and damaging consequences, impairing relationships, work productivity, quality of life, and overall well-being for veterans and their families.

RAND Corporation researchers have conducted multiple studies of the quality of mental health care received by veterans across the systems that deliver this care. This brief summarizes the main lessons from this work and shares recommendations for policies and further research.

RESEARCH BRIEF

To better serve the mental health needs of veterans, RAND research leads to six primary recommendations:

1. Increase the number of highly trained mental health providers within the Department of Veterans Affairs (VA) and in private practice.

2. Reduce barriers to care by educating veterans about treatment and expanding access to high-quality treatment.

3. Adopt and enforce appropriate, consistent quality-of-care standards by creating incentives and disincentives that support best practices.

4. Improve monitoring and performance measurement for VA community care programs.

5. Continue to develop and test new models of care, particularly as new interventions become available and show promise.

6. Strengthen the evidence base for understanding the effectiveness of complementary and alternative therapies for mental health conditions.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 2

13–20%

Experience PTSD

10–15%

Experience depression

47%

Feel sudden outbursts of

anger

48%

Experience strains in family life

44%

Have difficulty with

civilian life

15–44%

Have alcohol dependence

19–23%

Have traumatic

brain injury

FIGURE 1

Deployment increases risks of mental health conditions and related problems among veterans who have served since the September 11, 2001, attacks

SOURCE: Tanielian, Batka, and Meredith, 2017.

Percentage of deployed affected

Why Quality of Care MattersHigh quality in health care was defined by the Institute of Medicine in its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century as care that is safe, patient cen-tered, effective, equitable, timely, and efficient. Much research has focused on understanding the availability and use of treatment that is effective. Effective treatments are those that have been shown to work, based on scientific research and clinical experience. Evidence-based practice (EBP) refers to specific forms of care that meet these criteria (see Figure 2). EBPs have been peer reviewed by scientists and clini-cians, and there is empirical evidence for their effectiveness. In some cases, EBPs have been proven to produce significant reductions in symptoms in controlled experimental research studies, which represent the gold standard of scientific evidence for medical treatments. Clinical practice guidelines are systemati-cally developed statements based on scien-tific evidence that help providers and patients make decisions about appropriate health care

practices for specific clinical circumstances, according to the Institute of Medicine’s 2011 report Clinical Practice Guidelines We Can Trust. Guidelines are based on reviews of the scien-tific literature and expert consensus. Treatment recommendations are assigned a grade of A, B, C, or D based on the strength of the scientific evidence, with a grade of A being the equivalent of “strongly recommended.”

It is important that veterans who experience mental health conditions and substance use

EBPs have been peer reviewed by scientists and clinicians, and there is empirical evidence for their effectiveness.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 3

problems receive treatment and get the best quality care available. Evidence-based treatment improves recovery rates. It also reduces the likelihood of other negative consequences that can follow from mental health and substance use conditions, such as health deterioration and problems in

relationships and work. Poor-quality care, by contrast, is less likely to lead to recovery. Furthermore, poor experiences with care can discourage veterans from seeking further care. There are also substantial monetary costs associated with substandard and inaccessible mental health care. In 2008, RAND researchers estimated the two-year societal costs of post-deployment mental health problems, such as PTSD and depression, among veterans who had served since the September 11, 2001, attacks to be approximately $6.2 billion (in 2007 dollars) (Tanielian and Jaycox, 2008). The study estimated that if all veterans received high-quality care for these conditions, these costs could be reduced by $1.2 billion (in 2007 dollars). Thus, high-quality care can stem adverse consequences for veterans and families and also reduce the economic burden on society. See the next page for examples of some EBPs.

Current best evidence

Clie

nt/p

atie

nt v

alue

s Clinical expertise

FIGURE 2

Components of evidence-based practice

SOURCE: Carol B. Peterson, Carolyn Black Becker, Janet Treasure, Roz Shafran, and Rachel Bryant-Waugh, “The Three-Legged Stool of Evidence-Based Practice in Eating Disorder Treatment: Research, Clinical, and Patient Perspectives,” BMC Medicine, Vol. 14, No. 69, April 14, 2016.

Evidence- based

practice

High-quality care can stem adverse consequences for veterans and families and also reduce the economic burden on society.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 4

Examples of evidence-based practices

PTSDProlonged exposure

Cognitive processing therapy

Eye movement desensitization and reprocessing

Specific cognitive behavioral therapies (CBTs) for PTSD

Brief eclectic psychotherapy

Narrative exposure therapy

Written narrative exposure

MAJOR DEPRESSIONAcceptance and commitment therapy

Behavioral activation/behavioral therapy

CBT

Interpersonal psychotherapy

Mindfulness-based therapies

Problem-solving therapy

ALCOHOL USE DISORDERBehavioral couples therapy for alcohol use disorder

CBT for substance use disorders

Community reinforcement approach

Motivational enhancement therapy

12-step facilitation

SOURCE: Hepner et al., 2018.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 5

Systems of Mental Health Care for VeteransTwo medical systems are primarily responsible for meeting veterans’ mental health care needs: the VA health care system and nonmilitary, private-sector health care providers. In recent years, these systems have reacted to the grow-ing recognition of the need to expand access and improve the quality of mental health care for veterans by hiring more providers, conduct-ing increased trainings, expanding the use of telemental health services, and creating new programs in the community.

Quality of Mental Health Care in the VA Health Care SystemMore than 9 million veterans are enrolled to receive care from the VA health care system (see sidebar at left). To serve this population, VA operates the nation’s largest health care system providing both inpatient and outpatient ser-vices, with 172 VA medical centers and 1,069 out-patient clinics across the country. In 2018, VA delivered mental health care to an estimated 1.7 million veterans.1 Compared with nonvet-erans, veterans are disproportionately older, male, and less healthy. Veterans who use VA health care—VA patients—are typically older than other veterans. Fifty-two percent of vet-erans who use VA health care are over age 65, while only 39 percent of veterans who are not VA patients are over age 65. VA patients are also more likely than other veterans to have been deployed. Partly as a result of their older age and deployment experience, VA patients have higher rates of mental health conditions and chronic physical conditions than other veterans.

RAND researchers have conducted major studies of VA’s capacity for delivering high-quality mental health care, including a comprehensive evalua-tion of the VA mental health system (Watkins et al., 2011); a congressionally mandated analysis

VA operates thenation’s largest health care system

VA provides both inpatient and outpatient services

172 VA medical centers nationwide

1,069 VA outpatient clinics

In 2018, VA delivered mental health care to an estimated 1.7 million veterans

VA PATIENTS:

52% are over age 65

THOSE WHO ARE NOT VA PATIENTS:

39% are over age 65

VA patientsare older

1 VA, “VA Mental Health Services,” June 2019 (https://www.va.gov/health-care/health-needs-conditions/mental-health/).

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 6

FIGURE 3

VA outperformed private health plans on several measures

SOURCE: Watkins et al., 2011.

NOTES: Figure shows the national average percentage of the VA cohort and the private plan cohort meeting performance indicators, compared with the national average of private providers, based on 2007 data. BP = bipolar 1 disorder; SCHIZ = schizophrenia; MDD = major depressive disorder; SUD = substance use disorder.

n VA

n Private health plans

77.2%Medication lab tests

5.7%

86.9%Any laboratory screening tests 49.3%

50.1%Antipsychotics (SCHIZ)

24.3%

Antidepressants (MDD)48.8%

22.3%

Treatment initiation (SUD)

16.2%27.1%

14.9%Treatment engagement (SUD) 21.0%

Continuation phase antidepressants (MDD)

31.2%14.5%

31.3%Mood stabilizers (BP)

21.5%

Long-term antipsychotics (SCHIZ)

38.2%23.5%

of the quality of VA health care compared with that delivered by other health systems as part of a broader assessment of VA’s health care resources and capabilities (Hussey et al., 2015); and an analysis of the purchased care system, in which veterans receive care paid by VA but delivered by private providers (Farmer and Tanielian, 2019).

Several themes recur across this work:

• VA has substantial capacity to deliver evidence-based mental health care.

• In response to the mental health burden faced by veterans of the Afghanistan and Iraq conflicts, VA has continued to increase this capacity. This has included hiring more pro-viders, integrating mental health into primary care settings, and expanding the use of tele-mental health.

• Despite reports of access problems at VA facilities over the past decade, most enrollees

live within 30 minutes of VA mental health care and do not face long wait times for appoint-ments, though there is considerable variation in timeliness across facilities.

• On most measures, VA performs as well or better than the private sector in delivering high-quality care for mental health conditions (see Figure 3).

• However, quality varies considerably across VA facilities, with best practices not universally delivered.

• Most VA patients express satisfaction with the mental health care they receive. A major-ity of patients in a 2011 survey expressed sat-isfaction with VA mental health services. On a 10-point scale, the average rating given by veterans was 7.7, with nearly half of patients giving VA mental health care the highest rat-ings (9 or 10). Seventy-four percent of patients reported that they were helped by treatment.

Assessment

Medication management

Substance use disorder

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 7

Quality of Mental Health Care Among Private ProvidersVeterans receive a substantial amount of their care from providers in private or community settings, referred to hereafter as “private provid-ers.” Seventy percent of prescriptions, 70 percent of inpatient visits, and 85 percent of office visits for veterans occur outside VA. Even veterans enrolled in VA health care receive only 30 per-cent of their care on average from VA (Farmer, Hosek, and Adamson, 2016).

Information on the quality of mental health care delivered to veterans in private settings remains sparse. Using criteria developed from the requirements and expectations for VA providers, recent RAND research has shed some light on the quality of care delivered by private providers and found a mixed picture. For example:

• Forty-three percent of private mental health providers who were surveyed routinely screen for problems common among veterans, such as mental health and substance use issues or sleep-related problems.

• One-third of psychotherapists (33 percent) self-reported that, in the most recent typical workweek, they treated a substantial majority of their patients (75 percent or more) with an EBP.

• When asked to report the most common first-line medications that they would prescribe to a patient with PTSD or major depression, 89 percent of psychiatrists specified a medica-tion that the VA or U.S. Department of Defense clinical practice guidelines include as recom-mended, evidence-based treatments for these conditions.

Overall, the surveys showed that private pro-viders were less prepared than VA providers to deliver high-quality mental health care to veterans.

Recently, VA has taken steps to help private pro-viders serve veterans more effectively. For exam-ple, VA has created toolkits and other resources,

including training programs. In addition, many nongovernmental programs have been created to raise awareness and offer training to improve the ability of private providers to deliver high-quality mental health care to veterans. However, little is known about the quality of training programs, particularly with respect to how they improve provider competency and fidelity in delivering evidence-based psychotherapy. To shed light on this issue, RAND researchers developed the Training in Psychotherapy (TIP) tool (Hepner et al., 2018). TIP enables stakeholders to assess how a psychotherapy training incorporates evidence- and expert-derived core components, indicating the degree to which the training can support clinicians to competently deliver evidence-based psychotherapy to veterans.

Barriers to High-Quality Mental Health CareWhen veterans are unable to access or receive high-quality care, the reasons are strikingly similar across both VA and private care settings.

Organizational and provider-related barriers are prominent, including

• shortages in the mental health workforce, leading to inadequate availability of appoint-ments

• variability in use of evidence-based treat-ments and inadequate training in evidence- based psychotherapies and care tailored to veterans.

Patients report beliefs that can reduce the likeli-hood of seeking mental health care, including

• concern that admitting a mental health problem is a sign of weakness

• skepticism about the effectiveness of treat-ment and concerns about the negative side effects of medication

• fear of job or career repercussions from seek-ing mental health care.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 8

COMPLEMENTARY AND ALTERNATIVE MEDICINE:

What Does the Evidence Show?In recent years, meditation, acupuncture, and other treatments for mental health conditions drawn from complementary and alternative medicine (CAM) have become increasingly popular. Most VA mental health programs offer CAM approaches.2 RAND teams have examined what the science says about the effectiveness of such treatments for treating PTSD, depression, and anxiety. For some conditions, specific kinds of CAM treatment have been shown to have positive effects. For example, mindfulness-based CBT as a treatment for depression had significantly positive effects, and treatment of PTSD with needle acupuncture reduced symptoms (Grant, Colaiaco, et al., 2017). However, the evidence base for CAM treatments in mental health care is underdeveloped, and the strength of evidence is weak.

What the Evidence Shows About CAM Treatments for Mental Health Conditions

Condition Treatment Effect Strength of Evidence

PTSD Needle acupuncture

Significantly positive Weak

St. John’s wort Not significant Weak

Major depression

Needle acupuncture

Not significant Weak

St. John’s wort Small positive Weak

Omega-3 fatty acids

Small positive Weak

Mindfulness-based CBT

Significantly positive as adjunctive for reducing depressive symptoms and preventing relapse

Moderate

Substance use disorder

Needle acupuncture

Small positive (for with-drawal and anxiety)

Weak

Mindfulness-based relapse prevention therapy

Small positive Weak

The results from CAM treatments for mental health conditions show promise in many areas, but, as noted, more scientific research is need-ed to understand their effectiveness.

2 VA, “Complementary and Alternative Medicine (CAM) for PTSD,” last updated February 7, 2019 (https://www.ptsd.va.gov/professional/treat/txessentials/complementary_alternative_for_ptsd.asp).

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 9

Recommendations for Policy and ResearchIn the context of the current landscape for veterans’ mental health care, six broad recommendations emerge from RAND research.

Recommendations for Policy

1. Increase the number of highly trained mental health providers. The United States needs to expand efforts to strengthen the capacity of mental health providers to deliver evidence-based treatments, both within VA and among private providers. VA should continue its investment in disseminating and requiring delivery of evidence-based treatments. Private-sector mental health providers need to be better equipped to work with the veteran population, and, thus, there is a need to improve community provider training for treating veterans.

2. Reduce barriers to care. Efforts to promote help-seeking among veterans are necessary. Given the concerns that veterans have expressed about the effectiveness of mental health treatment, resources to help them understand what effective mental health care entails and where to find it are necessary. Veterans should be informed consumers when choosing mental health providers and work with their therapists to address any specific concerns to ensure that they are getting the best care possible. At the same time, VA and other providers should explore new delivery approaches that can help to expand access, including training additional providers in delivering evidence-based mental health treatment and telemental health care options.

3. Adopt and enforce appropriate and consistent quality standards. Policymakers can help motivate the use of evidence-based, high-quality treatment by setting and enforcing consistent standards across all payers for delivery of mental health services. One approach would be adjusting financial reimbursement for providers to offer appropriate compensation and incentives to attract and retain highly qualified professionals and ensure motivation for delivering quality care.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 10

Recommendations for Research

4. Improve monitoring and performance measurement of VA community care programs. Little is known about the timeliness or quality of care that veterans receive through these programs as mandated. In addition, VA needs to undertake a systematic analysis of quality and access in these programs.

5. Continue to develop and test new models of care, particularly as new interventions become available and show promise. These approaches should be rigorously evaluated to assess that the interventions produce symptom recovery and ensure safety and longer-term effectiveness.

6. Strengthen the evidence base for understanding the effectiveness of CAM therapies for mental health conditions. The use of these treatments has outpaced the underlying science. Rigorous studies of the impact of particular therapies on specific conditions are needed.

Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research | 11

RB-10087 (2019)

Abstracts of all RAND Health Care publications and full text of many research documents can be found on the RAND Health Care website at www.rand.org/health. To view this brief online, visit www.rand.org/t/RB10087. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. RAND® is a registered trademark. © RAND 2019.

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For more information about RAND’s work on improving access to and quality of mental health treatment for veterans, please visit www.rand.org/topics/veterans-health-care.

THIS BRIEF SUMMARIZES RAND HEALTH CARE RESEARCH REPORTED IN THE FOLLOWING PUBLICATIONS:

M. Audrey Burnam, Lisa S. Meredith, Terri Tanielian, and Lisa H. Jaycox, “Mental Health Care for Iraq and Afghanistan War Veterans,” Health Affairs, Vol. 28, No. 1, May/June 2009, pp. 771–782 (www.rand.org/t/EP20090509).

Carrie M. Farmer, Susan D. Hosek, and David M. Adamson, Balancing Demand and Supply for Veterans’ Health Care: A Summary of Three RAND Assessments Conducted Under the Veterans Choice Act, Santa Monica, Calif.: RAND Corporation, RR-1165/4-RC, 2016 (www.rand.org/t/RR1165z4).

Carrie M. Farmer and Terri Tanielian, “Ensuring Access to Timely, High-Quality Health Care for Veterans: Insights from RAND Research,” testimony submitted to the Senate Committee on Veterans’ Affairs on April 10, 2019, Santa Monica, Calif.: RAND Corporation, CT-508, 2019 (www.rand.org/t/CT508).

Sean Grant, Benjamin Colaiaco, Aneesa Motala, Roberta M. Shanman, Melony E. Sorbero, and Susanne Hempel, Needle Acupuncture for Posttraumatic Stress Disorder (PTSD): A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1433-OSD, 2017 (www.rand.org/t/RR1433).

Sean Grant, Susanne Hempel, Ryan Kandrack, Aneesa Motala, Roberta M. Shanman, Marika Booth, Jeremy N. V. Miles, Whitney Dudley, and Melony E. Sorbero, Needle Acupuncture for Substance Use Disorders: A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1030-OSD, 2015 (www.rand.org/t/RR1030).

Kimberly A. Hepner, Coreen Farris, Carrie M. Farmer, Praise O. Iyiewuare, Terri Tanielian, Asa Wilks, Michael Robbins, Susan M. Paddock, and Harold Alan Pincus, Delivering Clinical Practice Guideline–Concordant Care for PTSD and Major Depression in Military Treatment Facilities, Santa Monica, Calif.: RAND Corporation, RR-1692-OSD, 2017 (www.rand.org/t/RR1692).

Kimberly A. Hepner, Stephanie Brooks Holliday, Jessica Sousa, and Terri Tanielian, Training Clinicians to Deliver Evidence-Based Psychotherapy: Development of the Training in Psychotherapy (TIP) Tool, Santa Monica, Calif.: RAND Corporation, TL-306-BWF, 2018 (www.rand.org/t/TL306).

Lara Hilton, Alicia Ruelaz Maher, Benjamin Colaiaco, Eric Apaydin, Melony E. Sorbero, Marika Booth, Roberta M. Shanman, and Susanne Hempel, Meditation for Posttraumatic Stress Disorder: A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1356-OSD, 2017 (www.rand.org/t/RR1356).

Peter S. Hussey, Jeanne S. Ringel, Sangeeta C. Ahluwalia, Rebecca Anhang Price, Christine Buttorff, Thomas W. Concannon, Susan L. Lovejoy, Grant R. Martsolf, Robert S. Rudin, Dana Schultz, Elizabeth M. Sloss, Katherine E. Watkins, Daniel A. Waxman, Melissa Bauman, Brian Briscombe, James R. Broyles, Rachel M. Burns, Emily K. Chen, Amy Soo Jin DeSantis, Liisa Ecola, Shira H. Fischer, Mark W. Friedberg, Courtney A. Gidengil, Paul B. Ginsburg, Timothy R. Gulden, Carlos Ignacio Gutierrez, Samuel Hirshman, Christina Y. Huang, Ryan Kandrack, Amii M. Kress, Kristin J. Leuschner, Sarah MacCarthy, Ervant

J. Maksabedian Hernandez, Sean Mann, Luke J. Matthews, Linnea Warren May, Nishtha Mishra, Lisa Kraus, Ashley N. Muchow, Jason Nelson, Diana Naranjo, Claire E. O’Hanlon, Francesca Pillemer, Zachary Predmore, Rachel Ross, Teague Ruder, Carolyn M. Rutter, Lori Uscher-Pines, Mary E. Vaiana, Joseph Vesely, Susan D. Hosek, and Carrie M. Farmer, Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans, Santa Monica, Calif.: RAND Corporation, RR-1165/2-VA, 2015 (www.rand.org/t/RR1165z2).

Sydne Newberry, Susanne Hempel, Marika Booth, Brett Ewing, Alicia Ruelaz Maher, Claire E. O’Hanlon, Jennifer Sloan, Christine Anne Vaughan, Whitney Dudley, Roberta M. Shanman, and Melony E. Sorbero, Omega-3 Fatty Acids for Major Depressive Disorder: A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1079-OSD, 2015 (www.rand.org/t/RR1079).

Alicia Ruelaz Maher, Susanne Hempel, Eric Apaydin, Roberta M. Shanman, Marika Booth, Jeremy N. V. Miles, and Melony E. Sorbero, St. John’s Wort for Major Depressive Disorder: A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1048-OSD, 2015 (www.rand.org/t/RR1048).

Melony E. Sorbero, Kerry Reynolds, Benjamin Colaiaco, Susan L. Lovejoy, Coreen Farris, Christine Anne Vaughan, Jennifer Sloan, Ryan Kandrack, Eric Apaydin, and Patricia M. Herman, Acupuncture for Major Depressive Disorder: A Systematic Review, Santa Monica, Calif.: RAND Corporation, RR-1135-OSD, 2015 (www.rand.org/t/RR1135).

Terri Tanielian, Caroline Batka, and Lisa S. Meredith, “The Changing Landscape for Veterans’ Mental Health Care,” Santa Monica, Calif.: RAND Corporation, RB-9981/2-MTF, 2017 (www.rand.org/t/RB9981z2).

Terri Tanielian, Coreen Farris, Caroline Epley, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael Robbins, and Lisa H. Jaycox, Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families, Santa Monica, Calif.: RAND Corporation, RR-806-UNHF, 2014 (www.rand.org/t/RR806).

Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, Santa Monica, Calif.: RAND Corporation, MG-720-CCF, 2008 (www.rand.org/t/MG720).

Katherine E. Watkins, Harold Alan Pincus, Brad Smith, Susan M. Paddock, Thomas E. Mannle, Jr., Abigail Woodroffe, Jake Solomon, Melony E. Sorbero, Carrie M. Farmer, Kimberly A. Hepner, David M. Adamson, Lanna Forrest, and Catherine Call, Veterans Health Administration Mental Health Program Evaluation: Capstone Report, Santa Monica, Calif.: RAND Corporation, TR-956-VHA, 2011 (www.rand.org/t/TR956).

Cover: Dori Walker/RAND Photography (background), U.S. Marine Corps photo by Cpl. Aaron S. Patterson (left inset), laflor/Getty Images (right inset); p. 2: noipornpan/Getty Images; p. 3: U.S. Marine Corps photo by Cpl. Aaron S. Patterson; p. 4: Tim Evanson/Flickr; p. 5: nensuria/Getty Images (top), noipornpan/Getty Images (middle), Alina555/Getty Images (bottom right), asiseeit/Getty Images (bottom left); p. 6: Brankophoto/Getty Images; p. 9: eddiesimages/Getty Images; p. 10, left to right: asiseeit/Getty Images, U.S. Air Force photo by Staff Sgt. Vernon Young Jr., Patricia Montes Gregory/Flickr; p. 11, left to right: Patricia Montes Gregory/Flickr, DoD News photo by E. J. Hersom, U.S. Air Force photo by J. M. Eddins Jr.

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