Treatment for

POSTTRAUMATIC STRESS DISORDER

in Military and Vetern Populations

Initial Assessment

Committee on the Assessment of Ongoing Efforts in the
Treatment of Posttraumatic Stress Disorder

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. W81XWH-10-C-0290 between the National Academy of Sciences and the Department of Defense. Any opinions, find- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-25421-2 International Standard Book Number-10: 0-309-25421-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Treatment for posttraumatic stress disorder in military and veteran populations: Initial assessment. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.nationalacademies.org

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COMMITTEE ON THE ASSESSMENT OF ONGOING EFFORTS IN THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER Sandro Galea (Chair), Professor and Chair of the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY Kathryn Basham, Professor and Editor, Co-Director of the PhD Program, College of Social Work, Smith College, Northampton, MA Larry Culpepper, Professor and Chairman of the Department of Family Medicine, Boston University School of Medicine; Chief of Family Medicine, Boston Medical Center, MA Jonathan Davidson, Emeritus Professor, Department of Psychiatry, Duke University Medical Center, Durham, NC Edna Foa, Professor, Department of Psychiatry; Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine, Philadelphia Kenneth Kizer, Director, Institute for Population Health Improvement; Professor, School of Medicine and Nursing, University of California, Davis Karestan Koenen, Associate Professor, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY Douglas Leslie, Professor, Department of Public Health Sciences and Department of Psychiatry, Pennsylvania State University, State College Richard McCormick, Senior Scholar, Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH Mohammed Milad, Associate Professor, Department of Psychiatry, Harvard Medical School; Director of Behavioral Neuroscience Laboratory, Associate in Research Psychiatry, Massachussets General Hospital, Boston Elspeth Cameron Ritchie, Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences; Chief Clinical Officer, Washington, DC, Department of Mental Health Albert “Skip” Rizzo, Associate Director, Institute for Creative Technologies; Research Professor, Department of Psychiatry and School of Gerontology, University of Southern California, Los Angeles Barbara O. Rothbaum, Associate Vice Chair of Clinical Research, Department of Psychiatry; Director, Trauma and Anxiety Recovery Program, Emory University School of Medicine, Atlanta, GA v

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Douglas Zatzick, Professor, University of Washington School of Medicine; Associate Vice Chair for Health Services Research, Medical Director of the Inpatient Consultation Liaison Service, University of Washington Harborview Level I Trauma Center, Seattle Consultant Carol Tamminga, Professor, Chairman, University of Texas Southwestern Medical Center, Dallas Study Staff Roberta Wedge, Study Director Margot Iverson, Program Officer (through January 2012) Anne Styka, Associate Program Officer Rebecca Hebner, Senior Program Assistant (through March 2012) Joi Washington, Senior Program Assistant (since April 2012) Heidi Murray-Smith, Program Officer, Board on Environmental Studies and Toxicology Norman Grossblatt, Senior Editor Frederick Erdtmann, Director, Board on the Health of Select Populations vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Christopher K. Cain, Nathan Kline Institute for Psychiatric Research Joseph T. Coyle, Harvard Medical School Johanna T. Dwyer, Tufts Medical Center Mardi J. Horowitz, University of California, San Francisco Israel Liberzon, University of Michigan John Parrish, Massachusetts General Hospital Alan Peterson, University of Texas Health Science Center at San Antonio Gale S. Pollock, Pollock Associates, LLC William E. Schlenger, Abt Associates Inc. Murray Stein, University of California, San Diego Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions vii

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viii REVIEWERS or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Floyd E. Bloom, The Scripps Research Institute, and Jacquelyn C. Campbell, The Johns Hopkins University School of Nursing. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Contents Preface xiii Acronyms xv Summary 1 1 Introduction 17 Committee’s Charge, 19 Committee’s Approach, 19 Organization of the Report, 23 References, 24 History, Diagnostic Criteria, and Epidemiology 25 2 History of PTSD, 24 Diagnostic Criteria for PTSD, 26 Epidemiology of PTSD in the General Population, 29 Epidemiology of PTSD in Military and Veteran Populations, 37 Summary, 49 References, 49 3 Neurobiology 59 Adaptive and Maladaptive Stress Responses, 60 Models for the Development of PTSD, 66 Factors That Influence the Development of PTSD, 72 ix

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x CONTENTS Implications for PTSD Prevention, Diagnosis, and Treatment, 83 Biomarkers, 90 Summary, 91 References, 92 4 Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs 111 The Department of Defense Health Care System, 111 Mental Health Care in the Department of Defense, 114 Transitioning Between the Department of Defense and the Department of Veterans Affairs Health Care Systems, 132 The Department of Veterans Affairs Health Care System, 134 Mental Health Care in the Department of Veterans Affairs, 138 Collaborative Efforts Between the Department of Defense and the Department of Veterans Affairs, 151 Research in the Department of Defense and the Department of Veterans Affairs, 153 Cost Considerations, 155 Summary, 157 References, 168 5 Prevention 165 Overview of PTSD Prevention, 165 Pretrauma Prevention Efforts, 167 Interventions for Trauma-Exposed People, 170 Prevention in the Department of Defense, 176 Prevention in the Department of Veterans Affairs, 185 Summary, 186 References, 187 6 Screening and Diagnosis 195 Screening, 195 Considerations Regarding Screening in the Department of Defense and the Department of Veterans Affairs, 199 Screening in Primary Care, 204 Screening Tools, 209 Diagnosis, 217 Quality of Life, Disability, and Resilience Measures, 220 Summary, 221 References, 222

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xi CONTENTS 7 Treatment 231 Psychosocial Treatments for Chronic PTSD, 233 Pharmacotherapy, 246 Combined Psychotherapy and Pharmacotherapy Approaches, 254 Integrative Collaborative Care, 254 Emerging Therapies for PTSD, 255 Guidelines for Treatment of PTSD, 264 Summary, 273 References, 274 8 Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities 293 Co-Occurring Psychiatric Conditions and PTSD, 294 Co-Occurring Medical Conditions and PTSD, 296 Co-Occurring Psychosocial Problems and PTSD, 309 Summary, 323 References, 324 9 Access to Care 339 Barriers to Care, 340 Barriers to Delivery of Evidence-Based Care, 349 Facilitators of Care for PTSD, 351 Summary, 356 References, 356 10 Findings and Recommendations 363 Analyze, 364 Implement, 367 Innovate, 370 Overcome, 372 Integrate, 374 Phase 2, 376 References, 377 Appendixes A Committee Member Biographies 379 B Congressional Legislation 387 C Posttraumatic Stress Disorder Programs in the Department of Defense 391

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Preface P osttraumatic stress disorder (PTSD) is one of the signature injuries of the U.S. engagements in Iraq and Afghanistan. Of the more than 2.6 million active-duty, National Guard, and reserve service members who have been deployed to Operation Enduring Freedom (OEF) in Afghanistan since 2001 and Operation Iraqi Freedom (OIF) since 2003, an estimated 13–20% of them have or may develop PTSD. Managing PTSD in those populations is a huge task for the Department of Defense (DoD) and the Department of Veterans Affairs (VA). The DoD and the VA have responded with substantial funding to foster research, develop programs, and initiate services to combat PTSD. Both departments are making strides in identify- ing and treating people who have PTSD, but there are many obstacles to the achievement of effective and timely treatments, from identifying those at risk for PTSD to using the best evidence-based treatments—psychotherapy, pharmacotherapy, or some combination. Diagnostic procedures and treat- ment options are not standardized with respect to who uses which approach and when. There is a need to ensure that service members and veterans who seek treatment receive it in a timely and thorough manner, and to make treatments available to those who are in remote locations or for whom access to treatment is difficult. Research is being conducted to identify the physiologic bases of reactions to trauma and to identify biomarkers for preventing and diagnosing PTSD, and for treating it. The present two-phase Institute of Medicine (IOM) study is particularly timely, given the recent conclusion of OIF and the expectation that OEF will be winding down in the next few years. The charge given to this committee represents a serious commitment of the DoD and the VA to address health xiii

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xiv PREFACE care issues surrounding service members and veterans who have PTSD. This phase 1 report summarizes much of the literature on the burden of PTSD in service members and veterans, including National Guard and reservists, and explores the options available in the DoD and the VA for the prevention of, diagnosis of, and treatment for PTSD. In the second phase of its work, the committee will focus on the evaluation of data provided by the DoD and the VA and will investigate cost considerations, new neurobiologic findings, and the use of complementary and alternative treatments. Although the committee did visit one congressionally mandated site for this report (Fort Hood, Texas), in phase 2 it will undertake visits to at least two other Army sites—Fort Bliss, Texas, and Fort Campbell, Tennessee—and it hopes to visit other military bases and VA medical facilities to gain an appreciation of real-world successes and problems related to the diagnosis of and treat- ment for PTSD in these settings. The committee recognizes the burden that PTSD poses for many service members, veterans, and their families, and the pressing need to prevent it, diagnosis it, and treat for it in those who have given so much for this country. The committee gratefully acknowledges the many individuals and groups who generously gave their time and expertise to share their insights on particular aspects of PTSD, who provided reports and data, and who answered queries about their work and experience in dealing, personally and professionally, with PTSD. Among the many people who helped the committee are staff of the DoD and the VA, researchers, staff of veteran and service member organizations, and members of the public who attended the committee’s open meetings. The committee also visited U.S. Army Gar- rison Fort Hood in Killeen, Texas, and expresses its appreciation for the time, insights, and personal stories offered by a variety of base staff, mental health providers, and service members who have PTSD and their families. The committee is also grateful to Roberta Wedge, who served as study director for this project, and to the IOM staff members who contributed to this project: Rebecca Hebner, Margot Iverson, Heidi Murray-Smith, Anne Styka, and Joi Washington. A thank you is also extended to William McLeod, who conducted database and literature searches. Sandro Galea, Chair Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder

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Acronyms ACT acceptance and commitment therapy AFQT Armed Forces Qualification Test APA American Psychiatric Association ASD acute stress disorder BDNF brain-derived neurotrophic factor BHOP Behavioral Health Optimization Program BICEPS brevity, immediacy, centrality or contract, expectancy, proximity, and simplicity CAM complementary and alternative medicine CAPS Clinician-Administered PTSD Scale CBCT cognitive-behavioral conjoint therapy CBT cognitive behavioral therapy CBT-MVA cognitive behavioral therapy–motor vehicle accident CI confidence interval CIDI Composite International Diagnostic Interview CISD critical incident stress debriefing COSC combat and operational stress control COSR combat and operational stress reaction CPT cognitive processing therapy CRT cognitive rehabilitation therapy CSC combat stress control CSF Comprehensive Soldier Fitness CT cognitive therapy xv

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xvi ACRONYMS CWT compensated work therapy DART deployment anxiety reduction training DCoE Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury DCS d-cycloserine DIS-IV Diagnostic Interview Schedule DNA deoxyribonucleic acid DoD Department of Defense DSM-IV Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition EFT emotional freedom technique EMDR eye movement and desensitization reprocessing FOCUS Families OverComing Under Stress FORT functional and occupational rehabilitation treatment FY fiscal year GABA gamma-aminobutyric acid GAF global assessment of function GAO Government Accountability Office GAT global assessment tool HBOT hyperbaric oxygen therapy HOPE Helping to Overcome PTSD with Empowerment HPA hypothalamic-pituitary-adrenal HT hydroxytryptamine IED improvised explosive device IOM Institute of Medicine IPAP International Psychopharmacology Algorithm Project IPT interpersonal therapy IPV intimate partner violence IQ intelligence quotient IRT imagery rehearsal therapy ISTSS International Society for Traumatic Stress Studies MANSA Manchester Short Assessment of Quality of Life MAO monoamine oxidase MAOI monoamine oxidase inhibitor MHAT Mental Health Advisory Team MHS military health system

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xvii ACRONYMS MINI Mini-International Neuropsychiatric Interview MRI magnetic resonance imaging MST military sexual trauma mTBI mild traumatic brain injury MTF military treatment facility NCS National Comorbidity Study NCS-R National Comorbidity Study-Replication NHMRC National Health and Medical Research Council NICE National Institute for Health and Clinical Excellence NIH National Institutes of Health NIMH National Institute of Mental Health NMDA n-methyl-d-aspartate NVVRS National Vietnam Veterans Readjustment Study OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OMHO Office of Mental Health Operations (VA) OND Operation New Dawn OR odds ratio OSCAR operational stress control and readiness PCL PTSD Checklist PC-PTSD Primary Care PTSD screen PDHA Post-Deployment Health Assessment PDHRA Post-Deployment Health Reassessment PE prolonged exposure PHA Periodic Health Assessment PSS-I PTSD Symptom Scale—Interview Version PTSD posttraummatic stress disorder RAS reticular activating system RCT randomized controlled trial REACH Reaching Out to Educate and Assist Caring, Healthy Families REM rapid eye movement RESPECT-Mil Re-Engineering Systems for Primary Care Treatment of Depression and PTSD in the Military RNA ribonucleic acid rTMS repetitive transcranial magnetic stimulation SCCIP-ND Surviving Cancer Completely Intervention Program– Newly Diagnosed SIP Structured Interview for PTSD

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xviii ACRONYMS SIT stress inoculation training SKY Sudarshan Kriya yoga SNRI serotonin norepinephrine reuptake inhibitor SPRINT Short Post-Traumatic Stress Disorder Rating Interview SRI serotonin reuptake inhibitor SSRI selective serotonin reuptake inhibitor STAIR Skills Training in Affect and Interpersonal Regulation STRONG STAR South Texas Research Organizational Network Guiding Studies on Trauma and Resilience TBI traumatic brain injury TMH telemental health USUHS Uniformed Services University of the Health Sciences VA Department of Veterans Affairs VBA Veterans Benefit Administration VHA Veterans Health Administration VISN Veterans Integrated Service Network VR virtual reality VRE virtual reality exposure therapy WHOQOL-100 World Health Organization Quality of Life Assessment WL wait list