Summary

The hallmarks of the recent conflicts in Iraq (2003–2011) and Afghanistan (2001–present) are blast injuries and the psychiatric consequences of combat, particularly posttraumatic stress disorder (PTSD), the subject of this report. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), PTSD symptoms must be manifested in three clusters:

  1. Persistent re-experiencing, such as recurrent thoughts, nightmares, and flashbacks;
  2. Persistent avoidance of trauma-associated stimuli (for example, avoiding related thoughts, feelings, conversations, or places) and emotional numbing that was not present before the trauma; and
  3. Persistent hyperarousal that may be manifested as hypervigilance, an exaggerated startle response, or difficulty in concentrating.

Those symptoms must persist for at least a month and cause clinically significant distress or functional impairment. PTSD is unique among psychiatric disorders in that it is linked to a specific trigger—a traumatic event—such as combat, natural and accidental disasters, and victimization and abuse.

Recent estimates of the prevalence of PTSD in 2.6 million U.S. service members who have served in Iraq or Afghanistan since 2001 (including those who are currently there and 900,000 of whom have been deployed more than once) range from 13% to 20%.



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Summary T he hallmarks of the recent conflicts in Iraq (2003–2011) and Af- ghanistan (2001–present) are blast injuries and the psychiatric consequences of combat, particularly posttraumatic stress disorder (PTSD), the subject of this report. According to the American Psychiat- ric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), PTSD symptoms must be manifested in three clusters: 1. Persistent re-experiencing, such as recurrent thoughts, nightmares, and flashbacks; 2. Persistent avoidance of trauma-associated stimuli (for example, avoiding related thoughts, feelings, conversations, or places) and emotional numbing that was not present before the trauma; and 3. Persistent hyperarousal that may be manifested as hypervigilance, an exaggerated startle response, or difficulty in concentrating. Those symptoms must persist for at least a month and cause clinically significant distress or functional impairment. PTSD is unique among psy- chiatric disorders in that it is linked to a specific trigger—a traumatic event—such as combat, natural and accidental disasters, and victimization and abuse. Recent estimates of the prevalence of PTSD in 2.6 million U.S. service members who have served in Iraq or Afghanistan since 2001 (including those who are currently there and 900,000 of whom have been deployed more than once) range from 13% to 20%. 1

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2 PTSD IN MILITARY AND VETERAN POPULATIONS The risk of developing PTSD after exposure to a traumatic event de- pends on many factors, including sex, age, ethnicity, sexual orientation, education attainment, intelligence quotient, annual income, childhood be- havioral problems, prior exposure to a traumatic event, and a family history of psychologic disorders. Known risk factors for PTSD in military popula- tions include experiencing combat, being wounded or injured, witnessing death, serving on graves registration duty or handling remains, being taken captive or tortured, experiencing unpredictable and uncontrollable stressful exposure, and experiencing sexual harassment or assault. Severe combat stressors include an increased number of unpredictable insurgent attacks in the form of suicide and car bombs, improvised explosive devices, sniper fire, and rocket-propelled grenades, which all increase the risk of being wounded or killed and thereby exacerbate the psychologic stress. Higher rates of PTSD and depression are associated with longer deployments, multiple de- ployments, and greater time away from base camp. Conversely, protective factors for PTSD include good leadership, unit support, and training, all of which may help promote positive mental health and well-being during deployment and thus reduce the risk for PTSD. The current military population is all volunteer and has more women and racial or ethnic minorities than the military population in the Vietnam War or the 1990–1991 Gulf War. More National Guard and reservists have been deployed than in prior conflicts. COMMITTEE’S STATEMENT OF TASK AND APPROACH The National Defense Authorization Act for Fiscal Year 2010, reflect- ing congressional concern about the number of service members and veter- ans who were at risk for or had received a diagnosis of PTSD, required the Secretary of Defense, in consultation with the Secretary of Veterans Affairs, to sponsor this study of PTSD programs in the Department of Defense (DoD) and the Department of Veterans Affairs (VA). This report is the first of the two mandated in the legislation; the committee’s statement of task is shown in Box S-1. This phase 1 report is based on an extensive literature search, including government documents and data; two public information-gathering sessions with presentations from representatives of the DoD, the VA, veterans’ or- ganizations, and individual service members and veterans who had PTSD; meetings with a variety of mental health providers and with PTSD patients and their families at U.S. Army base Fort Hood in Killeen, Texas; and in- formation from the Veterans Health Administration provided in response to the committee’s request. The committee was unable to obtain comparable information from the DoD in time to include it in this phase 1 report. The

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3 SUMMARY BOX S-1 Statement of Task Phase 1 (initial report): The IOM will convene a committee to conduct a study of ongoing efforts in the treatment of posttraumatic stress disorder (PTSD). The study will be conducted in two phases: the focus in phase 1 will be on data gathering and will result in the initial study as noted in the congressional legislation; the focus in phase 2 will be on the analysis of data and result in the updated study. The work of the committee is dependent upon the timely delivery of data, in a usable format, from the DoD and the VA on their current PTSD programs. In phase 1 of the study, the committee will collect data from the DoD and the VA on programs and methods available for the prevention, screening, diagnosis, treatment, and rehabilitation of PTSD. The committee will highlight collaborative efforts between the DoD and the VA in those areas. Additionally, the committee will consider the status of studies and clinical trials involving innovative treatments of PTSD that are conducted by the DoD, the VA, or the private sector, with regard to • efforts to identify physiological markers of PTSD; • fforts to determine causation of PTSD, using brain imaging studies and e studies looking at the correlation between brain region physiology and PTSD diagnoses and the results (including any interim results) of such efforts; • he effectiveness of alternative therapies in the treatment of PTSD, includ- t ing the therapeutic use of animals; • he effectiveness of administering pharmaceutical agents before, during, or t after a traumatic event in the prevention and treatment of PTSD; and • dentification of areas in which the DOD and the VA may be duplicating i studies, programs, or research with respect to PTSD. Phase 2 (updated report): In phase 2 of the study, the committee will analyze the data received in phase 1 specifically to determine the rates of success for each program or method; and an estimate of the number of members of the Armed Forces and veterans diagnosed by the DoD or the VA as having PTSD and the number of such veterans who have been successfully treated. In addition, the committee will focus on targeted interventions at Fort Hood, Texas; Fort Bliss, Texas; Fort Campbell, Tennessee; and any other locations the committee deems necessary, including VA facilities. The committee will also exam- ine gender-specific and racial and ethnic group-specific mental health treatment services available for members of the Armed Forces, including the availability of such treatment and services; the access to such treatment and services; the need for such treatment and services; and the efficacy and adequacy of such treatment and services. Finally, the committee will examine the current and projected future annual expenditures by the DoD and the VA for the treatment and rehabilitation of PTSD; and provide recommendations for areas for future research with respect to PTSD.

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4 PTSD IN MILITARY AND VETERAN POPULATIONS committee expects to receive information from the DoD in time to complete phase 2 of the study. The committee did not develop an exhaustive list of all the available PTSD programs and services in the DoD; such a list may be found in the 2011 RAND report Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families. The committee did obtain a list of many PTSD programs in the VA. Although PTSD in military and veteran populations has a huge impact on spouses, children, parents, caregivers, and others, this report covers children and families only in the context of treatment of service members or veterans. NEUROBIOLOGIC RESEARCH ON PTSD Understanding of the neurobiology of PTSD is in a period of growth, but there is much to be learned before this knowledge can become the basis of effective treatments. The advent of neuroimaging tools and preclinical research has provided a platform upon which to begin to examine the neu- robiology of PTSD. Research has generally concentrated on the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, but other neurobiologic systems—such as the serotonin system, the opiate system, and sex steroidal systems—have been implicated in pathologic and protec- tive responses to stress. More research is needed to link any neurobiologic mechanism to PTSD risk or resilience, to identify environmental and bio- logic factors that contribute to the onset and severity of PTSD symptoms, to apply biomarkers and neuroimaging models to the diagnosis of PTSD (which would help to reduce the dependence on self-reported symptoms), and to locate potential targets for future pharmacologic treatment of PTSD or pharmacologic agents that could enhance current treatment therapies. Both the DoD and the VA fund research on the neurobiology of PTSD. For example, the DoD is funding a study on multimodal neurodiagnostic imaging of traumatic brain injury (TBI) and PTSD and a study on the neu- robiology of tinnitus with PTSD as a secondary outcome, but these studies are ongoing and results are not available. The VA is funding studies that include examinations of memory and the hippocampus in twins, brain imaging of psychotherapy for PTSD, and neural correlates of cognitive rehabilitation in PTSD. DOD AND VA PROGRAMS FOR PTSD The DoD and the VA provide an array of prevention, screening, diag- nosis, treatment, and rehabilitation options to maintain force readiness for the DoD and to enable veterans to function well in daily life.

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5 SUMMARY The DoD Military Health System (MHS) provides many health pro- grams and services for active-duty service members, retired personnel, and their families, including National Guard members and reservists when on active duty. TRICARE, a major component of the MHS, is a wide-reaching health care provider that delivers direct care through military treatment facilities and purchased care through network and non-network civilian health professionals, hospitals, and pharmacies. In 2011, about 9.7 mil- lion beneficiaries were eligible for DoD medical care, and 5.5 million were enrolled in TRICARE. TRICARE provides a spectrum of mental health practitioners, including psychiatrists, clinical psychologists, certified psy- chiatric nurse specialists, clinical social workers, certified marriage and family therapists, pastoral counselors, and mental health counselors. Those practitioners deliver inpatient or outpatient care (including mental health care, such as psychotherapy, psychoanalysis, testing, and medication man- agement), acute care, psychiatric partial hospitalization, and residential treatment center care. All the services have some type of PTSD treatment program, but no single source within DoD or any of the service branches maintains a complete listing of such programs, tracks the development of new or emerging programs, or has appropriate resources in place to direct service members to programs that may best meet their individual needs. PTSD treatment is an important part of the VA’s mission. During 2010, 438,091 veterans were treated for PTSD in the VA medical system. Although the VA has a system of specialized treatment programs that focus exclusively on PTSD, most PTSD-related services are offered in general mental health and medical settings, including primary care. The VA also supports Vet Centers that are staffed with social workers, clinical psycholo- gists, mental health counselors, and professionally trained counselors and therapists. Collaborative activities between the DoD and the VA with respect to the prevention, screening, diagnosis, and treatment of PTSD are reflected in the joint VA/DoD Clinical Practice Guideline for Management of Post- Traumatic Stress, originally developed in 2004 and updated in 2010. The VA and the DoD have also issued joint guidelines for other medical condi- tions that are frequently comorbid with PTSD, such as postdeployment health, concussion and mild TBI, substance use disorder, major depressive disorder, and several types of pain. Other collaborative efforts between the DoD and the VA include multiple joint executive councils, coordinating of- fices, working groups, and direct sharing agreements between VA medical centers and DoD medical facilities as well as a number of conferences on military health issues. In 2011, the VA and the DoD released the VA/DoD Collaboration Guidebook to Healthcare Research as part of the VA/DoD Joint Strategic Plan for 2009–2011.

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6 PTSD IN MILITARY AND VETERAN POPULATIONS Prevention The two primary approaches to prevention of PTSD are to prepare service members for combat and other deployment-related stressors and to intervene quickly after exposure. All of the services have instituted preven- tion programs that promote resilience and training for the rigors of deploy- ment, including the Army’s Comprehensive Soldier Fitness program, the Navy’s Combat and Operational Stress Continuum program, the Marine Corps’s Operational Stress Control and Readiness (OSCAR) program, and the Air Force’s Total Force Resiliency Program. Each of those programs has several layers of training for enlisted service members and officers and includes concepts of positive psychology and individual hardiness, and fac- tors such as a positive command climate, unit cohesion, social support, and confidence in the military mission and training. At present, however, there is no empirical evidence regarding the effectiveness of these approaches. Several of the DoD predeployment PTSD programs also have compo- nents to help service members and their families prevent the development of PTSD after deployment, including the Army Comprehensive Soldier Fitness program and the Navy and Marine Corps Families OverComing Under Stress (FOCUS) program. FOCUS is a family-centered and evidence-based resilience training program adapted for use by Marine Corps and Navy families. It helps families cope with the stresses and uncertainties of deploy- ment and reintegration after deployment. Since 2009, FOCUS Family Resil- iency Services have been made available to Army and Air Force families at some installations. The preventive interventions include psychoeducation, emotional regulation skills, problem-solving skills, communication skills, and management of traumatic stress reactions. The VA has several programs to prevent PTSD after exposure to trauma, including Life Guard and Moving Forward. The VA also refers veterans and their families to prevention programs such as FOCUS. Vet Centers also provide prevention services to veterans. Some clinical prevention efforts seek to detect and treat PTSD in its early stages (for example, treat those who meet the criteria for acute stress disorder) often before it presents clinically as chronic PTSD. Several studies have demonstrated that early interventions for acute stress disorder result in significant reductions of symptoms and the prevention of the onset of PTSD in the majority of individuals treated. Cognitive behavioral therapy and other interventions may be used when people show severe PTSD symptoms within the first month after trauma. Prevention may also involve mitigat- ing the consequences of existing symptoms by improving functioning and reducing complications.

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7 SUMMARY Screening The 2010 VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress found that screening improves health outcomes and that the benefits outweigh the potential harm or costs. Although screening may lead to anxiety and further testing, there are adverse implications of not screening: allowing problems to go undetected may compound them and lead to increased disability. Screening for PTSD is ineffective unless there is adequate follow-up to confirm or refute a positive screen and ad- equate capability to provide appropriate treatment. Many PTSD screening instruments are available, but the evidence is insufficient to support recommending one tool over another. The VA/DoD guideline recommends the use of one of the following instruments: the Primary Care PTSD screen (PC-PTSD), the PTSD Brief Screen, the Short Screening Scale for DSM-IV PTSD, and the PTSD Checklist (PCL). The four-item PC-PTSD is the most widely used screen in the VA. In the DoD, PC-PTSD screening questions are incorporated into the post-deployment health assessment (PDHA), which is administered immediately after de- ployment, and the post-deployment health reassessment (PDHRA), which is administered 3–6 months after deployment. The PDHA and the PDHRA require a credentialed health care provider to review and discuss a service member’s responses during a face-to-face assessment. In DoD clinic settings, the PCL is commonly used to screen for PTSD, and the screening results are usually integrated into a more comprehensive assessment and require interpretation by qualified professionals. Service members who received care in an integrated mental health and primary care setting had significantly reduced psychologic distress and improved clinical outcomes. The Army-specific RESPECT-Mil (Re- Engineering Systems for Primary Care Treatment of Depression and PTSD in the Military) program, in which primary care providers are trained to screen and treat soldiers for PTSD and depression at every visit, is one example of a successful screening program. The Air Force and Navy have also implemented programs that integrate mental health and primary care. The VA has increased the number of mental health professionals who work in integrated primary care teams. Every veteran seen in a VA primary care setting is screened for PTSD, depression, suicidality, sexual trauma that occurred during military service, and problem drinking, usually during the first appointment. PTSD screening occurs annually for the first 5 years and every 5 years thereafter.

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8 PTSD IN MILITARY AND VETERAN POPULATIONS Diagnosis The diagnosis of PTSD ultimately rests on a careful and comprehen- sive clinical evaluation performed by a qualified professional (a psycholo- gist, social worker, psychiatrist, or psychiatric nurse practitioner) under conditions of privacy and confidentiality. It may take some time to elicit the information necessary to determine the diagnosis. Such information should include chief complaints; lifetime history of exposures to trauma and physical injury to self or others; frequency and severity of symptoms of PTSD and other morbidity; level of function; quality of life and ongoing life stressors; medical history and present health; prior psychiatric diagnosis and treatment; details regarding family, recreation, and supports; personal strengths and vulnerabilities; coping styles; and details concerning experi- ences in the military. Several structured interviews have been validated for the diagnosis of PTSD, including the Clinician-Administered PTSD Scale, which is recommended by the VA/DoD guideline and widely, although not exclusively, used by the VA and the DoD; the Structured Clinical Interview for DSM-IV; and the Composite International Diagnostic Interview. Treatment There are numerous psychosocial and pharmacologic interventions for chronic PTSD, and the evidence supporting them varies considerably. The committee considered a wide variety of treatments that are used for PTSD from those with strong evidence bases such as exposure therapies, to pharmacologic agents such as serotonin reuptake inhibitors, and emerging therapies such as complementary and alternative medicines. Psychosocial Therapies The vast majority of treatments that have been examined via ran- domized controlled trials (RCTs) are in the general group of psychosocial therapies called cognitive behavioral therapy (CBT). They include expo- sure therapies such as prolonged exposure (PE), stress inoculation training or anxiety-management programs, cognitive therapies such as cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR). Many treatment programs combine components of each of those general treatment groups. Exposure therapies are first-line treatments designed to reduce PTSD symptoms and related problems such as depression, anger, and guilt, by helping patients confront their trauma-related memories, feelings, and stimuli. Exposure interventions may include imaginal exposure, in vivo exposure, or both types of exposure; programs such as PE that include

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9 SUMMARY both kinds of exposure tend to have better outcomes than those with only a single component. PE is effective for chronic PTSD as well as acute stress disorder and improvements are generally maintained at a year or more. Variations of exposure therapy, such as narrative exposure therapy and imagery rescripting, have also been shown to be efficacious in RCTs. In cognitive therapy, the therapist helps the patient who has PTSD iden- tify and modify negative thoughts and beliefs related to the traumatic event (for example, survival guilt, self-blame for causing the trauma, or feelings of personal inadequacy) that are believed to underlie pathological emotions and behaviors. RCTs have shown that cognitive therapy alone results in significant PTSD symptom reduction and improved mood and functioning. Cognitive processing therapy is a treatment that combines aspects of both cognitive therapy and PE. Other effective treatments include EMDR and imagery rehearsal ther- apy. EMDR assists patients in accessing and processing traumatic memories while bringing them to an adaptive resolution. Imagery rehearsal therapy specifically targets nightmares, a common symptom of PTSD, by changing the content of the patient’s nightmares to promote mastery over the content threat and thereby alter the importance of the nightmare. Imagery rehearsal therapy is an effective treatment for nightmares, but its efficacy as a treat- ment for PTSD is questionable. The committee considered the evidence base for numerous other psy- chosocial therapies, including psychodynamic psychotherapy, brief eclectic psychotherapy, hypnosis, relaxation, stress inoculation training, interper- sonal therapy, skills training in affect and interpersonal regulation, and group therapy. In particular, CBT-based group therapy has been studied in a number of RCTs that indicate that it is effective in reducing symptoms of PTSD. The efficacy of the other psychosocial therapies is supported by only a few RCTs or in some cases only one small RCT. Small RCTs and open trials of acceptance and commitment therapy have also been conducted because it is often used to address chronic PTSD experienced by veterans in many VA medical centers and warrants further review. Virtual reality exposure programs integrate computer graphics and head-mounted visual displays as a tool to deliver PE. For example, the Virtual Iraq/Afghanistan program is specific for combat-related PTSD and consists of a series of virtual scenarios designed to simulate service members’ experiences dur- ing deployment to Iraq or Afghanistan and serve as digital contexts for delivering PE. Pharmacologic Therapies PTSD treatment guidelines, including the 2010 VA/DoD guideline, all recommend the use of antidepressants, specifically, a selective serotonin

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10 PTSD IN MILITARY AND VETERAN POPULATIONS reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI), as a first-line treatment. However, although two studies of Bosnian and Iranian veterans demonstrated the efficacy of SSRI treatment for PTSD, no positive trials have been conducted in U.S. veterans. A 2008 IOM re- port on PTSD treatments concluded that neither SSRIs nor any other drugs could be considered effective for the treatment of PTSD, although one com- mittee member dissented. A 2006 Cochrane review found that there was good evidence for SSRIs and SNRIs in chronic PTSD as both short-term and maintenance treatment. The evidence base for other antidepressants, tricyclic and monoamine oxidase inhibitors, and other drugs as effective pharmacotherapy for PTSD is at best mixed and generally inconclusive. The committee examined the use of multiple drugs and combinations of traditional psychiatric medications with CBT for treatment of PTSD and found mixed evidence as to the effectiveness of this intervention. The majority of PTSD patients in the VA receive more than one psychotropic drug—about 80% of them receive an SSRI. Further research is needed on acute administration of novel medications, such as d-cycloserine, with psy- chotherapy as a combination treatment for PTSD. Emerging Therapies Some treatments that are being used for PTSD do not have a substantial evidence base with which to judge their efficacy. These treatments include couple and family therapy (such as cognitive behavioral conjoint therapy for couples) and numerous complementary and alternative medicine (CAM) treatments, including yoga, contemplative treatments, and acupuncture. Evidence of the effectiveness of these therapies for PTSD is based on small RCTs, case studies, or anecdotal reports. Nevertheless, the committee heard from numerous service members that they are using CAM treatments and that the treatments help to alleviate their PTSD symptoms. The VA offers a wide variety of CAM treatments at its facilities, and some military bases also offer CAM therapies, including animal-assisted therapy for service members who have mental health disorders. CO-OCCURRING CONDITIONS AND PSYCHOSOCIAL COMPLEXITIES Three categories of conditions frequently co-occur with PTSD: psychi- atric (depression and substance use disorders), medical (chronic pain, TBI, and spinal-cord injury), and psychosocial (relationship problems, difficul- ties in social settings, intimate partner violence [IPV], child maltreatment, unemployment or lack of employment, homelessness, and incarceration). Because those conditions can interfere with effective PTSD treatment, their

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11 SUMMARY presence necessitates integrating treatment for them into a comprehensive PTSD management program. Stepped-care approaches begin with low-intensity treatments, such as care management and support groups, and phase in more intensive proce- dures, such as CBT or pharmacotherapy for patients who have persistent or recurrent symptoms of PTSD and related comorbidities. Collaborative stepped-care interventions for PTSD, that is treatment by a team of health care providers, can help initiate early treatment, diminish such high-risk behaviors as binge drinking, and encourage the use of appropriate psycho- therapy and pharmacotherapy. Established treatments, such as PE, can also address some psychologic comorbidities, such as depression, anger, guilt, and general anxiety. Several medical conditions can occur with PTSD and result from the same traumatic event, such as explosions; these comorbidities include TBI and chronic pain. The overlapping symptoms of TBI and chronic pain (such as headache, irritability, sleep disturbance, and memory impairment) with PTSD often complicate diagnosis and treatment. Recent studies suggest that the co-occurrence of PTSD with mild TBI may prolong the duration of TBI symptoms and exacerbate them. No studies have examined treatment protocols that specifically target co-occurring TBI and PTSD symptoms. The effectiveness of CBT to treat both chronic pain and PTSD is supported by empirical evidence. Veterans who have PTSD have higher incidences of IPV, divorce, and aggression and violence than veterans who do not. Psychosocial rehabili- tation typically involves family psychoeducation and supported employ- ment, education, and housing. Data support an integrated, collaborative treatment plan for PTSD that combines trauma-focused therapies with psychosocial rehabilitation. Preliminary findings suggest that programs such as the Navy and Marine Corps FOCUS project reduce the risk of IPV in military couples. Veterans who have PTSD have higher rates of underemployment and unemployment than veterans who do not. Veterans who are disabled with combat-related PTSD may use the VA Vocational Rehabilitation and Employment Program, which includes funds for schooling or training, comprehensive vocational evaluation, work-readiness services, and case management and vocational placement services. PTSD is commonly associated with drug abuse, alcohol abuse, anger, and aggressive behavior, all of which may lead to legal problems. Stud- ies suggest that veterans who have PTSD and are incarcerated or were recently released from jail can benefit from comprehensive treatment and rehabilitation programs that address PTSD symptoms, substance abuse, and aggression. In general, the evidence base for treatment for PTSD and co-occurring problems—particularly such psychosocial conditions as home-

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12 PTSD IN MILITARY AND VETERAN POPULATIONS lessness, high-risk behaviors, and many medical conditions such as cardio- vascular disease—is sparse. ACCESS TO CARE Of the U.S. service members and veterans who served in Iraq and Afghanistan and have screened positive for PTSD, only slightly more than half of those have received treatment. Barriers to care exist at the patient, provider, and institutional levels. Patients might not seek care because of concerns about the effects of seeking PTSD treatment on employment or military career, a perception that mental health care is ineffective, a lack of information on resources for care, financial concerns, and logistical prob- lems, such as travel distance. For providers, barriers to treating patients with PTSD might include lack of training, lack of time, and treatment location issues, such as transportation in the theater of war. At the orga- nizational level, barriers can include the treatment setting (for example, limited treatment opportunities in combat zones), restrictions on when and where pharmacotherapy for PTSD can be used, and logistical difficulty in getting to appointments (for example, getting to a mental health provider in a combat zone for service members or getting to a specialized VA PTSD clinic for a veteran living in a rural area). The DoD and the VA have made progress in early identification of service members and veterans who have PTSD; this progress needs to be followed by timely access to the best evidence-based care. The DoD has increased the number of referrals to TRICARE mental health providers in an attempt to reduce waiting times for appointments. The VA has also increased the number of mental health providers and increased training in PTSD treatments for counselors in Vet Centers. Treatment Delivery Technologies New approaches are being used to improve the delivery of mental health services to military and veteran populations, including the use of comput- ers to deliver person-to-person therapy. Telemental health approaches take advantage of recent advances in computing and information technology to support user interaction with clinicians via videoteleconferencing or inter- action with websites via connectivity with the Internet. Telemental health methods may be used to deliver such services as screening assessments and general clinical information to users in remote locations. In some cases, guides allow users to self-manage mental health programs, often supported by interactions with a clinical provider. That approach decreases the bur- dens of travel time and costs and time away from work or family; it could improve access to services for traditionally underserved populations and

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13 SUMMARY for people in areas that may be difficult for therapists to access (such as combat zones). Several RCTs of Internet-based treatments for PTSD have found them to be effective in military populations. FINDINGS AND RECOMMENDATIONS The committee’s findings led to recommendations that could, in the short and long terms, improve the management of PTSD for service mem- bers, veterans, and their families. To emphasize recommendations that were, in many cases, applicable to both the DoD and the VA and that ad- dressed research topics, data collection, and gaps in DoD and VA programs, services, and facilities, the committee grouped its recommendations into five action items: analyze, implement, innovate, overcome, and integrate, which are delineated below. A. Analyze • A1. To study the efficacy of treatment and to move toward mea- surement-based PTSD care in the DoD and the VA, assessment data should be collected before, during, and after treatment and should be entered into patients’ medical records. This informa- tion should be made accessible to researchers with appropriate safeguards to ensure patient confidentiality. • A2. The DoD and the VA should institute programs of research to evaluate the efficacy, effectiveness, and implementation of all their PTSD screening, treatment, and rehabilitation services, in- cluding research in different populations of active-duty person- nel and veterans; the effectiveness of DoD prevention services should also be assessed. The DoD and the VA should coordi- nate, evaluate, and review these efforts continually and routinely and should disseminate the findings widely. B. Implement • B1. PTSD screening should be conducted at least once a year when primary care providers see service members at DoD mili- tary treatment facilities or at any TRICARE provider locations, as is currently done when veterans are seen in the VA. C. Innovate • C1. Specialized intensive PTSD programs and other approaches for the delivery of PTSD care, including combining different treatment approaches and such emerging treatments as comple- mentary and alternative medicine and couple and family ther- apy, need to be rigorously evaluated throughout DoD facilities

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14 PTSD IN MILITARY AND VETERAN POPULATIONS (including TRICARE providers) and VA facilities for efficacy, effectiveness, and cost. More rigorous assessment of symptom improvements (for example, such outcome metrics as follow-up rates) and of functional improvements (for example, improve- ments in physical comorbidities, memory, and return to duty) is needed. The evaluations of these programs should be made publicly available. • C2. The DoD and the VA should support neurobiology research that might help translate current knowledge of the neurobiology of PTSD to screening, diagnosis, and treatment approaches and might increase understanding of the biologic basis of evidence- based therapies. D. Overcome • D1. The DoD and the VA should support research that inves- tigates emerging technologic approaches (mobile, telemedicine, Internet-based, and virtual reality) that may help to overcome barriers to awareness, accessibility, availability, acceptability, and adherence to evidence-based treatments and disseminate the outcomes to a wide audience. E. Integrate • E1. Research to create an evidence base to guide the integration of treatment for comorbidities with treatment for PTSD should be encouraged by the DoD and the VA. PTSD treatment trials should incorporate assessment of comorbid conditions and the value of concurrent and sequential care. Effective treatments should be included in updates of the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. PHASE 2 The committee understood its objectives as given in the Statement of Task to be a comprehensive review and synthesis of the available literature and data on the prevention, screening, diagnosis, treatment, and rehabilita- tion of PTSD in military and veteran populations. Based on this review and synthesis, the recommendations in this phase 1 report are intended to be actionable by the DoD and the VA, ahead of the phase 2 report. Although the committee found a variety of information in the published literature and from other sources, particularly DoD, VA, and other government reports, this information was insufficient to make judgments on the efficacy of many of the PTSD services and programs offered by these departments. A variety of information has been requested from the DoD and the VA, including

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15 SUMMARY numbers of service members and veterans, respectively, who have PTSD, the treatments that they are receiving, the outcomes of those treatments, the programs that are being evaluated (or not), and the costs for those pro- grams. With the receipt of all these data in phase 2, the committee hopes to capitalize on the new DoD- and VA-specific information to refine the phase 1 findings and recommendations. Phase 2 calls for visits to three Army bases: Fort Hood and Fort Bliss in Texas and Fort Campbell in Tennessee. The committee has already visited Fort Hood and will visit the other two Army bases in phase 2. Because a large number of marines have deployed to Iraq and Afghanistan, the com- mittee also hopes to visit a Marine Corps base. To increase its understand- ing of veterans with PTSD, the committee expects to visit at least one VA medical center. The committee also anticipates that new information will continue to be published on many of the programs, treatments, and research covered in this report—including neurobiology and the use of complementary and alternative treatments for PTSD. Thus additional literature searches and discussions with researchers and patients will be conducted in phase 2 so that the growing body of evidence on the need for, use of, and outcomes from the programs and promising research on PTSD can be assessed.

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