10

Findings and Recommendations

The committee was asked by Congress to consider the efforts of the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to prevent posttraumatic stress disorder (PTSD) and to screen, diagnose, treat, and rehabilitate service members and veterans who have PTSD. The number of service members and veterans of all eras who have symptoms of PTSD is immense; of the 2.6 million service members who have been deployed to Iraq and Afghanistan alone since October 2001, about 13% to 20% are expected to develop PTSD.

In this phase 1 report, the committee provides an overview of the management of PTSD in the DoD and the VA, citing selected examples of programs and services that are available to service members, veterans, and their families; describes some of the innovations that are being explored for the prevention and diagnosis of and treatment for PTSD; and highlights substantial data gaps in and barriers to the evaluation, implementation, and use of the services. The committee’s findings led to recommendations that could, in the short and long term, improve the management of PTSD for service members, veterans, and their families. To emphasize recommendations that were, in many cases, applicable to both the DoD and the VA and that addressed programs, services, and facilities in both health care systems, the committee grouped its recommendations into five action items:

  • Analyze: Collect data on the implementation, delivery, and effectiveness of all prevention, screening, diagnosis, treatment, and rehabilitative services that are currently in use.


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10 Findings and Recommendations T he committee was asked by Congress to consider the efforts of the Department of Defense (DoD) and the Department of Veterans Af- fairs (VA) to prevent posttraumatic stress disorder (PTSD) and to screen, diagnose, treat, and rehabilitate service members and veterans who have PTSD. The number of service members and veterans of all eras who have symptoms of PTSD is immense; of the 2.6 million service members who have been deployed to Iraq and Afghanistan alone since October 2001, about 13% to 20% are expected to develop PTSD. In this phase 1 report, the committee provides an overview of the management of PTSD in the DoD and the VA, citing selected examples of programs and services that are available to service members, veterans, and their families; describes some of the innovations that are being explored for the prevention and diagnosis of and treatment for PTSD; and highlights substantial data gaps in and barriers to the evaluation, implementation, and use of the services. The committee’s findings led to recommendations that could, in the short and long term, improve the management of PTSD for service members, veterans, and their families. To emphasize recommenda- tions that were, in many cases, applicable to both the DoD and the VA and that addressed programs, services, and facilities in both health care systems, the committee grouped its recommendations into five action items: • Analyze: Collect data on the implementation, delivery, and ef- fectiveness of all prevention, screening, diagnosis, treatment, and rehabilitative services that are currently in use. 363

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364 PTSD IN MILITARY AND VETERAN POPULATIONS • Implement: Encourage and support the use of evidence-based meth- ods for PTSD screening, treatment, and rehabilitation. • Innovate: Instigate research to provide evidentiary support for the effectiveness of emerging prevention methods, treatments, and re- habilitative services. • Overcome: Remove barriers to the delivery of screening, diagnosis, treatments, and rehabilitative services. • Integrate: Screen for, assess, and treat PTSD comorbidities. The committee summarizes below some of its findings in this report that support those broad recommendations and presents more specific rec- ommendations for implementing them. ANALYZE A. The DoD and the VA should collect data on the implementation, delivery, and effectiveness of all prevention, screening, diagnosis, treatment, and rehabilitative services that are currently in use. The committee requested information from the DoD and the VA about PTSD programs and services offered by the departments, including the number of service members and veterans in each department who have re- ceived a diagnosis of PTSD. Although the need for PTSD services in the next few years in both the DoD and the VA is uncertain, tracking the prevalence of PTSD for this population of service members and veterans should not be difficult. The DoD and the VA, with their comprehensive electronic medical records, have the ability to track, collate, and analyze data on PTSD pro- grams and services for those receiving care in their facilities. For the DoD, this information should be collected both in garrison as well as in deployed locations. Data may also be collected for subpopulations of service mem- bers and veterans, such as those with co-occurring conditions, women, or older veterans, to help tailor treatments for those groups. The RESPECT-Mil program, initiated by the U.S. Army (see Chapters 4 and 6), is an example of a screening program that is being implemented servicewide (DoD, 2011). Although all soldiers are screened in the primary care setting under this program, data on long-term effectiveness are lack- ing. Follow-up will be necessary to ensure that service members who may not present initially with symptoms of PTSD, and therefore may not be referred for treatment, are not overlooked if they become symptomatic later or become more open to receive treatment. Treatments for PTSD are being practiced and evaluated in a variety of venues, including DoD specialty clinics, VA medical centers, and civilian settings. Many researchers are engaged in collecting data on both estab-

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365 FINDINGS AND RECOMMENDATIONS lished and experimental treatments for PTSD, but many gaps remain to be addressed. Among them are gaps in data on the effectiveness of such complementary and alternative treatments for PTSD as yoga, the timing of evidence-based treatment, long-term follow-up to assess relapse and treat- ment effects, and the integration of psychosocial and pharmacologic thera- pies. Randomized controlled trials (RCTs) would be the best approach to assess the efficacy of PTSD treatments. The committee recognizes, however, that there are considerable costs involved in conducting RCTs, in terms of not only money but also time and people. Therefore, small open trials or pilot studies might be a cost-effective approach to identify initially those treatments most likely to provide positive outcomes or populations most likely to benefit from them. The committee commends the DoD and the VA for the development of the joint VA/DoD Clinical Practice Guideline for Management of Post- Traumatic Stress (VA and DoD, 2010) that presents the evidence base for numerous PTSD treatments, but notes that there is little information on ad- herence to its use by DoD or VA mental health providers (Kirchner, 2011). Adherence to this guideline by mental health providers in the DoD and VA will help ensure that patients who have PTSD are first treated with therapies shown to be effective in a variety of populations. Other treatments may be used as adjuncts or as second-line treatments should the well-established treatments prove to be ineffective for some patients. Rehabilitation of service members and veterans who have PTSD has not received the attention that has been given to other elements of treatment. Many service members returning from the conflicts in Iraq and Afghanistan present with comorbid conditions ranging from apparent physical injuries, such as amputations, to subtle but more common problems, such as mild traumatic brain injury (TBI) and depression. Tracking the efficacy of diag- nosis of and treatment for PTSD in light of the additional medical problems can be daunting, but such information will help refine future treatments for both PTSD and comorbid conditions. Furthermore, as described in Chapter 8, PTSD affects all aspects of a service member’s life, including employment and family relationships. Dealing with those myriad problems requires a coordinated effort to identify service members and families that are at risk, to provide access to services, and to ensure programs and services are ap- propriate and effective. Data-gathering efforts may be difficult, particularly in the case of veterans who are in the National Guard and reserves, who live in the community and may not have ready access to VA facilities and their electronic medical records, or who may see private practitioners. To ad- dress the issues of collecting data to improve military readiness, identifying at-risk individuals and populations, and implementing effective programs for treating and rehabilitating service members and veterans, the committee offers the following recommendation:

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366 PTSD IN MILITARY AND VETERAN POPULATIONS A1. To study the efficacy of treatment and to move toward measurement- 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 information should be made accessible to researchers with appropriate safeguards to ensure patient confidentiality. Because of the immense scope of the PTSD problem, and the need to implement solutions immediately given that the conflict in Afghanistan is ongoing and the effects are immediate, a broad range of prevention, screen- ing, diagnosis, treatment, and rehabilitation programs have been imple- mented by the DoD and the VA. The U.S. Army is instituting a servicewide stress prevention program, Comprehensive Soldier Fitness, with the goal of preventing or reducing the prevalence of PTSD in service members (U.S. Army, 2012a). The Air Force (Morgan and Garmon Bibb, 2011), and Navy and Marine Corps (Meredith et al., 2011; Nash, 2011) have similar pro- grams to improve resilience and to better prepare service members for the rigors of deployment. However, the programs are still in the implementa- tion phase, and their efficacy is not yet known. The collection of such data will be critical for improving military readiness for conflicts. Although the DoD has also been a leader in promoting the preven- tion of sexual assault and harassment (see Chapter 5) and in initiating programs to help military families deal with the stress of having a family member deployed to a combat zone, little research has been published on the efficacy of its efforts. Follow-up may be difficult in the case of service members who have prolonged medical problems, including PTSD, who typically leave the service and enter the VA health care system, where the psychosocial sequelae—such as intimate partner violence, criminal activ- ity, and unemployment or underemployment—may be more obvious and pressing but long-term outcomes are difficult to assess. Some VA treatment programs and services enlist families in the treatment and rehabilitation of veterans who have PTSD, including Vet Centers that provide such family services as marital and employment counseling. The committee applauds the collaborative efforts of the DoD and the VA in the development of the VA/DoD Clinical Practice Guideline for Man- agement of Post-Traumatic Stress (2010), discussed in Chapter 7, and the joint guidelines for other medical conditions that are frequently comorbid with PTSD such as those for postdeployment health, concussion and mild TBI, substance use disorder, major depressive disorder, and several types of pain (for example, VA and DoD, 2009). These guidelines are recommended for use by health care providers in both the DoD (U.S. Army, 2012b) and the VA (Kirchner, 2011). Other collaborative efforts include a number of

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367 FINDINGS AND RECOMMENDATIONS conferences on military health issues. The committee is aware of at least one program, the Federal Recovery Coordination Program, that was jointly developed by the DoD and the VA “to assist some of the most severely wounded, ill, and injured service members, veterans, and their families.” However, two GAO reports (2011a,b) cited challenges in program enroll- ment, staffing needs, caseloads, and placement locations. The reports in- dicated there were substantial coordination problems with other DoD and VA programs that could result in duplication of effort, inefficiency, and confusion of enrollees. A third GAO report (2011c) on integrating DoD and VA care coordination programs was also critical of the lack of collaboration between the two departments in terms of case management and care coordi- nation. The committee notes that although the Federal Recovery Coordina- tion Program only serves about 2,000 service members and veterans, such efforts need to be carefully scrutinized as to their effectiveness before they are implemented more broadly; however, lack of such effective programs also leaves many service members and veterans underserved. The DoD and the VA have developed and implemented many programs and policies and have each dedicated portions of their research budgets to fund novel studies in an attempt to address prevention, screening, diagno- sis, treatment, and rehabilitation for PTSD. Many of the PTSD prevention and treatment programs in the DoD and the VA are or will be undergoing evaluation. Knowledge of the results will be critical for informing programs in other facilities so that ineffective programs may be discontinued and effective programs implemented. But not all such evaluations receive wide dissemination, particularly in the peer-reviewed literature. Those observa- tions and others noted in the report led the committee to the following recommendation: 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, including research in different populations of active-duty personnel and vet- erans; the effectiveness of DoD prevention services should also be assessed. The DoD and the VA should coordinate, evaluate, and review these efforts continually and routinely and should dissemi- nate the findings widely. IMPLEMENT B. Encourage and support the use of evidence-based methods for PTSD screening, treatment, and rehabilitation.

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368 PTSD IN MILITARY AND VETERAN POPULATIONS As described in Chapters 6, 7, and 8, there are many evidence-based ap- proaches that may be used to screen, treat, and rehabilitate service members and veterans who have PTSD. In Chapter 6, the committee discussed the many screening and diagnostic tools that have been used to identify service members, veterans, and civilians who have symptoms of PTSD. Because many of those symptoms are also present in other mental health disorders, particularly anxiety and depression, it is important to differentiate PTSD so the best treatments can be used. Thus, there is a need for validated tools for screening, assessing, and diagnosing PTSD and comorbid mental health disorders accurately. The committee recognized in Chapters 4 and 6 that all service members who deploy complete a predeployment and two postdeployment health assessments; the postdeployment assessments, conducted immediately and 3–6 months after return from deployment, include a screen for PTSD symptoms. Service members who screen positive for PTSD are not required to receive treatment, but they do meet with a provider who reviews the postdeployment health risk assessment with them and gives them referrals to mental health services, if need be, before signoff can occur. Whether the service member then seeks care for his or her mental health problem is unknown. Therefore, the committee considered such a screening by a primary care physician (whom a service member must see once a year as part of his or her periodic health assessment) to be a critical part of the PTSD care continuum. Many National Guard and reservists also may not see military mental health providers but rather see their own civilian pri- mary care physicians or use TRICARE primary care physicians. Unlike the primary care physicians in military treatment facilities, civilian physicians are not required to screen for PTSD and may not even know their patients are veterans. The prompt in the electronic medical record for a VA provider to ask a veteran about PTSD symptoms once a year presents a good op- portunity for a veteran to discuss any late-developing mental health issues without having to initiate the conversation. B1. PTSD screening should be conducted at least once a year when pri- mary care providers see service members at DoD military treatment facilities or at any TRICARE provider locations, as is currently done when veterans are seen in the VA. Although both the DoD and the VA have training programs for mental health providers in evidence-based treatments, the committee heard from mental health practitioners during its site visit to Fort Hood, Texas, and through the professional experience of several committee members that in the VA and the DoD that not all clinicians who treat service members and veterans have been trained in all these treatments, nor do they necessarily

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369 FINDINGS AND RECOMMENDATIONS use them. Nevertheless, the committee found that DoD and VA mental health providers may not always be familiar with military culture, posing a barrier to their understanding of the service member’s treatment needs. Many service members informed the committee they were unable to attend treatment sessions because of their duties. The VA has established a comprehensive training program for evidence- based psychosocial treatment for PTSD for its mental health providers (see Chapter 4). It had enlisted national experts to train about 3,300 VA clinicians in cognitive processing therapy (CPT), 1,500 in prolonged ex- posure (PE), and 800 in both by the end of 2011, and there are plans to train an additional 400 (Schiffner, 2011). Recently, the VA announced that it plans to hire an additional 1,900 nurses, psychiatrists, psychologists, social workers, and other mental health staff, which also has implications for training (VA, 2012). Training in the VA includes intensive workshops followed by consultation with senior staff to increase the likelihood that trained therapists will actually use the treatment with their patients. The VA reports it has adequate staffing capacity to provide CPT or PE for PTSD to all veterans of the Iraq and Afghanistan conflicts and is close to having full capacity to provide these therapies to all VA users. Vet Center staff members are also receiving training in PE and CBT. The increased use of mental health services notably by Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans has also meant that some clinicians do not have the time available to use resource-intensive treatments, such as CPT and PE, even if they are trained to do so (see Chapter 4). However, there are other evidence-based treatments, most notably pharmacotherapy, that are highly recommended by the VA/DoD guideline, but no comparable national training program for their use has been implemented. The VA also acknowledged there are other barriers to implementing evidence-based care after the practitioner is trained (Schiffner, 2011). The committee learned from the VA that it plans to add a template to its medical records to track psychotherapy progress notes (Desai, 2011). The committee does not know if the DoD has similar plans. Lack of a system to identify which treatments, other than pharmaceuticals, were provided to which patients makes it difficult to determine the extent to which CPT or PE therapy is being used at the local level and the outcomes of the treatments. New guidance from the DoD assistant secretary of defense for health affairs requires that training of DoD mental health providers be tracked (DoD, 2010), but there are no specifics on how such tracking is to be con- ducted or to whom the data are reported (see Chapter 4). Training in the DoD includes how to adjust treatments to meet a service member’s needs and the use of alternative treatments. The required training also includes an online course in military culture and terminology. Continuing educa-

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370 PTSD IN MILITARY AND VETERAN POPULATIONS tion is encouraged but not required. Because the DoD guidance was issued so recently (in 2010), no information is available on how the training has been implemented or on its results—that is, how many providers have been trained or mentored. INNOVATE C. Instigate research providing evidentiary support for the use of emerg- ing prevention methods, treatments, and rehabilitative services. The use of emerging programs and services for the prevention of PTSD in service members and veterans and treatment and rehabilitation of those who have it was discussed in Chapters 5, 7, and 8, respectively. The com- mittee was struck by the number of complementary and alternative medi- cine (CAM) treatments that are being proposed for managing PTSD, but was also surprised by the lack of rigorous evidence of their effectiveness. The committee heard from several service members that their experiences with CAM treatment such as yoga were beneficial for their PTSD. With regard to preventing PTSD, the DoD uses several programs to improve resilience and hardiness in service members before, during, and after deployment to a combat zone. In particular, the U.S. Army’s Compre- hensive Soldier Fitness program (U.S. Army, 2012) and the Marine Corps’ Operational Stress Control and Readiness program (Nash, 2011) are being instituted throughout those services to help soldiers deal with the stresses of deployment. The Air Force (Morgan and Garmon Bibb, 2011) and Navy (Meredith et al., 2011) are initiating similar programs to help service mem- bers adjust to the rigors of combat and enhance their coping and leadership skills. As noted in Chapter 5, although those programs build on widely used resilience programs, such as Battlemind (Adler et al., 2009), no pilot studies have been conducted to determine whether this type of program reduces the incidence of PTSD. Both the DoD and the VA are receptive to the use of emerging treat- ments for PTSD in their populations. The DoD has been in the forefront in developing early treatment interventions for service members exposed to traumatic events in combat zones. It has developed programs to include mental health providers in the theater of war and as close to the front lines as possible to counsel service members and prevent the exacerbation of stress reactions. A number of CAM treatments are being proposed and are being used for managing PTSD, but as with early treatment interventions, there is a lack of empirical evidence for their effectiveness. The differing missions of the DoD and the VA result in different ap- proaches to rehabilitation for service members, veterans, and their families. For example, the Comprehensive Soldier Fitness program has a component

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371 FINDINGS AND RECOMMENDATIONS to help families cope with the added stresses resulting from their service members’ deployment. The VA is able to provide a variety of services to veterans who have PTSD, including employment counseling and assistance with housing and education. Both the DoD and the VA are addressing the issue of comorbid conditions with respect to treatment and rehabilitation. The DoD and the VA have specialized mental health programs for service members and veterans who have PTSD, respectively, that may be provided in inpatient or outpatient settings. The treatment programs, such as the RESET program described to the committee at Fort Hood, have been developed specifically for military personnel who have PTSD. Data on ef- ficacy and effectiveness of many of these specialized programs are being collected, but they have not been evaluated or disseminated, so many new programs may be “reinventing the wheel” at different locations, and this might lead to redundancy and inefficiency. Evaluation methods and metrics have not been standardized, making comparisons among programs within and between the DoD and the VA difficult. Although most service members live and work close to or on military bases, and thus are near a military treatment facility of some level, gaps in the delivery of treatment are of particular concern. Delivery of PTSD treat- ment is also a challenge for service members deployed in theaters of combat. The VA serves a more dispersed population than does the DoD, inas- much as veterans may live in cities, small towns, or rural areas that have differing access to mental health care. The VA is responsible for long-term care of those who have permanent disabilities when they leave the military, including both psychologic and physical disabilities. Complicating the deliv- ery of mental health care to those and other veterans is that many of them are members of the National Guard and reserves who may seek care from civilian, non-VA, and non-DoD providers. As discussed in Chapter 9, both the DoD and the VA are exploring and in some cases implementing telemedicine, that is, the use of computers and technology for screening and providing interactive therapy for service members or veterans who may be reluctant to engage in or cannot access face-to-face therapy. Telemedicine may also offer promise for service mem- bers and veterans who fear the stigma of being in mental health clinics or for those in the theater of war, where opportunities for counseling may be sporadic. Computer-delivered virtual reality programs for PE therapy are also being evaluated (for example, Reger et al., 2011). C1. Specialized intensive PTSD programs and other approaches for the delivery of PTSD care, including combining different treatment approaches and such emerging treatments as complementary and alternative medicine and couple and family therapy, need to be rig- orously evaluated throughout DoD facilities (including TRICARE

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372 PTSD IN MILITARY AND VETERAN POPULATIONS 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 im- provements (for example, improvements in physical comorbidities, memory, and return to duty) is needed. The evaluations of these programs should be made publicly available. Chapter 3 provides an overview of the neurobiology of PTSD. Many advances have been made in understanding the stress response, particularly the roles of cortisol and the hypothalamic-pituitary-adrenal axis, but much remains to be discovered. Research into the neurobiologic mechanisms of PTSD is providing important knowledge to guide the development and use of pharmaceuticals for PTSD treatment, including selective serotonin reup- take inhibitors, catecholamines, and glucocorticoids (for example, Mueller et al., 2009; Norrholm and Jovanovic, 2010; Putman and Roelofs, 2011). Although there are no validated biomarkers of PTSD, this field of research has the potential to identify people who are at risk for PTSD, to diagnose it, and to provide the most effective treatments for it, whether psychosocial, pharmacologic, or otherwise. Biomarkers may also be of use in identifying people who are at risk for relapse or symptom exacerbation. The role of genetics in the development and treatment of PTSD is another promising field; for example, the use of gene expression patterns could be used to dis- tinguish between those who have and those who do not have PTSD. Such knowledge could ultimately help to prevent PTSD, target effective PTSD treatments, improve quality of life, and reduce treatment costs. 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. OVERCOME D. Remove barriers to the delivery of screening, diagnosis, treatments, and rehabilitative services. During its review of the literature and in discussions with service mem- bers, veterans, family members, and mental health providers in the DoD and the VA, the committee learned of numerous obstacles and barriers experienced by those who have PTSD when they seek diagnosis, treatment, and rehabilitative services (discussed in detail in Chapter 9). Barriers exist at many levels, from the individual to the organizational, and although

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373 FINDINGS AND RECOMMENDATIONS many are applicable to any health care system, such as recording treatments in medical records and allocating providers’ time, some of the barriers are peculiar to the DoD or the VA. For example, active-duty service members must request permission from their commanders to take time off from their duties to see health care providers, and this can prove difficult if it conflicts with duty requirements. Not all veterans receive care in VA medical facilities even if they are eligible for care. Of those who do, however, some live and work many miles from the nearest VA health care provider, particularly mental health provid- ers, and this burdens them with the challenge of accessing care. Although both departments are making efforts to reduce barriers to care for service members and veterans, many obstacles to maximizing the use of mental health care in the DoD and the VA remain. As described in Chapter 9, there are innovative approaches for the delivery of PTSD treatments that use telemedicine, but even these innovations have barriers, such as the need for an aging veteran population to have access to and facility with computers, limited Internet access in rural areas, and cost considerations. The committee recognizes that translating mental health research into practical screening, diagnosis, treatment, and rehabilitation programs for service members and veterans is an obstacle. Applying information on best practices or adapting research findings from a civilian population to an active-duty or veteran population can be challenging, but these are neces- sary if the unique requirements of treating service members in the theater of war, on a base, and in the community are to be met. For example, the use of some medications commonly prescribed for PTSD in civilian populations or nondeployed service members may be prohibited for some service members in a combat zone or performing some duties. In spite of considerable efforts to reduce stigma for active-duty service members by finding less obvious methods to deliver mental health care, the perception persists that those who seek such care are flawed or that receiving care can be a detriment to a military career. In Chapter 4, the committee identified many of the PTSD resources, programs, and services that are being used or developed in the DoD and the VA. The committee also talked with mental health providers, service members, veterans, and their families at Fort Hood, in the community, and at its open information-gathering sessions. Recently, the RAND Corpora- tion released a comprehensive compilation of programs in the DoD for psychologic health, including PTSD and TBI (Weinick et al., 2011). The committee found that many programs were base-specific and were being implemented because of a champion’s or promoter’s interest in them. The committee recognizes that both the DoD and the VA have made consider- able efforts to develop “one-stop shops” for mental health services. The DoD has developed www.militaryonesource.com, which provides a variety

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374 PTSD IN MILITARY AND VETERAN POPULATIONS of counseling services and referrals for service members and their families, and the VA has established www.myhealth.va.gov, a website that links to a variety of services and referrals and provides advice on health. Chapters 6, 7, and 9 discuss new technologies for the delivery of PTSD screening and treatment. The committee noted that more work needs to be done to evaluate access to and efficacy of these technologies although stud- ies are being conducted. The use of telemedicine for the delivery of PTSD psychosocial therapies is promising and may be of particular benefit for service members in the theater of war and veterans in rural areas. D1. The DoD and the VA should support research that investigates 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. INTEGRATE E. Screen for, assess, and treat for PTSD comorbidities. The committee found three types of integration that are necessary to provide the best treatment options for service members and veterans. First, the screening, diagnosis, and treatment of PTSD need to be integrated into a variety of clinical settings, particularly primary care, so those who have symptoms can be identified and treated as soon as appropriate. Second, treatment of PTSD needs to be integrated with treatment of the physical, psychological, and psychosocial co-occurring conditions that often accom- pany it. Third, there is the need to integrate various treatment options, such as psychotherapy with pharmacotherapy or other treatments, including CAM therapies, to address all aspects of PTSD morbidity. Although some service members and veterans have a diagnosis of PTSD alone, PTSD often occurs with other mental health conditions or physical disorders that complicate diagnosis and treatment. There is considerable evidence that PTSD is more common among veterans and active-duty ser- vice members who are diagnosed with other psychiatric problems such as depression and substance abuse or misuse, medical conditions such as TBI and pain, or who display other problematic psychosocial behaviors such as aggressive driving or intimate partner violence. In Chapter 8, the committee considered screening for, diagnosis of, and treatment and rehabilitation for PTSD in patients who have other health problems as well. In particular, as a result of the conflicts in Iraq and Afghanistan, TBI is frequently comorbid in service members who have PTSD. Other psychiatric and physical condi-

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375 FINDINGS AND RECOMMENDATIONS tions that often co-occur with PTSD include substance use disorders (for example, people may self-medicate with pain killers, sleep aids, or alcohol to alleviate their PTSD symptoms), chronic pain from injuries, and depres- sion and anxiety disorders. PTSD may also affect other aspects of a service member’s or veteran’s life, particularly social and familial relationships. Some common symptoms of PTSD—such as hyperarousal, numbing, and avoidance—may result in an afflicted person’s lashing out at or avoiding family members, employers, colleagues, and friends. They may also lead to intimate partner violence, child neglect or abuse, divorce, unemployment, incarceration, and homelessness. Integrating treatment of PTSD into treatment for comorbid conditions can prove challenging. There are no guidelines to help health and mental health providers to treat people for PTSD and other conditions simultane- ously or sequentially. The current VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress requires that patients be assessed for co-occurring conditions. Patients who have severe or unstable comorbid conditions should be considered for referral to a specialty clinic. If patients have comorbid psychiatric conditions, management of these disorders is also necessary. The VA and the DoD have developed clinical practice guide- lines for several of the common PTSD comorbidities—including substance use disorders, major depressive disorder, concussion and mild TBI—and postdeployment health, all of which are referred to in the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. The guideline also recommends a collaborative care strategy be developed in the primary care setting for patients who have comorbidities, with an emphasis on first treating the most severe symptoms and disorders and only calling in special- ists as needed. The presence of comorbidities may also influence the choice of PTSD treatment options. The VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury (VA and DoD, 2009), for example, calls for health care providers to screen patients who have mild TBI for PTSD and other psychiatric disorders and to treat them for PTSD as appropriate. The committee recognizes that the guidelines are a valuable reference for health care providers in the DoD and the VA, but had no data on which to assess provider training and implementation of the guidelines. E1. Research to create an evidence base to guide the integration of treatment for comorbidities with treatment for PTSD should be sponsored by the DoD and the VA. PTSD treatment trials should incorporate assessment of comorbid conditions and of 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.

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376 PTSD IN MILITARY AND VETERAN POPULATIONS PHASE 2 During phase 1 of this study, the committee reviewed literature and heard from service members and mental health care providers about pro- grams and services in the DoD and the VA on PTSD prevention, screening, diagnosis, assessment, treatment, and rehabilitation. The committee also heard from families of service members about the impact of PTSD on them. During its data-gathering efforts and deliberations, including a visit to Fort Hood, Texas, the committee identified many subjects on which further in- formation was necessary before conclusions could be drawn. Although the committee was not required to make any visits to military installations in phase 1, it believed that in order to refine its data requests for the services, it would be informative to visit a military base before asking for additional data. Subsequently, information was requested from the surgeons general of the Army, Navy, and Air Force; however, such information was largely unavailable to the committee for this phase 1 report. Cost considerations, new neurobiologic findings, and the use of complementary and alternative treatments for PTSD will be reconsidered in more depth in phase 2. The committee’s statement of task for phase 2 requires it to visit three Army bases: Fort Hood and Fort Bliss in Texas and Fort Campbell in Ten- nessee. The committee anticipates visiting the remaining two Army bases in the fall of 2012. Although most service members who served in Iraq and are serving in Afghanistan are Army soldiers, the Marine Corps also has a substantial presence and has sustained numerous casualties. The Navy and Air Force also have been engaged in these conflicts, but their personnel are far fewer (see Chapter 1). Because of the large number of marines who have fought in Iraq and Afghanistan, the committee hopes to visit a Marine Corps base in phase 2. The enabling legislation for this committee directed it to consider not only active-duty service members but also veterans, and the committee expects to visit at least one VA medical center in phase 2. The committee also expects that those visits will provide it with more in- formation on specialized services and programs, as well as the availability of and need for programs targeted specifically to racial, gender, and ethnic populations. The committee is not tasked with surveying all military and veteran health facilities for PTSD programs and services. Rather, it hopes through its visits to gain an appreciation of some of the particular issues surround- ing the diagnosis of and treatment for PTSD in current and past military personnel. The visits also allow the committee to hear directly from service members, veterans, and their families about programs and services that work well for them and about ones that do not and about possible ways to improve care. As noted in Chapter 1, the committee has requested information from

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377 FINDINGS AND RECOMMENDATIONS the DoD and the VA on numbers and demographics of personnel who have PTSD, on treatments they are receiving, on programs being evaluated (or not), and on costs. Some quantitative information has been received, par- ticularly from the VA, but many of the data requests are still outstanding. When the data are received, they will be evaluated and discussed in phase 2. The committee will conduct further literature reviews to identify where results from DoD or VA or civilian PTSD programs have been published. Until the committee receives more substantial information from the DoD on program outcomes, it will be difficult, perhaps impossible, to determine availability of, access to, and efficacy of each DoD PTSD program. The committee will also refine its data requests to the VA to try to clarify the use of and results from its PTSD programs. REFERENCES Adler, A. B., P. D. Bliese, D. McGurk, C. W. Hoge, and C. A. Castro. 2009. Battlemind de- briefing and battlemind training as early interventions with soldiers returning from Iraq: Randomization by platoon. Journal of Consulting & Clinical Psychology 77(5):928-940. Desai, R. 2011. NEPEC and PTSD program evaluation. Presentation to the Committee on the Assessment of Ongoing Efforts in the Treatment of PTSD. February 28, 2011. Wash- ington, DC. DoD (Department of Defense). 2010. Guidance for mental health provider training for the treatment of post-traumatic stress disorder and acute stress disorder. Memorandum. Washington, DC: Department of Defense, Office of the Assistant Secretary of Defense. December 13. DoD. 2011. Welcome to the RESPECT-MIL program. RESPECT-Mil Newsletter Fall. http:// www.pdhealth.mil/respect-mil/index1.asp (accessed January 30, 2012). GAO (U.S. Government Accountability Office). 2011a. DOD and VA health care—Action needed to strengthen integration across care coordination and case management pro- grams. GAO-12-129T. Washington, DC: GAO. GAO. 2011b. Federal Recovery Coordination Program: Enrollment, staffing, and care coordi- nation pose significant challenges. GAO-11-572T. Washington, DC: GAO. GAO. 2011c. DOD and VA health care: Federal recovery coordination program continues to expand but faces significant challenges. GAO-11-250. Washington, DC: GAO. Kirchner, J. E. 2011. Mental Health QUERI Center Strategic Plan. North Little Rock, AR: VA, Quality Enhancement Research Initiative (QUERI). December. Meredith, L. S., C. D. Sherbourne, S. Gaillot, L. Hansell, H. V. Ritschard, A. Parker, and G. Wrenn. 2011. Promoting psychological resilience in the U.S. military. Santa Monica, CA: RAND Corporation. Morgan, B. J., and S. C. Garmon Bibb. 2011. Assessment of military population-based pys- chological resilience programs. Military Medicine 176(9):976-885. Mueller, D., L. A. Olivera-Figueroa, D. S. Pine, and G. J. Quirk. 2009. The effects of yohim- bine and amphetamine on fear expression and extinction in rats. Psychopharmacology 204(4):599-606. Nash, W. P. 2011. US Marine Corps and Navy combat and operational stress continuum model: A tool for leaders. Chapter 7. In Textboooks of military medicine: Combat and operational behavioral health, edited by E. C. Ritchie. Fort Detrick, MD: Office of the Surgeon General, Borden Institute.

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