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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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate 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, findings, 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.
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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.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITITE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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 Academy 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 engineers. 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 engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president 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 Institute 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.
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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
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
Reviewers
This 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 confidential 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
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.
Implications for PTSD Prevention, Diagnosis, and Treatment
4 Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs
The Department of Defense Health Care System
Mental Health Care in the Department of Defense
The Department of Veterans Affairs Health Care System
Mental Health Care in the Department of Veterans Affairs
Collaborative Efforts Between the Department of Defense and the Department of Veterans Affairs
Research in the Department of Defense and the Department of Veterans Affairs
Interventions for Trauma-Exposed People
Prevention in the Department of Defense
Prevention in the Department of Veterans Affairs
Psychosocial Treatments for Chronic PTSD
Combined Psychotherapy and Pharmacotherapy Approaches
Integrative Collaborative Care
Guidelines for Treatment of PTSD
8 Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities
Co-Occurring Psychiatric Conditions and PTSD
Co-Occurring Medical Conditions and PTSD
Co-Occurring Psychosocial Problems and PTSD
Barriers to Delivery of Evidence-Based Care
10 Findings and Recommendations
Appendixes
A Committee Member Biographies
C Posttraumatic Stress Disorder Programs in the Department of Defense
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Posttraumatic 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 identifying 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 treatment 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
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 treatment 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 Garrison 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
ACT | acceptance and commitment therapy |
AFQ | TArmed Forces Qualification Test |
APA | American Psychiatric Association |
ASD | acute stress disorder |
BDN | Fbrain-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 |
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 |
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, HealthyFamilies |
REM | rapid eye movement |
RESPECT-Mil | Re-Engineering Systems for Primary Care Treatmentof 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 |
SIT | stress inoculation training |
SKY | Sudarshan Kriya yoga |
SNRI | serotonin norepinephrine reuptake inhibitor |
SPRINT | Short Post-Traumatic Stress Disorder RatingInterview |
SRI | serotonin reuptake inhibitor |
SSRI | selective serotonin reuptake inhibitor |
STAIR | Skills Training in Affect and Interpersonal Regulation |
STRONG STAR | South Texas Research Organizational NetworkGuiding 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 LifeAssessment |
WL | wait list |