4

Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs

This chapter introduces the programs and services provided by the Department of Defense (DoD) and the Department of Veterans Affairs (VA) health care systems with a special emphasis on care of those who have posttraumatic stress disorder (PTSD). The two health care systems are distinct entities that serve different, but at times overlapping, populations. Together they cover the many stages of a military career, including service on multiple bases, service in the theater of war, the transition from the DoD to the VA, and being a veteran (see Figure 4-1).

The chapter first provides an introduction to the DoD health care system; a summary of current PTSD programs for prevention or resilience, screening, diagnosis, and treatment in the DoD (including on base, off base, and in the theater of war); and a brief discussion of training opportunities for PTSD treatment. It then focuses on the transition between the DoD and the VA health care systems before providing an introduction to the VA health care system; a summary of current PTSD programs for resilience, screening, diagnosis, and treatment in the VA; and a discussion of training in evidence-based PTSD treatments. The chapter ends with a short discussion of current and future research directions and cost considerations for mental health care.

THE DEPARTMENT OF DEFENSE HEALTH CARE SYSTEM

The DoD is tasked with providing “the military forces needed to deter war and to protect the security of our country” (DoD, 2012). Its mission is carried out by more than 1.4 million active-duty personnel and 1.1



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4 Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs T his chapter introduces the programs and services provided by the Department of Defense (DoD) and the Department of Veterans Af- fairs (VA) health care systems with a special emphasis on care of those who have posttraumatic stress disorder (PTSD). The two health care systems are distinct entities that serve different, but at times overlapping, populations. Together they cover the many stages of a military career, in- cluding service on multiple bases, service in the theater of war, the transition from the DoD to the VA, and being a veteran (see Figure 4-1). The chapter first provides an introduction to the DoD health care system; a summary of current PTSD programs for prevention or resilience, screening, diagnosis, and treatment in the DoD (including on base, off base, and in the theater of war); and a brief discussion of training opportunities for PTSD treatment. It then focuses on the transition between the DoD and the VA health care systems before providing an introduction to the VA health care system; a summary of current PTSD programs for resilience, screening, diagnosis, and treatment in the VA; and a discussion of training in evidence-based PTSD treatments. The chapter ends with a short discus- sion of current and future research directions and cost considerations for mental health care. THE DEPARTMENT OF DEFENSE HEALTH CARE SYSTEM The DoD is tasked with providing “the military forces needed to deter war and to protect the security of our country” (DoD, 2012). Its mission is carried out by more than 1.4 million active-duty personnel and 1.1 mil- 111

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112 PTSD IN MILITARY AND VETERAN POPULATIONS Predeployment FIGURE 4-1 Potential points of mental health contact for service members during their careers. Figure 4-1 new Landscape All type is “outlined” (no longer a font) lion reservists who serve domestically and internationally for a variety of purposes, from fighting wars to humanitarian and peace-keeping missions (DoD, 2012). The military consists of three departments—the Army, the Navy (which includes the Marine Corps), and the Air Force. Although all branches have a reserve component, only the Army and the Air Force have a National Guard component. Active-duty service members are employed full-time in the military, but members of the National Guard and reserve components serve in the military on a part-time basis. In general, they are required to work one weekend each month and serve a 2-week active-duty tour each year. The National Guard is under state jurisdiction unless feder- ally activated. National Guard and reservists live in the civilian community (not on bases), work in civilian jobs, and do not have continuous access to DoD sources of health care (unless they are on active duty). The availability of health care for National Guard and Reservists is discussed in more detail later in this chapter. The Military Health System (MHS) provides many health programs and services in an effort to keep active service members, retired personnel, and their families healthy. Overseen by the Office of the Assistant Secretary of Defense for Health Affairs, the MHS is responsible for maintaining the readiness of military personnel by promoting physical and mental fitness, providing emergency and long-term casualty care, and ensuring the delivery of health care to all service members, retirees, and their families through coordinated efforts of the medical departments of the Army, Navy (includes the Marine Corps), and Air Force; the joint chiefs of staff, the combatant command surgeons; and private-sector health care providers, hospitals, and pharmacies (IOM, 2010a). Figure 4-2 shows the organizational structure of the major health care services provided by the DoD. In addition to several offices and programs, the MHS provides health care services through sev- eral military-wide organizations: Force Health Protection and Readiness, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), Uniformed Services University of the Health Sciences

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Secretary of Defense Deputy Secretary of Defense Chairman, Joint Chiefs of Staff USD Secretary of Secretary of Secretary of Personnel and the Air Force the Army the Navy Readiness Military Readiness Personnel Policy Military Army Chief of Chief of Naval AF Chief of Community Commandant Staff (Line Opera ons Staff (Line and Family Marine Corps, Health Affairs (Line Related Related Related Policy Asst. Programs) Programs) Programs) Commandant TRICARE Force Health AF Surgeon Navy Surgeon Army Surgeon (Purchased Protec on General, General, General, Care) Director AF Director and Commander, Readiness Medicine BUMED Army Medical Command MTF TRICARE TRICARE MTF MTF R&D Commanders Support Regional Commanders Commanders (Direct Care) Office Offices (Direct Care) (Direct Care) Providers Contractors (Networked and Non- Networked) FIGURE 4-2 Organization of health care services provided by the DoD. The Office of the Assistant Secretary of Defense for Health Affairs oversees Force Health Protection and Readiness programs and the purchased portion of TRICARE, and it has an administra- tive and policy relationship to the military treatment facilities 4-2 new(as indicated by the dotted line). Figure (MTFs) NOTE: BUMED = Bureau of Medicine and Surgery, R&D = Research and Development, USD = Undersecretary of Defense. Landscape SOURCE: Glover et al., 2011. 113

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114 PTSD IN MILITARY AND VETERAN POPULATIONS (USUHS), and TRICARE (DoD, 2012). A description of each of those or- ganizations is in Table 4-1. Although TRICARE is sometimes used to describe only purchased care, its network of services and programs is far reaching. The present commit- tee uses the term TRICARE in a broader sense: as a wide-reaching health care provider for service members, retirees, and their families that delivers direct care through military treatment facilities (MTFs) and purchased care through network and non-network civilian health professionals, hospitals, and pharmacies (TRICARE, 2011). The relationship between TRICARE and MTFs is shown in Figure 4-2. The purchased care portion of TRICARE offers three primary plans: TRICARE Standard, TRICARE Extra, and TRICARE Prime (see TRICARE, 2011, for details of these three primary plans). To enroll in any TRICARE plan, service members, their families, and retirees must first establish eligibility through the Defense Enrollment Eligibility Reporting System. Active-duty service members, veterans, and reservists who have been activated for at least 30 consecutive days are automatically enrolled, but service members must register family members and update their status. In FY 2011, about 9.7 million beneficiaries were eligible for DoD medi- cal care, and 5.5 million beneficiaries were enrolled in TRICARE. Care of beneficiaries was provided through a network of 59 hospitals and medical centers and 363 health clinics in the direct-care system, and almost 380,000 individual providers and more than 3,000 network acute-care hospitals in the purchased-care system. There has been an increase in the number of TRICARE enrollees (particularly retirees) assigned to civilian primary-care managers because of a continued lack of resources and capacity in MTFs. Of the 9.7 million beneficiaries in the United States, about 34% were retirees and family members under 65 years old, 21% were retirees and family members 65 years old or older, 21% were active-duty family mem- bers, 14% were active-duty service members, 6% were National Guard or reserve family members, and 4% were members of the National Guard or reserves (TRICARE, 2011). MENTAL HEALTH CARE IN THE DEPARTMENT OF DEFENSE TRICARE authorizes a wide spectrum of practitioners to provide mental health care to its beneficiaries, including “psychiatrists and other physicians, clinical psychologists, certified psychiatric nurse specialists, clinical social workers, certified marriage and family therapists, pastoral counselors, and mental health counselors” (IOM, 2010b). The authorized practitioners may deliver inpatient or outpatient care (including mental health care, such as psychotherapy, psychoanalysis, testing, and medication

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115 PROGRAMS AND SERVICES FOR PTSD TABLE 4-1 Mental Health Components of the Military Health System MHS Component Organizations Descriptions TRICARE TRICARE is a “health care plan using military health care as the main delivery system.” It is “augmented by a civilian network of providers and facilities” and provides services to the “uniformed services, activated National Guard and Reserve, retired military, and their families worldwide” (TRICARE, 2012). Force Health Protection “The Deputy Assistant Secretary of Defense (DASD) and Readiness for Force Health Protection and Readiness (FHP&R) is the principal staff assistant and advisor to the Assistant Secretary of Defense (Health Affairs) for all medically related Department of Defense policies, programs, and activities. The office is responsible for deployment medicine, force health protection, medical readiness, international health agreements, deployment related health policy, theater information systems, humanitarian and health missions, and national disaster support” (FHP&R, 2012). Defense Centers DCoE “assesses, validates, oversees and facilitates prevention, of Excellence for resilience, identification, treatment, outreach, rehabilitation, Psychological Health and and reintegration programs for psychological health (PH) Traumatic Brain Injury and traumatic brain injury (TBI) to ensure the Department of Defense meets the needs of the nation’s military communities, warriors and families” (DCoE, 2012a). Uniformed Services The USUHS is the nation’s federal health sciences university. University of the Health It is focused on education, research, service, and consultation Sciences specifically as they are related to military medicine, disaster medicine, military medical readiness, and public health during peace and war (USUHS, 2012). Surgeons general of each The organization of the MHS includes the surgeons general service of the Army, Navy, Air Force, and Coast Guard. In the Army and Navy, these three-star generals also have command of their medical personnel, clinics, and hospitals. In all branches, the surgeons general have overall responsibility for the medical operations within their specific branches. MHS offices and programs MHS offices and programs include •  Chief Human Capital Office •  Clinical and Program Policy •  Council of Review Boards  •  Defense Health Board  •  Information Management  •  Innovation Investment Process  •  inTransition  •  Office of Strategy Management  •  Patient Safety Program  •  Physical Disability Board of Review 

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116 PTSD IN MILITARY AND VETERAN POPULATIONS management), acute care, psychiatric partial hospitalization, and residential treatment center care. Mental health care can also be described in terms of preclinical and clinical care. Preclinical care is commonly called counseling, and the sev- eral types of counseling are usually loosely defined. For example, service members and their families have the opportunity to seek counseling from chaplains, unit-embedded mental health care providers, community service programs (Tanielian and Jaycox, 2008) and from such facilities as Marine Corps counseling centers. The more formal route for clinical care is gener- ally through MTFs in outpatient clinic or inpatient psychiatric-ward set- tings (Tanielian and Jaycox, 2008). Costs of intensive outpatient programs for mental health care that have become common in the private sector and the VA may not be reimbursed under TRICARE. Instead, patients may need to be referred to residential or inpatient care, which can be much more expensive and farther away from home (DoD, 2007). In response to previous reports that noted particular problems with the education on and implementation of evidence-based practice guide- lines (DoD, 2007; IOM, 2006), the MHS has worked to improve in these respects. On the basis of recommendations from the DoD Task Force on Mental Health (DoD, 2007), the MHS is pursuing implementation of evidence-based practices, training and education, quality measures, and monitoring (IOM, 2010a). The MHS has resolved to improve primary care for mental health conditions by 2016. It also aims to make improve- ments by increasing the number of providers that accept the purchased-care portion of TRICARE by “bridging cultural differences between military and civilian providers” and by increasing outreach to civilian providers (TRICARE, 2011). The DoD is also concerned with mental health care in the theater of war and has undertaken research to try to gain a better understanding of this topic. Since 2003, mental health advisory teams (MHATs) have been assembled annually in Iraq and, beginning in 2007, in Afghanistan to ob- tain information on symptoms of PTSD, anxiety, and depression; on barri- ers to care (including stigma); and on other mental health care issues in the theater of war. The first three MHATs were sponsored by the U.S. Army surgeon general and focused solely on Army soldiers. Starting with MHAT IV in 2006, both soldiers and marines were sampled. In 2010, the MHAT team included representation of the Army, Navy, and Air Force. It collected anonymous survey results from soldiers and marines and from behavioral health personnel in an effort to assess theater-wide mental health and well- being, to examine the delivery of behavioral health care, and to provide recommendations for sustainment and improvement of mental health care (MHAT VII, 2011). It was found that about 20% of service members re- ported symptoms of acute stress (PTSD), depression, or anxiety; that higher

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117 PROGRAMS AND SERVICES FOR PTSD rates of psychologic problems and lower morale are associated with lon- ger deployments, multiple deployments, and greater time away from base camp; and that good leadership provides the support necessary to promote positive mental health and well-being in the deployed (MHAT VII, 2011). Services and Programs for PTSD This section gives some examples of PTSD services and programs that are commonly used in the DoD and provides an overview of the pathways through which a service member is screened for PTSD, a diagnosis is made, and treatment is instituted; it is not a catalog of all PTSD services and programs provided by the DoD. It should be noted that no single source within the DoD or any of the service branches maintains a complete list 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. However, a recent review by Weinick et al. (2011) includes a list of DoD programs that address psycho- logic health and traumatic brain injury. Of the 211 programs identified in the review, 103 were PTSD-related programs for service members, veterans, civilians, and their families. See Appendix C for a list of the PTSD-specific programs offered in the DoD. (For a list of all programs in the DoD that address psychologic health [including PTSD] and traumatic brain injury of U.S. service members, veterans, and their families, see Appendixes A.1, A.2, A.3, and A.4 of Weinick et al. [2011].) Resilience Programs DoD resilience programs help to prepare service members for stressful encounters and traumatic events while they serve on military missions. The goal of such programs is to reduce the number of service members who de- velop mental health problems and to keep all service members as physically and mentally fit as possible during deployment. DoD Directive 6490.05 im- plemented combat and operational stress control (COSC) programs for all services. Directive 6490.05 was reissued as Instruction 6490.05 (November 22, 2011) Maintenance of Psychological Health in Military Operations “to enhance readiness, contribute to combat effectiveness, enhance the physical and mental health of military personnel, and prevent or minimize adverse effects associated with combat and operational stress” (DoD, 2011a). It included principles for COSC, procedures for COSC-specific education programs, guidance for military leaders (including a command that lead- ers ensure access to mental health services without stigma), a model for delivering COSC programs, and guidance on surveillance and monitoring. In addition, the instruction established specific requirements for the early

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118 PTSD IN MILITARY AND VETERAN POPULATIONS detection and management of any “physical, emotional, cognitive or behav- ioral reactions, adverse consequences, or psychological injuries of service members who have been exposed to stressful or traumatic events in combat or military operations” (DoD, 2011a). The Navy and Marine Corps have a strong COSC program called Op- erational Stress Control and Readiness (OSCAR), which has two specific goals: to maintain an active force and to promote the health of service members and their family members. The program works through mentors who try to identify and assist fellow service members who have combat and operational stress problems, extenders who are nonmental health clinicians or chaplains, and embedded mental health personnel (Meredith et al., 2011; U.S. Marine Corps, 2012). One resource through which Navy and Marine Corps members can find assistance for mental health concerns is the Naval Center for Combat and Operational Stress Control, which is part of the Navy Bureau of Medicine and Surgery. The center promotes psychologic resilience, recommends best practices for the diagnosis of and treatment for PTSD, seeks to reduce stigma for service members who are looking for or receiving mental health care, and provides support for family members. In the Air Force, traumatic stress response teams have been established to provide support to service members that are expected to be exposed to traumatic situations (U.S. Air Force, 2006). The teams provide pre- exposure consultations to units and communities and implement combat stress control programs. The Army has a long history of COSC and other resilience programs and services that target prevention of PTSD and other stress reactions. It is working to integrate a program called Comprehensive Soldier Fitness into basic training. Comprehensive Soldier Fitness is “a structured, long-term assessment and development program to build the resilience and enhance the performance of every Soldier, Family member, and [Department of the Army] civilian” (U.S. Army, 2012a). The program, which began in 2009, focuses on positive psychology and building resilience. It includes an assess- ment tool that provides a baseline for a soldier’s emotional, social, spiritual, and family strengths. Specific resilience modules include institutional (life- cycle) resilience training that is specific to the different phases of a soldier’s career; operational (deployment-cycle) resilience training that prepares a soldier for deployment; and family resilience training that prepares a sol- dier and his or her family for the transition back from deployment. There has been some controversy over the Comprehensive Soldier Fitness model. Brunwasser et al. (2009) completed a meta-analysis to evaluate the effec- tiveness of the Penn Resiliency Program, the program on which Compre- hensive Soldier Fitness was based, for alleviating symptoms of depression in youth; they concluded that the program showed modest and inconsistent results. The Comprehensive Soldier Fitness program is not a research pro-

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119 PROGRAMS AND SERVICES FOR PTSD gram, but there are concerns that it was launched without pilot testing, that it was based on a model that was developed for a different population, and that there are few data to indicate whether it promotes resilience (Eidelson, 2011; Quick, 2011). Some of the concerns have been addressed by the Of- fice of Comprehensive Soldier Fitness, as described by Seligman (2011). (See Chapter 5 for further discussion on prevention programs in the DoD.) Screening and Diagnosis The DoD has implemented a series of screenings and assessments dur- ing the deployment cycle—the pre-deployment health assessment, the post- deployment health assessment (PDHA), and the post-deployment health reassessment (PDHRA). The pre-deployment health assessment was initi- ated in 1998 and is administered within 60 days before deployment. It documents general health information on each service member. A health care provider reviews the service member’s responses and may refer him or her for further evaluation if a health concern that may potentially af- fect the service member’s ability to deploy is identified. However, there is only one mental health question: “During the past year, have you sought counseling or care for your mental health?” This question is of limited usefulness for the assessment of predeployment mental health concerns (see Chapter 6 for more discussion of predeployment screening). An affirmative response to the question results in referral for an interview by a trained medical provider who may then sign a form indicating medical readiness for deployment. During the 1990–1991 Gulf War, no system or screen was in place to document exposure to environmental toxicants and therefore no records to indicate exposures in the case of later claims of “Gulf War syndrome.” To try to prevent that type of problem in the future, the PDHA was cre- ated and implemented in 1998. The assessment is given to service members within 30 days after they leave their assigned posts or after their return from deployment. It documents exposure to toxic substances, such as pe- troleum and chemical weapons, and questions on PTSD, depression, and suicide were added in later iterations (GAO, 2008b). The PTSD questions (questions 10–14 on the screen) were drawn from standardized scales for PTSD and depression with input from civilian and military subject-matter experts. A service member completes the assessment independently, and a health care provider then reviews the form, interviews the service member about any identified deployment-related concerns, and makes referrals for further evaluation if it is appropriate (GAO, 2008b). In 2003, discussions regarding people who had various symptoms that emerged months after they returned from deployment took place. To capture the population, the DoD developed the PDHRA and began its

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120 PTSD IN MILITARY AND VETERAN POPULATIONS implementation in 2005. Standard PTSD and depression questions were added in later updates (questions 11, 12a–d, and 14a–b on the screen). The assessment is administered 3–6 months after deployment and focuses on latent health concerns of service members that have emerged after de- ployment. Like the pre-deployment health assessment and the PDHA, the PDHRA is first completed by the service member, who is then interviewed by a health care provider about any deployment-related health concerns. If it is appropriate, the service member is referred for further evaluation. The PDHRA was first fielded in the Army in 2005 and is now administered in all the services, including the National Guard and reserve components. Because many service members have had repeat deployments, many have multiple forms on file. Information from these screening instruments is centralized in a database maintained by the Armed Forces Surveillance Center, which allows researchers and health care providers to review them on a popula- tion basis and individually. About one-fourth of those deployed to Iraq and Afghanistan have been National Guard and reservists (IOM, 2010b). Like active-duty ser- vice members, National Guard and reserve service members are required to complete the predeployment and postdeployment health assessments. Because the PDHRA is administered 3–6 months after return from deploy- ment and National Guard and reserve service members may have returned to their civilian roles by that time, the PDHRA may be administered on drill weekends or by telephone. In 2006, the Periodic Health Assessment (PHA) was initiated for all active-duty and selected reserve service members (DoD, 2004, 2006). Those “who are not TRICARE beneficiaries and not eligible for services under any DoD program, but who require further evaluations, treatments, care, or clinical preventive services should be referred to their civilian health care providers” (DoD, 2006). Reservists who are not part of the selected group are given a similar periodic examination, the Reserve Component Periodic Health Assessment. Both health assessments are annual screens to assess changes in health status and medical readiness, especially changes in health that may affect a service member’s ability to perform military duties. The PHA and the Reserve Component Periodic Health Assessment are given by a health care provider and include information about current and previ- ous medical conditions, laboratory tests and other screening results (for example, tests for cholesterol and triglycerides, vision, hearing, and dental conditions), immunizations, and health behaviors (for example, tobacco use, alcohol and substance dependence, occupational stresses, suicidal ide- ation, and other mental health concerns). The health care provider reviews the medical record and makes referrals for additional care or evaluation as necessary (GAO, 2008a). The benefit of the annual screen for all service

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121 PROGRAMS AND SERVICES FOR PTSD members is that it identifies changes in health status in people who have not been recently deployed. The committee heard during its open sessions about the controversy associated with receiving a diagnosis of PTSD during deployment. In com- bat settings, military mental health providers assess fitness for duty and work with commanders who are focused on maintaining readiness, combat power, and unit cohesion (Warner et al., 2011). Although traumatic-event management—whose purpose is to decrease the effect of the potentially traumatic event and prevent long-term adverse consequences—is provided to individuals and units after an incident, military mental health providers may be hesitant to diagnosis acute stress disorder (ASD) or PTSD in a war zone. The committee heard that some possible explanations for this reluc- tance include providers believing or being taught that PTSD cannot be di- agnosed in the theater of war because the trauma is still ongoing, although the termination of potential trauma exposure is not part of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria (APA, 2000); some providers may feel pressure to evacu- ate people who have PTSD from the theater of war, potentially adversely affecting unit cohesion and readiness; and providers are encouraged to use another less stigmatizing term for PTSD, such as combat stress reaction or adjustment reaction, to explain symptoms of ASD or PTSD. In some cases, the use of those terms might be accurate, but a potential consequence of not diagnosing ASD or PTSD is the subsequent failure to then use appro- priate evidence-based treatments for these disorders. For example, combat stress reaction is treated through the use of the BICEPS model—brevity, immediacy, centrality or contact, expectancy, proximity, and simplicity. However, the BICEPS model does not include a recommendation for the use of evidence-based cognitive behavioral treatments for ASD or PTSD, and therefore, may result in the DoD overlooking or avoiding the use of treat- ments that appear to have the strongest evidence for their efficacy for the treatment of these disorders. Some mental health providers related concerns from service members who believed that focusing on their trauma while deployed would result in a loss of their ability to remain mission ready, and some mental health providers thought that effective treatments in combat settings would require hospitalization or aeromedical evacuation out of the theater of war, and that some treatments for ASD and PTSD might increase a service member’s risk for suicide. However, mental health providers do not express the same reservations about the use of psychotropic and sleep medications by a deployed service member as they did about the use of cognitive behavioral therapy (CBT) in combat settings. Screening for PTSD in the DoD most commonly uses questions from the Primary Care PTSD (PC-PTSD) screen that are incorporated into lon- ger surveys (such as the PDHA and the PDHRA) or the PTSD Checklist.

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154 PTSD IN MILITARY AND VETERAN POPULATIONS Medical Research and Material Command, which is headquartered at Fort Detrick, Maryland. Psychologic health research managed by the Medical Research and Material Command totaled $524 million in FY 2006–2011 (255 projects); 57% of that research ($297 million, 162 projects) pertained to PTSD, 21% ($110 million, 24 projects) pertained to suicide, and 10% ($53 million, 25 projects) pertained to resilience (Hoover, 2011). The VA has a separate line-item appropriation for research and devel- opment. During FY 2010, the VA research and development budget was $581 million (OMB, 2010), which supported more than 2,000 studies at VA facilities (U.S. Congress, 2011). The research portfolio is broad—from preclinical studies that use animal models or human biologic specimens, to health services and translational research—and includes large cooperative studies. VA researchers collaborate closely with academic affiliates and also receive funding from sources outside VA, including the NIH, nonprofit associations, and industry. Many VA medical centers have established VA- affiliated nonprofit research foundations that facilitate collaboration and that leverage VA research funding. A recent GAO report noted that during FY 2009, VA research fund- ing for PTSD totaled $24.5 million (4.8% of the VA research budget, an increase from 2.5% in FY 2005) (GAO, 2011e). The funding supported 96 intramural research studies in PTSD. VA research funding ($6.6 million) for one of the largest randomized controlled trials of PE in female veterans has recently concluded. The study provided a foundation for the VA’s initiative to expand evidence-based treatment for PTSD throughout the system. The VHA Office of Research and Development has focused its efforts on prevention and diagnosis of, and treatment for, PTSD using many ap- proaches. Research related to psychotherapy has included virtual reality simulations and guided imagery, and on the basis of strong positive research findings, the VA has systematically adopted PE. Other research has focused on pharmacotherapy, determining the biologic basis of PTSD (by eliciting the role of stress-related hormones and examining functional brain images), and examining clinical and lifestyle factors that may increase or decrease a person’s risk of PTSD. Additional research initiatives include collaborat- ing with the DoD to create a PTSD registry and developing and improving telehealth models to improve PTSD care, especially for veterans in rural areas (VA, 2010b). With clinical-care appropriations, the VA funds 10 mental illness re- search, education, and clinical centers that are located throughout the system. The centers were established to research the causes and treatments of mental disorders and to apply new knowledge to the VA’s routine clini- cal practice. Four of the centers have at least a partial emphasis on PTSD and postdeployment issues, and all may conduct studies relevant to PTSD and its comorbidities. Two new VA PTSD centers of excellence focus on

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155 PROGRAMS AND SERVICES FOR PTSD TABLE 4-3 Current Clinical Trials on PTSD Funded by the DoD, the VA, and the NIH by Topic Areaa Topic Area DoD VA NIH Epidemiologic 1 13 1 Neurobiologic 3 4 8 Resilience/Prevention 2 6 Assessment 1 Treatment CAM 7 16 Comorbidities 3 31 5 Delivery 8 17 Pharmacotherapy 8 29 5 Psychosocial 10 32 5 Rehabilitation/Disability 1 4 Otherb 2 8 4 Totalc 33 131 21 a This list reflects the number of studies that were found on Clinicaltrials.gov on April 4, 2012. b Primary focus of study is not PTSD. c This sum denotes the total number of studies identified on the website. Studies were classified under multiple categories, so the sum of studies for each organization may exceed the total. coordinated care for veterans returning from OIF and OEF, including co- ordination of care for those who have PTSD. The VA’s strategic plans for PTSD research include increased cooperation with DoD, the NIMH, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration. Clinical trials on PTSD that are sponsored by the DoD, the VA, and the NIH are shown in Table 4-3. The committee categorized these studies by topic area. The number of studies on the Clinicaltrials.gov website changes frequently as studies are funded, completed, or discontinued. As can be seen from the table, the VA funds about four times as many studies on PTSD as does the DoD. Most of the studies funded by the NIH might be considered basic research on PTSD. COST CONSIDERATIONS It is difficult to estimate the costs of screening and treating for PTSD in DoD and VA settings. Screening for PTSD in civilian primary care settings is likely to be similar in cost to screening for depression, which cost $23 per patient in 2004 (National Business Group on Health, 2011). However, that is unlikely to reflect the costs of screening in VA or DoD settings because of differences in how care is organized and delivered. In addition to the cost of resources directly involved in screening (which

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156 PTSD IN MILITARY AND VETERAN POPULATIONS primarily involve caregiver time), false positive results increase the cost of screening by leading to further testing and inconvenience. For people who screen positive, adequate resources need to be in place to cover the costs of treatment. Finally, in addition to the direct benefits of treatment to people, screening and early intervention may lead to economic benefits in averting productivity loss associated with PTSD. Not factored into the cost projections are substantial administrative expenditures associated with managing and overseeing the screening and general and specialized mental health treatment programs. To the committee’s knowledge, there have been only two studies of the costs associated with PTSD. The first, originally published in a RAND report (Eibner, 2008) and later updated by Kilmer et al. (2011), used a microsimulation model to estimate the burden of PTSD from a societal perspective. The second was a naval postgraduate school master of science thesis (Kwan and Tan, 2008) that used administrative data from MTFs and TRICARE to estimate costs of PTSD treatment. In the RAND microsimulation model (Eibner, 2008; Kilmer et al., 2011), future costs of PTSD in a hypothetical group of simulated people were computed. The group was based on the 261,827 soldiers who were deployed as part of OEF or OIF on June 30, 2008, and their health care trajectories and costs were modeled over a 2-year period. As part of the simulation, the hypothetical people were allowed to experience comorbid conditions, health care treatments, and secondary outcomes, such as un- employment. An advantage of that approach is that PTSD could be treated as a chronic condition with episodes of remission and relapse. Probabilities associated with the course of disease (for example, receipt of evidence-based treatment, remission, and relapse) were based on published studies. Costs of health care services were based on published TRICARE and Medicare reimbursement rates, and pharmaceutical costs were based on average wholesale prices. Costs of secondary outcomes, such as unemployment and suicide, were gathered from published studies. The studies estimated that costs associated with PTSD for service members returning from Iraq and Afghanistan ranged from $708 million to $1.2 billion, which translated into a cost per patient of $5,904–$10,298 in the 2 years after discharge from the military. The majority of the costs were due to productivity loss, which accounted for 55.3–94.5% of total costs (Eibner, 2008). Only 4% of the cost was attributable to treatment (Kilmer et al., 2011). The Kwan and Tan study (2008) took a different approach, using ad- ministrative data from FY 2001–2006 to estimate costs from the perspec- tive of the military health care system of treatment for PTSD. The analyses examined officers and enlisted personnel separately and estimated costs by branch of service. Overall, the authors found that costs varied considerably by location of care (MTF versus TRICARE) and branch of service. Among

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157 PROGRAMS AND SERVICES FOR PTSD officers, inpatient costs per patient ranged from $7,027 to $12,954 for PTSD treatment among the four military services, outpatient costs from $1,812 to $3,514, and pharmacy costs from $125 to $238. TRICARE inpatient costs ranged from $2,917 to $28,986, and outpatient costs from $976 to $1,106; no pharmacy costs under TRICARE were reported. Costs among enlisted personnel were similar, ranging from $10,723 to $12,954 for inpatient care in an MTF and from $684 to $1,130 for outpatient care received from TRICARE providers. It was not clear whether these were an- nual costs or costs over the entire study period (FY 2001–2006). Another limitation was the small sample sizes for some types of care in some of the services and outliers, which can have a considerable effect on the mean. For example, only two people who served in the Marine Corps received inpatient services from a TRICARE provider. In addition to those published studies, there are some data from the VA on the costs of specialized PTSD programs, which treat about 25% of veterans who have PTSD. In FY 2010, the VA spent $112,460,032 on specialized outpatient PTSD programs that served 105,531 veterans, for an average cost of $1,066 per veteran. Veterans averaged 10.2 visits per year in those programs, for a cost of $105 per visit (NEPEC, 2012b). The VA also spent $42,716,581 on specialized intensive PTSD programs in FY 2010 (NEPEC, 2012c); the 5,128 admissions during the year cost an average of $8,330. Cost data on PTSD services delivered outside the specialized pro- grams have not been reported (NEPEC, 2012c). Thus, it is difficult to monetize the costs of PTSD treatment. Although the microsimulation model estimated societal costs associated with PTSD, few details were given about the costs of treatment. The Kwan and Tan study also lacked the detail needed for a thorough assessment of PTSD treatment costs. Although some data are available from the VA, they are limited to specialized programs, which treat a minority of PTSD patients. Finally, no data on costs of PTSD services have been reported by the DoD. SUMMARY The DoD and the VA have played an active and pivotal role in the prevention of, screening for, diagnosis of, and treatment for PTSD. This chapter has sought to describe what is known about mental health care, specifically care for PTSD, in the DoD and the VA. Both organizations have contributed much time, funding, and effort to PTSD health care and research. The foundational information provided in this chapter has set the stage for further discussion of PTSD prevention and prophylaxis, screen- ing, diagnosis, treatment, co-occurring medical conditions and psychosocial complexities, and barriers to, facilitators of, and access to care. In phase 2 of this study, the committee will gather data from the DoD

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