5

Prevention

Prevention of posttraumatic stress disorder (PTSD) in active-duty and veteran populations is important to support their overall health and well-being, to preserve personnel resources, and to maximize force readiness. This chapter examines prevention of and prophylaxis for PTSD in active-duty and veteran populations. It begins by defining primary, secondary, and tertiary prevention and then summarizes the state of the science with regard to prevention programs and current research. That is followed by a discussion of what the Department of Defense (DoD) and the Department of Veterans Affairs (VA) are doing with regard to prevention at each level and a discussion of the VA/DoD guideline and other guidelines and programs, including evidence of the efficacy of prevention programs.

OVERVIEW OF PTSD PREVENTION

Prevention is broadly defined as measures taken to avoid the occurrence of disease or “interventions that are applied before the onset of a clinically diagnosable disorder with the aim of reducing the number of new cases of that disorder” (Munoz et al., 1996, as cited by Boyce et al., 2007). The term can also be applied to an intervention aimed at limiting the disorder’s progression, relapse, or associated disability. Prevention of PTSD in active-duty personnel is provided via programs aimed at preparing service members for combat and other deployment-related stressors. Some programs focus on reducing the risk of exposure to traumatic events (such as interventions aimed at reducing the risk of military sexual trauma) and on training service members to respond effectively to such events if they occur.



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5 Prevention P revention of posttraumatic stress disorder (PTSD) in active-duty and veteran populations is important to support their overall health and well-being, to preserve personnel resources, and to maximize force readiness. This chapter examines prevention of and prophylaxis for PTSD in active-duty and veteran populations. It begins by defining primary, sec- ondary, and tertiary prevention and then summarizes the state of the science with regard to prevention programs and current research. That is followed by a discussion of what the Department of Defense (DoD) and the Depart- ment of Veterans Affairs (VA) are doing with regard to prevention at each level and a discussion of the VA/DoD guideline and other guidelines and programs, including evidence of the efficacy of prevention programs. OVERVIEW OF PTSD PREVENTION Prevention is broadly defined as measures taken to avoid the occurrence of disease or “interventions that are applied before the onset of a clinically diagnosable disorder with the aim of reducing the number of new cases of that disorder” (Munoz et al., 1996, as cited by Boyce et al., 2007). The term can also be applied to an intervention aimed at limiting the disorder’s pro- gression, relapse, or associated disability. Prevention of PTSD in active-duty personnel is provided via programs aimed at preparing service members for combat and other deployment-related stressors. Some programs focus on reducing the risk of exposure to traumatic events (such as interventions aimed at reducing the risk of military sexual trauma) and on training service members to respond effectively to such events if they occur. 165

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166 PTSD IN MILITARY AND VETERAN POPULATIONS Other prevention efforts seek to detect and treat disorder in its early stages (for example, treat those who meet the criteria for acute stress dis- order [ASD]) often before it presents clinically as chronic PTSD. Several studies (for example, Bryant et al., 1999, 2003; Shalev et al., 2011) have demonstrated that early interventions for ASD result in significant reduc- tions of ASD symptoms and the prevention of the onset of PTSD in the majority of individuals treated. Prophylactic interventions can be imple- mented immediately after a trauma (within 48 hours) or during the acute period (within weeks) to prevent full onset of PTSD symptoms (Litz, 2008), although the efficacy of this approach is unknown. And prevention may refer to measures taken to mitigate the consequences of existing symptoms by improving functioning and reducing complications. The latter type of PTSD prevention includes interventions in patients who have subthreshold PTSD symptoms, ASD, and ancillary problems; it provides treatment for clinical PTSD and recurrence prevention through rehabilitation programs. Treatment and rehabilitation programs for PTSD are covered in depth in Chapter 7 and 8, respectively; the present chapter discusses interventions to limit the development of clinical PTSD (that is, beyond subclinical symp- toms) and to prevent recurrence. Prevention is considered here in three phases: 1. Interventions that are applied to an entire population before a traumatic event and regardless of the potential for exposure. These are often called primary or universal interventions. 2. Interventions that are applied to individuals who are known to have been exposed to a traumatic event and thus to be at risk for PTSD and who may or may not be showing symptoms of stress. These are called secondary or selective interventions. 3. Interventions aimed at individuals who are displaying symptoms of or have received a diagnosis of PTSD with the goals of preventing worsening of the symptoms and improving functioning. These are called tertiary or indicated interventions. As noted by Lau and Rapee (2011), universal interventions do not require screening, and they reduce the possibility that specific persons will be labeled unfavorably by others for having a mental illness. Selective and indicated interventions are targeted at persons viewed to be vulnerable, and therefore, pose a risk that such persons will be labeled as mentally disor- dered and viewed unfavorably.

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167 PREVENTION PRETRAUMA PREVENTION EFFORTS Much research related to the prevention of trauma has focused on the prevention of unwanted sexual contact in civilian and military populations (Casey and Lindhorst, 2009; Exner and Cummings, 2011; Langhinrichsen- Rohling et al., 2011; McMahon and Banyard, 2012; Moor, 2011; Moynihan and Banyard, 2008; Rau et al., 2011; Vladutiu et al., 2011). Research has identified modifiable and nonmodifiable risk factors for unwanted sexual contact in these populations. Those data have been used to inform the development of preventive interventions in both civilian and military per- sonnel. Modifiable factors include unit culture, whereby reporting sexual assault by a fellow service member may considered to be “breaking a code” and may result in ostracization; leadership behavior that may implicitly or explicitly condone, tolerate, or ignore sexual assault and harassment; and facilitating situations such as excessive use of alcohol by any of the involved parties (Allard et al., 2011; Sadler et al., 2001; Street et al., 2009; Suris and Lind, 2008). Nonmodifiable risk factors among service members include female sex, young age, low rank, and prior sexual abuse history. Several prevention programs in civilian populations and in the U.S. military have focused on decreasing the likelihood that individuals exposed to trauma will develop PTSD. Many of the programs emphasize the devel- opment of mental or emotional resilience. In this context, mental resilience refers to a person’s capacity to adapt or change successfully in the face of adversity (Pietrzak et al., 2010b). Most importantly, resilience and PTSD appear to be inversely correlated (Nishi et al., 2010). Those who perceive a trauma as a crisis but are able to confront distressing memories and emo- tions and integrate them into a coherent meaning may be resilient, whereas those who cope by avoiding distressing emotions appear to be at risk for PTSD (Larner and Blow, 2011). In a RAND report on resilience factors in military personnel, Meredith et al. (2011) found 20 evidence-informed factors associated with resilience. Individual-level factors were positive cop- ing, positive affect, positive thinking, realism, behavioral control, physical fitness, and altruism. Family-level factors were emotional ties, communi- cation, support, closeness, nurturing, and adaptability. Military unit-level factors were positive command climate, teamwork, and cohesion. And community-level factors were belongingness, cohesion, connectedness, and collective efficacy. Other factors thought to protect against the development of PTSD are social support and confidence in the military mission and training. Pietrzak et al. (2010b) found that resilience, unit support, and postdeployment social support are psychosocial buffers of PTSD even at 2 years after deployment in veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). In a study of U.S. Air Force medical personnel deployed

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168 PTSD IN MILITARY AND VETERAN POPULATIONS to Iraq or Afghanistan, unit cohesion, positive attitudes about the military mission and the military in general, and confidence in their military training were all protective factors for PTSD when service members were experienc- ing increased combat-related or health-care–related stressors (Dickstein et al., 2010). Some early work suggested that characteristics of deployment condi- tions and support are risk factors or protective factors for PTSD. The Mental Health Advisory Team surveyed marines and soldiers deployed to OEF and OIF in 2006 and found the level of combat experienced was the most important determinant of their mental health (MHAT, 2006). Similar to deployment stressors reported by 1990–1991 Gulf War veterans, OEF and OIF deployment stressors include being in the vicinity of explosions, direct combat duty, witnessing death of a person, being exposed to dead and dismembered bodies, and having a combat-related injury (IOM, 2008). In a sample of active-duty, National Guard, and reserve soldiers deployed in the 1990–1991 Gulf War, the stressors most highly associated with PTSD were all combat related and included having a buddy killed or wounded in action, exposure to dead or dying people, and being fired on by the enemy (Stretch et al., 1996). In a 2003 survey of combat infantry service members (2,856 soldiers and 815 marines) deployed to either Iraq or Afghanistan, Hoge et al. (2004) found the majority had been attacked or ambushed; shot at; saw dead bodies or human remains; received incoming artillery, rocket, or mortar fire; or knew someone who was seriously injured or killed. Fewer combat experiences were reported for soldiers deployed to Afghanistan than those deployed to Iraq; however, rates of PTSD increased with more exposure to firefights and for service members who were wounded or in- jured. See Table 5-1 for the combat experiences reported by the soldiers and marines surveyed. A recent study found that soldiers who reported higher preparedness appraised the threat involved in different levels of combat exposure more realistically, whereas less prepared soldiers perceived even low-level combat as highly threatening (Renshaw, 2011). Perceived threat is thought to be an important link between combat experience and PTSD (the greater the perceived threat, the greater the likelihood of developing PTSD after the experience) (Green et al., 1990; King et al., 1995, 2008; Vogt and Tanner, 2007). Preparedness, therefore, may play a role in the development of PTSD through its relation with perceived threat. If service members are better prepared, they may perceive specific situations as less threatening (Renshaw, 2011). Other studies suggest a positive influence of high levels of unit sup- port and cohesion on mental health in UK and U.S. soldiers in OEF and OIF who experienced combat (Brailey et al., 2007; Dickstein et al., 2010; Du Preez et al., 2012; Rona et al., 2009). Receiving support from one’s unit during deployment may promote soldiers’ resilience to PTSD by increasing

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169 TABLE 5-1 Combat Experiences Reported by Members of the U.S. Army and Marine Corps Following Deployment to Iraq or Afghanistan Army Groups Marine Group % in Afghanistan % in Iraq % in Iraq Experience (n = 1,962) (n = 894) (n = 815) Being attacked or ambushed 58 89 95 Receiving incoming artillery, 84 86 92 rocket, or mortar fire Being shot at or receiving small- 66 93 97 arms fire Shooting or directing fire at the 27 77 87 enemy Being responsible for the death 12 48 65 of an enemy combatant Being responsible for the death 1 14 28 of a noncombatant Seeing dead bodies or human 39 95 94 remains Handling or uncovering human 12 50 57 remains Seeing dead or seriously injured 30 65 75 Americans Knowing someone who was 43 86 87 seriously injured or killed Participating in demining 16 38 34 operations Seeing ill or injured women or 46 69 83 children and being unable to help them Being wounded or injured 5 14 9 Having a close call, being shot Not asked 8 10 or hit, but being saved by protective gear Having a buddy shot or hit Not asked 22 26 nearby Clearing or searching homes or 57 80 86 buildings Engaging in hand-to-hand 3 22 9 combat Saving the life of a soldier or 6 21 19 civilian SOURCE: Adapted with permission from Hoge et al., 2004.

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170 PTSD IN MILITARY AND VETERAN POPULATIONS self-efficacy (belief in one’s ability to handle situations or perform well) or mitigating the psychologic consequences of war zone stressors through strengthened coping abilities. Studies of OEF, OIF, and Vietnam veterans have also documented post-event social support as a strong predictor of PTSD and other psycho- pathologic conditions (Brewin et al., 2000; Fikretoglu et al., 2006; Fontana et al., 1997; King et al., 1998; Pietrzak et al., 2009; Taylor and Seeman, 1999). Receiving support from others after a traumatic event may enhance a person’s coping abilities or influence how he or she evaluates the stressful situation and later reacts to it emotionally and behaviorally and may buffer the psychologic consequences of traumatic events. Psychologic resilience and social support are hypothesized to protect against the development of both PTSD and depression and may preserve or improve functioning in those with PTSD. In a study of 284 OEF and OIF veterans with and with- out PTSD, Pietrzak et al. (2009) found that veterans without PTSD had a higher resilience score than those with PTSD; the greatest difference was in personal control, and this suggests lower coping self-efficacy in those with PTSD. Longer dwell time, at least twice the length of the deployment, has also been shown to reduce the odds of PTSD and other mental health disorders (MacGregor et al., 2012). See Chapter 2 for a longer discussion on the effect of dwell time and PTSD. A relatively new concept associated with PTSD is that of posttraumatic growth—positive personal changes resulting from coping with a traumatic event. This concept is being explored, as is enhancement of resilience and hardiness, as a method for protecting against adverse sequelae, such as PTSD and depression, in military personnel who experience extreme stress and trauma (Gallaway et al., 2011; Larner and Blow, 2011; MacDermott, 2010; Nelson, 2011; Pietrzak et al., 2010a; Prati and Pietrantoni, 2009; Tedeschi, 2011). The effectiveness of programs to encourage posttraumatic growth has yet to be determined. INTERVENTIONS FOR TRAUMA-EXPOSED PEOPLE Interventions to prevent PTSD in trauma-exposed persons are aimed at interfering with overconsolidation of the fear memory and accelerating ex- tinction of the fear memory. The interventions may be pharmacologic or be- havioral and may be given to all exposed persons or targeted to people who show high levels of acute distress. This section reviews research on early psychosocial interventions for the prevention of PTSD. First, psychologic debriefing that is usually conducted immediately or within few days after a traumatic event is reviewed and then the literature on cognitive behavioral therapy (CBT) and non-CBT interventions used for severe PTSD symptoms or ASD within the first month after the trauma is discussed.

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171 PREVENTION Immediate psychoeducation and advice for acute distress management and such interventions as psychologic support, nonspecific stress man- agement, family interventions, and family-centered decision making have all been proposed to prevent PTSD, but no randomized controlled trials (RCTs) have been conducted to demonstrate their efficacy. Psychoeducation can be used to encourage resiliency and adaptation and, ultimately, help- seeking, but its content and dissemination need to be appropriate for the audience and time after trauma exposure (Wessely et al., 2008). The use of CBT in the weeks or days after exposure for people who display symptoms of posttraumatic stress have proved to be effective in RCTs and meta- analytic reviews, but there are no studies of the use of CBT immediately after trauma exposure. These effective trauma-focused therapies include psychoeducation, relaxation and stress management, affective expression and modulation, cognitive coping, prolonged imaginal exposure, in vivo exposure, and cognitive reprocessing. The use of multisession psychologic interventions delivered up to 72 hours after trauma does not appear to be effective in preventing PTSD (Agorastos et al., 2011). Evidence on the use of collaborative care interventions (discussed in more detail later in the chapter) and virtual-reality–based interventions (Agorastos et al., 2011) is still lacking. Psychologic Debriefing Psychologic debriefing includes a variety of single-session individual and group interventions that involve survivors’ or other affected persons’ revisiting of the trauma for the purpose of encouraging them to talk about their experiences during the trauma; to recognize and express their thoughts, emotions, and physical reactions during and since the event; and to learn coping methods. Specially trained debriefers lead the sessions, which usu- ally focus on normalization of symptoms, group support, and provision of psychoeducation and information about resources. Two main psychologic debriefing protocols have been examined empirically. Critical incident stress debriefing (CISD) is a group-based formalized structured review that was first developed to assist first responders, such as fire and police personnel, and has expanded to include disaster victims and their relatives. Critical incident stress management includes precrisis intervention, disaster or large- scale incident demobilization and informational briefings, “town meetings,” staff advisement, defusing, CISD, one-on-one crisis counseling or support, family crisis intervention, organizational consultation, and follow-up and referral mechanisms for assessment and treatment. Most RCTs that have examined psychologic debriefing for the preven- tion of PTSD have used individually administered, one-time debriefings of victims of motor vehicle incidents or crimes, such as rape. Numerous

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172 PTSD IN MILITARY AND VETERAN POPULATIONS reviews and meta-analyses of these studies have determined that this treat- ment is ineffective and sometimes even harmful (McNally et al., 2003; Rose et al., 2002). In particular, two RCTs that included long-term follow-up indicated that psychologic debriefing may be related to a poorer outcome than that in controls (Bisson et al., 1997; Mayou et al., 2000). However, the two studies suffered from methodologic flaws so it cannot be presumed that early interventions can interfere with recovery. Bisson et al. (2009) re- viewed 10 studies that compared psychologic debriefing with wait list (WL) and found that two studies showed that psychological debriefing decreased PTSD symptoms compared with results of WL, five showed no difference between the two methods, and three showed that people who received the intervention experienced worsened PTSD symptoms compared with results of WL. Overall, Bisson et al. found no evidence to support the preventive value of individual debriefing delivered in a single session. Cuijpers et al. (2005) reviewed studies examining psychologic debriefing and found the risk of PTSD was somewhat, but not statistically significantly, increased after debriefing. Similarly, a meta-analysis of individual, single-session in- terventions immediately after a trauma found that non-CISD interventions (which typically included 30 minutes of individual counseling, education, and group debriefing focusing on the objective facts pertaining to the disas- ter or trauma) and an absence of intervention improved symptoms of PTSD but that CISD did not (van Emmerik et al., 2002). Deahl et al. (2000) found no difference in PTSD symptoms between patients who received group-based debriefing and those who received as- sessment. Campfield and Hills (2001) randomly assigned robbery victims to immediate CISD (sooner than 10 hours) or delayed CISD (later than 48 hours) and found that immediate CISD produced more pronounced reduc- tion in PTSD symptoms. However, the findings are limited by the lack of a control group, and it is unclear how many people would have recovered without the need for an intervention. No conclusions regarding treatment efficacy can be drawn from other studies (e.g., Eid et al., 2001; Richards, 2001) because they used small samples and nonrandom assignment. Two RCTs conducted by Adler et al. examined group psychologic de- briefing in military samples. Adler et al. (2008) randomized 1,050 soldiers who served in Kosovo as peacekeepers into 62 groups that were subjected to three conditions—CISD (23 groups), stress education (20 groups), and WL (19 groups)—and focused on the entire deployment period. No dif- ferences were found between groups with respect to all mental health outcomes, although it should be noted that soldiers in this study experi- enced relatively few traumas. In a second RCT, Adler et al. (2009) studied U.S. soldiers returning from Iraq who had been exposed to direct combat throughout their deployment. Soldiers received either stress education or Battlemind debriefing (Battlemind is an Army program to foster resilience;

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173 PREVENTION see the “Prevention Efforts in the Army” section for more information on Battlemind). The authors (2009) found that Battlemind debriefing did not result in a reduction in PTSD symptoms compared with stress education. In a review of RCTs of psychologic debriefing immediately after trauma exposure, Agorastos et al. (2011) found no evidence of its efficacy in re- ducing PTSD symptoms. In summary, there is no evidence of efficacy of psychologic debriefing in preventing PTSD in trauma-exposed people. And there is insufficient evidence of the efficacy of group psychologic debriefing in PTSD prevention. Brief Early Interventions Treatment of early symptoms of PTSD usually begins with CBT in an effort to prevent the development of chronic PTSD (Feldner et al., 2007). Brief specialized interventions (for example, four or five sessions) delivered within weeks of a traumatic event may effectively prevent PTSD in survi- vors of sexual and nonsexual assault (Foa et al., 1995), motor vehicle inci- dents, industrial accidents, and traumatic brain injuries (Bryant et al., 1998, 1999, 2003). Trauma-focused CBT has also been found to be effective in both reducing and preventing PTSD symptoms in people who experienced PTSD symptoms soon after a traumatic event and those who met the crite- ria for ASD (Roberts et al., 2009a; Stapleton, 2006). This particular inter- vention focused on the traumatic experience through memories and trauma reminders, sometimes combined with cognitive therapy or other behavioral interventions. Another study showed that combined imaginal and in vivo exposure is significantly more effective than cognitive restructuring only in reducing PTSD in people diagnosed with ASD (Bryant et al., 2008). Ehlers et al. (2003) found that CBT was more effective in reducing symptoms than a self-help booklet or repeated assessment. In a pilot RCT, Kazak et al. (2005) studied stress in caregivers of chil- dren who had new diagnoses of cancer. A three-session integrated CBT and family-therapy intervention, surviving cancer competently intervention program—newly diagnosed (SCCIP-ND), was compared with the usual treatment. Results indicated that families who received SCCIP-ND had lower anxiety and parental posttraumatic stress symptoms than families that did not. Zatzick et al. (2004) found that in acutely injured trauma survivors, a stepped-care approach of CBT, pharmacotherapy, or a combination of the two for 6–12 months after injury did not reduce PTSD, but fewer patients developed PTSD than in the usual-care group when pharmacotherapy or CBT was initiated 3 months after injury. Roberts et al. (2009b) conducted a meta-analysis of early interventions (within 3 months of trauma) for the prevention of PTSD. If patients received an intervention regardless of

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174 PTSD IN MILITARY AND VETERAN POPULATIONS their symptoms, there was no statistically significant difference between those who received and those who did not receive an intervention. If pa- tients who manifested traumatic-stress symptoms received an intervention within 3 months of a traumatic event, significant differences were found in those who received trauma-focused CBT and supportive counseling (but not structured writing) compared with controls. In those who were given a diagnosis of ASD or acute PTSD within 3 months of a trauma, only trauma-focused CBT resulted in significant improvement compared with the WL control or supportive counseling. The authors concluded that multiple-session interventions aimed at everyone exposed to trauma were ineffective and that people who were symptomatic but did not have a diag- nosis of PTSD showed a variable response. Those who had diagnosed ASD or PTSD showed the greatest response to intervention within 3 months of the trauma. A few other non-CBT interventions have been examined as potential preventive treatments for PTSD, but none have been found to be effective in reducing or preventing PTSD symptoms. For example, brief structured writ- ing has been found ineffective in preventing PTSD in two studies (Bugg et al., 2009; van Emmerik et al., 2008) and a memory-restructuring interven- tion was no more effective than a control condition (Gidron et al., 2007). Providing self-help information as a preventive psychoeducation strategy has not been found efficacious (Scholes et al., 2007; Turpin et al., 2005). Two caveats should be noted. First, it has yet to be determined how much time should pass before CBT interventions are used in traumatized people (Litz and Bryant, 2009). If prophylactic treatment is provided too early, people who may not need therapy will consume valuable resources; it is for this reason that trials do not usually begin before 2 weeks after the trauma (Bryant et al., 1998, 1999, 2003). Second, studies that have targeted all trauma survivors, regardless of the levels of stress reactions, have not been effective in preventing PTSD (Roberts et al., 2009a). Pharmacotherapy It is standard practice to manage acute PTSD symptoms by using phar- maceuticals to inhibit sleep disturbance, pain, or hyperarousal. However, it is unknown whether that helps to prevent the development of PTSD. The VA/DoD guideline states that “due to the limited support of evidence, the use of medications in the early posttrauma period to prevent PTSD cannot be recommended” (VA and DoD, 2010). Drugs that are mentioned in the 2010 VA/DoD guideline as having the potential to prevent PTSD are opi- oids, benzodiazepines, and propranolol. Research has been conducted on the use of pain medicines, especially the opioid morphine, and the preven- tion of PTSD. The work of Bryant et al. (2009) and Holbrook et al. (2010)

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175 PREVENTION showed lower rates of PTSD in patients who received pain medication after traumatic injury. The guideline states that pharmacotherapy aids in treat- ing some PTSD symptoms like pain, but it does not recommend the use of morphine to prevent PTSD. Although benzodiazepines have historically been used as effective treat- ments for anxiety and insomnia, the guidelines do not recommend their use as preventive measures “due to lack of evidence for effectiveness and risks that may outweigh potential benefits” (VA and DoD, 2010). Studies using propranolol have had mixed results, and overall the VA/DoD guideline con- cludes that despite some positive results “the size and weak study designs of the investigations do not allow for definitive conclusions regarding the value of these medications in preventing the development of PTSD symp- toms after traumatic events.” The use of hydrocortisone has also been studied in small trials. Two controlled trials in high-risk patients who had septic shock or who un- derwent cardiac surgery found that stress (high) doses of hydrocortisone administered over a few days were associated with lower rates of PTSD at long-term follow-up (Schelling et al., 2001, 2004). In a third study by the same group, hydrocortisone given at stress doses over a 4-day taper resulted in better post-operative adjustment after cardiac surgery, on the basis of measures of quality of life, stress, and PTSD (Weis et al., 2006). A prospective, randomized, placebo-controlled, double-blind trial in civilians found the best results at 1-month and 3-month follow-up with a single high intravenous dose (100–400 mg) of hydrocortisone given within hours of trauma (Zohar et al., 2011). In an RCT of early interventions with psychopharmaceuticals (Shalev et al., 2011), Israeli trauma survivors who met the criteria for PTSD received one of the following treatments for 12 weeks: weekly prolonged exposure (PE) therapy, CBT, the selective serotonin reuptake inhibitor (SSRI) escita- lopram, placebo pills, or WL. At 5 months, the prevalence of PTSD was significantly lower in the PE group (21.6%) and CBT group (20.0%) com- pared with the two WL groups (57.1% and 58.7%) (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.09–0.46, and OR 0.18, 95% CI 0.06–0.48, respectively), the SSRI group (55.6%), and the placebo group (61.9%). There was no difference in PTSD outcome between those receiving PE versus CBT (OR 0.87, 95% CI 0.29–2.62). At 9 months, the prevalence of PTSD in the PE (21.2%), CBT (22.9%), and WL (22.8%) groups was about half that in the SSRI (42.1%) and placebo (47.1%) groups. About 40% of those on the WL who initially met the criteria for PTSD no longer did so at 5 months, and only 23% met the criteria at 9 months. Trauma survivors who had symptoms of PTSD but did not meet the full criteria for PTSD at the first assessment did not benefit from CBT. Fletcher et al. (2010) reviewed the evidence on the use of pharmaceu-

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184 PTSD IN MILITARY AND VETERAN POPULATIONS • Strengthen perceived ability to cope—Practice in responding to traumatic stimuli and positive encouragement from peers and su- periors to reinforce appropriate coping techniques. • Create supportive interpersonal work environments—Social sup- port through team building, families, peer stress-management con- sultants, and leadership to protect against adverse psychologic reactions. • Develop and maintain adaptive beliefs—Realistic expectations about the experience of combat and ensuing stress reactions bol- stered by confidence in coping ability, leadership management, and the value of military service. • Develop workplace-specific comprehensive traumatic-stress man- agement programs—Encouragement of the use and promotion of the benefits of programs tailored to support service members after trauma. Other Prevention Activities Decompression at a “third location” is used by Canada and the UK to provide a transition back into the home environment. Although no formal definition exists, decompression in this situation refers to a stopover at a lo- cation that is neither home or in the theater of war, where service members may begin to unwind after leaving the theater of war (Hacker Hughes et al., 2008). A literature review by Fertout et al. (2011) states that decompression programs have common elements, including permitting units to unwind together in a structured but informal manner and having the environment of the decompression location be superior to the deployment location. The length of the decompression program is variable: the UK uses 36 hours, and Canada 5 days. Questions surrounding the use of decompression programs focus on the optimal length of the program, who should participate (all troops versus only those exposed to combat or trauma), and whether the program should be carried out at a location that is neither home nor the deployment position (Cyprus is used by the UK and Canada) but rather conducted on the troops’ home base but with adjustments (the third loca- tion). Fertout notes that the use of decompression programs has not been subjected to formal trials of efficacy, but one survey of troops just returned from decompression (Jones et al., 2011) found that although the majority initially resisted the use of the decompression program, the overwhelming majority found it to be useful after they completed the decompression pe- riod. Officers found that the time was not helpful in that they were still in charge of their troops and could not decompress. The committee will consider the emerging evidence on these and other PTSD prevention activities in phase 2 of this study.

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185 PREVENTION PREVENTION IN THE DEPARTMENT OF VETERANS AFFAIRS The VA is not involved in the early military life of active-duty personnel and thus does not have a role in preventing service members’ exposure to traumatic events. As discussed in Chapter 4, the VA/DoD integrated mental health strategy focuses on broad psychologic health and resilience activities and builds on the resilience programs in the DoD. Vet Centers also provide prevention services to veterans who may have been exposed to trauma or who are suffering from PTSD symptoms. The services are available to any veteran and have the advantage of being available for the veterans’ families as well as veterans themselves. They include individual, group, and family counseling; employment counseling; sexual counseling; and referrals to other mental health and medical health programs. There are other considerations for veterans who receive treatment at VA medical facilities. Many veterans are members of the National Guard or reserve and never expected to be deployed to a war zone. Unlike active- duty service members, National Guard and reservists may cycle between civilian and military life over several deployments with little or no support from colleagues who are familiar with the stresses of deployment, and they can face stressors such as job loss that do not affect active-duty personnel (Riviere et al., 2011). Furthermore, these service members may not receive the same level of predeployment training as active-duty personnel, and this increases the risk of PTSD after exposure to a traumatic event during deployment. VA programs and services specific to prevention and resilience include • Life Guard—This program promotes psychologic resilience based on acceptance and commitment therapy. It has been implemented at one local site and is designed to facilitate reintegration of return- ing OEF and OIF veterans (Blevins et al., 2011; Schiffner, 2011). • FOCUS—This is a family-centered preventive intervention pro- gram. It was designed on the basis of a skills-building pyschoedu- cational model that integrates traumatic-stress research, theories of child development, and the COSC model. FOCUS has been piloted and expanded to encompass more issues surrounding couples and issues surrounding wounded veterans (Schiffner, 2011); see the discussion of the Navy FOCUS program in this chapter and in Chapter 4. • Moving Forward—A Problem-Solving Approach to Achieving Life’s Goals—This is a multisite (12 sites) pilot training program that includes a four-session group-based curriculum focused on early intervention and prevention of mental health problems (not

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186 PTSD IN MILITARY AND VETERAN POPULATIONS specifically PTSD) by teaching “specific skills that veterans can use to constructively address a wide range of problems that may arise in their lives” (Schiffner, 2011). The VA has also developed a program on MST. The VA has a different definition of sexual trauma than the DoD. MST is a VA-specific term, and thus the prevalence of MST pertains only to the VA. The prevalence of MST in VA users is tracked by the Veterans Health Administration and includes experiences of sexual assault or repeated, threatening acts of sexual harass- ment (VA, 2012). The VA mandated that each facility identify a MST coor- dinator to oversee the universal screening and treatment referral process for MST. Each Vet Center also has one staff member to address issues of MST. The VA provides a guide for returning service members on what to expect after deployment and return to civilian life, including how to deal with children, spouses, family and friends, finances, and emotions. Advice is given on coping with common reactions to trauma and how to resume routine activities of work, family, and life. SUMMARY The DoD supports a number of programs that are aimed at prevent- ing the development of PTSD by building resilience and helping service members to anticipate some of the traumatic events they may experience in a combat zone. In particular, the Army has had a variety of prevention programs including Battlemind and, most recently, the CSF program that will be used for all Army personnel before deployment. The Navy and Ma- rine Corps and the Air Force have similar training. All four services also have programs to help service members who have symptoms of PTSD avoid chronic PTSD by using a variety of treatments. The VA does not have the responsibility for predeployment programs but, like the DoD, it does attempt to prevent chronic PTSD by working with veterans who have symptoms. Furthermore, the VA has programs that help veterans with PTSD to regain functioning in civilian life and to prevent further PTSD-related disability. The VA and the DoD have collaborated in the development of PTSD management guidelines to minimize the impact of PTSD on service members, veterans, and their families. While there are a variety of DoD and VA programs that target PTSD prevention, it is important to note that, at present, none of them has evi- dence for their effectiveness in preventing or reducing PTSD or stress in service members or their families. Evaluation of some of these programs is ongoing, and the committee hopes that such information will be available for phase 2 of this study.

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