1

Introduction

In response to the terrorist attacks of September 11, 2001, the U.S. military engaged in conflicts in the Middle East. Operation Enduring Freedom (OEF) began in October 2001 with troops stationed in and around Afghanistan for military and humanitarian purposes. Operation Iraqi Freedom (OIF) began in March 2003 as American-led coalition forces invaded Iraq, and it officially ended on August 31, 2010. Operation New Dawn (OND) was initiated on September 1, 2010, to reflect the changing mission of and reduction in U.S. military personnel in Iraq and officially ended on December 15, 2011; the last U.S. military personnel left that country on December 18, 2011. The conflict continues in Afghanistan, where 90,000 service members were deployed as of January 20, 2012 (ISAF, 2012). Since the beginning of the OEF and the OIF/OND conflicts, approximately 2.6 million U.S. service members have been deployed, 900,000 of them more than once (GAO, 2011b). Table 1-1 shows the breakdown of deployed service members by component and branch through April 2009 (IOM, 2010). As of April 30, 2012, a total of 1,831 American service members had been killed and 15,713 wounded in OEF. Casualty totals for OIF and OND are 4,475 military deaths and 32,225 wounded (DoD, 2012). Hereafter in this report, the term OIF will encompass both OIF and OND, unless otherwise stated.

The engagements of the U.S. military in Iraq and Afghanistan have been markedly different from prior conflicts with regard to both the service populations and the signature injuries sustained. Unlike previous wars and conflicts, OEF and OIF are distinguished by the large number of National Guard and reservists that have been deployed to Iraq and Afghanistan in



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1 Introduction I n response to the terrorist attacks of September 11, 2001, the U.S. military engaged in conflicts in the Middle East. Operation Enduring Freedom (OEF) began in October 2001 with troops stationed in and around Afghanistan for military and humanitarian purposes. Operation Iraqi Freedom (OIF) began in March 2003 as American-led coalition forces invaded Iraq, and it officially ended on August 31, 2010. Operation New Dawn (OND) was initiated on September 1, 2010, to reflect the changing mission of and reduction in U.S. military personnel in Iraq and officially ended on December 15, 2011; the last U.S. military personnel left that country on December 18, 2011. The conflict continues in Afghanistan, where 90,000 service members were deployed as of January 20, 2012 (ISAF, 2012). Since the beginning of the OEF and the OIF/OND conflicts, approxi- mately 2.6 million U.S. service members have been deployed, 900,000 of them more than once (GAO, 2011b). Table 1-1 shows the breakdown of deployed service members by component and branch through April 2009 (IOM, 2010). As of April 30, 2012, a total of 1,831 American service mem- bers had been killed and 15,713 wounded in OEF. Casualty totals for OIF and OND are 4,475 military deaths and 32,225 wounded (DoD, 2012). Hereafter in this report, the term OIF will encompass both OIF and OND, unless otherwise stated. The engagements of the U.S. military in Iraq and Afghanistan have been markedly different from prior conflicts with regard to both the service populations and the signature injuries sustained. Unlike previous wars and conflicts, OEF and OIF are distinguished by the large number of National Guard and reservists that have been deployed to Iraq and Afghanistan in 17

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18 PTSD IN MILITARY AND VETERAN POPULATIONS TABLE 1-1 Service Members Deployed by Component as of April 30, 2009 Air Marine Coast Army Navy Force Corps Guard Total Active 582,733 320,140 269,220 209,175 3,539 1,384,807 component National 239,336 N/A 65,295 N/A N/A 304,631 Guard* Reserves 125,595 33,891 38,056 37,602 228 235,372 Total 947,664 354,031 372,571 246,777 3,767 1,924,810 * Unlike the Army and Air Force, the Navy, Marine Corps, and Coast Guard do not have National Guard components. SOURCE: Adapted from IOM, 2010. addition to active-duty service members from all the services. Whereas infectious diseases and catastrophic gunshot wounds were the signature injuries of prior conflicts and wars, the hallmarks of the recent conflicts are blast injuries and the psychiatric consequences of exposure to com- bat, particularly posttraumatic stress disorder (PTSD). Recent estimates of prevalence of PTSD in service members deployed to OEF and OIF are 13% to 20% (Hoge et al., 2004; Seal et al., 2007; Tanielian and Jaycox, 2008; Vasterling et al., 2010). Of growing concern to both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) is the high prevalence of PTSD in active-duty and veteran populations. As the conflicts in the Middle East scale down and service members return home, the VA and the DoD may expect a commensurate rise in the number of OEF and OIF veterans need- ing services. To address this concern, the DoD and the VA have allocated substantial funding to foster research, develop programs, and initiate ser- vices to combat PTSD. The focus of the DoD is to maintain force readi- ness; therefore, it has invested heavily in building psychologic resilience, education, health maintenance, screening, and PTSD treatment services and programs. The VA has more than doubled its funding for PTSD research since 2005 (GAO, 2011a), targeting treatment and rehabilitation of veter- ans. Since FY 2005, the VA has added more than 7,500 full-time mental health staff and has trained, through national training initiatives, more than 3,400 VA clinicians in two evidence-based therapies for the treatment of PTSD—cognitive processing therapy (CPT) and prolonged exposure (PE). In addition, the VA has trained more than 900 DoD mental health providers in CPT and more than 120 in PE. The VA requires that all mental

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19 INTRODUCTION health services should be recovery-oriented, which means that services are strengths-based, individualized, and person-centered and allow veterans to have input into their own treatment within the range of evidence-based approaches (Schoenhard, 2011). COMMITTEE’S CHARGE In response to the number of service members and veterans who are at risk for and have received a diagnosis of PTSD, in 2009 Congress passed the National Defense Authorization Act for FY 2010. Section 726 of the act required the Secretary of Defense, in consultation with the Secretary of Veterans Affairs, to enter into an agreement with the Institute of Medicine (IOM) of the National Academy of Sciences to assess PTSD treatment programs and services in the DoD and the VA. The statement of task is shown in Box 1-1, and the legislative language calling for the study is in Appendix B. COMMITTEE’S APPROACH The present report is the first of two mandated in the legislation. Dur- ing phase 1 the committee held six meetings over about 12 months. In the first two meetings, the committee held information-gathering sessions that were open to the public, and these meetings included presentations from the sponsor (the DoD), several subject-matter experts in the DoD and the VA, veterans organizations, and service members who have PTSD. As required by the authoring legislation, the committee also visited the U.S. Army base at Fort Hood in Killeen, Texas. During its visit, the committee heard from a variety of mental health providers and from PTSD patients and their families. Additional site visits—including congressionally mandated visits to Fort Bliss in Texas and Fort Campbell in Tennessee—will be conducted during phase 2. The committee began its deliberations by determining what informa- tion would be necessary in order for it to assess the effectiveness of the multitude of treatments that are available to and used by service members and veterans who have PTSD. Information that the committee deemed important to collect included how many service members and veterans have been screened for and diagnosed with PTSD, what treatments (psy- chosocial, pharmacologic, and other) are they currently receiving, where do service members and veterans receive treatment (for example, primary care clinic, outpatient mental health clinic, specialized PTSD program, inpatient residential program), the duration and frequency of the treatment, what outcomes are tracked and for how long, what is the ratio of mental health providers to patients, and what training is given to health care providers

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20 PTSD IN MILITARY AND VETERAN POPULATIONS BOX 1-1 Statement of Task* The Institute of Medicine will convene a committee to conduct a study of on- going efforts in the treatment of posttraumatic stress disorder (PTSD). The study will be conducted in 2 phases: the focus in phase 1 will be on data gathering and will result in the initial study as noted in the congressional legislation; the focus in phase 2 will be on the analysis of data and result in the updated study. The work of the committee is dependent upon the timely delivery of data, in a usable format, from the DOD and the VA on their current PTSD programs. Phase 1 (initial report): In phase 1 of the study, the committee will collect data from the DoD and the VA on programs and methods available for the prevention (Chapter 5), screen- ing (Chapter 6), diagnosis (Chapter 6), treatment (Chapter 7), and rehabilitation (Chapter 8) of post-traumatic stress disorder. The committee will highlight col- laborative efforts between DoD and the VA in those areas (Chapter 4). Addition- ally, the committee will consider the status of studies and clinical trials involving innovative treatments of post-traumatic stress disorder that are conducted by the DoD, the VA, or the private sector, with regard to • fforts to identify physiological markers of PTSD (Chapter 3); e • fforts to determine causation of PTSD, using brain imaging studies and e studies looking at the correlation between brain region physiology and PTSD diagnoses and the results (including any interim results) of such efforts (Chapter 3); • he effectiveness of alternative therapies in the treatment of PTSD, includ- t ing the therapeutic use of animals (Chapter 7); • he effectiveness of administering pharmaceutical agents before, during, or t after a traumatic event in the prevention and treatment of PTSD (Chapter 5); and • dentification of areas in which the DoD and the VA may be duplicating i studies, programs, or research with respect to PTSD. Phase 2 (updated report): In phase 2 of the study, the committee will analyze the data received in phase 1 specifically to determine the rates of success for each program or method; and an estimate of the number of members of the Armed Forces and veterans diagnosed by the DoD or the VA as having PTSD and the number of such veterans who have been successfully treated. In addition, the committee will focus on targeted interventions at Fort Hood, Texas; Fort Bliss, Texas; Fort Campbell, Tennessee; and any other locations the committee deems necessary, including VA facilities. The committee will also exam- ine gender-specific and racial and ethnic group-specific mental health treatment services available for members of the Armed Forces, including the availability of such treatment and services; the access to such treatment and services; the need for such treatment and services; and the efficacy and adequacy of such treatment and services. Finally, the committee will examine the current and projected future annual expenditures by the DoD and the VA for the treatment and rehabilitation of PTSD; and provide recommendations for areas for future research with respect to PTSD. * Chapter references were not part of the original statement of task and are intended to guide the reader to the chapter where this topic is discussed.

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21 INTRODUCTION for treating PTSD. The committee also asked both the DoD and the VA to provide information on PTSD-related programs and services, including who is eligible for the program, where it is offered (for example, primary care, mental health clinic), what treatments are used in the program, how much it costs per participant, and what the program outcomes are. Any PTSD ser- vices and programs whether for screening, diagnosis, prevention, treatment, or rehabilitation were to be included. The committee encountered several barriers in obtaining information. The VA was helpful, and the committee was able to obtain much of the requested information from the Veterans Health Administration in a timely manner. Information received from the VA has been included in the report where relevant, but much of it may be found in Chapter 4, “Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs,” where the health systems of the VA and the DoD, their organizations, the communities they serve, and their PTSD services and programs, are described. It was more difficult to obtain information from the DoD, in part because committee’s data re- quests had to go to each of the service branches who then had to task the request to various data repositories, and once tasked, the data needed to be collected, analyzed, and approved. Identifying the correct personnel to task with the request, in spite of the assistance and preliminary information given to the committee by the staff at the DoD Defense Center of Excel- lence for Psychological Health and Brain Injury, was difficult with the result that although the information requests eventually were tasked to the Army, Air Force, Navy, and Marine Corps, the data had not been received by the committee in time to include them in this phase 1 report. The information will be updated and included in the phase 2 report. Collaborative efforts between the DoD and the VA with regard to the prevention and treatment of PTSD are described in Chapter 4. This information was obtained from expert knowledge of the committee members, Internet searches, and discus- sions with DoD and VA staff. During its deliberations, the committee conducted numerous focused searches of peer-reviewed literature, government reports, and books, manu- als, and documents relevant to PTSD. Although it is not a comprehensive literature review itself, this report constitutes a synthesis of evidence with the intent of highlighting PTSD prevention, screening, diagnosis, treatment, and rehabilitation options that are or could be used in the DoD and the VA mental health care systems. The committee did not take its task to be an evaluation of the current guidelines for the management of PTSD that are available from several organizations such as the American Psychiatric Association and the joint guideline from the VA and the DoD. Therefore, although the committee considered many studies in this report, it did not systematically review and rank each study. The committee felt that to do so would essentially be preparing another guideline, which was unnecessary and beyond its charge. Rather, the goal of presenting the studies, particu-

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22 PTSD IN MILITARY AND VETERAN POPULATIONS larly randomized controlled trials (RCTs) for the many treatment options described in Chapter 7, was to identify those widely used by the DoD and the VA as well as to help the committee identify treatments and approaches that may need further evaluation for phase 2. The term evidence based as used by the committee refers to the use of RCTs or other well-conducted studies that provide the basis for judging the efficacy of a particular treat- ment, program, or approach. The report does not discuss every aspect of PTSD: the committee con- sidered related disorders (such as acute stress disorder, depression, and ad- justment disorders) and comorbidities (such as traumatic brain injury) only as they may complicate treatment for PTSD; this is not to minimize the im- pact of those conditions and disorders on service members and veterans but rather to note that attention to ancillary illnesses is outside the committee’s charge. Furthermore, the committee did not develop an exhaustive list of all of the available PTSD programs and services available through the DoD or the VA, although both the DoD and the VA were asked to provide infor- mation on their programs in the data requests discussed earlier. However, such a list for the DoD may be found in the recent RAND report Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families (Weinick et al., 2011). The VA provided examples of prevention and specialized treatment programs, and these are described in Chapter 4. Because of the lack of information from the DoD, the committee was unable to compare all DoD services, programs, and research with those of the VA as required in the statement of task. The committee will consider the feasibility of doing this in phase 2. This report is centered on PTSD in service members and veterans that has resulted from their time in service and acknowledges that some service members may have entered the military with symptoms of PTSD and that PTSD may result from exposure to traumatic events not related to mili- tary service. PTSD in military and veteran populations has a huge impact on spouses, children, parents, and others; however, these populations do not fall within the purview of this report. The impact of PTSD on service members’ and veterans’ caregivers is presented when relevant information is available. Finally, the committee concluded that it was important to include some recommendations for the DoD and the VA in this phase 1 report rather than waiting until the completion of the phase 2 report. There are several reasons for this. First, the committee concluded that many of its recommendations could be implemented relatively quickly and that the DoD and the VA (and thus service members and veterans) should not have to wait 4 years to learn of them. Some of the recommendations might initiate or reinforce data-gathering and -tracking efforts in the DoD and the VA. Lastly, the recommendations provide action items for the DoD and the VA.

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23 INTRODUCTION ORGANIZATION OF THE REPORT This report addresses the committee’s tasks. In Chapter 2, the commit- tee summarizes the criteria necessary for a diagnosis of PTSD, discusses the epidemiology of the disorder, and introduces some of the challenges faced by mental health care providers in the diagnosis of and treatment for PTSD in military and veteran populations. Chapter 3 explains adaptive and mal- adaptive responses to stress and the neurobiology of PTSD and addresses some of the research being conducted to identify physiological markers of PTSD. The chapter also includes a discussion of innovative work to deter- mine who is at risk for PTSD and techniques such as brain imaging that may be used to more effectively diagnose and treat it. The intent of these chapters is to provide an overview of the science as the basis of prevention and treatment for PTSD. Chapter 4 offers a summary of the DoD and the VA health care systems and examples of PTSD programs and services of- fered in both departments. It also describes some examples of collaborative efforts between the DoD and the VA with regard to PTSD services, pro- grams, and research. The chapter provides a summary of some the research currently or recently being funded by the DoD, the VA, and the National Institutes of Health. Approaches to the prevention of PTSD both before and after exposure to a traumatic event, including the use of pharmacologic agents, and particularly in the military, are described in Chapter 5. Chapter 6 discusses the goals of and considerations in screening for PTSD, includ- ing the most common tools and instruments used by the DoD and the VA. The second part of the chapter differentiates screening from diagnosis and reviews the types of clinician-administered interviews used to assess PTSD symptoms and severity. Chapter 7 evaluates the evidence supporting the many options for PTSD treatment. The chapter covers not only widely used evidence-based psychosocial and pharmacologic therapies but also the evidence supporting complementary and alternative therapies such as animal-assisted therapy, and emerging treatments, such as couple therapy and virtual reality exposure. Chapter 8 is a continuation of the treatment discussion but with a focus on the treatment and rehabilitation needs of service members and veterans who have both PTSD and comorbid medical and psychiatric conditions and psychosocial treatment needs. Novel and emerging interventions are addressed where pertinent in Chapters 7 and 8, although the innovative and emerging approaches will be tackled more fully in the phase 2 report. The barriers to PTSD diagnosis and effective care encountered by service members, veterans, and their families are dis- cussed in detail in Chapter 9. This chapter also includes a description of some facilitators for the treatment of PTSD such as the use of the Internet to deliver therapy. The report ends with a summary of the committee’s key findings and recommendations and a brief discussion of plans for phase 2.

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24 PTSD IN MILITARY AND VETERAN POPULATIONS REFERENCES DoD (Department of Defense). 2012. DoD casualty reports. http://www.defense.gov/news/ casualty.pdf (accessed January 20, 2012). GAO (U.S. Government Accountability Office). 2011a. VA health care—VA spends millions on post-traumatic stress disorder research and incorporates research outcomes into guidelines and policy for post-traumatic stress disorder services. Washington, DC: GAO. GAO. 2011b. VA mental health: Number of veterans receiving care, barriers faced, and efforts to increase access. GAO 12-12. Washington, DC: GAO. Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351(1):13-22. IOM (Institute of Medicine). 2010. Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of veterans, service members, and their families. Wash- ington, DC: The National Academies Press. ISAF (International Security Assistance Force). 2012. Troop numbers & contributions: United States. http://www.isaf.nato.int/troop-numbers-and-contributions/united-states/index.php (accessed January 20, 2012). Schoenhard, W. 2011. Statement to the Senate Committee on Veterans’ Affairs. July 14, 2011. http://veterans.senate.gov/hearings.cfm?action=release.display&release_id=796c41ee- 3006-4647-b461-920653c6425e (accessed April 27, 2012). Seal, K. H., D. Bertenthal, C. R. Miner, S. Sen, and C. Marmar. 2007. Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine 167(5):476-482. Tanielian, T. L., and L. Jaycox. 2008. Invisible wounds of war: Psychological and cogni- tive injuries, their consequences, and services to assist recovery. Arlington, VA: RAND Corporation. Vasterling, J. J., S. P. Proctor, M. J. Friedman, C. W. Hoge, T. Heeren, L. A. King, and D. W. King. 2010. PTSD symptom increases in Iraq-deployed soldiers: Comparison with non- deployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. Journal of Traumatic Stress 23(1):41-51. Weinick, R. M., E. B. Beckjord, C. M. Farmer, L. T. Martin, E. M. Gillen, J. D. Acosta, M. P. Fisher, J. Garnett, G. C. Gonzalez, T. C. Helmus, L. Jaycox, K. A. Reynolds, N. Salcedo, and D. M. Scharf. 2011. Programs addressing psychological health and traumatic brain injury among U.S. military servicemembers and their families. Santa Monica, CA: RAND Corporation.