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9
Access to Care
T
he purpose of this chapter is to examine the available evidence on
barriers to (that is, factors that reduce use of) and facilitators of (that
is, factors that increase use of) high-quality care for posttraumatic
stress disorder (PTSD) in military and veteran populations. The chapter
first provides an overview of the types of barriers to high-quality PTSD care
followed by a historical overview of research on barriers to and facilitators
of PTSD treatment and related comorbid conditions for veterans in previ-
ous wars, beginning with Vietnam. The chapter then reviews the empirical
literature on barriers to and facilitators of care, distinguishing between
barriers experienced by service members and veterans in three markedly
different health care service delivery environments: in the theater of war, in
military treatment facilities in the United States, and in the Department of
Veteran Affairs (VA) health care system.
Although the existence of barriers to PTSD care (such as stigma) is
widely recognized, empirical evidence on some aspects of these barriers
remains sparse. In this chapter, the committee chose to review and place
an emphasis on peer-reviewed materials. It also chose to augment peer-
reviewed literature with information from military reports (for example,
the Mental Health Advisory Team [MHAT] reports), presentations to the
committee, and site visit meetings.
A 2008 study by the RAND Corporation of psychologic injuries and
associated treatment in military and veteran populations found that 14%
of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veterans had screened positive for PTSD. The study also found that only
slightly more than half the veterans who had psychologic injuries, including
339
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340 PTSD IN MILITARY AND VETERAN POPULATIONS
PTSD, received “minimally adequate” treatment for these injuries (Tanielian
and Jaycox, 2008). The authors of the report were unable to determine the
percentage of veterans with a PTSD diagnosis who received high-quality
care for PTSD, but their research strongly suggested that there was a large
gap between the number of service members and veterans who had PTSD
and the number who received high-quality care for it. That gap represents
extensive human suffering and lost productivity. One possible reason for the
gap between those who need care and those who are receiving high-quality
care is the existence of barriers that prevent access to high-quality care.
BARRIERS TO CARE
Research on posttraumatic care for active-duty service members and
veterans has identified a large number of possible barriers to and facilitators
of care. Barriers to care exist at the patient, provider, and institutional lev-
els. For example, patient barriers could include concern about the employ-
ment effects of seeking treatment for PTSD, a perception that mental health
care is ineffective, a lack of information on resources for care, financial con-
cerns, and logistical problems, such as travel distance (Hoge et al., 2004,
2006; Milliken et al., 2007; Warner et al., 2011). For providers, barriers
could include lack of training, lack of time, and treatment location issues,
such as transportation in the theater of war (MHAT VII, 2011a,b; Sayer et
al., 2009b; Warner et al., 2011). At the organizational level, barriers could
include rigid organizational requirements for screening and treatment and
the competing demands of force readiness in the Department of Defense
(DoD). Treatment programs requiring significant time commitments, such
as the 3-week Functional and Occupational Rehabilitation Treatment pro-
gram, are a challenge to receiving treatment because commanders may be
hesitant to approve leave for such long periods of time.
Although such external barriers as logistics and financial pressures
exist, barriers to care may also be internal and be related to a person’s at-
titudes and beliefs (Curry et al., 2011). Some internal barriers are closely
related to the construct of stigma. Stigma has been defined as a negative
and erroneous stereotype about a person (Corrigan and Penn, 1999). The
stigma process has been further described as consisting of cues, prejudice,
and discrimination (Corrigan, 2004) and may be categorized as public
stigma or self-stigma. In public stigma, a naive public exhibits prejudice
toward a stigmatized group; self-stigma occurs when members of a stig-
matized group internalize public stigma (Corrigan and Watson, 2002).
The stigma attached to having a mental illness and receiving a psychiatric
diagnosis has been the subject of extensive study in military and in civil-
ian contexts (Britt et al., 2007; Corrigan, 2004; Corrigan and Penn, 1999;
Corrigan and Watson, 2002; Hoge et al., 2004; Warner et al., 2011).
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An additional type of barrier in the DoD and the VA occurs in the
translation of research findings into practice. Factors that contribute to this
kind of barrier include application to target settings, research-design issues,
and a combination of these (Glasgow and Emmons, 2007). From a public-
health perspective, such barriers result from an inability to generalize the
results of research studies to representative samples of patients, providers,
and practice settings (Zatzick and Galea, 2007).
Another barrier to accessing care is that active-duty service members
may have difficulty in keeping regularly scheduled appointments for treat-
ment or may not be able to complete a full treatment regimen because of
deployment, transfer of duty station, or work schedule. On the basis of such
variations, the committee decided to structure its analysis around separate
considerations of the barriers and facilitators in the three most common
service sectors for PTSD care: in the theater of war, in domestic DoD set-
tings, and in VA facilities, as illustrated in Figure 9-1.
Adding to the complexity of treating some cases of PTSD, are the high
rates of co-occurring medical and psychosocial conditions. Some treat-
ments, however, such as prolonged exposure therapy, are effective for both
PTSD and for frequently co-occurring conditions such as depression, other
anxiety disorders, alcohol and drug use disorders, and mild traumatic brain
injury (TBI). In addition, there is ample evidence that community mental
health providers who are not expert in cognitive behavior therapy or PTSD
can deliver these treatments effectively.
There have been several assessments of barriers to the use of mental
health care in military and veteran populations. As part of the National
Vietnam Veterans Readjustment Study, conducted during the 1980s, Kulka
(1990) asked veterans about their reasons for not seeking treatment for
Predeployment
FIGURE 9-1 PTSD services throughout the military life cycle.
Figure 9-2 new
Landscape
All type outlined
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342 PTSD IN MILITARY AND VETERAN POPULATIONS
their mental health issues. The most frequently cited reasons were the “hope
or belief that the individual could solve the problem on his own” and “the
hope or belief that the problem would get better on its own.” Vietnam vet-
erans who had PTSD sought mental health care at a higher rate than other
veterans, but the authors cautioned that this finding did not support claims
that the PTSD programs at that time were sufficient in either quality or ac-
cessibility (Kulka, 1990). A report from the Institute of Medicine described
barriers to delivery of adequate mental health service for 1990–1991 Gulf
War veterans who had unexplained physical symptoms (IOM, 2000). They
outlined barriers at the provider level, such as competing demands on pro-
vider time. They also identified more tacit barriers, such as lack of provider
recognition of the symptom complex as a diagnosable entity and reluctance
of patients to discuss their illness. Embedding mental health treatment in
primary care settings might help to ameliorate specific barriers, particularly
the stigma associated with presenting to specialty mental health settings
(IOM, 2000).
A 2008 RAND report on treatment for and the burden of psychologic
and cognitive injuries in OEF and OIF, The Invisible Wounds of War,
looked at inadequacies in access to care and in the quality of mental health
care for the current Iraq and Afghanistan cohort of veterans (Burnam et
al., 2008). Burnam et al. (2008) identified two categories of barriers: the
first are structural or financial barriers, and include limited availability of
services and financial limitations; the second are personal or social barriers,
which include personal values and military culture (Figure 9-2).
Several barriers to and facilitators of mental health care in the DoD
and the VA health care systems were identified through focus groups and
interviews with health providers and OEF and OIF service members and
veterans, including reservists and National Guardsmen. Service members
rarely considered seeking mental health care in the military health care
system because of privacy concerns related to perceived stigma. Many
people stated that if they needed care, they would choose to see an off-base
provider or seek counseling from a peer or chaplain. The potential loss of a
security clearance, loss of professional opportunities, and the adverse judg-
ment of peers were among the feared outcomes most commonly identified.
Another barrier was the tendency to not immediately report mental health
problems after deployment so as to avoid delay in reuniting with their
families. In the words of one focus group participant, “I lied on my post-
deployment forms. Whatever got me back to my family quicker” (Burnam
et al., 2008). One facilitator of care was the availability of fellow OEF and
OIF veterans with whom to share mental health concerns.
Burnam et al. (2008) used the Institute of Medicine (IOM) definition
of high-quality care as safe, effective, patient-centered, timely, efficient,
and equitable (IOM, 2001). They concluded that a substantial gap existed
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FIGURE 9-2 Barriers to, facilitators of, and access to care for PTSD and related
comorbid presentations.
SOURCE: Tanielian and Jaycox, 2008; adapted with permission from RAND
Figure 9-1New
Corporation.
Landscape
All type outlined
between the need for and the use of mental health services for active-duty
service members. For veterans who were receiving services in the VA sys-
tem, the report suggested that improving access would require addressing
two major challenges: expanding service capacity and appealing to younger
veterans. The authors concluded that both the VA and the DoD should
undertake substantial efforts to monitor and enhance the quality of care
received by patients who have PTSD.
In the Department of Defense
As discussed in Chapter 4, service members and veterans who have
PTSD live, work, and receive mental health care in various settings, rang-
ing from combat zones to specialized PTSD treatment facilities in the VA.
Each setting may have specific barriers to and facilitators of care. For
example, the use of pharmacotherapy varies markedly depending on the
treatment setting (in the theater of war, on U.S. military bases, and in the
VA). There are many restrictions on psychiatric medications that a service
member may use because of potentially hazardous side effects. Lithium, for
example, may not be used in the theater of war, although it is prescribed
stateside for service members and is routinely prescribed by the VA. Se-
rotonin reuptake inhibitors, especially selective serotonin and serotonin/
norepinephrine—prescribed for depression, anxiety, PTSD, and some other
disorders—are prescribed in the VA and in the DoD, but long-term use
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344 PTSD IN MILITARY AND VETERAN POPULATIONS
may adversely affect a service member’s career. In the Navy, sailors and
marines on selective serotonin reuptake inhibitors cannot carry firearms
or deploy unless granted a waiver by their prescribing provider. For other
types of psychiatric medications, waivers may be issued case by case by psy-
chiatrists, but the waivers must be consistent with DoD or service-specific
guidelines (U.S. Navy, 2009). For some job categories, such as pilot, the use
of psychiatric medications while one is on flight status is prohibited (U.S.
Air Force, 2009).
In the Theater of War
In the context of service delivery in the theater of war, the best avail-
able sources of information on barriers to and facilitators of mental health
care are MHAT reports. The series of reports documents improvements in
access to mental health treatment in combat settings and the increased need
for this treatment for service members who have had multiple deployments.
The MHAT reports also show there is persistent stigma and logistical barri-
ers to accessing PTSD care for service members in the theater of war.
In 2003, the first MHAT was assembled and surveyed 756 OIF soldiers,
82% of whom had engaged in combat (MHAT I, 2003). Almost half the
soldiers surveyed reported they did not know how to obtain needed men-
tal health services. Only one-third of soldiers who reported they wanted
mental health services received the care they needed. That initial MHAT
survey recommended immediate improvements in delivery of mental health
services, including appointment of in-theater behavioral health consultants
and provision of services closer to soldiers’ units (MHAT I, 2003).
Later MHAT surveys have continued to document improvements, but
they also have identified barriers to receiving high-quality mental health
care in the theater of war. For example, the MHAT II survey, conducted in
2005, found that 40% of soldiers who had mental health problems reported
receiving some formal mental health services during their deployment, but
stigma and organizational barriers, such as time off to receive care and loca-
tion of facilities, continued to limit access for many soldiers in the theater
of war (MHAT II, 2005).
The MHAT VI survey, conducted in 2009 in Iraq and Afghanistan, dif-
fered from previous MHAT surveys in a number of ways. The MHAT VI
survey was designed to randomly sample preselected platoons, and sampled
units were from both support and sustainment units, and maneuver bat-
talions. Current data were compared with data collected in earlier MHAT
surveys to investigate service delivery trends. Of enlisted soldiers in Iraq
who reported mental health problems, an estimated 7% (support and sus-
tainment sample) and 15% (maneuver sample) did not know that mental
health services were available, 16% of support and sustainment soldiers
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and 29% of maneuver soldiers thought that it was difficult to get an ap-
pointment, 36% and 50% thought that it would be difficult to get time off
from work for treatment, 9% and 29% had logistic barriers to obtaining
treatment, 15% and 24% were discouraged by their leaders from using
mental health services, and 13% and 12% did not know where to get help
(MHAT VI, 2009). Sampling of support and sustainment units, and maneu-
ver units deployed to Afghanistan yielded similar results (MHAT VI, 2009).
Undertaken in 2010, the joint MHAT VII (surveyed soldiers and ma-
rines) extended the findings and assessment methods of previous MHAT
surveys. MHAT VII respondents reported the highest level of combat expo-
sures of any MHAT respondents. MHAT VII also reported higher numbers
of multiple deployments than MHAT VI. Soldiers on their third and fourth
deployments reported increased psychologic problems and use of psycho-
tropic medications than soldiers on their first and second deployments,
and overall 4% of respondents reported using psychotropic medications.
Although enlisted soldiers who screened positive for any mental health
problem reported substantial reductions in barriers to mental health care
from what was found in MHAT VI, 29% still reported embarrassment as
a factor in not seeking mental health services, 29% reported that it would
harm their career, 42% reported that their units would have less confidence
in them, 46% reported that their leaders might treat them differently, 34%
thought that their leaders might blame them for the problem, and approxi-
mately 50% reported that they would be seen as weak. Furthermore, 27%
reported that mental health services were not available, 29% reported diffi-
culty in getting appointments, 48% reported that it would be difficult to get
time off from work for appointments, and 32% reported that it would be
too difficult to get to the mental health specialists’ locations. The number of
soldiers who reported “I did not know where to get help” (16%) and “my
leaders discouraged me from getting services” (14%) were relatively similar
to those in the MHAT VI survey. Marines had more mental health concerns
in 2010 than in 2006 or 2007 and perceived fewer barriers to mental health
care, including reduced stigma associated with receiving mental health care.
Mental health providers noted that outreach efforts had been successful
in providing behavioral health services outside combat stress control unit
locations. Multiple barriers to telehealth delivery were noted by service
members and mental health providers (MHAT VII, 2011a,b). Those results
show that barriers to seeking care improved but remained.
In Garrison
In one of the earliest studies of soldiers and marines serving in OEF and
OIF, Hoge et al. (2004) described mental health service use, stigma, and
other barriers to care in four active-duty combat infantry units returning
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346 PTSD IN MILITARY AND VETERAN POPULATIONS
to the United States after deployment. Soldiers and marines who screened
positive for mental health problems reported significantly higher rates of
perceived barriers than those who screened negative. Of those who screened
positive for PTSD, depression, or anxiety disorders, 38% of soldiers de-
ployed to Afghanistan, 43% of soldiers deployed to Iraq, and 45% of
marines deployed to Afghanistan expressed interest in receiving help; 23%,
40%, and 29% of persons in these respective groups had seen a health care
provider in the preceding year, and those that had seen a mental health pro-
vider in the past year ranged from 13% in soldiers deployed to Afghanistan
to 27% for soldiers deployed to Iraq. Hoge et al. (2004) concluded that ef-
forts to address barriers to and stigma surrounding mental health treatment
in the military should include outreach, education, and changes in service-
delivery models, such as integration of mental health services into primary
care settings in garrison (that is, on permanent military installations).
In a cross-sectional investigation of mental health problems in active-
duty service members returning from Iraq and Afghanistan, Hoge et al.
(2006) reported that 19% of OIF and 11% of OEF service members re-
ported a mental health problem and that 31% of OIF veterans had at least
one mental health visit in the first year after deployment. Approximately
56% of OIF and 48% of OEF service members who were referred for
mental health treatment received it. In a follow-up longitudinal assess-
ment of mental health problems and service use, Milliken et al. (2007)
found that 20.3% of active-duty and 42.4% of reserve component soldiers
required mental health treatment based on their responses to the post-de-
ployment health assessment (PDHA) and post-deployment health reassess-
ment (PDHRA) after returning from Iraq. Furthermore, soldiers were much
more likely to report PTSD symptoms on the PDHRA than on the PDHA,
and about half of those who reported PTSD symptoms on the PDHA had
improved by the time they took the PDHRA.
Warner et al. (2011) assessed reporting of mental health symptoms and
needs for care in 2,500 returning OEF and OIF veterans. Study participants
completed both the PDHA and an anonymous survey. Items in both surveys
were used to assess the presence of PTSD, depression, and suicidal ideation.
Reported symptoms of depression, PTSD, and suicide were 2–4 times
higher on the anonymous survey than on the PDHA. More than 20% of
soldiers who screened positive for PTSD or depression reported discomfort
in answering routine PDHA screening items honestly. Those who screened
positive for PTSD or depression also had increased perceptions of stigma
and barriers. Those results empirically demonstrate the potential effect
of stigma on the reporting of mental health symptoms and care seeking.
McGeary et al. (2011) documented that persistent concerns of stigma and
fear of potential long-term implications, including separation from the
military, also inhibit reporting.
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A series of other studies examined barriers and stigma associated with
receiving mental health care in active-duty military populations. Wright
et al. (2009) found that improved unit leadership ratings and high unit
cohesion were associated with lower perceptions of stigma and dimin-
ished barriers to care; the association persisted after adjustment for mental
health symptom levels. Kim et al. (2010) found that active-duty soldiers
who reported a mental health problem perceived greater stigma and had
significantly lower rates of service use than did National Guard soldiers.
Negative beliefs about mental health care and diminished perceptions of
unit social support were associated with decreased visits for mental health
counseling and education (Pietrzak et al., 2009). Olmsted et al. (2011) de-
termined that soldiers in treatment perceived greater stigma than soldiers
not receiving treatment. Two common barriers to receiving care were not
being able to ask for help and not being able to admit to having a problem
(Stecker et al., 2007).
Research on barriers to, stigma associated with, and facilitators of
PTSD care for active-duty service members seeking care stateside has fo-
cused on DoD facilities or has not specified the source of care, but ser-
vice members can also receive care through the TRICARE purchased-care
program. Multiple reports have raised concerns about access to and ad-
equacy of mental health services available from TRICARE contract net-
work providers, including the availability of providers who are willing
to see TRICARE beneficiaries, the familiarity of TRICARE mental health
providers with military culture, and the training and expertise of TRICARE
mental health providers (APA, 2007; DoD, 2007; IOM, 2010). The 2010
IOM report on TRICARE and licensed professional counseling found an
absence of guidelines or designated scope of practice for a wide array of
behavioral health providers who treat TRICARE patients; this led to a
recommendation that TRICARE evaluate its goals for level of prepared-
ness and training of all its health care providers. A GAO report (2011a)
reviewed access to TRICARE Standard and Extra providers, including an
analysis of concerns about access to mental health providers. The report
acknowledged the DoD’s efforts in response to earlier reports to address
access problems but concluded that serious barriers to access mental health
providers, particularly psychiatrists, nevertheless continue. Data for ac-
curately assessing the shortfall in providers or the success of recent DoD
initiatives to improve access are still inadequate. Data for determining the
degree to which providers have the appropriate training and expertise to
treat combat-related PTSD are also lacking.
In its reports to Congress, the DoD has noted the increased use of
TRICARE contract mental health providers (GAO, 2011a), which is con-
sistent with what the committee found on its site visit to Fort Hood in
September 2011. During the site visit, mental health staff acknowledged
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348 PTSD IN MILITARY AND VETERAN POPULATIONS
to the committee that a substantial and increasing number of active-duty
personnel have been referred to TRICARE contract providers because of
inadequate staffing in the military mental health clinics to meet the needs
of service members seeking PTSD care.
In the Department of Veterans Affairs
Sayer et al. (2009a,b) used qualitative interviews with patients and
providers to document barriers to and facilitators of care for veterans who
have PTSD and are seen in the VA. They conducted in-depth interviews
with veterans who were filing claims related to service-connected disability.
The investigation identified multiple barriers to treatment, including beliefs
that discouraged seeking mental health treatment, concerns about the abil-
ity of the health care system to meet a patient’s needs, lack of knowledge
about PTSD, treatment access, and trauma-related avoidance. Facilitators
of VA services included recognition and acceptance of PTSD, availability of
help, beliefs that encouraged seeking treatment, system facilitation (such as
promotion of help-seeking by primary care providers), and encouragement
of treatment seeking by members of a patient’s social network.
In a study of barriers experienced by providers, Sayer et al. (2009b) in-
terviewed 40 providers in VA clinical teams that provide specialized services
for TBI or PTSD. Providers were asked questions about referral processes,
assessment and treatment challenges, terminology, comorbidities, and col-
laborations. They found screening and referral challenges that included
false negative TBI screening results; assessment challenges derived from
retrospective evaluations of TBI, PTSD, and functional impairments; sec-
ondary gain issues; high no-show rates; uncertainty about evidence-based
PTSD treatments for mild TBI; lack of coordination of care with other VA
services; and questionable availability of services, including psychiatric
staffing. Although these two studies are small, they could serve as a model
for assessing barriers to PTSD care in the VA.
In 2011, the GAO identified four key barriers that might prevent vet-
erans from seeking mental health care at VA facilities: stigma and beliefs
about mental health care, lack of understanding or awareness of mental
health care, logistical challenges to accessing mental health care, and con-
cerns about VA health care in general (GAO, 2011b). On the basis of a
literature review and interviews with officials of the VA and veteran service
organizations, particular concerns included perception by veterans that
seeking help would negatively affect their careers, that treatment may be
painful and bring up bad memories, and that they would be able to solve
their problems without treatment. The VA and veteran service organization
officials also noted that barriers affected different demographic groups dif-
ferently, for example, younger veterans might think that only older veter-
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ans go to the VA for health care, women may perceive the VA health care
system as primarily male-oriented, National Guard and reservists may have
more concerns about privacy and stigma, and veterans who live in rural
locations may have greater distances to travel to receive care.
A 2011 survey of VA mental health care providers in five Veteran In-
tegrated Service Networks (VISNs) found many perceived system barriers
to veterans’ seeking mental health care (VA, 2011). Of the 272 providers
surveyed (a mixture of social workers, psychologists, psychiatrists, and
nurses), 63% could schedule an appointment for a new patient within 14
days in their clinic, but 18% could not see a new veteran for at least 30
days, and 7% thought the waiting time would be longer than 60 days. Some
also noted long waiting times for established patients: 25% could see an
established patient at the earliest preferred date, 36% within 14 days of
the preferred date, 22% within a month, 11% in more than a month, and
7% in more than 60 days. Providers also noted there were waiting times
for referrals to specialty mental health care, such as for PTSD or substance
abuse. Most (71%) of the providers thought that current staffing levels were
inadequate. When they were asked about other system barriers to provision
of mental health care, 46% cited a need for more off-hours appointments
(evenings and weekends), 27% said that participating in compensation and
pension examinations took time they could otherwise spend with patients,
and 25% cited shortages of other staff (clerical and scheduling) (VA, 2011).
In a nonrandomized study of rural veterans of all eras who had never
enrolled for VA health benefits or had not used VA health services in the
preceding 2 years, the primary veteran-reported barrier to accessing health
care of any kind was perceived cost (Davis et al., 2011). Of veterans whose
last deployment was in Iraq, Afghanistan, or Kuwait, 22% reported a delay
in obtaining or an inability to obtain mental health care compared with
5.6% of veterans who had been deployed elsewhere. The study authors
suggested that lack of mental health screening and evaluation may also be
a barrier to obtaining mental health care.
BARRIERS TO DELIVERY OF EVIDENCE-BASED CARE
As noted in Chapter 7, the VA/DoD clinical practice guideline and other
practice guidelines have identified psychosocial treatments—specifically
prolonged exposure (PE) and cognitive processing therapy (CPT)—and
pharmacologic treatments as having the strongest evidence base for treat-
ment for PTSD. The VA has trained over 4,000 clinicians who provide
care in many settings (such as specialized programs, mental health clinics,
and Vet Centers) in PE and CPT. The VA has reported adequate capacity
to provide CPT or PE for all OEF and OIF veterans who have PTSD and
are enrolled in the Veterans Health Administration, and it plans to train
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352 PTSD IN MILITARY AND VETERAN POPULATIONS
IOM, 2007; Tanielian and Jaycox, 2008) have cited two major needs for
improvement: support for randomized controlled trials (RCTs) that assess
the efficacy, effectiveness, and implementation of treatment methods and
lead to wider dissemination of evidenced-based approaches; and identifica-
tion and implementation of ways to enhance health care dissemination and
delivery for military personnel and their families in ways that provide better
awareness of and access to care while reducing stigma.
Telemental Health-Based Interventions
Telemental health (TMH or telemedicine) approaches take advantage
of recent advances in computer and information technology that support
user interaction with clinicians or clinical applications via low-cost, high-
bandwidth connectivity with the Internet. TMH methods constitute more
of a delivery medium for providing services to users in remote locations
and are not specific to any one model of assessment or treatment. The core
methods of TMH delivery are videoteleconferencing (real-time synchronous
interaction with a live provider over the Internet), interaction with Internet-
based sites that can provide screening assessments and general clinical
information (for example, DCoE, 2012, or VA, 2012a), and in some cases
programmed guides that allow users to embark on self-managed mental
health programming, sometimes supported by additional synchronous or
asynchronous interaction with a clinical provider.
In recent years, there has been growing recognition of the value of
TMH technologies—such as videoconferencing, Internet use, or telephone
use—to conduct therapy for patients who have PTSD (Frueh et al., 2007a).
These approaches decrease the burdens of travel time, costs, and time away
from work or family and could improve access to services for traditionally
underserved populations (for example, patients in rural settings and people
who have transportation difficulties or physical disabilities) and people in
regions that may be difficult for therapists to reach (such as combat zones).
Continuing advances in low-cost, faster, and more sophisticated Internet
technologies have led to a substantial investment in TMH infrastructure
by government agencies (Godleski et al., 2008), and a growing literature
details the structure and mechanics of a variety of TMH applications, as
well as research into their effectiveness and efficiency (Frueh et al., 2000;
Monnier et al., 2003; Norman, 2006; Richardson et al., 2009).
Videoconferencing
Early research has shown that videoconferencing can be implemented
cost-effectively (Bose et al., 2001; Elford et al., 2000; Fortney et al., 2005).
Much attention has focused on this medium for providing evidence-based
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treatments to veterans, and the VA is promoting telemedicine as an impor-
tant means of providing care to veterans who live in remote areas (IOM,
2005). Several uncontrolled studies have indicated that telemedicine has
resulted in a reduction in PTSD symptoms in veterans (Deitsch et al., 2000;
Germain et al., 2009; Morland et al., 2004). For example, Tuerk et al.
(2011) administered PE to veterans via videoconferencing and compared
responses with those in a sample of veterans who were treated with PE in a
standard clinical setting. There were few differences between the two for-
mats, apart from the weekly express posting of the audiorecording of the PE
session to the patient. Although the trial was not an RCT, it demonstrated
that this delivery mode was safe and resulted in effect sizes comparable with
those observed in patients treated the traditional way.
In an initial group-based RCT that compared videoconferencing with
standard PE treatment, Frueh et al. (2007b) reported videoconferencing and
face-to-face therapy resulted in comparable reductions in symptoms; how-
ever, patients who had videoconferencing reported less comfort with ther-
apy and poorer adherence to homework exercises than their counterparts
who received treatment in person. A larger nonrandomized study of 89
patients found that whereas telemedicine-delivered PE resulted in significant
symptom reduction, it was not as effective as face-to-face treatment (Gros et
al., 2011b). Encouraging findings also came from a strongly designed RCT
that found comparable results in treating anger in veterans who had PTSD
via telemedicine and with in-person therapy (Morland et al., 2010). Such
results have supported a growing recognition of the potential usefulness of
delivering PE via a telemedicine approach. Large well-controlled trials with
OIF and OEF veterans that will permit more definitive conclusions about
the effectiveness of this medium are under way (Gros et al., 2011a).
Internet-Based Interventions
Several RCTs of Internet-based treatments for PTSD have been con-
ducted. Litz et al. (2007) assessed DE-STRESS, an 8-week Internet-delivered
CBT program, in a military population. Participants were randomly as-
signed to the DE-STRESS group or an Internet-based supportive coun-
seling program. DE-STRESS entailed therapist-guided exploration of
self-monitoring triggers, development of a hierarchy of trauma triggers,
stress management, in vivo exposure, trauma writing sessions, and relapse
prevention. The treatment group had significantly greater decreases in
symptoms of PTSD, depression, and anxiety 6 months after treatment;
however, the overall dropout rate was 30%, which is high and reduces the
benefit of the intervention (Cukor et al., 2009).
Another Internet-based treatment, Interapy (Lange et al., 2000, 2001,
2003), is a CBT approach that uses exposure and cognitive restructuring
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354 PTSD IN MILITARY AND VETERAN POPULATIONS
techniques. Interapy involves 2 sessions a week for 5 weeks, during which
participants have 10 writing sessions lasting 45 minutes each to describe
their trauma in detail, work on cognitive reappraisal, and address their
perception of the effect of the trauma on their lives. The largest assess-
ment of Interapy was conducted in a community sample of 69 subjects and
32 wait list controls (Lange et al., 2003). The treatment group improved
significantly more than the controls, and there were large effect sizes for
PTSD symptoms and general psychopathologic conditions. However, many
of the traumas reported in this population may not have met criterion A for
PTSD (such as losing a loved one, divorce, or a personal attack). Interapy
and DE-STRESS share several intervention components, including repeated
writing about the traumatic experience and provision of various levels of
therapist assistance (Cukor et al., 2009).
Hirai and Clum (2005) used an Internet-based, 8-week self-help pro-
gram for traumatic event-related consequences (SHTC) to compare people
who had experienced a traumatic event, but had only subclinical PTSD
symptoms, with a wait list control group. No therapist aid was provided.
SHTC consisted of CBT modules, such as psychoeducation; relaxation
training, including breathing retraining, muscle relaxation, and imagery-
induced relaxation; cognitive restructuring; and exposure. Participants had
to master the material in each module independently before proceeding to
the next module. Treatment decreased avoidance behavior, frequency of
intrusive symptoms, state anxiety, and depressive symptoms and increased
coping skills and coping self-efficacy significantly more than the wait list
condition. However, given the low symptom severity in the sample, it is not
possible to determine whether a person who has more severe PTSD would
benefit from the program without some provider contact.
A recent meta-analysis of outcomes of Internet-based programs for
anxiety disorders found that among four wait-list–controlled studies of
PTSD yielded preliminary support for the use of Internet-based approaches
for PTSD (Reger and Gahm, 2009). In a literature review, Richardson et
al. (2009) also found strong evidence of patient satisfaction and successful
clinical assessment with Internet-based programs. However, both groups
of authors concluded that more evidence is needed on the effectiveness of
these approaches for specific mental health diagnoses, such as depression
and anxiety disorders. Future research on such Internet-based therapies as
DE-STRESS, Interapy, and SHTC should focus on the effectiveness of CBT
techniques delivered online to more severely traumatized populations, fac-
toring in ethical and legal considerations regarding the amount of provider
contact (Tate and Zabinski, 2004). It should be noted that evidence from
research on other mental health problems indicates that rates of attrition
after Internet-based interventions are higher in the absence of provider
contact to facilitate completion (Gros et al., 2011b).
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355
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The pressure of increased demands on the DoD and the VA health care
systems and the need to break down barriers to care and to reduce costs will
probably support continued interest and research in TMH. From an eco-
nomics perspective, research has demonstrated cost reductions in provid-
ing care with telemedicine and Internet-based applications (Harley, 2006;
Jong, 2004; Persaud et al., 2005; Shore et al., 2007a), and this trend will
probably continue with advances in low-cost, high-fidelity computer and
information technology. However, large-scale studies using robust design
and sampling methodology is needed to identify the clinical interventions
that can be delivered in this format effectively and ethically. Richardson et
al. (2009) report that several telemedicine services for mental health care
have been operating for more than 12 years, such as Virginia’s Appal-Link
network, South Australia’s Rural and Remote Mental Health Service, and
services at the University of Arizona; the University of California, Davis;
the University of Michigan; and the University of Nebraska. More robust
quantitative indicators of the success or failure of large-scale programs like
those may soon be available.
Telemedicine programs will necessarily demand attention to ethical
and practice issues. Practice guidelines are gradually emerging (Rizzo et al.,
2004; Shore and Manson, 2004; Shore et al., 2007b) to address such issues
as protection of privacy and security, standard-of-care assurances, cross-
state licensure, practice behavior and treatment approaches, and clinical
risk management. Those issues will inform decision making with respect
to when care can be delivered via computer and information technology or
in person safely and effectively (Hyler and Gangure, 2004; McGinty et al.,
2006; Miller et al., 2005; Schopp et al., 2006; Shore et al., 2007b).
Novel technologies being developed to enhance TMH systems will
require both clinical and ethical scrutiny. For example, advanced online
systems have recently been developed that leverage artificially intelligent
“virtual humans” to serve as health care guides and personal screening
agents (Rizzo et al., 2011). These systems are undergoing evaluations with
service members, veterans, and their families to determine whether such
interactive virtual human representations that can be anonymously accessed
and interacted with will promote awareness of service options. Such aware-
ness may help people who otherwise might not seek care to jump-start the
search for help with a live provider.
Other Facilitators
A recent development has the potential to expand treatment opportuni-
ties for service members who have PTSD at bases without large hospitals
or mental health care. The National Defense Authorization Act for 2012
lifted a restriction against mental health consultations across state lines and
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356 PTSD IN MILITARY AND VETERAN POPULATIONS
exempts the requirement that health care providers be licensed in the state
in which their patients are treated. Although the state licensure require-
ments for military health care providers providing care in federal facilities
are exempt, the new exemption includes care provided at any location.
A further facilitator to care is the incorporation of PTSD screening,
diagnosis, and treatment into primary care settings at military treatment
facilities. For example, the U.S. Army RESPECT-Mil model (see Chapters 4
and 6) provides service members with an annual opportunity to discuss any
PTSD symptoms with a primary care clinician without the stigma of going
to a mental health clinic. Integrated primary care and mental health teams
are also being used by the other services such as the Air Force Behavioral
Health Optimization Program. Similar collaborative care models are also
being implemented in the VA. The development of such models has the
potential to greatly expand access to and the acceptability of mental health
care for service members and veterans.
SUMMARY
Many service members and veterans have PTSD, so there is a growing
demand for PTSD treatment services in the DoD and the VA. However,
many of the service members and veterans do not seek or successfully ac-
cess those services. Although there are some published studies of the use of
PTSD services and programs in the DoD and the VA, the committee found
there is a need for more empirical data on barriers to accessing high-quality
PTSD care for military and veteran populations. Information and data
related to barriers experienced by service members transitioning from the
DoD into the VA health care system and the nature and impact of stigma
that is perceived by service members and veterans are lacking.
An overarching goal of the committee’s analysis of barriers and facilita-
tors is to identify ways of improving access to high-quality care. In phase
2, the committee will continue to assess barriers to PTSD care, including
barriers that are sex specific, race specific, or ethnicity specific. The com-
mittee believes that a sound conceptual framework that comprehensively
elucidates barriers to and facilitators of access to high-quality PTSD services
can result in effective change.
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