Treatment for
POSTTRAUMATIC STRESS DISORDER
in Military and Veteran Populations

Final Assessment

Committee on the Assessment of Ongoing Efforts in the
Treatment of Posttraumatic Stress Disorder

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. W81XWH-10-C-0290 between the National Academy of Sciences and the Department of Defense. Any opinions, find- ings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13:  978-0-309-30173-2 International Standard Book Number-10:  0-309-30173-4 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.nationalacademies.org

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COMMITTEE ON THE ASSESSMENT OF ONGOING EFFORTS IN THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER Sandro Galea (Chair), Professor and Chair of the Department of Epidemiology, Mailman School of Public Health, Columbia University Kathryn K. Basham, Professor, Codirector of the Ph.D. Program, and Editor of Smith College Studies in Social Work, Smith College Larry Culpepper, Professor, Department of Family Medicine, Boston University School of Medicine Jonathan R. Davidson, Emeritus Professor, Department of Psychiatry, Duke University Medical Center Edna B. Foa, Professor, Department of Psychiatry; Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine Kenneth W. Kizer, Distinguished Professor, Department of Emergency Medicine, University of California, Davis, School of Medicine and Betty Irene Moore School of Nursing; Director, Institute for Population Health Improvement, Davis Health System Karestan C. Koenen, Associate Professor, Department of Epidemiology, Mailman School of Public Health, Columbia University Douglas L. Leslie, Professor, Department of Public Health Sciences and Department of Psychiatry, The Pennsylvania State University Richard A. McCormick, Senior Scholar, Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center Mohammed R. Milad, Associate Professor, Department of Psychiatry, Harvard Medical School; Director of Behavioral Neuroscience Laboratory and Associate in Research Psychiatry, Massachussets General Hospital William P. Nash, University of California, San Diego, and Virginia Commonwealth University Elizabeth A. Phelps, Silver Professor of Psychology and Neural Science, Department of Psychology and Center for Neural Science, New York University Elspeth Cameron Ritchie, District of Columbia Department of Behavioral Health; Clinical Professor of Psychiatry, Georgetown University Albert “Skip” Rizzo, Associate Director, Institute for Creative Technologies; Research Professor, Department of Psychiatry and School of Gerontology, University of Southern California v

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Barbara O. Rothbaum, Associate Vice Chair of Clinical Research, Professor in Psychiatry, and Director, Trauma and Anxiety Recovery Program, Emory University School of Medicine Douglas F. Zatzick, Professor, and Associate Vice Chair for Health Services Research, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine Study Staff Roberta Wedge, Study Director Anne Styka, Program Officer Heidi Murray-Smith, Program Officer, Board on Environmental Studies and Toxicology Heather Chiarello, Senior Program Assistant (from April 2013) Emily Morden, Associate Program Officer (until November 2013) Joi Washington, Senior Program Assistant (until March 2013) Norman Grossblatt, Senior Editor Frederick Erdtmann, Director, Board on the Health of Select Populations vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Christopher K. Cain, Nathan Kline Institute for Psychiatric Research Peter Chiarelli, One Mind for Research Colleen Conway-Welch, Vanderbilt University Terri DeRoon-Cassini, Medical College of Wisconsin David Gustafson, University of Wisconsin–Madison Anand Kumar, University of Illinois at Chicago Thomas G. McGuire, Harvard Medical School Alan Peterson, University of Texas Health Science Center at San Antonio Harold Pincus, Columbia University/RAND Corporation Terri Tanielian, RAND Corporation Shelley MacDermid Wadsworth, Purdue University vii

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viii REVIEWERS Stephen Xenakis, Uniformed Services University of the Health Sciences Antonette Zeiss, Consultant Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Ellen Wright Clayton, Vanderbilt University, and Kristine M. Gebbie, Flinders University of South Australia. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the author- ing committee and the institution.

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Contents Preface xi Abbreviations and Acronyms xiii Summary 1 1 Introduction 13 2 Diagnosis, Course, and Prevalence of PTSD 29 3 PTSD Programs and Services in the Department of Defense and the Department of Veterans Affairs 47 4 Performance Management 79 5 High-Value Care 89 6 Workforce 105 7 Effective and Safe Care 129 8 Access to Care 149 9 Research on PTSD 175 10 Findings and Recommendations 215 ix

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x CONTENTS Appendixes A Committee Member Biographies 231 B Congressional Legislation 239 C Phase 2 Open Sessions 243 D Centers, Consortiums, and Collaborations for PTSD Research 249 E Detailed Descriptions of PTSD Research in the Department of Defense, the Department of Veterans Affairs, and the National Institutes of Health 261

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Preface P osttraumatic stress disorder (PTSD) remains one of the signature in- juries of the U.S. engagements in Afghanistan and Iraq. The burden of PTSD in service members who have been deployed in support of Operation Enduring Freedom in Afghanistan since 2001 and Operation Iraqi Freedom since 2003 is staggering. Fortunately, national awareness of the toll that PTSD has had on the health and well-being of service members, veterans, their families, and their communities has been increasing. Both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) have, in a variety of reports and activities, demonstrated keen understand- ing of the challenges posed by PTSD. Each department has responded to the challenges with substantial funding to foster research, develop programs, and initiate services to combat PTSD. Although both departments are mak- ing strides in identifying and treating people who have PTSD symptoms, many obstacles remain before they will have a comprehensive, integrated, and high-performing approach to managing PTSD. The 2010 National Defense Authorization Act asked the Institute of Medicine (IOM) to look at the effectiveness of the growing number of PTSD programs and services that are available for service members and veterans in DoD and VA, respectively. The present report is the second of a two-phase study. In this phase, the committee focused on the opportunities and challenges that each department faces in developing, implementing, and evaluating services and programs in the context of achieving a high- performing system to care for service members and veterans who have PTSD. The committee also conducted a focused review of DoD, VA, and other organizations’ portfolios of PTSD-related research to identify where xi

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xii PREFACE gaps or new emphases might be addressed to improve prevention of, screen- ing for, diagnosis of, and treatment and rehabilitation for the disorder. During its review of the literature and ongoing research and preparation of this report, it was obvious to the committee that although there is a wealth of information on PTSD, there are also substantial gaps in our knowledge of how best to manage PTSD in service members and veterans who have it. This report attempts to recognize both progress and stasis in improving care for PTSD in DoD and VA. The committee gratefully acknowledges the many individuals and groups that generously shared their time, expertise, and insights with the committee. They provided valuable information on particular aspects of PTSD, including reports and data, and answered committee queries about their work and experience in dealing, personally and professionally, with PTSD. Among the numerous people who helped the committee are those who worked tirelessly on the committee’s data requests, specifically Keith Hoffman and Wendy Funk, of Kennell and Associates; Mary Schohn, of the VA Office of Mental Health Operations; Rani Hoff, of the VA Northeast Program Evaluation Center; and many others in the Army, Navy, Marine Corps, and Air Force. The committee also visited many DoD and VA fa- cilities and expresses its appreciation for the time, insights, and personal stories offered by a variety of leaders, mental health providers, primary care providers, specialty program directors, researchers, and purchased care pro- viders. The committee appreciates especially the many service members and veterans who were receiving or had received treatment for PTSD and who took time to share their experiences with the committee. The committee is grateful to Roberta Wedge, who served as study director for this project, and to the IOM staff members who contributed to the project: Heather Chiarello, Emily Morden, Heidi Murray-Smith, and Anne Styka. A thank you is also extended to Daniel Bearss and Ellen Kimmel, who conducted the literature searches. Sandro Galea, Chair Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder

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Abbreviations and Acronyms APA American Psychiatric Association Army STARRS Army Study to Assess Risk and Resilience in Service Members BDNF brain-derived neurotrophic factor BHDP Behavioral Health Data Portal C5 Comprehensive Combat and Complex Casualty Care CBOC community-based outpatient clinic CBT cognitive behavioral therapy CDP Center for Deployment Psychology COSC combat and operational stress control CPT cognitive processing therapy CSF2 Comprehensive Soldier and Family Fitness DCoE Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury DCS D-cycloserine DoD Department of Defense DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition, Text Revision DSM-5 Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition EMDR eye movement desensitization and reprocessing xiii

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xiv ABBREVIATIONS AND ACRONYMS fMRI functional magnetic resonance imaging FY fiscal year GAO Government Accountability Office ICD International Classification of Diseases IDES Integrated Disability Evaluation System IMHS DoD/VA Integrated Mental Health Strategy INTRuST Injury and Traumatic Stress consortium IOM Institute of Medicine MDMA 3,4-methylenedioxy-N-methylamphetamine MFLC military and family life counselor MHAT mental health advisory team MHS military health system MIRECC Mental Illness Research, Education, and Clinical Center MST military sexual trauma MTF military treatment facility NDAA National Defense Authorization Act NEPEC Northeast Program Evaluation Center NICoE National Intrepid Center of Excellence NIH National Institutes of Health NIMH National Institute of Mental Health NQF National Quality Forum OASD(HA) Office of the Assistant Secretary of Defense for Health Affairs OASIS Overcoming Adversity and Stress Injury Support OEF Operation Enduring Freedom OIF Operation Iraqi Freedom OMHO Office of Mental Health Operations (VA) OSCAR Operational Stress Control and Readiness PACT patient-aligned care team PCL PTSD Checklist PCL-M PTSD Checklist-Military Version PCMH patient-centered medical home PDHA Post-Deployment Health Assessment PDHRA Post-Deployment Health Reassessment PE prolonged exposure therapy PHRAMS Psychological Health Risk Adjusted Model for Staffing PTSD posttraumatic stress disorder

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ABBREVIATIONS AND ACRONYMS xv RePORT Research Portfolio Online Reporting Tools database RESPECT-Mil Re-engineering Systems for Primary Care Treatment of Depression and PTSD in the Military rTMS repetitive transcranial magnetic stimulation SIPP specialized intensive PTSD program SNRI serotonin norepinephrine reuptake inhibitor SOPP specialized outpatient PTSD program SSRI selective serotonin reuptake inhibitor STRONG STAR South Texas Research Organizational Network Guiding Studies on Trauma and Resilience T2 National Center for Telehealth and Technology TBI traumatic brain injury TMS transcranial magnetic stimulation TrIOPS Tri-service Integrator of Outpatient Programming Systems VA Department of Veterans Affairs VBA Veterans Benefits Administration VHA Veterans Health Administration VISN veterans integrated service network VLER virtual lifetime electronic record WRC Warrior Resilience Center WSDTT Women’s Stress Disorder Treatment Team WTRP Women’s Trauma Recovery Program

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