Many service members and veterans who have posttraumatic stress disorder (PTSD) have other conditions that require treatment and rehabilitation with treatment for PTSD—such psychiatric and medical conditions as depression, anxiety, substance abuse, chronic pain, and traumatic brain injury (TBI) and psychosocial conditions such as relationship problems, unemployment or underemployment, intimate partner violence (IPV), homelessness, and incarceration. This chapter focuses on co-occurring conditions that are most likely to interfere with effective PTSD-specific treatments (which themselves are discussed in Chapter 7) and whose treatment should be integrated into a comprehensive treatment program for PTSD. Three major categories of co-occurring conditions are considered: psychiatric (including depression and substance use disorders), medical (including chronic pain, TBI, and spinal cord injury), and psycho-social (including IPV, child maltreatment, homelessness, and incarceration). Discussion of each category includes a brief overview of the conditions and their co-occurrence with PTSD in military and veteran populations followed by a presentation of how to integrate their treatment into treatment for PTSD. The committee notes that evidence of the effectiveness of these approaches, as part of a broad overall rehabilitation program for service members or veterans who have PTSD, is sparse.
The committee recognizes that the prevalence of co-occurring psychiatric and medical conditions and psychosocial issues differs among the varied cohorts and subpopulations of service members and veterans (for example between women and men) and that the treatment needs of different groups will be different. For example, homelessness and vocational training are
issues for veteran populations but not for active-duty service members. Among current service members, the needs of active-duty personnel differ from those of National Guard and reserve members and may vary according to service branch. Within veteran populations, the most important co-occurring medical and psychosocial treatment needs for patients who have PTSD may vary according to era and location of service. Dementia and other neurologic conditions that occur more frequently in aging populations, for example, constitute important comorbidity issues for veterans of World War II and Vietnam, but not for veterans of more recent conflicts.
Comorbid conditions that include symptoms of depressive or anxiety disorders, substance use disorders, and high-risk behaviors appear to affect at least as many veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) as PTSD alone (Hoge et al., 2004; Santiago et al., 2010). A large body of literature on trauma-exposed veteran and civilian populations supports the frequent co-occurrence of PTSD symptoms with depression (Erickson et al., 2001; Freuh et al., 2000; O’Donnell et al., 2004; Perlman et al., 2011; Shalev et al., 1998), traumatic grief (Prigerson, 2009; Shear, 2001, 2005), and alcohol use and drug use problems (Cerda et al., 2008; Cisler et al., 2011; Kulka, 1990; Zatzick and Galea, 2007) that may lead affected people to engage in high-risk behaviors that, in turn, are associated with exposure to additional traumatic events (Hearst et al., 1986; Kulka, 1990; Pat-Horenczyk et al., 2007). High rates of moral injury (defined as the perpetration of or failure to prevent atrocities or the witnessing of acts that transgress moral beliefs) (Litz et al., 2009) have been documented in active-duty military personnel deployed in the OEF and OIF theaters of war (MHAT IV, 2006).
The National Vietnam Veterans Readjustment Study, one of the first major epidemiologic investigations of Vietnam veterans, documented high rates of co-occurrence of PTSD and psychiatric disorders (Kulka, 1990). Three-fourths of male Vietnam veterans who had PTSD also had a lifetime diagnosis of alcohol abuse or dependence, 44% had a lifetime diagnosis of generalized anxiety disorder, and at least 20% had a lifetime diagnosis of depression or dysthymia. Of female Vietnam veterans who had PTSD, 44% had a lifetime diagnosis of depression and 23% had current depression. Research conducted in the 1980s also suggested that men who served in Vietnam were at increased risk for trauma, including fatal motor vehicle crashes and completed suicide (Hearst et al., 1986).
Stepped-care approaches begin with lower-intensity treatments, such as support groups, and phase in more intensive procedures, such as evidence-based interventions—such as cognitive behavioral therapy (CBT) and
pharmacotherapy—for patients who have recalcitrant or recurrent symptoms of PTSD and related comorbidities (Engel and Katon, 1999). Collaborative stepped-care approaches and rehabilitative interventions that simultaneously target PTSD and comorbid conditions and psychosocial complexities have been proposed as an essential treatment delivery model for active-duty military and veteran populations (Engel and Katon, 1999; Engel et al., 2008; Gilbody et al., 2006; Zatzick et al., 2004, 2011, 2012). Collaborative stepped-care interventions are implemented by interdisciplinary teams of medical and mental health providers. Central to stepped-care approaches is regular assessment of PTSD symptoms and related comorbid-ities, coincident with evidence-based treatments. Collaborative stepped-care interventions that include care management and motivational interviewing can enhance a patient’s initial engagement with treatment and diminish high-risk behaviors, such as binge drinking, and thereby optimize entry into and completion of evidence-based psychotherapy and pharmacotherapy for PTSD (Geiss Trusz et al., 2011; Zatzick et al., 2011). Those interventions can also incorporate emergency evaluations and treatments to target immediate and critical problems (such as suicide and interpersonal violence) directly.
Established treatments for PTSD, such as prolonged exposure (PE) therapy, can also address comorbid conditions, such as depression, anger, guilt, and general anxiety symptoms (Foa, 2011). Additional support for a stepped-care treatment approach comes from studies of veterans who have received multiple treatments that targeted their comorbidities before being randomized into efficacy trials of PTSD-targeted interventions. For example, a review of two major CBT efficacy trials found that many veterans in the studies received treatment for comorbid psychiatric and substance use conditions before their enrollment in the PTSD-specific treatment protocol, and following CBT treatment they had significant improvements in their PTSD and comorbid symptoms (Monson et al., 2006; Schnurr et al., 2007).
Combat experience is a known risk factor for both PTSD and substance use disorders (Jacobsen et al., 2001, 2008; Norman et al., 2010). In one study of OEF and OIF veterans who were treated in a Department of Veterans Affairs (VA) facility, 17% had co-occurring PTSD and a substance use disorder (Norman et al., 2010). One widely used treatment model is Seeking Safety, a manualized CBT program used to treat co-occurring PTSD and substance use disorder (Najavitz, 2009). A VA consensus conference noted that although there have been no randomized controlled trials (RCTs) of Seeking Safety, it may be an option for patients who are not ready for evidence-based treatment for PTSD (VA, 2010b). Central principles of the model include safety, both physically and psychologically in one’s internal and external worlds; integrated treatment of PTSD and substance abuse; a focus on ideas and a search for meaning; and case
management with an emphasis on cognitive, behavioral, and interpersonal domains (Najavitz, 2002). Several studies have evaluated the effectiveness of Seeking Safety in different populations and settings, including several veteran populations (Boden et al., 2012; Cook et al., 2006; Desai et al., 2008, 2009; Norman et al., 2010; Weaver et al., 2007; Weller, 2005); the results have been mixed.
In a recent RCT of 98 male veterans who had both substance use disorder and PTSD symptoms and who were recruited from an outpatient VA substance use disorders clinic, substituting Seeking Safety for part of the usual treatment was associated with better drug use outcomes than in the controls. However, alcohol use and PTSD severity decreased equally under both treatments (Boden et al., 2012). Findings of a pilot study of 14 male OEF and OIF veterans suggest that Seeking Safety may help to reduce alcohol use, depression, and PTSD in some participants at clinically significant levels. The investigators identified several features of the model that are especially helpful with combat veterans, including the case management component that helps persons to engage in other mental health and substance use disorder services. Veterans identified reintegration into civilian life and peer connections with other veterans as central to their recovery (Norman et al., 2010).
In another study, two nonequivalent cohorts of homeless female veterans who had psychiatric and substance abuse problems were recruited from VA homelessness programs. Seeking Safety appeared to have a moderately beneficial effect over 1 year on several clinical outcomes, including employment, social support, general symptoms of psychiatric distress, and symptoms of PTSD (Desai et al., 2008). In an uncontrolled pilot study of 18 male and female veterans in a VA setting, efficacy data on Seeking Safety indicated significant reduction in PTSD and substance use disorder symptoms, but in the absence of a randomized controlled condition it is unclear whether the reduction in symptoms was due to Safety Seeking or to other factors (Cook et al., 2006).
This section examines the treatment needs of people who have PTSD and co-occurring medical conditions. Chronic pain, TBI, amputation, spinal-cord injury, and severe burns—which may also result from the same trauma as that underlying PTSD—are each discussed. The section then examines the effect of PTSD on long-term health outcomes, including cardiovascular disease, inflammatory and autoimmune diseases, and diabetes mellitus.
Chronic pain is defined as pain that persists for at least 3 months after the resolution of a physical injury or disease process (Merskey and Bogduk, 1994). Such pain can affect social, occupational, and recreational function and can lead to problems of motivation, mood, social isolation, and estimates of self-worth.
The occurrence of physical injury that results in chronic pain is relatively common in the military, occurring from basic training to after discharge. Some 25% of male recruits and 50% of female recruits are predicted to experience at least one pain-related injury during basic combat training (McGeary et al., 2011). Chronic pain is the primary reason that OIF service members are evacuated from the theater of war (Harman et al., 2005), and combat-related orthopedic pain and musculoskeletal pain are the primary causes of disability (Masini et al., 2009). A review of medical records of OEF and OIF veterans who were seeking treatment at a VA polytrauma clinic found that 82% of them had documented chronic pain (Lew et al., 2009). Other studies of veterans have found that 50% of men and up to 78% of women report regular pain (Haskell et al., 2006; Kerns et al., 2003).
Chronic pain has adverse consequences on the cardiovascular, pulmonary, gastrointestinal, immunologic, and muscular systems. It also has been associated with increased anxiety, fear, anger, and depression and with a reduction in patient satisfaction and slower recovery from injury (Joshi and Ogunnaike, 2005). Starr et al. (2004) estimated the comorbidity of pain and PTSD to be greater than 50% for persons who sustained an orthopedic traumatic injury, and McGeary et al. (2011) report significantly higher rates of health care use by and poorer prognoses in patients who have comorbid PTSD and pain than those who have either diagnosis alone.
Treatment for Chronic Pain
Improvements in battlefield medicine practices and protective gear (body armor and helmet design) have led to increased survival of severely injured service members. Service members are also at risk for PTSD stemming from their physical injuries and the context in which they occurred. The symptoms that characterize chronic pain (for example, headache, irritability, sleep disturbance, and memory impairments) overlap with many symptoms of PTSD, and this complicates the diagnosis of, appropriate treatment for, and management of both conditions. The U.S. Army Surgeon General Pain Management Task Force Report (U.S. Army, 2010b) suggested the absence of pain-management practice guidelines in the theater of war
has resulted in an “overreliance on opioid-based pain solutions, from point of injury throughout the care continuum.”
Although a systematic literature review of treatments that targeted both chronic pain and PTSD symptoms found no combined treatment protocols, there is empirical evidence on the treatment of chronic pain in civilian and military populations with CBT and rehabilitation programs to restore function. Interdisciplinary chronic pain rehabilitation programs have empirical support for reducing pain and improving function in civilian populations (Gatchel et al., 2009; Gatchel and Okifuji, 2006; Guzman et al., 2001; Turk and Okifuji, 2002). Components of this approach typically include physical therapy, occupational therapy, CBT—including relaxation and biofeedback—and self-managed physical exercise. The U.S. Army Surgeon General Pain Management Task Force Report (U.S. Army, 2010b) made several recommendations for a comprehensive DoD and VA pain-management strategy that acknowledges the importance of treating pain. A number of studies have found CBT to be efficacious in reducing lower back pain (Hoffman et al., 2007), back and neck pain (Linton and Ryberg, 2001), osteoarthritis (Heinrich et al., 1985), and tension headache (Holroyd et al., 2001) and in improving function (Van Tulder et al., 2000). Key components of CBT pain programs include cognitive restructuring, relaxation training, time-based activity pacing, and graded homework assignments designed to target activity avoidance and improve engagement in an active lifestyle (Otis et al., 2011).
The functional-restoration approach is one example of an interdisciplinary program. Originally developed for use in sports medicine, this musculoskeletal pain management approach is individually tailored to the patient (on the basis of self-reported pain, medical history, structural measures, and functional-capacity measurements) with the goal of returning him or her to activity rather than focusing on pain symptoms (Mayer et al., 2003). Program components include objective and physical evaluation of physical and functional capacity, psychosocial assessment, identification of potential socioeconomic barriers to recovery, physician-directed treatment, and an interdisciplinary treatment-team approach. Evidence of the efficacy and robustness of functional-restoration approaches has been reported in several international populations (Gatchel and Okifuji, 2006).
The DoD Functional and Occupational Rehabilitation Treatment (FORT) program began in 2003 and uses a functional-restoration approach to decrease chronic musculoskeletal pain and increase functioning in service members (Gatchel et al., 2009). An RCT compared the FORT program with the usual treatment, standard anesthesia. The study used repeated measures in a treatment design that compared both groups immediately after and 6 and 12 months after treatment. The FORT participants had significantly better improvements in both psychosocial and physical outcomes
immediately after treatment and at the 12-month follow-up than the treatment-as-usual group. The FORT group also had significant improvements in self-reported pain severity and intensity, perceived disability, pain-related concerns about physical activity and quality of life, sleep problems, emotional distress (depression and fear avoidance), functional lifting capacity (both floor-to-waist and waist-to-eye level), and lumbar active range of motion. At the 12-month follow-up, FORT participants were significantly less likely to seek high levels of treatment for pain, significantly less likely to rely on multiple pain medications, and twice as likely to remain on active duty. The DoD endorsed the functional-restoration approach in 2009 with a call for physical therapists to implement principles of sports medicine on the battlefield by 2013 (DoD, 2009).
An RCT is being conducted by the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR) to evaluate the effectiveness of combined PE for PTSD and chronic pain treatment in active-duty orthopedic-trauma patients. The STRONG STAR RCT will compare outcomes in four study arms: a combined abbreviated PE and FORT-based pain approach, a PE group, a FORT group, and a treatment-as-usual group assessed immediately after treatment and at 6-month and 12-month follow-ups. This will be the first RCT to empirically test an integrated PTSD and pain treatment approach to improve functional outcomes in service members who have these co-occurring conditions (STRONG STAR, 2012).
Treatment for Co-Occurring Chronic Pain and PTSD
Besides the occurrence of physical combat wounds, extended time in service and multiple deployments have produced a population of active-duty service members who have had substantial wear and tear on their musculoskeletal systems. Because of concerns about stigma and appearing weak, service members often ignore or self-manage their pain until their condition impairs their ability to function and puts others at risk, at which time they are most likely to seek care (McGeary et al., 2011).
High levels of PTSD symptoms immediately after an injury have been shown to predict impairments in physical, role, and social functioning (Holbrook et al., 2005; O’Donnell et al., 2005; Ramchand et al., 2008; Zatzick et al., 2008a, b). Zatzick et al. (2008a) found that PTSD symptoms were independently associated with an inability to return to work 12 months after injury even after adjustment for all other relevant clinical, injury, and demographic characteristics. PTSD has also been shown to affect patient reports of physical symptoms and is a leading predictor of functional outcome after injury, including physical limitations and inability to return to work (Michaels et al., 1999). Co-occurring pain and PTSD from
orthopedic trauma impede a patient’s ability to benefit from pain treatment; such patients frequently have long periods of disability after trauma and poorer outcomes (McGeary et al., 2011). In a retrospective study of severely injured accident victims, Schnyder et al. (2001) found that PTSD predicted “perceived general health” more than injury severity or degree of physical functioning did. Thus, PTSD may lead to an increased focus on and perception of pain or an increased likelihood of reporting of pain symptoms. People who have PTSD also have a more negative perception of their general health, and this may also lead to complications in pain assessment and treatment. When chronic pain and PTSD are combined with a negative view of the future, there may be less participation in pain management programs that could lead to a reduction in symptoms.
Comorbid PTSD, depression, and chronic pain may interact to confound symptom presentation and treatment for each condition. PTSD and depression work together to exacerbate pain symptoms (Ahman and Stalnacke, 2008; Poundja et al., 2006; Roth et al., 2008). Several studies have found that pain and depression severity are strong predictors of each other and of functional status and quality of life (Bair, 2004; Kroenke et al., 2011; Lin et al., 2006). Treating depression with a selective serotonin reuptake inhibitor or other antidepressant or treating chronic pain with CBT has been shown to improve outcomes of both conditions (Bair, 2004; Institute for Clinical Systems Improvement, 2009; Kroenke et al., 2011). Concurrent treatment for pain and the psychiatric condition may result in greater improvement in both than sequential care. For example, when either pain or depression is initially treated with the goal of maximizing its treatment before addressing the comorbidity, neither is effectively treated, and treatment effect decreases as symptom severity of both the pain and the psychiatric condition increases (Kroenke et al., 2007, 2008, 2011; Lin et al., 2003, 2006). Therefore, combining pharmacologic and psychologic treatments for PTSD, depression, and chronic pain is likely to result in improved outcomes.
Traumatic Brain Injury
TBI is defined by the DoD and the VA (DCoE and DVBIC, 2009) as a traumatically induced structural injury and/or physiological disruption of brain function as a result of external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event:
- Any period of loss of or a decreased level of consciousness;
- Any loss of memory for events immediately before or after the injury;
- Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.);
- Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient; and
- Intracranial lesion.
From 2000 through the end of 2011, a total of 229,106 service members in all services suffered TBI, of whom 77% experienced mild TBI (mTBI), as shown in Table 8-1 (DVBIC, 2011). On the basis of data collected from the postdeployment health questionnaires, 12% of returning service members had experienced mTBI while deployed (Schneiderman et al., 2008); when a structured interview was used, the prevalence of mTBI was almost twice as high (23%) as the questionnaire rate (Terrio et al., 2009).
TBI may be caused by a bump, blow, or jolt to the head; by acceleration or deceleration force without impact; or by penetration to the head that disrupts the normal function of the brain (DVBIC, 2011). The primary cause of TBI in OEF and OIF service members and veterans is an explosion or blast injury (Owens et al., 2008); the majority are closed head injuries that result from improvised explosive devices (IEDs) (Galarneau et al., 2008). Falls, motor vehicle incidents, and assault also cause TBIs in this population. However, blast-related TBI has been a focus of research because of its frequency and the difficulties that it presents for diagnosis. For example, concussive injuries associated with strong blasts may not be identified immediately if they occurred at the same time as more life-threatening injuries that dominate medical treatment. Additionally, mTBI resulting from a blast may produce no outward sign of injury and leave service members reluctant to report acute symptoms because they do not want to be medically evacuated and separated from their units. Thus, mTBI may not be identified as
TABLE 8-1 Incidence of TBI by Severity in All Armed Forces (Cumulative, 2000–2011)
|SOURCE: DVBIC, 2011.|
a concern until a service member returns home from deployment (DVBIC, 2011).
The higher-level cognitive domains typically affected by TBI include attention, speed of processing, working memory, visuospatial ability and praxis, language and communication, and executive function. In the case of mTBI, postconcussion syndrome is considered to have occurred when three or more concussion symptoms persist for 3 months or more after injury (APA, 2000). Symptoms of concussion include fatigue, disordered sleep, headache, vertigo or dizziness, irritability or aggression with little or no provocation, anxiety, depression or affective liability, changes in personality, and apathy or lack of spontaneity. Postconcussion syndrome has been reported to occur in 10–20% of TBI cases (e.g., Ruff, 2005; Wood, 2004) and as many as 44% of hospitalized mTBI cases (Dikmen et al., 2010). In a U.S. Army brigade sample of clinically confirmed mTBI, memory deficits (16%), headache (20%), and irritability (21%) were reported to be the most frequent symptoms of postconcussion syndrome (Terrio et al., 2009). Belanger et al. (2005) failed to show a difference in neuropsychologic performance between blast and non-blast TBI, although anecdotal reports suggest otherwise (no data were available to confirm this observation). Many authors cite the need for more research to determine the effect of multiple trauma because they suspect the brain may adapt to the first concussion quickly but be more susceptible to injury with additional trauma owing to residual effects of the first one (Bigler, 2008; Moser et al., 2005; Omalu et al., 2005; Wall, 2006).
Co-Occurrence of TBI and PTSD
Symptoms of PTSD and mTBI may have considerable overlap, and this presents a diagnostic challenge. Studies indicate that the co-occurrence of TBI, pain, and psychosocial health problems is more common than is their isolated occurrence in OEF and OIF service members and veterans. The presence of PTSD after mTBI may prolong the duration of and potentially exacerbate the mTBI symptoms (Brenner et al., 2010). A recent systematic review found the frequency of comorbid probable PTSD in people who had probable mTBI was 33–39% (Carlson et al., 2010). Sayer et al. (2009) found there was a high comorbidity of pain, PTSD, and mTBI in patients who were treated at VA level-1 polytrauma rehabilitation centers (treatment facilities for the most-impaired veterans). Of 188 combat-injured service members, 93% had incurred combat-related TBI, 81% reported a pain problem, and 53% received some type of mental health service. A similar study of 50 OEF and OIF veterans who were treated at a VA level-1 polytrauma rehabilitation center found that 80% reportedly incurred combat-related TBI (58% were penetrating, 22% were closed), 96% reported at
least one pain problem, and 44% reported experiencing PTSD (Clark et al., 2007). Of 62 patients at a level-2 polytrauma network site, Lew et al. (2007) found that 97% reported three or more postconcussive symptoms (for example, headache, dizziness, and fatigue), 97% reported chronic pain, and 71% met the criteria for PTSD. In a comprehensive review of medical records of 340 OEF and OIF veterans seen at a level-2 polytrauma network site, Lew et al. (2009) found that 82% had more than one diagnosis and 42% had three co-occurring diagnoses, including pain, PTSD, and post-concussion syndrome. Veterans who had positive TBI screens were also more likely to have a diagnosis of PTSD, depression, and substance abuse disorder; these three conditions were present in isolation in only 5%, 10%, and 3% of veterans, respectively—significantly lower frequencies than those at which they were present in combination (Lew, 2009). In another study by Ruff et al. (2008), approximately 66% of veterans who presented with headache and TBI had cognitive deficits on examination, more severe and more frequent headaches, more reports of pain, higher rates of PTSD, and impaired sleep with nightmares than veterans with mTBI who did not have a neurologic impairment.
A large study of approximately 3,000 hospitalized patients found that those who had mild, moderate, or severe TBI and PTSD had significantly worse physical, role, and social functioning than patients who had TBI of any severity without PTSD. Regardless of TBI severity, patients who had PTSD had greater impairments in self-reported cognitive functioning—including reasoning, memory, problem solving, concentration, and thinking—than those who did not have PTSD. Patients who had severe TBI had the highest cognitive impairments and had the least improvement during the 12-month follow-up. Increasing severity of TBI (moderate and severe) was associated with lower rates of PTSD symptoms in this population than mTBI; this supports the theory that a more severe head injury may disrupt memory consolidation and associated PTSD symptoms (Zatzick et al., 2010).
Depression is frequently reported in people who have chronic postcon-cussion syndrome (Hesdorffer et al., 2009). People who have mTBI and experience depression after the injury report more symptoms and more severe symptoms than those who have mTBI without depression (Lange et al., 2010). People who have mTBI report more problems with cognitive function if they have comorbid depression, anxiety, or PTSD than if they do not have these conditions (Spencer et al., 2010). Depression after mTBI has been associated with older age at time of injury and higher levels of depressive symptoms in the week after injury (Bay, 2009).
When the Minneapolis VA Evidence Synthesis Program reviewed the literature on patient care for TBI and PTSD from 1980 to April 2009 (VA, 2009), they had two key findings: the reported prevalence of comorbid
TBI and PTSD varied widely among study populations, none of which was a large, representative population; and no published studies reviewed the accuracy of diagnostic tests that were used for assessing co-occurring mTBI and PTSD. Those findings suggest that the frequent, albeit variable, co-occurrence of TBI, PTSD, and other health conditions presents serious challenges for optimizing treatment-planning and outcomes. PTSD may also exacerbate other conditions that are often reported after deployment, including pain and headache, because of its effects on sleep and the perception of pain. There is some question as to whether the neuropathology of PTSD associated with TBI differs from that of PTSD arising from trauma that is not due to direct physical or neurologic injury to the brain (Stein and McAllister, 2009; see also Chapter 3).
Treatment for Co-Occurring TBI and PTSD
Few empirical studies have examined treatment protocols that specifically targeted co-occurring TBI and PTSD symptoms in civilian populations (Bryant et al., 2003; McAllister, 2009; McMillan et al., 2003). In recognition of this, the VA Consensus Conference report (2010) stated that, “there was complete consensus that the current VA/DoD clinical practice guidelines for PTSD, mTBI, and pain should be followed at this time, until new research suggests other approaches or demonstrates that current clinical practice guidelines are ineffective or inappropriate for this complex population.”
Many approaches to the rehabilitation of the neurocognitive, vocational, and psychosocial sequelae of TBI have been developed and evaluated over the last 30 years. Cognitive neurorehabilitation has been defined by Robertson and Fitzpatrick (2008) as a “structured, planned experience derived from an understanding of brain function which ameliorates dysfunctional cognitive and brain processes caused by disease or injury and improves everyday life function.” The efforts are as varied as the types of impairments they try to address.
The American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest Group Cognitive Rehabilitation Task Force has published three systematic reviews of the efficacy of neurocognitive rehabilitation after TBI or stroke (Cicerone et al., 2000, 2005, 2011). The most recent presented a set of practice standards, guidelines, and options based on the array of evidence supporting various cognitive rehabilitation strategies. This provided clear standards for implementation of cognitive rehabilitation therapy (CRT) primarily on the basis of civilian TBI literature on the remediation of neurocognitive impairments (attention, visuospa-tial, and praxic deficits and impairments in language and communication, memory, and executive function).
Two efforts have served as the basis of the most up-to-date and specific analysis of the treatment literature and of practice recommendations for the remediation of TBI-related impairments in neurocognitive, emotional, and psychosocial functioning and for addressing the future of assessment of and intervention in co-occurring TBI and PTSD: the 2010 VA Consensus Conference and the Institute of Medicine (IOM) consensus report on CRT after TBI. The VA Consensus Conference (VA, 2010a) provided a series of recommendations that address comorbid TBI and PTSD in veterans, including the following:
- Identify best practices for co-occurring TBI, PTSD, and pain through further research.
- Enhance collaborative-care coordination among disciplines.
- Determine special and unique issues for PTSD, mTBI, and pain patients in rural health settings.
- Improve collection and monitoring of treatment outcomes of patients who have these comorbidities to examine variables relevant to the wide variety of treatment approaches that are being implemented.
- Include family members in the treatment planning and process.
- Provide support to family members when possible.
- Increase opportunities for educating clinical care providers regarding outcome measurement.
Clear action plans for research priorities, with timelines, for treating persons who have PTSD, mTBI, and pain were also recommended (VA, 2010a).
The IOM (2011) report on the use of CRT for TBI reviewed 90 TBI studies. The report described CRT as, “a collection of treatments, generally tailored to an individual depending on the pattern of the impairments and activity limitations, related disorders (e.g., preexisting conditions or comorbidities), and the presence of a family or social support system” and acknowledged that although there is some benefit of some forms of CRT for TBI, the evidence of its therapeutic value is variable and insufficient overall to provide definitive guidance for clinical best practices. The report also acknowledged the many current limitations in the literature, including lack of operational definitions of different forms of CRT, small sample sizes, and the many premorbid conditions, comorbidities, and environmental factors that may affect the outcome of CRT in heterogeneous populations. Because of the lack of a heterogeneous definition and varied study designs, a substantial effort is needed to address TBI and co-occurring conditions, such as PTSD.
The Co-occurring Conditions Toolkit: Mild Traumatic Brain Injury and Psychological Health (DCoE, 2011) evolved from a 2009 VA conference
to develop consensus recommendations for the treatment of veterans who have comorbid concussion, PTSD, and pain. At the conference, subject-matter experts in the VA and the DoD determined that current VA/DoD clinical practice guidelines aimed at patients who presented with a single condition would be applicable to patients who had comorbid conditions until there was evidence that the guidelines were contraindicated. The toolkit was designed to assist primary care providers in evaluating and managing patients who present with multiple conditions by synthesizing information from the existing guidelines. The primary focus of the toolkit is on improving the evaluation and specification of conditions that may result from conflicting sets of presenting symptoms rather than on diagnosing co-morbid conditions. An electronic version of the toolkit was recently created for smartphones and tablet devices by the National Center for Telehealth and Technology. The application contains the entire contents of the hard-copy form of the toolkit and provides digital interactive decision trees to aid in the identification of appropriate interventions and timing of services for patients who have co-occurring conditions, including PTSD, depression, chronic opioid therapy, and substance use disorders (DoD, 2012).
Amputation, Spinal Cord Injury, and Burns
IEDs and other blasts have caused many of the physical injuries sustained in OEF and OIF. Adoption of body armor and armored vehicles has improved battlefield injury survival rates; however, the enhanced protection from injuries to vital organs has meant that a number of service members have survived catastrophic spinal cord injury, amputation, and burns (in addition to TBI). Compared with the incidence of TBI, the number of service members who have suffered such polytrauma is relatively small. For example, as of September 2010, there have been 1,222 major limb amputations and 399 minor (finger, toe, hand, and foot) amputations in OEF and OIF service members (Fischer, 2010). As of September 2007, spinal cord injury was reported in approximately 100 active-duty service members, often as a result of blast injuries that damaged the more exposed cervical spinal region and typically led to quadriplegia (Weaver et al., 2009).
Polytrauma survivors who have suffered complex combinations of injuries and are at risk for developing PTSD will require substantial, and in many cases long-term, care and rehabilitation. In a recent study of 382 military amputees, Melcer et al. (2010) reported that two-thirds had at least one mental health diagnosis, the most prevalent of which was PTSD, followed by acute stress reaction and depressive disorder. Virtually all the injuries (91.4%) were caused by traumatic exposures to explosions, including those of IEDs, rocket-propelled grenades, mortars, and landmines. In an analysis of 221 amputee veterans (92.3% served in OEF and OIF) dis-
charged between July 1, 2005, and September 30, 2006, 61.5% had been diagnosed with PTSD in the VA compared with 11.7% of all nonamputee veterans discharged from the military during this same time period (n = 490,936) (VA, 2012a).
Gaylord et al. (2009) followed 372 service members whose burns were treated at an Army burn center during the period October 2003–May 2008 and found 25% of them screened positive for PTSD. Those findings are within the range of previous estimates of the 12-month prevalence of PTSD in civilian burn patients, which have been estimated to range from 9% to 45% (Dyster-Aas et al., 2008; McKibben et al., 2008).
In a 2001 review of spinal cord injury and co-occurring mental disorders, Kennedy and Duff (2001) reported the prevalence of PTSD after spinal cord injury to be 16% in veterans who had suffered combat trauma and 10–40% in the general population (Radnitz et al., 1998a, b). In civilian victims of fire and motor vehicle incidents, depression is the most common comorbid disorder for those diagnosed with PTSD (Maes et al., 2000). As in the case of TBI, no empirical studies have examined treatment protocols specifically targeted at PTSD after multiple, complex traumatic injuries.
Other Medical Conditions and PTSD
Conditions other than those related to the trauma co-occur with PTSD in military and veteran populations and have implications for treatment of both PTSD and the comorbid condition. For example, many studies have shown PTSD to be associated with increased risk of cardiovascular disease (Boscarino, 2008a; Cohen et al., 2009a; Kubzansky et al., 2007), specifically, coronary heart disease, which may be an effect of PTSD on hypertension, hyperlipidemia, and obesity (Coughlin, 2011). Cohen et al. (2010) examined the effect of mental health diagnoses on cardiovascular risk factors—including hypertension, dyslipidemia, and diabetes—in a sample of approximately 303,000 OEF and OIF veterans who received care at VA facilities from 2001 through 2008. Veterans were categorized as having no mental health diagnoses, having mental health diagnoses but not PTSD, or having PTSD with or without comorbid mental health diagnoses. When the group that had no mental health diagnoses was used as the reference and after adjustment for demographic and military factors and for number of visits to primary care subspecialties, both men and women in the PTSD group and the group that had mental health diagnoses but not PTSD had significantly higher rates of hypertension and dyslipidemia.
Three prospective studies indicate that PTSD may be involved in the etiology of coronary heart disease. In the first, of 1,002 veterans enrolled in the Normative Aging Study, the authors found that after controlling for depressive symptoms and other factors, the adjusted relative risk of combined
nonfatal myocardial infarction and fatal coronary heart disease increased significantly for each standard deviation increase in score on the Mississippi Scale for Combat-Related PTSD. That a similar significant association was found when angina was included constituted evidence that higher levels of PTSD symptoms may increase the risk of incident coronary heart disease in older male veterans (Kubzansky et al., 2007). In a related study of Vietnam Army veterans, Boscarino (2008a) found that after adjustment for coronary risk factors and depression, a diagnosis of PTSD more than doubled the risk of death from early-age heart disease. The third prospective study, which sampled 1,059 civilian women, found that after adjustment for coronary risk factors and depression, participants who had five or more PTSD symptoms were at significantly higher risk of incident coronary heart disease than participants who had no PTSD symptoms (Kubzansky et al., 2009). PTSD is also associated with decreased adherence to treatment regimens for myocardial infarction (Shemesh et al., 2004).
Metabolic syndrome is defined as a cluster of several risk factors—such as hypertension, obesity, diabetes, and hyperlipidemia—that when they occur together increase the risk of cardiovascular diseases (including coronary heart disease, coronary artery disease, and stroke). Psychologic factors have been associated with the individual components of metabolic syndrome and with metabolic syndrome as a whole (Vaccarino et al., 2008). Cohen et al. (2009a) found that higher levels of depression, anger expression, hostility, and pessimism, assessed with validated measures, were significantly associated with increased prevalence of metabolic syndrome. However, the association was largely explained by income and lifestyle mediators (smoking, body mass index, regular alcohol use, physical activity).
In addition to the significant association between PTSD and cardiac disease, PTSD is associated with lower health-related quality of life. In a sample of 1,022 men and women who had coronary heart disease (about 40% of whom were veterans), after adjustment for cardiovascular risk factors, including demographic factors and smoking status, objective measures of cardiac function (such as exercise capacity and ejection fraction) and comorbid depression, PTSD was independently associated with greater symptom burden, greater physical limitation, and worse quality of life (Cohen et al., 2009b).
In addition to its association with heart disease, PTSD has been associated with inflammatory and autoimmune diseases (Boscarino, 2008b; O’Toole and Catts, 2008), proinflammatory and anti-inflammatory activity (von Känel et al., 2007), endothelial dysfunction (von Känel et al., 2008), and diabetes mellitus (Boyko et al., 2010; Qureshi et al., 2009). The association between PTSD and diabetes has been mixed. Qureshi et al. (2009) reviewed four studies that examined the relationship between physical disease and PTSD. Two of the studies of the general population (Lauterbach
et al., 2005; Weisberg et al., 2002) found positive associations, and two (Boscarino, 2004; Norman et al., 2006), including one that used a sample of 2,490 male Vietnam veterans, were negative. Using a large sample from the Millennium Cohort Study, Boyko et al. (2010) found that after adjustment for several factors—including demographic factors, military service characteristics, physical health factors, and mental health conditions— baseline PTSD was the only factor significantly associated with increased risk of diabetes. Cohen et al. (2009a) found that after adjustment for demographic factors and number of deployments, a PTSD diagnosis (and mental health diagnoses but not PTSD) was significantly associated with diabetes in both men and women; however, after adjustment for number of primary care visits and number of subspecialty visits, PTSD was not statistically associated with diabetes in men.
There is also evidence that PTSD is associated with an increased susceptibility to future health conditions (such as dementia) and with an increased use of health care services; the latter finding suggests that the successful early treatment of PTSD may contribute to future health care savings (Boscarino, 2004, 2008a, b; Cohen et al., 2010; Spiro, 1994; Yaffe et al., 2010).
Recently, more recognition that some people who have PTSD also have severe psychologic symptoms; experience difficulties with their partnerships and families, social environments, and work settings; and make more use of community and psychiatric services has resulted in improved treatment for PTSD. Psychosocial rehabilitation typically involves family psychoeduca-tion and supported employment, education, and housing. Some clinicians may serve as case managers for their patients; in other cases, patients work with peer counselors. The 2010 VA/DoD guideline recommends psycho-social rehabilitation and expanding services offered by inpatient and outpatient programs in primary care settings, outpatient clinics, Vet Centers, and home-based care programs, including partnerships with agencies and providers in the communities (VA and DoD, 2010).
Empirically validated data support an integrated and collaborative treatment plan for PTSD (VA and DoD, 2010). Although currently underused, this approach combines trauma-focused therapies with psychosocial rehabilitation. Once a patient and a clinician identify the patient’s PTSD-related problems, they must determine whether the issues are associated with core symptoms of PTSD or with some other problem and ensure that any interventions are provided in the context of integrative treatment for PTSD. The timing and pacing of interventions are critical because safety,
self-care, and stabilization must be ensured before any of the treatment approaches are introduced to a client and his or her family.
Most research findings emphasize that positive social support is a central moderating influence in mitigating the adverse effects of trauma (IOM, 2008). Social support also facilitates effective treatment, healing, and recovery for service members, veterans, and their families. Consequently, health care providers should be attuned to a patient’s psychosocial issues, and these issues should be central to all phases of a multimodal, integra-tive, comprehensive treatment and rehabilitation approach, including assessment, engagement, and planning of interventions (VA and DoD, 2010).
Most service members, veterans, and their families handle deployment and combat stressors without developing mental health problems. However, trauma can disrupt social connections, and deployment-related separations and reunions can exacerbate already stressful situations. Many service members confront substantial problems with relationships throughout the deployment cycle, including relationships with partners, family members, friends, extended family members, and coworkers (Davidson et al., 1989).
Although the committee did not find any studies that specifically associate divorce with the presence of PTSD in one or both partners, some general divorce statistics are applicable. Recent research consistently shows a higher prevalence of marital conflict and higher rates of divorce in OEF and OIF veteran couples than in civilian couples (Finley et al., 2010; Foran et al., 2011). That finding is similar to the significantly higher divorce rate in Vietnam veterans than in the general population; rates of divorce are even higher in Vietnam veterans who have PTSD (Kulka, 1990). An estimated 38% of Vietnam veterans’ marriages failed within 6 months of veterans’ return from deployment (PCMH, 1978). In addition to divorce, increasing rates of intimate partner violence (IPV) and child maltreatment by OEF and OIF couples have been noted (IOM, 2010; Rentz et al., 2007; Tanielian and Jaycox, 2008). This section discusses those and other psychosocial problems and clinical and program interventions to address them.
Multiple types of acts and degrees of violence fall under the umbrella definition of IPV. Milder, but no less serious, acts include pushing and slapping; more severe forms of IPV include punching, strangling, and burning. The U.S. military has recently adopted the definition of clinically significant IPV—physical aggression by a partner that results in injury, significant potential for injury, or significant fear—as the standard definition of abuse to be used as a threshold for whether IPV allegations should be labeled as abusive, and thereby result in more severe consequences (Slep et al., 2011). Recent research findings indicate high rates of IPV by returning OEF and
OIF service members and veterans (IOM, 2010; Jakupcak et al., 2007; Wadsworth and Riggs, 2010). A study of the prevalence of IPV, clinically significant IPV, and clinically significant emotional abuse found widespread partner maltreatment in military samples. Lower rank was a risk factor for perpetration and victimization. Men were more likely than women to perpetrate clinically significant IPV (Foran et al., 2011). Veterans who have PTSD have consistently had a higher incidence of IPV and significantly higher rates of aggression and violence than veterans who do not have PTSD (Beckham et al., 1997; Byrne and Riggs, 1996; Freeman and Roca, 2001; Jordan et al., 1992; Kulka, 1990; Taft et al., 1999; Teten et al., 2010; Tinney and West, 2011).
Teten et al. (2010) grouped OEF and OIF veterans according to their results on the PTSD Checklist–Military version (PTSD, subthreshold, and no PTSD) and compared the groups on self-report measures of hostility, aggression, and trait anger. Veterans in the PTSD group reported significantly greater anger and hostility than those in the subthreshold PTSD group, and those who did not have PTSD reported the least anger and hostility. There were no significant differences between the subthreshold PTSD and PTSD groups with respect to aggression, but both groups were significantly more likely to have endorsed aggression than the non-PTSD group. Those results suggest that it may be beneficial for clinicians to screen for anger and aggression in veterans who exhibit symptoms of PTSD in order to incorporate early treatment interventions that address affect dysregulation and problems with anger management. Jakupcak et al. (2007) examined partner aggression in male OIF and OEF veterans and compared their aggressiveness with that reported by Vietnam veterans who had PTSD. When age was controlled for, odds ratios showed that male OEF and OIF veterans who had PTSD were 1.9–3.1 times more likely to perpetrate aggression toward their female partners and 1.6–6.0 times more likely to report experiencing female-perpetrated aggression than OEF and OIF veterans who did not have PTSD and Vietnam veterans who had PTSD.
Typically, deployment and reintegration stressors weigh heavily on service members or veterans and their partners as they navigate complicated adjustments and transitions back into the community. Coping with wartheater combat and deployment stressors is moderated by the resilience and problem-solving capacities of service members, veterans, and their partners. In many cases, couples renew their connections after deployment without engaging in acute interpersonal conflict, but some service members and veterans who have PTSD, depression, TBI, or substance use disorders may find themselves more vulnerable to behaving in abusive and violent ways (Martin et al., 2010; Teten et al., 2010).
Several hypotheses have been offered to explain the heightened volatility. The hyperarousal cluster (Criterion D) of PTSD symptoms translates
into affect dysregulation, alternating numbness and hyperarousal, emotional lability, and intermittent rage outbursts. The physiologic traumatic stress response can be triggered by stimuli that are associated with the original traumatic event. The biologic determinants intersect with a full range of intense emotions to create an incendiary milieu in the home (Finley et al., 2010). Such emotions may include estrangement; feelings of abandonment, loss, and rejection; isolation; and powerlessness related to a loss of military identity or a gap in resuming family and work roles on homecoming. In a study of returning OEF and OIF service members, the intensity of combat experience and exposure to violent human trauma were predictive of verbal and physical aggression toward others 3 months after deployment (Killgore et al., 2008).
A small study that examined IPV in a sample of mainly OEF and OIF veterans (84% who had PTSD) and their spouses found three general patterns of PTSD-related partner violence: violence committed in anger, dissociative violence, and parasomniac/hypnopompic violence (violence occurring during sleep or just before waking). The form of violence may be related to the specific PTSD symptom clusters affecting the veteran. Recognition of the form partner violence may take, when it may occur, and how both the veteran and his or her partner may perceive and respond to it has important implications for informing and developing appropriate plans for coping and safety-seeking (Finley et al., 2010). A recent study investigated the association between committing IPV and PTSD in a clinical sample of 302 men who sustained intimate terrorism—a form of IPV that involves intense violence—and a community sample of 520 men. Men who sustained intimate terrorism were at a much higher risk for exceeding the clinical cutoff on the PTSD measure than men who sustained common couple violence or no violence. The authors suggest that treatment approaches might also differ according to the degree of violence suffered (Hines and Douglas, 2011).
To facilitate a smooth transition after deployment, the DoD and the VA each use many treatment programs, but there is a lack of empirical evidence to support their efficacy. In the DoD, family advocacy programs are supported by each service branch. After a partner, family member, or clinician reports an incident of IPV to a superior officer, the command activates a referral for an assessment with a family advocacy program. If a victim reports to a victim advocate or health care provider, the victim can request a restricted report, in which case the command is not notified and a full assessment is not performed. If the provider feels that some aspects of the case are too risky to warrant a restricted report, he or she may refuse to issue a restricted report and may inform command while starting the assessment process.
Treatment programs typically involve individual and group therapy
for the offender and individual support and therapy for the victimized partner. When safety has been achieved for both partners, couples therapy is often indicated to renew connections, foster sound problem solving and communication skills, and discuss symptoms and phenomena associated with PTSD (Robichaux and McCarroll, 2011). Anger-management groups constitute another common treatment option for offenders. For example, the VA Medical Center in Boston sponsors a 12-session program for men to help with anger management and conflict resolution in intimate relationships. The program has not been evaluated, but evaluation data are being collected (VA, 2012b).
A number of prevention and treatment programs that address IPV in the civilian and military sectors are being evaluated. For example, Families OverComing Under Stress (FOCUS), is a family-centered and evidence-based resilience training program adapted for use by the U.S. Marine Corps at Camp Pendleton, California (the largest Marine base on the West Coast), in 2006. In 2008, the Navy Bureau of Medicine and Surgery collaborated with the University of California, Los Angeles, in launching a large demonstration project with Navy and Marine Corps families. In 2009, FOCUS services were made available to Army and Air Force families at selected installations throughout the United States. The preventive interventions in the program use psychoeducation, emotional regulation skills, problem solving skills, communication skills, and management of traumatic stress reactions (Lester et al., 2011).
A recent RCT conducted by Iverson et al. (2011) explored the efficacy of CBT for reducing the risk of IPV in 150 civilian women who experienced interpersonal trauma and who had PTSD. After controlling for recent IPV, reduced symptoms of PTSD and depression were associated with a decreased likelihood of IPV victimization within 6 months; this highlights the importance of treating the co-occurring conditions of PTSD and depression in survivors of IPV as one method of reducing the risk of IPV. However, the study included only civilians, and it should be replicated in a military population to assess the generalizability of the findings.
Tinney and West (2011) emphasize the importance of ensuring the safety of the victims, the veterans, and all family members, and they recommend a coordinated, integrated multimodal community response to IPV and family violence. They describe an integrated best-practice model called the Praxis International “Saint Paul Blueprint for Safety” to respond to IPV in families affected by military service. The model involves a nexus of agencies that address domestic violence to maximize safety while holding offenders accountable and facilitating change (Praxis International, 2010). The program is a prototype that can be used by any community to link its criminal justice agencies in a coherent, research-informed domestic violence
model. Although it has not been evaluated for IPV in military couples, the program developers report positive outcomes in addressing IPV crimes.
Effects of Parental Deployment and PTSD on Children
Slightly more than 2 million children have been affected by parental deployment to OEF and OIF, including 40% younger than 5 years old (Boston University School of Social Work, 2012). Although many military families harness their resilience and handle deployments well, some have difficulties with reconnecting and parenting, especially when a returning service member has PTSD (Chandra et al., 2010; Davidson et al., 1989; MacDermid et al., 2005; MHAT 7, 2011). Very young children are particularly vulnerable to deployment separations as a result of normative developmental challenges, including their emotional and cognitive immaturity and their reliance on parents for healthy development (Cozza and Lieberman, 2007; Paris et al., 2010). The relationship between parental functioning and the adaptation of children in the context of trauma and separation is well established. For example, studies of the effects of PTSD in Vietnam War veterans on family and marital functioning, including effects on children, found reduced family cohesion and less effective coping by both partners (Galovski and Lyons, 2004) and problematic parenting styles of over control, overprotection, disengagement, or enmeshment (extreme or inappropriate closeness) with children (Rosenheck and Nathan, 1985). Researchers have established the relationship between specific symptom clusters associated with PTSD (for example, intrusion, avoidance and numbing, and hyperarousal) and the quality of parent–child relationships. In particular, the emotional numbing associated with PTSD interferes with a parent’s capacity to engage with and sustain interactions with his or her children (Ruscio et al., 2002).
Child maltreatment typically refers to physical, sexual, or emotional abuse inflicted by adults or adolescents toward children or neglect of basic needs of safety, shelter, nutrition, and education. A historical perspective provides a window into shifting rates of child maltreatment from 1990, before the 1990–1991 Gulf War to the present. In 1990, the child maltreatment rate was 6.9 per 1,000 children based on data from the Army Central Registry (Robichaux and McCarroll, 2011). In general, the rates of child maltreatment in military families decreased through the 1990s, increased to 5.2 per 1,000 children in 2000 and 6.2 per 1,000 children in 2004, and decreased to 5.0 per 1,000 children in 2007, the latest year for which data are available (Robichaux and McCarroll, 2011).
Child neglect as a form of maltreatment appears to be correlated with deployment. Cases of neglect of children in military families decreased from a high of 3.6 per 1,000 children in 1991 (during the 1990–1991 Gulf War)
to a low of 2.7 per 1,000 in 2000 (before the start of OEF and OIF)—an overall decline of 25%. Child neglect rates rose to 4.5 per 1,000 in 2004, fell to 3.3 per 1,000 in 2006 and rose to 3.7 per 1,000 in 2007 (the latest data available). Neglect rates were highest in the youngest children. Clinical depression of the nondeployed spouse may contribute substantially to the observed increase in child neglect rates during combat deployments. PTSD has not been designated as a co-occurring condition but may exist in some of the nondeployed partners; however, the rate of PTSD in this group is unknown. The rates of physical child abuse decreased from 3.1 per 1,000 children in 1990 to 1.0 per 1,000 in 2007 (Robichaux and McCarroll, 2011).
Although it has not been PTSD specific, research points to a probable positive association between increased length of deployment and risk of child maltreatment, especially child neglect (Gibbs et al., 2007; McCarroll et al., 2008; Rentz et al., 2007). Most prevention and treatment approaches for reducing violence related to child maltreatment have not been systematically evaluated. One RCT found child–parent psychotherapy to be more efficacious than case management plus treatment-as-usual for preschool children exposed to IPV. Children in the child–parent psychotherapy group had decreased total behavior problems and PTSD symptoms, and their mothers (most of whom had PTSD) had significantly fewer PTSD avoidance symptoms at the end of treatment than did the control mothers (Lieberman et al., 2005). Two other programs, a Nurse–Family Partnership home-visiting program and the Positive Parenting Program (Triple P) have been shown to reduce child maltreatment. Other prevention and treatment programs are focused on supporting children and families of combat-injured service members and seek to enhance family cohesion, communication, secure attachments, education, and, when necessary, capacities for bereavement. All those programs have been found to serve as protective factors in reducing the risk of child maltreatment, including abuse and neglect (Cozza et al., 2011).
Strong Families Strong Forces is a three-phase project funded through a DoD grant and administered by a team of researchers in the Boston University School for Social Work (2012) to help veterans of OEF and OIF to reintegrate into their families after deployment. Phases 1 and 2 of the 4-year research program served to develop and test a home-based intervention to mitigate the stresses of the deployment life cycle on families, particularly those with children 1–5 years old, including the effects of a parent’s PTSD on young children. Preliminary results found strains related to deployment separation, parenting, role adjustments, and mental health concerns, including PTSD. An eight-module home-based therapeutic program was developed to address the emotional cycle of deployment and reintegration and to provide guidance on more effective parenting and reestablishing relationships with children. The research team is in phase 3 of the project
and is using an RCT to compare the efficacy of this treatment with the efficacy of usual treatment of a control group that takes place 1 month after the treatment group completes the program (Paris et al., 2011).
At the start of OEF, the rate of suicide in the U.S. Army (10 suicides per 100,000 soldiers per year) was about half the civilian suicide rate of 18 per 100,000 (adjusted for age and sex). However, in 2003–2010, coinciding with the conflicts in Afghanistan and Iraq, the suicide rate in active-duty soldiers nearly doubled to about 22 suicides per 100,000 soldiers per year (CDC and NCHS, 2009; Ritchie, 2012). Although the suicide rate has leveled off in active-duty soldiers, it has continued to rise in National Guard soldiers (Ritchie, 2012). In response, the Army and the DoD have created task forces to understand the risk factors for suicide, especially factors peculiar to the military. The task forces’ recommendations include standardized treatment protocols for at-risk military personnel and expanded primary health screenings that include mental health assessments (U.S. Army, 2010a).
As is the case with civilian suicides, many military suicides involve relationship problems with intimate partners, parents, or fellow unit members (CDC, 2012). Approximately two-thirds of military suicides appeared to be triggered by a relationship breakup. Like most civilian suicides, most military suicides are males, who tend to be more impulsive and use more violent methods of suicide (Styka et al., 2010). Black et al. (2011) found that the accumulation of multiple stressors—including relationship problems, job difficulties, and physical problems that many soldiers experience during their active-duty careers—is associated with completing suicide. In 2009, 9% of soldiers who committed suicide had received a diagnosis of PTSD (U.S. Army, 2010a). The National Comorbidity Survey found that PTSD (but not other anxiety disorders) was significantly associated with both suicidal ideation and attempts (Sareen et al., 2005). Therefore, monitoring for suicidal ideation and providing appropriate preventive interventions for persons being treated for PTSD in any sector is imperative. There are often concerns that some treatments for PTSD, such as prolonged exposure, may increase the risk for suicide or psychiatric hospitalization. However, these concerns do not appear to be supported by the scientific literature. For example, in a RCT of female veterans who had PTSD, Schnurr et al. (2007) compared PE (n = 141) with present-centered therapy (n = 143). Women who received PE experienced a significantly greater reduction of PTSD symptoms and were significantly less likely to meet PTSD diagnostic criteria than women who received present-centered therapy. Furthermore, there were more suicide attempts (3 vs. 1) and more than twice as many
psychiatric hospitalizations (9 vs. 4) for the women who received the present-centered therapy compared with those who received PE. Those results suggest that rather than increasing risk, effective treatments for PTSD may reduce the risk for suicide and psychiatric hospitalization in those who have PTSD.
Unemployment and Vocational Rehabilitation
Rates of unemployment are high in OEF and OIF veterans. The Bureau of Labor Statistics reported that during 2011 the overall unemployment rate in veterans who had served in the military since 2001 was 12.1%. The rate was especially high (29.1%) in younger male veterans (18–24 years old) and was also higher in members of the National Guard and reserves (9.1%) and in veterans who had served in a combat zone since 2001 (11.6%). Veterans who had more education had an increased likelihood of employment (DoL, 2010).
Using data from the National Survey of the Vietnam Generation, Savoca and Rosenheck (2000) found that a lifetime diagnosis of PTSD was associated with an almost 50% lower likelihood of current employment. Similar findings have been reported by other large-scale studies of Vietnam veterans (McCarren et al., 1995; Zatzick et al., 1997). More recently, Smith et al. (2005) found that the severity of PTSD symptoms correlated with work performance. Of Vietnam veterans who were in treatment for PTSD in the VA, those with more severe symptoms were more likely to be working only part-time or not at all. The high rates of general unemployment, particularly in those who experienced combat, and earlier employment findings on Vietnam veterans who have PTSD underscore the importance of addressing vocational issues for veterans who have PTSD.
Veterans who have been adjudicated to have PTSD that is at least 20% disabling and related to their time in service are offered a comprehensive array of vocational services by the VA Vocational Rehabilitation and Employment Program, including funds for schooling or training, comprehensive vocational evaluation, work-readiness services, and case management and vocational-placement services. The program reimburses employers for initial on-the-job training and provides other incentives to hire veterans who have service-connected PTSD. A comprehensive rehabilitation plan is developed in collaboration with the veteran. The VA also provides vocational services through its compensated work therapy (CWT) program, which includes preemployment programs to prepare veterans for seeking work, sheltered workshops managed by VA staff, transitional housing while veterans begin work and become financially established in the community, and a robust supportive employment program that consists of competitive employment with integrated therapeutic supports. The focus of supportive
employment is on assisting veterans who have mental illnesses in gaining access to meaningful employment.
In a study conducted more than 10 years ago, veterans who had PTSD were 19% less likely to be employed after discharge from the CWT program than veterans who had substance abuse disorders or who were homeless but did not have PTSD (Crowther, 2010). However, a recent RCT found that an evidence-based intervention for vocational rehabilitation was successful in veterans who had PTSD. This study randomized 85 veterans who had PTSD into a supportive employment program—Individual Placement and Support—or standard vocational rehabilitation and followed them for 12 months after enrollment. The manualized Individual Placement and Support program had previously been shown to be effective in improving employment outcomes in seriously mentally ill patients. Veterans enrolled in the Individual Placement and Support intervention were much more likely to obtain competitive employment in the community than those who did not receive the intervention (76% vs. 28%), worked more of the eligible weeks (42% vs. 16%), and had significantly more earnings during the follow-up period ($9,264 vs. $2,601). The study did not specify the era of service of the participants, who had a mean age of 40 years and were enrolled in the study during 2006–2010. Patients had high rates of co-occurring other psychiatric conditions, including alcohol dependence (42%), alcohol abuse (21%), drug dependence (37%), drug abuse (18%), and major depression (89%) (Davis et al., 2011).
Service members returning from combat deployment are prone to high-risk behaviors that may endanger themselves and others. The most common high-risk behaviors include hazardous use of alcohol, aggressive or dangerous driving, and excessive gambling. Those behaviors can cause substantial adjustment problems for service members and veterans and may contribute to and compound other problems, including PTSD. Recent evidence suggests that high-risk behaviors are associated with the intensity of combat experienced during deployment. Deployed service members have a greater probability of morbidity and mortality from motor vehicle incidents and other unintentional sources of injury than nondeployed service members. A few studies of earlier conflicts suggest this vulnerability decreases over time, but there are few data on a similar decline in risk for service members returning from Iraq and Afghanistan, especially those who had repeated deployments and are at higher risk of PTSD (Killgore et al., 2008). Addressing these behaviors should be considered part of overall PTSD treatment and rehabilitation in such populations.
High-risk behaviors are seldom noted in clinical records of service
members or veterans who are seeking mental health treatment in military or VA settings. Moreover, many clinicians do not perceive themselves as adequately trained to treat high-risk behaviors (Drebing et al., 2001; Weis and Manos, 2007). Short, validated screening and assessment tools exist for the most studied behaviors, such as the three-item AUDIT-C (Kriston et al., 2008) for hazardous use of alcohol; problem gambling (Westermeyer et al., 2005); and aggressive and unsafe driving (Killgore et al., 2008). Screening for those behaviors in high-risk populations, such as veterans who have had multiple deployments, may be an important first step in initiating treatment for these and related psychiatric comorbidities.
Separate from the psychiatric condition of alcohol abuse discussed earlier in this chapter, the hazardous or harmful use of alcohol is a major public health problem, accounting for as much disability and mortality as tobacco use and hypertension (Room et al., 2005). Alcohol-related incidents have increased since the beginning of OEF and OIF (DoD, 2007). A recent analysis from the Millennium Cohort Study of 48,481 active-duty, reserve, and National Guard service members found that rates of the following alcohol consumption behaviors were particularly high in reserve and National Guard members (Jacobson et al., 2008): heavy weekly drinking— men who consumed greater than 14 alcoholic drinks per week or women who consumed greater than 7—(9%), binge drinking—consuming 5 or more alcoholic drinks (4 or more for women) on at least one day per week or on a single occasion—(53%), and alcohol-related problems—positive response to one of several scenarios including consuming alcohol against physician orders; drinking, intoxicated, or hung over from alcohol while working, going to school, or taking care of children; and driving a vehicle after consuming several drinks—(15%). Similarly, a recent study of 1,508 OEF and OIF veterans who were using VA medical, surgical, or mental health services found that 40% screened positive for hazardous alcohol use (Calhoun et al., 2008). A recent survey of 596 OEF and OIF veterans from all services and components found 39% screened positive for probable alcohol abuse. Although OEF and OIF veterans did not differ significantly with regard to PTSD symptoms, OIF veterans reported significantly more depression, alcohol use, and substance use than OEF veterans (Eisen et al., 2012).
A recent study surveyed 1,252 OIF combat soldiers immediately after and 3 months after deployment to assess the relationship between combat experiences, selected high-risk behaviors, alcohol use, and aggression. Greater exposure to violent combat, human trauma, and killing another person were predictive of risk-taking behaviors, including more frequent
alcohol use and consuming alcohol in increased quantities (Killgore et al., 2008). Similarly, in a study of 1,120 OIF infantry soldiers, 25% screened positive for alcohol misuse, and those reporting higher rates of exposure to threats of death and injury were significantly more likely to screen positive for alcohol misuse (Wilk et al., 2010). Moreover, PTSD has repeatedly been correlated with abuse of alcohol in veteran and active-duty populations. For example, alcohol misuse was recently shown to be related to PTSD symptoms in OEF and OIF veterans (Jakupcak, 2010). In response, the military has developed and piloted programs to identify and reduce alcohol misuse in active-duty service members. Williams et al. (2009) reported the results of the modification of two Internet-based alcohol interventions delivered to active-duty military personnel: 2,171 received the intervention and 919 served as controls. The modified drinker-checkup program (Hester et al., 2005) was effective in reducing alcohol misuse. Similarly, an Internet-based intervention for marines was found to be generally acceptable to many potential participants (Simon-Arndt et al., 2006). In a study of 963 Army National Guard members recently returned from deployment, of the 113 (11.7%) who reported an alcohol abuse disorder that first occurred during or following deployment, 35 reported coincident depression, 23 reported coincident PTSD, and 15 reported both depression and PTSD. After adjustment for several potentially confounding factors, peri- and postdeploy-ment PTSD was found to be significantly associated with alcohol abuse disorders. The authors concluded that coincident PTSD and depression were predictive of developing peri- and postdeployment alcohol abuse, and therefore, deployment-related exposures may increase the risk of alcohol-related problems and disorders (Marshall et al., 2012). Although it did not examine temporality of diagnoses, a large study of 18,305 active-duty and National Guard soldiers found that at 3 months and 12 months following deployment to Iraq, about half of the soldiers who screened positive, using the strictest definition developed for the study, for PTSD or depression also screened positive for alcohol misuse or aggressive behaviors (Thomas et al., 2010).
During its site visit to Fort Hood, Texas, the committee heard about the intensive outpatient program in which PTSD treatment is embedded in alcohol- and substance-abuse treatment. Practitioners and patients both reported that the program is less stigmatizing than PTSD-specific programs.
Unsafe and Aggressive Driving
Aggressive and unsafe driving can be problematic for active-duty service members (Killgore et al., 2008). Although most research focuses on veterans from earlier eras, the likelihood of high-risk behavior is expected to be high in OEF and OIF veterans because this population is younger and
unsafe driving correlates highly with age. For example, UK military personnel who had been deployed to Iraq had higher rates of dangerous driving than older veterans. OEF and OIF service members who drove in combat areas were often attacked and had learned to adapt more aggressive driving techniques and to not use seat belts so they could leave their vehicles quickly (Kuhn et al., 2010). A recent study explored unsafe driving in 474 male U.S. veterans who were receiving treatment for PTSD. Approximately two-thirds of them reported lifetime aggressive driving, and one-third reported current aggressive driving. Severity of PTSD was associated with aggressive driving but not with other forms of unsafe driving, such as lack of seatbelt use. OEF and OIF veterans had higher rates of aggressive driving and other forms of unsafe driving than Vietnam and 1990–1991 Gulf War veterans even after controlling for age, other demographics, and severity of PTSD (Kuhn et al., 2010).
Problem gambling has been associated with anxiety disorders in large epidemiologic studies of civilians (Kessler et al., 2008), and several studies have corroborated the significant association between PTSD and problem gambling in veteran populations. Lifetime PTSD was related to current pathologic gambling in Vietnam twin-study veterans, and active PTSD symptoms predicted gambling problems in older veterans (Levens et al., 2005; Scherrer et al., 2007). In a national survey of more than 8,000 male Vietnam-era veterans, 10% had a lifetime diagnosis of PTSD and 2.3% had pathologic gambling, but the overlap between the two conditions was not given (Eisen et al., 2004). In a study of pathologic gambling in American Indian and Hispanic veterans of all eras combined, a diagnosis of current PTSD was significantly associated with lifetime pathologic gambling (Westermeyer et al., 2005).
In a sample of 111 male and female veterans who were admitted to a VA gambling treatment program, 64% reported a history of emotional trauma, 41% reported physical trauma, and 24% reported sexual trauma, primarily in childhood (Kausch et al., 2006). A group of 149 treatment-seeking problem gamblers were assessed for PTSD symptoms; 34% reported a high frequency of PTSD symptoms and were found to have greater lifetime gambling severity, psychiatric symptom severity, and impulsivity than those who had a low frequency of PTSD symptoms (Ledgerwood and Petry, 2006). Conversely, a study of 153 Australian veterans who were in treatment for PTSD found that although 28% screened positive for problem gambling, no significant relationship was found between problem gambling and PTSD (Biddle et al., 2005).
As noted earlier in this chapter, PTSD is commonly associated with substance abuse, unregulated anger, aggressive behavior, and hazardous use of alcohol, all of which are themselves associated with legal problems and incarceration. Few studies have examined the association between PTSD and incarceration.
Saxon et al. (2001) studied 129 jailed veterans, 87% of whom reported a history of trauma and 39% of whom screened positive for PTSD. Those who screened positive for PTSD reported more trauma, more serious legal problems, higher lifetime alcohol and drug use, and more mental health and general health problems. In those who screened positive for PTSD, the most common trauma was witnessing the death or serious injury of someone; 28% had been in combat. Those findings in veterans are consistent with findings of other studies of incarcerated adults in the general population. Black et al. (2005) studied 4,886 subjects randomly drawn from four groups: active-duty and National Guard and reserve veterans of the 1990–1991 Gulf War and active-duty and National Guard and reserve veterans from other periods. Overall, 23% had been incarcerated at some time in their lives. Veterans of the 1990–1991 Gulf War who had been incarcerated were three times more likely to report PTSD symptoms and depression and twice as likely to report alcohol abuse and anxiety. Gulf War veterans who had participated in combat had a higher rate of incarceration than those who had not. The findings from those two studies suggest that outreach to veterans who have PTSD and who are incarcerated or have been recently released may help them to access comprehensive treatment and rehabilitation options to improve functioning and reduce the risk of recidivism and future legal problems.
Homelessness is an impediment to the rehabilitation and recovery of veterans who have PTSD. Although estimates of homelessness of veterans vary, the federal government estimates that 75,609 veterans were homeless on a single night in January 2009, and that at least 136,334 were homeless at some time from October 2008 to September 2009 (HUD and VA, 2010). Veterans are twice as likely to be homeless as other adults, and minority-group veterans are 2–3 times more likely to be homeless than non-Hispanic white veterans. Disability is a major factor in homelessness of veterans: 52% of the homeless are estimated to have a disability, most often a mental disorder or substance abuse. A 2011 report found that homelessness of veterans had declined by 11% since January 2009. That may, in part, be a result of the national initiative by the VA and the U.S.
Department of Housing and Urban Development to reduce homelessness of veterans (VA, 2012c).
The VA provided specialized homelessness services to 92,625 veterans during 2009, including case-management services at every medical center, a national 24-hour help line, programs for incarcerated veterans and mentally ill veterans in the justice system, Stand Downs (health outreach efforts in conjunction with communities), supportive housing services, community partnerships, and more intensive residential services. In 2011, the VA announced grants to 85 community organizations in 40 states to establish a new homeless-prevention program for veterans and their families (VA, 2012bc).
VA homelessness programs predominantly serve veterans who have mental disorders and substance abuse. These programs have demonstrated through program evaluations that they are effective in reducing homeless-ness. A recent uncontrolled study of three residential care programs, the most intensive interventions, indicated that of 1,003 participating veterans, all but 11% had a serious mental health or substance abuse disorder. Although 47% had a substance abuse disorder, only 9% had PTSD and 37% had a dual diagnosis of substance abuse and a psychiatric diagnosis. A co-morbid psychiatric disorder and substance abuse disorder was predictive of poorer mental health functioning and quality of life outcomes, but does not appear to adversely affect the ability to gain independent housing through these programs. At 12-month follow-up, 78% were no longer homeless, a result comparable to other reports of VA residential homelessness care (McGuire et al., 2011).
Other factors associated with homelessness are experiencing sexual assault while serving in the military and being a member of the National Guard or reserves. With the increasing number of women in the military, sexual assault during military service is an increasingly important trauma-associated risk factor for homelessness evidenced by one study that compared housed and homeless female veterans in Los Angeles and found that sexual assault during military service was associated with increased rates of homelessness (Washington et al., 2010).
Many service members returning from deployments in Iraq and Afghanistan suffer a constellation of signature injuries that include PTSD, depression, substance abuse, TBI, and IPV. Given the complexity of those mental health and psychosocial problems, treatment approaches need to provide complex solutions. The committee finds that treatment for co-occurring conditions and functional impairments is critical for the success of treatment of all service members and veterans who have PTSD. As in-
formed by the review of the empiric literature on the treatment of PTSD and related physical, mental, and psychosocial comorbidities presented in the chapter, a collaborative care model should be introduced before or concurrently with evidence-based PTSD treatment models.
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