Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment (2012)

5

Prevention

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

OVERVIEW OF PTSD PREVENTION

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

Other prevention efforts seek to detect and treat disorder in its early stages (for example, treat those who meet the criteria for acute stress disorder [ASD]) often before it presents clinically as chronic PTSD. Several studies (for example, Bryant et al., 1999, 2003; Shalev et al., 2011) have demonstrated that early interventions for ASD result in significant reductions of ASD symptoms and the prevention of the onset of PTSD in the majority of individuals treated. Prophylactic interventions can be implemented immediately after a trauma (within 48 hours) or during the acute period (within weeks) to prevent full onset of PTSD symptoms (Litz, 2008), although the efficacy of this approach is unknown. And prevention may refer to measures taken to mitigate the consequences of existing symptoms by improving functioning and reducing complications. The latter type of PTSD prevention includes interventions in patients who have subthreshold PTSD symptoms, ASD, and ancillary problems; it provides treatment for clinical PTSD and recurrence prevention through rehabilitation programs. Treatment and rehabilitation programs for PTSD are covered in depth in Chapter 7 and 8, respectively; the present chapter discusses interventions to limit the development of clinical PTSD (that is, beyond subclinical symptoms) and to prevent recurrence.

Prevention is considered here in three phases:

1. Interventions that are applied to an entire population before a traumatic event and regardless of the potential for exposure. These are often called primary or universal interventions.
2. Interventions that are applied to individuals who are known to have been exposed to a traumatic event and thus to be at risk for PTSD and who may or may not be showing symptoms of stress. These are called secondary or selective interventions.
3. Interventions aimed at individuals who are displaying symptoms of or have received a diagnosis of PTSD with the goals of preventing worsening of the symptoms and improving functioning. These are called tertiary or indicated interventions.

As noted by Lau and Rapee (2011), universal interventions do not require screening, and they reduce the possibility that specific persons will be labeled unfavorably by others for having a mental illness. Selective and indicated interventions are targeted at persons viewed to be vulnerable, and therefore, pose a risk that such persons will be labeled as mentally disordered and viewed unfavorably.

PRETRAUMA PREVENTION EFFORTS

Much research related to the prevention of trauma has focused on the prevention of unwanted sexual contact in civilian and military populations (Casey and Lindhorst, 2009; Exner and Cummings, 2011; Langhinrichsen-Rohling et al., 2011; McMahon and Banyard, 2012; Moor, 2011; Moynihan and Banyard, 2008; Rau et al., 2011; Vladutiu et al., 2011). Research has identified modifiable and nonmodifiable risk factors for unwanted sexual contact in these populations. Those data have been used to inform the development of preventive interventions in both civilian and military personnel. Modifiable factors include unit culture, whereby reporting sexual assault by a fellow service member may considered to be “breaking a code” and may result in ostracization; leadership behavior that may implicitly or explicitly condone, tolerate, or ignore sexual assault and harassment; and facilitating situations such as excessive use of alcohol by any of the involved parties (Allard et al., 2011; Sadler et al., 2001; Street et al., 2009; Suris and Lind, 2008). Nonmodifiable risk factors among service members include female sex, young age, low rank, and prior sexual abuse history.

Several prevention programs in civilian populations and in the U.S. military have focused on decreasing the likelihood that individuals exposed to trauma will develop PTSD. Many of the programs emphasize the development of mental or emotional resilience. In this context, mental resilience refers to a person’s capacity to adapt or change successfully in the face of adversity (Pietrzak et al., 2010b). Most importantly, resilience and PTSD appear to be inversely correlated (Nishi et al., 2010). Those who perceive a trauma as a crisis but are able to confront distressing memories and emotions and integrate them into a coherent meaning may be resilient, whereas those who cope by avoiding distressing emotions appear to be at risk for PTSD (Larner and Blow, 2011). In a RAND report on resilience factors in military personnel, Meredith et al. (2011) found 20 evidence-informed factors associated with resilience. Individual-level factors were positive coping, positive affect, positive thinking, realism, behavioral control, physical fitness, and altruism. Family-level factors were emotional ties, communication, support, closeness, nurturing, and adaptability. Military unit-level factors were positive command climate, teamwork, and cohesion. And community-level factors were belongingness, cohesion, connectedness, and collective efficacy.

Other factors thought to protect against the development of PTSD are social support and confidence in the military mission and training. Pietrzak et al. (2010b) found that resilience, unit support, and postdeployment social support are psychosocial buffers of PTSD even at 2 years after deployment in veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). In a study of U.S. Air Force medical personnel deployed

to Iraq or Afghanistan, unit cohesion, positive attitudes about the military mission and the military in general, and confidence in their military training were all protective factors for PTSD when service members were experiencing increased combat-related or health-care–related stressors (Dickstein et al., 2010).

Some early work suggested that characteristics of deployment conditions and support are risk factors or protective factors for PTSD. The Mental Health Advisory Team surveyed marines and soldiers deployed to OEF and OIF in 2006 and found the level of combat experienced was the most important determinant of their mental health (MHAT, 2006). Similar to deployment stressors reported by 1990–1991 Gulf War veterans, OEF and OIF deployment stressors include being in the vicinity of explosions, direct combat duty, witnessing death of a person, being exposed to dead and dismembered bodies, and having a combat-related injury (IOM, 2008). In a sample of active-duty, National Guard, and reserve soldiers deployed in the 1990–1991 Gulf War, the stressors most highly associated with PTSD were all combat related and included having a buddy killed or wounded in action, exposure to dead or dying people, and being fired on by the enemy (Stretch et al., 1996). In a 2003 survey of combat infantry service members (2,856 soldiers and 815 marines) deployed to either Iraq or Afghanistan, Hoge et al. (2004) found the majority had been attacked or ambushed; shot at; saw dead bodies or human remains; received incoming artillery, rocket, or mortar fire; or knew someone who was seriously injured or killed. Fewer combat experiences were reported for soldiers deployed to Afghanistan than those deployed to Iraq; however, rates of PTSD increased with more exposure to firefights and for service members who were wounded or injured. See Table 5-1 for the combat experiences reported by the soldiers and marines surveyed.

A recent study found that soldiers who reported higher preparedness appraised the threat involved in different levels of combat exposure more realistically, whereas less prepared soldiers perceived even low-level combat as highly threatening (Renshaw, 2011). Perceived threat is thought to be an important link between combat experience and PTSD (the greater the perceived threat, the greater the likelihood of developing PTSD after the experience) (Green et al., 1990; King et al., 1995, 2008; Vogt and Tanner, 2007). Preparedness, therefore, may play a role in the development of PTSD through its relation with perceived threat. If service members are better prepared, they may perceive specific situations as less threatening (Renshaw, 2011). Other studies suggest a positive influence of high levels of unit support and cohesion on mental health in UK and U.S. soldiers in OEF and OIF who experienced combat (Brailey et al., 2007; Dickstein et al., 2010; Du Preez et al., 2012; Rona et al., 2009). Receiving support from one’s unit during deployment may promote soldiers’ resilience to PTSD by increasing

TABLE 5-1 Combat Experiences Reported by Members of the U.S. Army and Marine Corps Following Deployment to Iraq or Afghanistan

SOURCE: Adapted with permission from Hoge et al., 2004.

self-efficacy (belief in one’s ability to handle situations or perform well) or mitigating the psychologic consequences of war zone stressors through strengthened coping abilities.

Studies of OEF, OIF, and Vietnam veterans have also documented post-event social support as a strong predictor of PTSD and other psycho-pathologic conditions (Brewin et al., 2000; Fikretoglu et al., 2006; Fontana et al., 1997; King et al., 1998; Pietrzak et al., 2009; Taylor and Seeman, 1999). Receiving support from others after a traumatic event may enhance a person’s coping abilities or influence how he or she evaluates the stressful situation and later reacts to it emotionally and behaviorally and may buffer the psychologic consequences of traumatic events. Psychologic resilience and social support are hypothesized to protect against the development of both PTSD and depression and may preserve or improve functioning in those with PTSD. In a study of 284 OEF and OIF veterans with and without PTSD, Pietrzak et al. (2009) found that veterans without PTSD had a higher resilience score than those with PTSD; the greatest difference was in personal control, and this suggests lower coping self-efficacy in those with PTSD. Longer dwell time, at least twice the length of the deployment, has also been shown to reduce the odds of PTSD and other mental health disorders (MacGregor et al., 2012). See Chapter 2 for a longer discussion on the effect of dwell time and PTSD.

A relatively new concept associated with PTSD is that of posttraumatic growth—positive personal changes resulting from coping with a traumatic event. This concept is being explored, as is enhancement of resilience and hardiness, as a method for protecting against adverse sequelae, such as PTSD and depression, in military personnel who experience extreme stress and trauma (Gallaway et al., 2011; Larner and Blow, 2011; MacDermott, 2010; Nelson, 2011; Pietrzak et al., 2010a; Prati and Pietrantoni, 2009; Tedeschi, 2011). The effectiveness of programs to encourage posttraumatic growth has yet to be determined.

INTERVENTIONS FOR TRAUMA-EXPOSED PEOPLE

Interventions to prevent PTSD in trauma-exposed persons are aimed at interfering with overconsolidation of the fear memory and accelerating extinction of the fear memory. The interventions may be pharmacologic or behavioral and may be given to all exposed persons or targeted to people who show high levels of acute distress. This section reviews research on early psychosocial interventions for the prevention of PTSD. First, psychologic debriefing that is usually conducted immediately or within few days after a traumatic event is reviewed and then the literature on cognitive behavioral therapy (CBT) and non-CBT interventions used for severe PTSD symptoms or ASD within the first month after the trauma is discussed.

Immediate psychoeducation and advice for acute distress management and such interventions as psychologic support, nonspecific stress management, family interventions, and family-centered decision making have all been proposed to prevent PTSD, but no randomized controlled trials (RCTs) have been conducted to demonstrate their efficacy. Psychoeducation can be used to encourage resiliency and adaptation and, ultimately, help-seeking, but its content and dissemination need to be appropriate for the audience and time after trauma exposure (Wessely et al., 2008). The use of CBT in the weeks or days after exposure for people who display symptoms of posttraumatic stress have proved to be effective in RCTs and meta-analytic reviews, but there are no studies of the use of CBT immediately after trauma exposure. These effective trauma-focused therapies include psychoeducation, relaxation and stress management, affective expression and modulation, cognitive coping, prolonged imaginal exposure, in vivo exposure, and cognitive reprocessing. The use of multisession psychologic interventions delivered up to 72 hours after trauma does not appear to be effective in preventing PTSD (Agorastos et al., 2011). Evidence on the use of collaborative care interventions (discussed in more detail later in the chapter) and virtual-reality–based interventions (Agorastos et al., 2011) is still lacking.

Psychologic Debriefing

Psychologic debriefing includes a variety of single-session individual and group interventions that involve survivors’ or other affected persons’ revisiting of the trauma for the purpose of encouraging them to talk about their experiences during the trauma; to recognize and express their thoughts, emotions, and physical reactions during and since the event; and to learn coping methods. Specially trained debriefers lead the sessions, which usually focus on normalization of symptoms, group support, and provision of psychoeducation and information about resources. Two main psychologic debriefing protocols have been examined empirically. Critical incident stress debriefing (CISD) is a group-based formalized structured review that was first developed to assist first responders, such as fire and police personnel, and has expanded to include disaster victims and their relatives. Critical incident stress management includes precrisis intervention, disaster or large-scale incident demobilization and informational briefings, “town meetings,” staff advisement, defusing, CISD, one-on-one crisis counseling or support, family crisis intervention, organizational consultation, and follow-up and referral mechanisms for assessment and treatment.

Most RCTs that have examined psychologic debriefing for the prevention of PTSD have used individually administered, one-time debriefings of victims of motor vehicle incidents or crimes, such as rape. Numerous

reviews and meta-analyses of these studies have determined that this treatment is ineffective and sometimes even harmful (McNally et al., 2003; Rose et al., 2002). In particular, two RCTs that included long-term follow-up indicated that psychologic debriefing may be related to a poorer outcome than that in controls (Bisson et al., 1997; Mayou et al., 2000). However, the two studies suffered from methodologic flaws so it cannot be presumed that early interventions can interfere with recovery. Bisson et al. (2009) reviewed 10 studies that compared psychologic debriefing with wait list (WL) and found that two studies showed that psychological debriefing decreased PTSD symptoms compared with results of WL, five showed no difference between the two methods, and three showed that people who received the intervention experienced worsened PTSD symptoms compared with results of WL. Overall, Bisson et al. found no evidence to support the preventive value of individual debriefing delivered in a single session. Cuijpers et al. (2005) reviewed studies examining psychologic debriefing and found the risk of PTSD was somewhat, but not statistically significantly, increased after debriefing. Similarly, a meta-analysis of individual, single-session interventions immediately after a trauma found that non-CISD interventions (which typically included 30 minutes of individual counseling, education, and group debriefing focusing on the objective facts pertaining to the disaster or trauma) and an absence of intervention improved symptoms of PTSD but that CISD did not (van Emmerik et al., 2002).

Deahl et al. (2000) found no difference in PTSD symptoms between patients who received group-based debriefing and those who received assessment. Campfield and Hills (2001) randomly assigned robbery victims to immediate CISD (sooner than 10 hours) or delayed CISD (later than 48 hours) and found that immediate CISD produced more pronounced reduction in PTSD symptoms. However, the findings are limited by the lack of a control group, and it is unclear how many people would have recovered without the need for an intervention. No conclusions regarding treatment efficacy can be drawn from other studies (e.g., Eid et al., 2001; Richards, 2001) because they used small samples and nonrandom assignment.

Two RCTs conducted by Adler et al. examined group psychologic debriefing in military samples. Adler et al. (2008) randomized 1,050 soldiers who served in Kosovo as peacekeepers into 62 groups that were subjected to three conditions—CISD (23 groups), stress education (20 groups), and WL (19 groups)—and focused on the entire deployment period. No differences were found between groups with respect to all mental health outcomes, although it should be noted that soldiers in this study experienced relatively few traumas. In a second RCT, Adler et al. (2009) studied U.S. soldiers returning from Iraq who had been exposed to direct combat throughout their deployment. Soldiers received either stress education or Battlemind debriefing (Battlemind is an Army program to foster resilience;

see the “Prevention Efforts in the Army” section for more information on Battlemind). The authors (2009) found that Battlemind debriefing did not result in a reduction in PTSD symptoms compared with stress education.

In a review of RCTs of psychologic debriefing immediately after trauma exposure, Agorastos et al. (2011) found no evidence of its efficacy in reducing PTSD symptoms. In summary, there is no evidence of efficacy of psychologic debriefing in preventing PTSD in trauma-exposed people. And there is insufficient evidence of the efficacy of group psychologic debriefing in PTSD prevention.

Brief Early Interventions

Treatment of early symptoms of PTSD usually begins with CBT in an effort to prevent the development of chronic PTSD (Feldner et al., 2007). Brief specialized interventions (for example, four or five sessions) delivered within weeks of a traumatic event may effectively prevent PTSD in survivors of sexual and nonsexual assault (Foa et al., 1995), motor vehicle incidents, industrial accidents, and traumatic brain injuries (Bryant et al., 1998, 1999, 2003). Trauma-focused CBT has also been found to be effective in both reducing and preventing PTSD symptoms in people who experienced PTSD symptoms soon after a traumatic event and those who met the criteria for ASD (Roberts et al., 2009a; Stapleton, 2006). This particular intervention focused on the traumatic experience through memories and trauma reminders, sometimes combined with cognitive therapy or other behavioral interventions. Another study showed that combined imaginal and in vivo exposure is significantly more effective than cognitive restructuring only in reducing PTSD in people diagnosed with ASD (Bryant et al., 2008). Ehlers et al. (2003) found that CBT was more effective in reducing symptoms than a self-help booklet or repeated assessment.

In a pilot RCT, Kazak et al. (2005) studied stress in caregivers of children who had new diagnoses of cancer. A three-session integrated CBT and family-therapy intervention, surviving cancer competently intervention program—newly diagnosed (SCCIP-ND), was compared with the usual treatment. Results indicated that families who received SCCIP-ND had lower anxiety and parental posttraumatic stress symptoms than families that did not.

Zatzick et al. (2004) found that in acutely injured trauma survivors, a stepped-care approach of CBT, pharmacotherapy, or a combination of the two for 6–12 months after injury did not reduce PTSD, but fewer patients developed PTSD than in the usual-care group when pharmacotherapy or CBT was initiated 3 months after injury. Roberts et al. (2009b) conducted a meta-analysis of early interventions (within 3 months of trauma) for the prevention of PTSD. If patients received an intervention regardless of

their symptoms, there was no statistically significant difference between those who received and those who did not receive an intervention. If patients who manifested traumatic-stress symptoms received an intervention within 3 months of a traumatic event, significant differences were found in those who received trauma-focused CBT and supportive counseling (but not structured writing) compared with controls. In those who were given a diagnosis of ASD or acute PTSD within 3 months of a trauma, only trauma-focused CBT resulted in significant improvement compared with the WL control or supportive counseling. The authors concluded that multiple-session interventions aimed at everyone exposed to trauma were ineffective and that people who were symptomatic but did not have a diagnosis of PTSD showed a variable response. Those who had diagnosed ASD or PTSD showed the greatest response to intervention within 3 months of the trauma.

A few other non-CBT interventions have been examined as potential preventive treatments for PTSD, but none have been found to be effective in reducing or preventing PTSD symptoms. For example, brief structured writing has been found ineffective in preventing PTSD in two studies (Bugg et al., 2009; van Emmerik et al., 2008) and a memory-restructuring intervention was no more effective than a control condition (Gidron et al., 2007). Providing self-help information as a preventive psychoeducation strategy has not been found efficacious (Scholes et al., 2007; Turpin et al., 2005).

Two caveats should be noted. First, it has yet to be determined how much time should pass before CBT interventions are used in traumatized people (Litz and Bryant, 2009). If prophylactic treatment is provided too early, people who may not need therapy will consume valuable resources; it is for this reason that trials do not usually begin before 2 weeks after the trauma (Bryant et al., 1998, 1999, 2003). Second, studies that have targeted all trauma survivors, regardless of the levels of stress reactions, have not been effective in preventing PTSD (Roberts et al., 2009a).

Pharmacotherapy

It is standard practice to manage acute PTSD symptoms by using pharmaceuticals to inhibit sleep disturbance, pain, or hyperarousal. However, it is unknown whether that helps to prevent the development of PTSD. The VA/DoD guideline states that “due to the limited support of evidence, the use of medications in the early posttrauma period to prevent PTSD cannot be recommended” (VA and DoD, 2010). Drugs that are mentioned in the 2010 VA/DoD guideline as having the potential to prevent PTSD are opi-oids, benzodiazepines, and propranolol. Research has been conducted on the use of pain medicines, especially the opioid morphine, and the prevention of PTSD. The work of Bryant et al. (2009) and Holbrook et al. (2010)

showed lower rates of PTSD in patients who received pain medication after traumatic injury. The guideline states that pharmacotherapy aids in treating some PTSD symptoms like pain, but it does not recommend the use of morphine to prevent PTSD.

Although benzodiazepines have historically been used as effective treatments for anxiety and insomnia, the guidelines do not recommend their use as preventive measures “due to lack of evidence for effectiveness and risks that may outweigh potential benefits” (VA and DoD, 2010). Studies using propranolol have had mixed results, and overall the VA/DoD guideline concludes that despite some positive results “the size and weak study designs of the investigations do not allow for definitive conclusions regarding the value of these medications in preventing the development of PTSD symptoms after traumatic events.”

The use of hydrocortisone has also been studied in small trials. Two controlled trials in high-risk patients who had septic shock or who underwent cardiac surgery found that stress (high) doses of hydrocortisone administered over a few days were associated with lower rates of PTSD at long-term follow-up (Schelling et al., 2001, 2004). In a third study by the same group, hydrocortisone given at stress doses over a 4-day taper resulted in better post-operative adjustment after cardiac surgery, on the basis of measures of quality of life, stress, and PTSD (Weis et al., 2006). A prospective, randomized, placebo-controlled, double-blind trial in civilians found the best results at 1-month and 3-month follow-up with a single high intravenous dose (100–400 mg) of hydrocortisone given within hours of trauma (Zohar et al., 2011).

In an RCT of early interventions with psychopharmaceuticals (Shalev et al., 2011), Israeli trauma survivors who met the criteria for PTSD received one of the following treatments for 12 weeks: weekly prolonged exposure (PE) therapy, CBT, the selective serotonin reuptake inhibitor (SSRI) escita-lopram, placebo pills, or WL. At 5 months, the prevalence of PTSD was significantly lower in the PE group (21.6%) and CBT group (20.0%) compared with the two WL groups (57.1% and 58.7%) (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.09–0.46, and OR 0.18, 95% CI 0.06–0.48, respectively), the SSRI group (55.6%), and the placebo group (61.9%). There was no difference in PTSD outcome between those receiving PE versus CBT (OR 0.87, 95% CI 0.29–2.62). At 9 months, the prevalence of PTSD in the PE (21.2%), CBT (22.9%), and WL (22.8%) groups was about half that in the SSRI (42.1%) and placebo (47.1%) groups. About 40% of those on the WL who initially met the criteria for PTSD no longer did so at 5 months, and only 23% met the criteria at 9 months. Trauma survivors who had symptoms of PTSD but did not meet the full criteria for PTSD at the first assessment did not benefit from CBT.

Fletcher et al. (2010) reviewed the evidence on the use of pharmaceutical

agents to prevent PTSD after a traumatic event. Alcohol is the most frequently used prophylactic, and it has been shown that intoxicated people have less PTSD after trauma than those who are not intoxicated, but the harmful effects of alcohol outweigh the beneficial effects.

Many psychopharmacologic agents have been proposed to prevent the development of PTSD if administered in the acute aftermath of a traumatic event, but the current evidence of the effectiveness of these agents, such as glucocorticoids and benzodiazepines, is disappointing (see Chapter 3 for a description of the agents). Chapter 7 discusses the use of psychopharma-cologic agents in combination with psychotherapies for PTSD treatment.

PREVENTION IN THE DEPARTMENT OF DEFENSE

In this section the committee considers service-wide PTSD prevention efforts that have been mandated by the DoD, including directives and instructions for establishing plans, procedures, and responsibilities for managing stress before it causes PTSD, and treating symptoms of PTSD after they develop. The committee then looks at examples of PTSD prevention programs in each service. The examples are not exhaustive but are used to indicate the wide variety of approaches that are used to acclimate service members to the rigors of deployment and combat, to help them mitigate the effects of traumatic exposure after they occur, and to assist service members who have symptoms of PTSD to regain function.

Service-wide Prevention Efforts

The DoD has issued directives and instructions on stress control programs for many years; however, the instructions and programs deal with general combat stress and are not always PTSD-specific (Brusher, 2011; Stokes et al., 2003). For example, DoD Instruction 6490.05 (DoD, 2011) “Maintenance of Psychological Health in Military Operations” (which replaced Directive 6490.05 “Combat Stress Control [CSC] Programs” [DoD, 1999]) is applicable to all service branches and established requirements for the “early detection and management of combat and operational stress reactions in order to preserve mission effectiveness and war fighting capabilities and mitigate the adverse physical and psychological consequences of exposure to severe stress.” The goal of CSC programs is to manage combat stress reactions as close to unit level as possible. Furthermore, “psychological interventions for combat and operational stress reactions shall be implemented by first-responders on the same parity with physical injuries in order to mitigate the risk of potential longer-term physical and psychological consequences of combat and other military operations.” The instruction also requires the mental health providers “be trained in command consultation,

coaching techniques, resilience skills, motivational interviewing, psychological first aid, management of COSRs [combat and operational stress reactions], cognitive-behavioral techniques for managing post-traumatic stress disorder and acute stress disorder, and all related regulations pertinent to the COSC [combat and operational stress continuum] mission” and that other health care providers be familiar with the general principles of COSR management. It should be noted that Instruction 6490.05 deals with all types of combat stress and is not PTSD-specific.

CSC primary prevention “involves the effort to monitor, identify, modify, avoid, or reduce stressors before they cause dysfunction—and build stress-coping skills within individuals” (Stokes et al., 2003). CSC personnel talk with service members at the squad and crew levels to provide advice on stress control techniques and other preventive measures. CSC personnel work at the individual level to teach and build “confidence, competence, communication and coordination” and at the organizational level to foster “community, cooperation, comfort and concern” (Stokes et al., 2003). Those principles need to be incorporated into the functioning of a military unit, and the unit’s force-health protection team, which comprises personnel in mental health and preventive medicine, must demonstrate its own usefulness to its unit by understanding the unit, developing a sense of membership and identification with the unit, and doing actual force-health protection work.

Prevention efforts in the DoD are directed to all service personnel who face the risk of exposure to traumatic events during deployment. Preparing service members for the stressful environment they may encounter in the theater of war before an encounter occurs may make it possible to limit the development or severity of PTSD. Primary prevention within the DoD is intended to promote the skills in at-risk populations necessary to cope with the traumatic experiences associated with combat. A large number of PTSD prevention programs have been developed by each service and are discussed in the RAND report Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families (Weinick et al., 2011).

The DoD Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) have a Resilience and Prevention Directorate that assists the services and the DoD in optimizing resilience, psychologic health, and readiness for service members and their families (Meredith et al., 2011). Navy and Marine Corps COSC is color-coded to indicate a service member’s ability to function (see Chapter 4 for more details on the Marine Corps Operational Stress Control and Readiness [OSCAR] program). DCoE has a Resiliency Continuum that is similar and emphasizes a leader’s responsibility to mitigate service members’ risk of psychologic damage.

The focus on stress resilience training before deployment reflects a quantum shift in military culture and can now be seen to emanate from the highest levels of command in the military. For example, in a recent article in American Psychologist, Army General George Casey (Casey, 2011) makes the case that “soldiers can ‘be’ better before deploying to combat so they will not have to ‘get’ better after they return,” and he then calls for a shift in the military “to a culture in which psychological fitness is recognized as every bit as important as physical fitness.” That level of endorsement can be seen in practice in the substantial funding and resources applied to stress-resilience training in the Comprehensive Soldier Fitness program (Cornum et al., 2011). The core aims of such approaches are to promote psychologic fitness to better prepare service members for the psychologic stressors they may experience during combat deployment, and ultimately to reduce the incidence of stress reactions and PTSD on their return home.

The DoD has a number of programs to promote psychologic resilience in service members and their families, but most have not been evaluated. Of the ones that have, few have been subject to RCTs, and therefore, do not appear to have used evidence-based practices (Meredith et al., 2011). Furthermore, there were numerous barriers to the use of the programs in the military, but the barriers were not peculiar to these types of programs; that is, the barriers existed for other DoD programs as well. RAND recommended that the DoD define resilience, integrate the concept of resilience into policy decisions for each service, strengthen existing resilience programs by evaluating and publishing the evaluations, base the evaluations on such standardized resilience measures as the Global Assessment Tool being developed for the Army’s Comprehensive Soldier Fitness program, provide a resource guide to service members and their families, have new programs incorporate factors supported by the most evidence, engage senior military leaders in building resilience, and promote a flexible program curriculum, such as the Marine Corps OSCAR program, to coordinate with existing training and community-based programs (Weinick et al., 2011).

In a review of DoD approaches to primary care, Hourani et al. (2011) note that educational briefings and stress control techniques are two types of primary prevention that have been used in civilian populations to reduce stress reactions and are being used by the U.S. military. Prevention efforts in the DoD are built on the recognition that stressors and traumatic exposures can vary among the services. The cultures of the services are different, and these differences can affect service members’ training, exposures, and perceptions of possible traumatic events. The committee considers service-specific prevention efforts next.

Prevention Efforts in the Army

U.S. Army activities to prevent or mitigate mental health symptoms after exposure to combat and deployment stress have included the use of Army CSC teams (Reger and Moore, 2006). The mission of the teams is to provide prevention and treatment as close to a soldier’s unit as possible to keep the soldier with his or her unit in the theater of war. Guidelines for treating COSRs focus on proximity, immediacy, expectancy, and simplicity. Proximity is based on the premises that soldiers will seek refuge from stress but want to remain loyal to their unit and that if they are removed from their unit they will have more incentive not to return, which may increase the potential for long-term psychiatric issues. A CSC team consists of a psychologist or psychiatrist, a social worker, and two mental health specialists. Prevention consists of presentations at command meetings or informally on how to recognize initial signs of COSRs and assess unit climate surveys. Teams also work directly with soldiers via briefings on suicide, stress and anger management, home-front issues, and reintegration tips for returning home. Walkouts to talk informally with soldiers are conducted to mitigate soldiers’ fear of stigmatization. CSC members can also provide crisis de-briefings after a traumatic event to help normalize feelings and challenge distressing beliefs in a safe environment.

Resilience training (formerly called Battlemind) is an Army program designed to foster resilience to combat stress by teaching self-confidence and mental toughness in the context of deployment and transitioning home. It is a psychologic-educational intervention given to all U.S. Army soldiers and uses a cognitive and skills-based approach to normalize reactions to operational stress, build resilience, and promote self-recognition of psychologic problems, help-seeking, and identification of difficulties in others (Brusher, 2011). Resilience training is also used at intervals during deployment to reduce mental health symptoms in a deployed unit overall (Hourani et al., 2011). Some randomized trials of the earlier Battlemind training have been conducted (Adler et al., 2009). Although the benefits of Battlemind training were modest, it did appear to reduce binge drinking after deployment. The program is being implemented and evaluated in service members, but there is no empirical evidence of the effectiveness of the current resilience training in preventing or reducing mental health problems, including PTSD.

Attitudes regarding mental health screening, stigma, and barriers to mental health care were examined in 2,678 soldiers returning from OEF and OIF (Warner et al., 2008). Participants reported fewer barriers and diminished stigma relative to the Hoge et al. (2004) study. Approximately 41% of respondents reported receiving Battlemind psychological resiliency training, and those that did reported that they were more likely to seek treatment for mental health problems. These findings suggest that preventive

interventions may help reduce mental health stigma and enhance access to care in active-duty populations. However, RCTs are needed to determine whether Battlemind psychological resiliency training itself or nonspecific factors such as receiving any type of psychologic training are responsible for stigma reduction.

Morgan and Bibb (2011) describe several programs used by the services to promote postdeployment resilience to the development of PTSD. One prevention program that has received wide attention is the Army’s Comprehensive Soldier Fitness (CSF) program. The CSF program is based, in part, on the Penn Resiliency Program, which was developed by Martin Seligman (Seligman and Fowler, 2011). The Penn Resiliency Program is based on cognitive-behavioral theories of depression and includes training in assertiveness, negotiation, social skills, creative problem-solving, and decision making. The CSF program is designed to prevent adverse mental health consequences of trauma exposure by increasing resilience in service members before deployment.

The CSF resilience-building program encompasses four components that enhance the service member’s mental, spiritual, physical, and social capabilities: master resilience training, a 10-day, hands-on, face-to-face training course that includes the principles of positive psychology (Reivich et al., 2011); comprehensive resilience modules (formerly known as Battle-mind) are online training modules that focus on specific resilience skills using precepts of positive psychology, cognitive restructuring, mindfulness, and research on posttraumatic stress, unit cohesion, occupational health models, organizational leadership, and deployment to prepare service members for military life, combat, and transitioning home; the global assessment tool (GAT), a confidential online 105-question survey that must be taken annually; and institutional resilience training that is expected to occur at every level of the Noncommissioned Officer Education System and the Officer Education System (U.S. Army, 2012). Master resilience training for noncommissioned officers and midlevel supervisors is a “train the trainer” component of CSF for sergeants to use with their troops. Versions of the CSF program are also available for military families and Army civilians. Anecdotal feedback from those attending the course has been favorable, but there is no evidence on the short-term or long-term effectiveness of the program in increasing resilience among either the sergeants or the troops they train. The CSF GAT measures psychosocial well-being in four domains: emotional fitness, social fitness, family fitness, and spiritual fitness. Results of the GAT are used to refer soldiers to programs to enhance their strengths and improve in elements of weakness, for example, training in flexible thinking if scores are lower than the norm. A similar instrument, the Family GAT, is being developed for soldiers’ spouses and partners to provide advice about possible resources for building assets.

Prevention Efforts in the Navy and Marine Corps

The Marine Corps developed the OSCAR program in the 1990s to prevent and manage stress reactions as early as possible. It is not PTSD-specific, but attempts to provide support to marines in dealing with deployment and nondeployment stressors. It uses embedded personnel who have been trained to combat stigma and to connect marines with mental health professionals when necessary. This peer support can also help marines to handle daily stress. OSCAR is being expanded throughout the corps and is in the process of being evaluated by the RAND Corporation (Meredith et al., 2011).

The Navy and Marine Corps COSC program, based on the stress injury model, assesses service members’ resilience. A color-coded continuum for indicating stress ranges from red, representing illness, to green, representing readiness (Nash, 2011). The COSC program distinguishes between combat stress and operational stress, with the understanding that the latter can be experienced with or without deployment. The program focuses on positive emotions to foster resilience (Morgan and Garmon Bibb, 2011).

The Navy provides boot camp survival training for new recruits (Boot Strap) in which it uses a series of COSC modules to target specific issues and phases before, during, and after deployment, including modules for spouses and significant others. The Navy also has training for caregiver occupational stress control (Morgan and Garmon Bibb, 2011).

Families OverComing Under Stress (FOCUS) is a Navy and Marine Corps family-centered stress preventive-intervention strategy for military families, particularly those affected by multiple deployments. FOCUS incorporates COSC and the Stress Continuum Model and was piloted at Camp Pendleton, California, by the Navy Bureau of Medicine and Surgery. The eight-module program focuses on individual family-resilience training for parents and children (separately and combined) by offering a variety of services aimed at prevention of family dysfunction. Other services include training or briefing base commanders and workshops and consultations for groups of families, individual families, and family members. The resilience training was modified to address the needs of young children and children of service members who are wounded or ill. FOCUS staff work with mental health providers, and families may be referred to the program from a variety of sources, including self-referral, school, military social service, and mental health providers. The program is based on evidence-based interventions, and although no RCTs have been conducted, some program evaluation has occurred (Beardslee et al., 2011; Lester et al., 2011).

Prevention Efforts in the Air Force

The Air Force has also been studying risk factors for PTSD and resilience in its OEF- and OIF-deployed members. Service members deployed to the Air Force Theater Hospital at Joint Base Balad, Iraq, were surveyed before, during, and at 1, 6, and 12 months after deployment to identify factors related to psychologic risk and resiliency (Peterson et al., 2011). Although no PTSD prevention interventions were used, results of the survey indicated that increased preparedness and training of high-risk groups, such as those who are not normally exposed to combat or medical-exposure incidents, would be beneficial in reducing war zone stress.

The Air Force also has several tiers of resilience training in the Total Force Resiliency Program, including airman resilience training for new recruits; and the Comprehensive Airman Fitness program, on whose effectiveness information is lacking (Morgan and Garmon Bibb, 2011). The authors note that virtually all these new programs lack empirical evidence of effectiveness.

The Air Force is helping to develop the Deployment Anxiety Reduction Training (DART) program to prevent PTSD in service members exposed to combat stress. DART is being launched as a small pilot program in Afghanistan; medical personnel are training service members to recognize their own stress responses and teaching them exercises to monitor and control them. DART includes muscle relaxation and grounding; the latter focuses on deflecting attention from a traumatizing event. Service members can complete the training within hours of experiencing a traumatic battlefield event (UCSF News Release, 2010). There is no information on the efficacy of the program or expanding its use.

Prevention of Sexual Trauma in the Military

The DoD has made substantial efforts to reduce service members’ exposure to sexual trauma, which is a known risk factor for PTSD (Allard et al., 2011). Suris and Lind (2008) in a review of the literature on sexual trauma in the military reported that the overall prevalence rates of sexual trauma in military personnel and veterans ranges from 20% to 43%. They also found that female respondents who were using VA services reported “significantly higher rates of sexual assault while on active duty compared with current active-duty [respondents]”; this suggested that such trauma “results in mental and physical health conditions that require further medical attention … or that those with [military sexual trauma] MST receive medical services from VA for service-connected injuries.” Female veterans who had a history of sexual assault were five times more likely to meet the criteria for PTSD than female veterans who had no such history; in those

with a history of MST specifically, the risk of PTSD was ninefold higher (Suris and Lind, 2008).

The DoD Defense Manpower Data Center tracks the incidence of unwanted sexual contact, which includes unwanted sexual touching, with the Workplace and Gender Relations Survey of Active Duty Members. In 2010, 4.4% of women and 0.9% of men indicated experiencing unwanted sexual contact (DMDC, 2011). The survey also showed that the vast majority of respondents in all service branches had had sexual-assault prevention training in the prior 12 months; of those, 85% of women and 88% of men indicated that their training was moderately or very effective in reducing or preventing sexual assault or behaviors related to sexual assault.

The DoD has instituted the myduty.mil website to encourage service members to participate in active-bystander intervention to prevent sexual assault (DoD, 2012b). That program seeks to engage service members to be responsible for their own behavior, to help those who may be targets of sexual assault, and to prevent other service members from perpetrating sexual assault. The site provides practical suggestions for ensuring everyone’s safety, gauging whether a situation requires intervention, and preventing situations in which sexual assault may occur. The site also provides a confidential 24/7 hotline, “Safe Helpline,” for sexual-assault victims (www.SafeHelpline.org; DoD, 2012a). The DoD also provides a sexual assault response coordinator and a victim advocate at each installation or ship and Sexual Assault Awareness Month programs at each installation or ship (DMDC, 2011).

VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress

In an attempt to ameliorate the adverse stress response that some service members may experience during and after deployment, the 2010 VA/DoD guideline recommends a dual system of education and resilience training to prepare them for possible deployment experiences and to maintain their psychologic health. The 2007 DoD Task Force on Mental Health encourages the use of crisis intervention and management to prevent the progression of subclinical to clinically significant PTSD.

To that end, the DoD programs to enhance the psychologic resilience and promote the concept of hardiness as protective against the development of PTSD rely on the following precepts (VA and DoD, 2010):

• Provide realistic training—Repeated exposure to stimuli consistent with combat in a controlled environment in an effort to condition a response of reduced anxiety or reduced emotional arousal.

• Strengthen perceived ability to cope—Practice in responding to traumatic stimuli and positive encouragement from peers and superiors to reinforce appropriate coping techniques.
• Create supportive interpersonal work environments—Social support through team building, families, peer stress-management consultants, and leadership to protect against adverse psychologic reactions.
• Develop and maintain adaptive beliefs—Realistic expectations about the experience of combat and ensuing stress reactions bolstered by confidence in coping ability, leadership management, and the value of military service.
• Develop workplace-specific comprehensive traumatic-stress management programs—Encouragement of the use and promotion of the benefits of programs tailored to support service members after trauma.

Other Prevention Activities

Decompression at a “third location” is used by Canada and the UK to provide a transition back into the home environment. Although no formal definition exists, decompression in this situation refers to a stopover at a location that is neither home or in the theater of war, where service members may begin to unwind after leaving the theater of war (Hacker Hughes et al., 2008). A literature review by Fertout et al. (2011) states that decompression programs have common elements, including permitting units to unwind together in a structured but informal manner and having the environment of the decompression location be superior to the deployment location. The length of the decompression program is variable: the UK uses 36 hours, and Canada 5 days. Questions surrounding the use of decompression programs focus on the optimal length of the program, who should participate (all troops versus only those exposed to combat or trauma), and whether the program should be carried out at a location that is neither home nor the deployment position (Cyprus is used by the UK and Canada) but rather conducted on the troops’ home base but with adjustments (the third location). Fertout notes that the use of decompression programs has not been subjected to formal trials of efficacy, but one survey of troops just returned from decompression (Jones et al., 2011) found that although the majority initially resisted the use of the decompression program, the overwhelming majority found it to be useful after they completed the decompression period. Officers found that the time was not helpful in that they were still in charge of their troops and could not decompress.

The committee will consider the emerging evidence on these and other PTSD prevention activities in phase 2 of this study.

PREVENTION IN THE DEPARTMENT OF VETERANS AFFAIRS

The VA is not involved in the early military life of active-duty personnel and thus does not have a role in preventing service members’ exposure to traumatic events. As discussed in Chapter 4, the VA/DoD integrated mental health strategy focuses on broad psychologic health and resilience activities and builds on the resilience programs in the DoD.

Vet Centers also provide prevention services to veterans who may have been exposed to trauma or who are suffering from PTSD symptoms. The services are available to any veteran and have the advantage of being available for the veterans’ families as well as veterans themselves. They include individual, group, and family counseling; employment counseling; sexual counseling; and referrals to other mental health and medical health programs.

There are other considerations for veterans who receive treatment at VA medical facilities. Many veterans are members of the National Guard or reserve and never expected to be deployed to a war zone. Unlike active-duty service members, National Guard and reservists may cycle between civilian and military life over several deployments with little or no support from colleagues who are familiar with the stresses of deployment, and they can face stressors such as job loss that do not affect active-duty personnel (Riviere et al., 2011). Furthermore, these service members may not receive the same level of predeployment training as active-duty personnel, and this increases the risk of PTSD after exposure to a traumatic event during deployment.

VA programs and services specific to prevention and resilience include

• Life Guard—This program promotes psychologic resilience based on acceptance and commitment therapy. It has been implemented at one local site and is designed to facilitate reintegration of returning OEF and OIF veterans (Blevins et al., 2011; Schiffner, 2011).
• FOCUS—This is a family-centered preventive intervention program. It was designed on the basis of a skills-building pyschoedu-cational model that integrates traumatic-stress research, theories of child development, and the COSC model. FOCUS has been piloted and expanded to encompass more issues surrounding couples and issues surrounding wounded veterans (Schiffner, 2011); see the discussion of the Navy FOCUS program in this chapter and in Chapter 4.
• Moving Forward—A Problem-Solving Approach to Achieving Life’s Goals—This is a multisite (12 sites) pilot training program that includes a four-session group-based curriculum focused on early intervention and prevention of mental health problems (not

     specifically PTSD) by teaching “specific skills that veterans can use to constructively address a wide range of problems that may arise in their lives” (Schiffner, 2011).

The VA has also developed a program on MST. The VA has a different definition of sexual trauma than the DoD. MST is a VA-specific term, and thus the prevalence of MST pertains only to the VA. The prevalence of MST in VA users is tracked by the Veterans Health Administration and includes experiences of sexual assault or repeated, threatening acts of sexual harassment (VA, 2012). The VA mandated that each facility identify a MST coordinator to oversee the universal screening and treatment referral process for MST. Each Vet Center also has one staff member to address issues of MST.

The VA provides a guide for returning service members on what to expect after deployment and return to civilian life, including how to deal with children, spouses, family and friends, finances, and emotions. Advice is given on coping with common reactions to trauma and how to resume routine activities of work, family, and life.

SUMMARY

The DoD supports a number of programs that are aimed at preventing the development of PTSD by building resilience and helping service members to anticipate some of the traumatic events they may experience in a combat zone. In particular, the Army has had a variety of prevention programs including Battlemind and, most recently, the CSF program that will be used for all Army personnel before deployment. The Navy and Marine Corps and the Air Force have similar training. All four services also have programs to help service members who have symptoms of PTSD avoid chronic PTSD by using a variety of treatments.

The VA does not have the responsibility for predeployment programs but, like the DoD, it does attempt to prevent chronic PTSD by working with veterans who have symptoms. Furthermore, the VA has programs that help veterans with PTSD to regain functioning in civilian life and to prevent further PTSD-related disability. The VA and the DoD have collaborated in the development of PTSD management guidelines to minimize the impact of PTSD on service members, veterans, and their families.

While there are a variety of DoD and VA programs that target PTSD prevention, it is important to note that, at present, none of them has evidence for their effectiveness in preventing or reducing PTSD or stress in service members or their families. Evaluation of some of these programs is ongoing, and the committee hopes that such information will be available for phase 2 of this study.

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