This chapter introduces the programs and services provided by the Department of Defense (DoD) and the Department of Veterans Affairs (VA) health care systems with a special emphasis on care of those who have posttraumatic stress disorder (PTSD). The two health care systems are distinct entities that serve different, but at times overlapping, populations. Together they cover the many stages of a military career, including service on multiple bases, service in the theater of war, the transition from the DoD to the VA, and being a veteran (see Figure 4-1).
The chapter first provides an introduction to the DoD health care system; a summary of current PTSD programs for prevention or resilience, screening, diagnosis, and treatment in the DoD (including on base, off base, and in the theater of war); and a brief discussion of training opportunities for PTSD treatment. It then focuses on the transition between the DoD and the VA health care systems before providing an introduction to the VA health care system; a summary of current PTSD programs for resilience, screening, diagnosis, and treatment in the VA; and a discussion of training in evidence-based PTSD treatments. The chapter ends with a short discussion of current and future research directions and cost considerations for mental health care.
The DoD is tasked with providing “the military forces needed to deter war and to protect the security of our country” (DoD, 2012). Its mission is carried out by more than 1.4 million active-duty personnel and 1.1
FIGURE 4-1 Potential points of mental health contact for service members during their careers.
million reservists who serve domestically and internationally for a variety of purposes, from fighting wars to humanitarian and peace-keeping missions (DoD, 2012). The military consists of three departments—the Army, the Navy (which includes the Marine Corps), and the Air Force. Although all branches have a reserve component, only the Army and the Air Force have a National Guard component. Active-duty service members are employed full-time in the military, but members of the National Guard and reserve components serve in the military on a part-time basis. In general, they are required to work one weekend each month and serve a 2-week active-duty tour each year. The National Guard is under state jurisdiction unless federally activated. National Guard and reservists live in the civilian community (not on bases), work in civilian jobs, and do not have continuous access to DoD sources of health care (unless they are on active duty). The availability of health care for National Guard and Reservists is discussed in more detail later in this chapter.
The Military Health System (MHS) provides many health programs and services in an effort to keep active service members, retired personnel, and their families healthy. Overseen by the Office of the Assistant Secretary of Defense for Health Affairs, the MHS is responsible for maintaining the readiness of military personnel by promoting physical and mental fitness, providing emergency and long-term casualty care, and ensuring the delivery of health care to all service members, retirees, and their families through coordinated efforts of the medical departments of the Army, Navy (includes the Marine Corps), and Air Force; the joint chiefs of staff, the combatant command surgeons; and private-sector health care providers, hospitals, and pharmacies (IOM, 2010a). Figure 4-2 shows the organizational structure of the major health care services provided by the DoD. In addition to several offices and programs, the MHS provides health care services through several military-wide organizations: Force Health Protection and Readiness, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), Uniformed Services University of the Health Sciences
FIGURE 4-2 Organization of health care services provided by the DoD. The Office of the Assistant Secretary of Defense for Health Affairs oversees Force Health Protection and Readiness programs and the purchased portion of TRICARE, and it has an administrative and policy relationship to the military treatment facilities (MTFs) (as indicated by the dotted line).
NOTE: BUMED = Bureau of Medicine and Surgery, R&D = Research and Development, USD = Undersecretary of Defense.
SOURCE: Glover et al., 2011.
(USUHS), and TRICARE (DoD, 2012). A description of each of those organizations is in Table 4-1.
Although TRICARE is sometimes used to describe only purchased care, its network of services and programs is far reaching. The present committee uses the term TRICARE in a broader sense: as a wide-reaching health care provider for service members, retirees, and their families that delivers direct care through military treatment facilities (MTFs) and purchased care through network and non-network civilian health professionals, hospitals, and pharmacies (TRICARE, 2011). The relationship between TRICARE and MTFs is shown in Figure 4-2. The purchased care portion of TRICARE offers three primary plans: TRICARE Standard, TRICARE Extra, and TRICARE Prime (see TRICARE, 2011, for details of these three primary plans). To enroll in any TRICARE plan, service members, their families, and retirees must first establish eligibility through the Defense Enrollment Eligibility Reporting System. Active-duty service members, veterans, and reservists who have been activated for at least 30 consecutive days are automatically enrolled, but service members must register family members and update their status.
In FY 2011, about 9.7 million beneficiaries were eligible for DoD medical care, and 5.5 million beneficiaries were enrolled in TRICARE. Care of beneficiaries was provided through a network of 59 hospitals and medical centers and 363 health clinics in the direct-care system, and almost 380,000 individual providers and more than 3,000 network acute-care hospitals in the purchased-care system. There has been an increase in the number of TRICARE enrollees (particularly retirees) assigned to civilian primary-care managers because of a continued lack of resources and capacity in MTFs. Of the 9.7 million beneficiaries in the United States, about 34% were retirees and family members under 65 years old, 21% were retirees and family members 65 years old or older, 21% were active-duty family members, 14% were active-duty service members, 6% were National Guard or reserve family members, and 4% were members of the National Guard or reserves (TRICARE, 2011).
TRICARE authorizes a wide spectrum of practitioners to provide mental health care to its beneficiaries, including “psychiatrists and other physicians, clinical psychologists, certified psychiatric nurse specialists, clinical social workers, certified marriage and family therapists, pastoral counselors, and mental health counselors” (IOM, 2010b). The authorized practitioners may deliver inpatient or outpatient care (including mental health care, such as psychotherapy, psychoanalysis, testing, and medication
TABLE 4-1 Mental Health Components of the Military Health System
|MHS Component Organizations||Descriptions|
|TRICARE||TRICARE is a “health care plan using military health care as the main delivery system.” It is “augmented by a civilian network of providers and facilities” and provides services to the “uniformed services, activated National Guard and Reserve, retired military, and their families worldwide” (TRICARE, 2012).|
|Force Health Protection and Readiness||“The Deputy Assistant Secretary of Defense (DASD) for Force Health Protection and Readiness (FHP&R) is the principal staff assistant and advisor to the Assistant Secretary of Defense (Health Affairs) for all medically related Department of Defense policies, programs, and activities. The office is responsible for deployment medicine, force health protection, medical readiness, international health agreements, deployment related health policy, theater information systems, humanitarian and health missions, and national disaster support” (FHP&R, 2012).|
|Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury||DCoE “assesses, validates, oversees and facilitates prevention, resilience, identification, treatment, outreach, rehabilitation, and reintegration programs for psychological health (PH) and traumatic brain injury (TBI) to ensure the Department of Defense meets the needs of the nation's military communities, warriors and families” (DCoE, 2012a).|
|Uniformed Services University of the Health Sciences||The USUHS is the nation's federal health sciences university. It is focused on education, research, service, and consultation specifically as they are related to military medicine, disaster medicine, military medical readiness, and public health during peace and war (USUHS, 2012).|
|Surgeons general of each service||The organization of the MHS includes the surgeons general of the Army, Navy, Air Force, and Coast Guard. In the Army and Navy, these three-star generals also have command of their medical personnel, clinics, and hospitals. In all branches, the surgeons general have overall responsibility for the medical operations within their specific branches.|
|MHS offices and programs||MHS offices and programs include|
|• Chief Human Capital Office|
|• Clinical and Program Policy|
|• Council of Review Boards|
|• Defense Health Board|
|• Information Management|
|• Innovation Investment Process in Transition|
|• Office of Strategy Management|
|• Patient Safety Program|
|• Physical Disability Board of Review|
management), acute care, psychiatric partial hospitalization, and residential treatment center care.
Mental health care can also be described in terms of preclinical and clinical care. Preclinical care is commonly called counseling, and the several types of counseling are usually loosely defined. For example, service members and their families have the opportunity to seek counseling from chaplains, unit-embedded mental health care providers, community service programs (Tanielian and Jaycox, 2008) and from such facilities as Marine Corps counseling centers. The more formal route for clinical care is generally through MTFs in outpatient clinic or inpatient psychiatric-ward settings (Tanielian and Jaycox, 2008). Costs of intensive outpatient programs for mental health care that have become common in the private sector and the VA may not be reimbursed under TRICARE. Instead, patients may need to be referred to residential or inpatient care, which can be much more expensive and farther away from home (DoD, 2007).
In response to previous reports that noted particular problems with the education on and implementation of evidence-based practice guidelines (DoD, 2007; IOM, 2006), the MHS has worked to improve in these respects. On the basis of recommendations from the DoD Task Force on Mental Health (DoD, 2007), the MHS is pursuing implementation of evidence-based practices, training and education, quality measures, and monitoring (IOM, 2010a). The MHS has resolved to improve primary care for mental health conditions by 2016. It also aims to make improvements by increasing the number of providers that accept the purchased-care portion of TRICARE by “bridging cultural differences between military and civilian providers” and by increasing outreach to civilian providers (TRICARE, 2011).
The DoD is also concerned with mental health care in the theater of war and has undertaken research to try to gain a better understanding of this topic. Since 2003, mental health advisory teams (MHATs) have been assembled annually in Iraq and, beginning in 2007, in Afghanistan to obtain information on symptoms of PTSD, anxiety, and depression; on barriers to care (including stigma); and on other mental health care issues in the theater of war. The first three MHATs were sponsored by the U.S. Army surgeon general and focused solely on Army soldiers. Starting with MHAT IV in 2006, both soldiers and marines were sampled. In 2010, the MHAT team included representation of the Army, Navy, and Air Force. It collected anonymous survey results from soldiers and marines and from behavioral health personnel in an effort to assess theater-wide mental health and well-being, to examine the delivery of behavioral health care, and to provide recommendations for sustainment and improvement of mental health care (MHAT VII, 2011). It was found that about 20% of service members reported symptoms of acute stress (PTSD), depression, or anxiety; that higher
rates of psychologic problems and lower morale are associated with longer deployments, multiple deployments, and greater time away from base camp; and that good leadership provides the support necessary to promote positive mental health and well-being in the deployed (MHAT VII, 2011).
Services and Programs for PTSD
This section gives some examples of PTSD services and programs that are commonly used in the DoD and provides an overview of the pathways through which a service member is screened for PTSD, a diagnosis is made, and treatment is instituted; it is not a catalog of all PTSD services and programs provided by the DoD. It should be noted that no single source within the DoD or any of the service branches maintains a complete list of such programs, tracks the development of new or emerging programs, or has appropriate resources in place to direct service members to programs that may best meet their individual needs. However, a recent review by Weinick et al. (2011) includes a list of DoD programs that address psychologic health and traumatic brain injury. Of the 211 programs identified in the review, 103 were PTSD-related programs for service members, veterans, civilians, and their families. See Appendix C for a list of the PTSD-specific programs offered in the DoD. (For a list of all programs in the DoD that address psychologic health [including PTSD] and traumatic brain injury of U.S. service members, veterans, and their families, see Appendixes A.1, A.2, A.3, and A.4 of Weinick et al. .)
DoD resilience programs help to prepare service members for stressful encounters and traumatic events while they serve on military missions. The goal of such programs is to reduce the number of service members who develop mental health problems and to keep all service members as physically and mentally fit as possible during deployment. DoD Directive 6490.05 implemented combat and operational stress control (COSC) programs for all services. Directive 6490.05 was reissued as Instruction 6490.05 (November 22, 2011) Maintenance of Psychological Health in Military Operations “to enhance readiness, contribute to combat effectiveness, enhance the physical and mental health of military personnel, and prevent or minimize adverse effects associated with combat and operational stress” (DoD, 2011a). It included principles for COSC, procedures for COSC-specific education programs, guidance for military leaders (including a command that leaders ensure access to mental health services without stigma), a model for delivering COSC programs, and guidance on surveillance and monitoring. In addition, the instruction established specific requirements for the early
detection and management of any “physical, emotional, cognitive or behavioral reactions, adverse consequences, or psychological injuries of service members who have been exposed to stressful or traumatic events in combat or military operations” (DoD, 2011a).
The Navy and Marine Corps have a strong COSC program called Operational Stress Control and Readiness (OSCAR), which has two specific goals: to maintain an active force and to promote the health of service members and their family members. The program works through mentors who try to identify and assist fellow service members who have combat and operational stress problems, extenders who are nonmental health clinicians or chaplains, and embedded mental health personnel (Meredith et al., 2011; U.S. Marine Corps, 2012). One resource through which Navy and Marine Corps members can find assistance for mental health concerns is the Naval Center for Combat and Operational Stress Control, which is part of the Navy Bureau of Medicine and Surgery. The center promotes psychologic resilience, recommends best practices for the diagnosis of and treatment for PTSD, seeks to reduce stigma for service members who are looking for or receiving mental health care, and provides support for family members.
In the Air Force, traumatic stress response teams have been established to provide support to service members that are expected to be exposed to traumatic situations (U.S. Air Force, 2006). The teams provide pre-exposure consultations to units and communities and implement combat stress control programs.
The Army has a long history of COSC and other resilience programs and services that target prevention of PTSD and other stress reactions. It is working to integrate a program called Comprehensive Soldier Fitness into basic training. Comprehensive Soldier Fitness is “a structured, long-term assessment and development program to build the resilience and enhance the performance of every Soldier, Family member, and [Department of the Army] civilian” (U.S. Army, 2012a). The program, which began in 2009, focuses on positive psychology and building resilience. It includes an assessment tool that provides a baseline for a soldier’s emotional, social, spiritual, and family strengths. Specific resilience modules include institutional (life-cycle) resilience training that is specific to the different phases of a soldier’s career; operational (deployment-cycle) resilience training that prepares a soldier for deployment; and family resilience training that prepares a soldier and his or her family for the transition back from deployment. There has been some controversy over the Comprehensive Soldier Fitness model. Brunwasser et al. (2009) completed a meta-analysis to evaluate the effectiveness of the Penn Resiliency Program, the program on which Comprehensive Soldier Fitness was based, for alleviating symptoms of depression in youth; they concluded that the program showed modest and inconsistent results. The Comprehensive Soldier Fitness program is not a research program,
but there are concerns that it was launched without pilot testing, that it was based on a model that was developed for a different population, and that there are few data to indicate whether it promotes resilience (Eidelson, 2011; Quick, 2011). Some of the concerns have been addressed by the Office of Comprehensive Soldier Fitness, as described by Seligman (2011). (See Chapter 5 for further discussion on prevention programs in the DoD.)
Screening and Diagnosis
The DoD has implemented a series of screenings and assessments during the deployment cycle—the pre-deployment health assessment, the post-deployment health assessment (PDHA), and the post-deployment health reassessment (PDHRA). The pre-deployment health assessment was initiated in 1998 and is administered within 60 days before deployment. It documents general health information on each service member. A health care provider reviews the service member’s responses and may refer him or her for further evaluation if a health concern that may potentially affect the service member’s ability to deploy is identified. However, there is only one mental health question: “During the past year, have you sought counseling or care for your mental health?” This question is of limited usefulness for the assessment of predeployment mental health concerns (see Chapter 6 for more discussion of predeployment screening). An affirmative response to the question results in referral for an interview by a trained medical provider who may then sign a form indicating medical readiness for deployment.
During the 1990–1991 Gulf War, no system or screen was in place to document exposure to environmental toxicants and therefore no records to indicate exposures in the case of later claims of “Gulf War syndrome.” To try to prevent that type of problem in the future, the PDHA was created and implemented in 1998. The assessment is given to service members within 30 days after they leave their assigned posts or after their return from deployment. It documents exposure to toxic substances, such as petroleum and chemical weapons, and questions on PTSD, depression, and suicide were added in later iterations (GAO, 2008b). The PTSD questions (questions 10–14 on the screen) were drawn from standardized scales for PTSD and depression with input from civilian and military subject-matter experts. A service member completes the assessment independently, and a health care provider then reviews the form, interviews the service member about any identified deployment-related concerns, and makes referrals for further evaluation if it is appropriate (GAO, 2008b).
In 2003, discussions regarding people who had various symptoms that emerged months after they returned from deployment took place. To capture the population, the DoD developed the PDHRA and began its
implementation in 2005. Standard PTSD and depression questions were added in later updates (questions 11, 12a–d, and 14a–b on the screen). The assessment is administered 3–6 months after deployment and focuses on latent health concerns of service members that have emerged after deployment. Like the pre-deployment health assessment and the PDHA, the PDHRA is first completed by the service member, who is then interviewed by a health care provider about any deployment-related health concerns. If it is appropriate, the service member is referred for further evaluation. The PDHRA was first fielded in the Army in 2005 and is now administered in all the services, including the National Guard and reserve components. Because many service members have had repeat deployments, many have multiple forms on file. Information from these screening instruments is centralized in a database maintained by the Armed Forces Surveillance Center, which allows researchers and health care providers to review them on a population basis and individually.
About one-fourth of those deployed to Iraq and Afghanistan have been National Guard and reservists (IOM, 2010b). Like active-duty service members, National Guard and reserve service members are required to complete the predeployment and postdeployment health assessments. Because the PDHRA is administered 3–6 months after return from deployment and National Guard and reserve service members may have returned to their civilian roles by that time, the PDHRA may be administered on drill weekends or by telephone.
In 2006, the Periodic Health Assessment (PHA) was initiated for all active-duty and selected reserve service members (DoD, 2004, 2006). Those “who are not TRICARE beneficiaries and not eligible for services under any DoD program, but who require further evaluations, treatments, care, or clinical preventive services should be referred to their civilian health care providers” (DoD, 2006). Reservists who are not part of the selected group are given a similar periodic examination, the Reserve Component Periodic Health Assessment. Both health assessments are annual screens to assess changes in health status and medical readiness, especially changes in health that may affect a service member’s ability to perform military duties. The PHA and the Reserve Component Periodic Health Assessment are given by a health care provider and include information about current and previous medical conditions, laboratory tests and other screening results (for example, tests for cholesterol and triglycerides, vision, hearing, and dental conditions), immunizations, and health behaviors (for example, tobacco use, alcohol and substance dependence, occupational stresses, suicidal ideation, and other mental health concerns). The health care provider reviews the medical record and makes referrals for additional care or evaluation as necessary (GAO, 2008a). The benefit of the annual screen for all service
members is that it identifies changes in health status in people who have not been recently deployed.
The committee heard during its open sessions about the controversy associated with receiving a diagnosis of PTSD during deployment. In combat settings, military mental health providers assess fitness for duty and work with commanders who are focused on maintaining readiness, combat power, and unit cohesion (Warner et al., 2011). Although traumatic-event management—whose purpose is to decrease the effect of the potentially traumatic event and prevent long-term adverse consequences—is provided to individuals and units after an incident, military mental health providers may be hesitant to diagnosis acute stress disorder (ASD) or PTSD in a war zone. The committee heard that some possible explanations for this reluctance include providers believing or being taught that PTSD cannot be diagnosed in the theater of war because the trauma is still ongoing, although the termination of potential trauma exposure is not part of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria (APA, 2000); some providers may feel pressure to evacuate people who have PTSD from the theater of war, potentially adversely affecting unit cohesion and readiness; and providers are encouraged to use another less stigmatizing term for PTSD, such as combat stress reaction or adjustment reaction, to explain symptoms of ASD or PTSD. In some cases, the use of those terms might be accurate, but a potential consequence of not diagnosing ASD or PTSD is the subsequent failure to then use appropriate evidence-based treatments for these disorders. For example, combat stress reaction is treated through the use of the BICEPS model—brevity, immediacy, centrality or contact, expectancy, proximity, and simplicity. However, the BICEPS model does not include a recommendation for the use of evidence-based cognitive behavioral treatments for ASD or PTSD, and therefore, may result in the DoD overlooking or avoiding the use of treatments that appear to have the strongest evidence for their efficacy for the treatment of these disorders. Some mental health providers related concerns from service members who believed that focusing on their trauma while deployed would result in a loss of their ability to remain mission ready, and some mental health providers thought that effective treatments in combat settings would require hospitalization or aeromedical evacuation out of the theater of war, and that some treatments for ASD and PTSD might increase a service member’s risk for suicide. However, mental health providers do not express the same reservations about the use of psychotropic and sleep medications by a deployed service member as they did about the use of cognitive behavioral therapy (CBT) in combat settings.
Screening for PTSD in the DoD most commonly uses questions from the Primary Care PTSD (PC-PTSD) screen that are incorporated into longer surveys (such as the PDHA and the PDHRA) or the PTSD Checklist.
However, committee expertise and interviews during the committee’s visit to Fort Hood indicated that many patients who show symptoms of PTSD are not identified through screens but through a family care physician, self-referral, or referral from a family member, work colleague, or friend. After a service member screens positive for PTSD, whether through a screen or through an interview with a primary care provider, the service member is often referred to a mental health professional for evaluation. Patients who have been referred are to receive an initial evaluation within 24 hours and a full evaluation within 14 days after referral. The diagnosis of PTSD can be made only after a careful and comprehensive clinical evaluation performed by a qualified professional, such as a psychologist or psychiatrist. The interviewer should obtain details of chief complaints, lifetime history of exposures to trauma, frequency and severity of symptoms of PTSD and other morbidity, level of function (disability), quality of life, medical history and present health, family and supports, recreation, personal strengths and vulnerabilities, styles of coping with stress, and experiences in the military.
Many service members are returning from deployment in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), and a small percentage of them are returning with PTSD and mental health concerns. That is supported by data from a large population-based study of Army and Marine Corps service members after deployment (Hoge et al., 2006). The total study sample was made up of 16,318 OEF service members and 222,620 who served in OIF. The service members who screened positive for PTSD on the PDHA (two or more affirmative responses to the four questions) made up 4.7% of those deployed to Afghanistan and 9.8% of those deployed to Iraq (Hoge et al., 2006). In addition, data presented to the committee showed that although the percentage of service members who screen positive for PTSD on the PDHA or PDHRA has remained roughly constant over the last year (about 10% of service members returning from deployment report symptoms of PTSD), the number of referrals for additional evaluation or treatment increased from 20% in 2005 to 40% in 2009 (Dinneen, 2011). It should be noted that not everyone who is given a referral seeks treatment; 32% of those who are referred by MTFs for outpatient mental health care do not activate the referral. As of the first quarter of 2010, data indicate treatment rates are about 65% of those referred (Dinneen, 2011).
Service members can be treated for PTSD in numerous services, programs, and settings, including counseling centers, general inpatient and outpatient mental health services, and specialized treatment programs. As previously mentioned, the committee did not create a catalog of all the
services, programs, and settings. However, a recent review of programs and services for psychologic health in the DoD shows that 98 DoD programs are specific to PTSD care for service members (Weinick et al., 2011). They include programs that are DoD-wide and programs that are specific to the Army, Air Force, Navy, Marine Corps, reserves, or National Guard. Treatment for PTSD in the DoD is performed by a variety of health professionals, in the theater of war and in other settings on and off base. Many service members who have a diagnosis of PTSD receive counseling, medication, or both at an outpatient setting through a mental health department (DCoE, 2012b; VA, 2012a). Figure 4-3 illustrates the different treatment pathways available to service members who seek treatment for PTSD, and the pathways are discussed below.
FIGURE 4-3 PTSD treatment pathways available in the DoD. Military OneSource and care through private practitioners is available off base, but these treatment options do not originate from an initial diagnosis and referral from an on-base provider. To distinguish these two treatment options from treatment through TRICARE providers or VA facilities, a dotted line has been used to differentiate the different treatment pathways.
aTreatment for service members in VA facilities is rare, but it is an option.
Additionally, an increasing number of programs and individual service members use some form of complementary and alternative medicine (CAM) to treat symptoms of anxiety, depression, and pain. McPherson and Schwenka (2004) found that of 291 soldiers, retirees, and spouses who were surveyed, 81% used one or more forms of CAM therapy. Of the respondents who used CAM therapy, 16% used it for anxiety and 14% used it for depression (PTSD was not specified as a condition to be treated). A larger study of 1,305 active-duty and reserve Navy and Marine Corps personnel found that 37% has used at least one CAM therapy in the preceding year, with herbal therapies being the most commonly used therapy (16%) (Smith et al., 2007). Fifty percent of those using a CAM treatment reported moderate or severe body pain; other medical conditions treated by CAM therapies were not identified. The types of CAM treatments and therapies are diverse and may include nutrition supplements and herbal supplements, yoga, massage, or meditation alone or in combination. White et al. (2011) using data from the Millennium Cohort Study found that of 44,287 military participants, 39% reported using at least one CAM therapy, and that those who used CAM therapies had more physician-based medical services (hos-pitalizations and outpatient care) than those who did not use CAM therapies, possibly because they report more health conditions and symptoms.
Service members can receive PTSD treatment on base from a primary care provider, through referrals to mental health specialists or social workers, and in both inpatient and outpatient treatment settings. The VA and the DoD created a clinical practice guideline in 2010 to provide health care professionals with algorithms and evidence-based practice recommendations to guide their provision of PTSD treatment (VA and DoD, 2010). Although the guideline does not have the same enforcement capabilities as policies, it is expected that clinicians will adhere to this guideline in accordance with their own clinical experience.
Primary care. Service members who seek help for PTSD symptoms are not limited to on-base treatment through mental health professionals. In fact, about 90% of service members who receive a diagnosis of a mental health illness are seen in primary care settings (VA and DoD, 2010). The Clinical Practice Guideline for Management of Post-Traumatic Stress suggests that “Primary Care providers who identify patients with possible PTSD should consider referral to a Mental Health or PTSD clinic” (VA and DoD, 2010). The provider should consider a patient’s desire and preferences for the referral, the patient’s mental health status, and the severity of the mental health symptoms and could consider initiating and monitoring such treatments as
pharmacotherapy or supportive counseling. The guideline also suggests that a multidisciplinary approach be taken that includes the patient’s primary care provider.
The U.S. Army Medical Command has implemented a three-component treatment model called RESPECT-Mil for the management of PTSD by primary care clinicians. The training manual for the model follows the clinical guideline described above (VA and DoD, 2010). In the RESPECT-Mil treatment model, the primary care clinician is responsible for the recognition, diagnosis, and management of PTSD in the patient; is supported by the work of care facilitators; and is responsible for continued support and monitoring of the patient and communication with the patient and a behavioral specialist (Oxman et al., 2008). As part of the RESPECT-Mil initiative, primary care practices are working to include behavioral health consultants in the clinical staff. The consultants provide in-clinic consultations and focused interventions for service members who need support. After diagnosis and assessment, the primary care clinician presents a variety of treatment options—counseling, medication, or a combination of both—and considers patient preferences when drawing up a treatment plan. When a treatment plan has been established, the primary care clinician will explain the role of the care facilitator and offer continued services to coordinate and monitor care (Oxman et al., 2008).
As of Fall 2011, RESPECT-Mil had been implemented in 32 of 37 Army sites and in 84 primary care clinics. In the clinics where RESPECT-Mil had been implemented, providers screened service members for PTSD and other mental illness in more than 1.1 million separate clinical visits (DoD, 2011b). About 13% of the visits resulted in a positive screen for PTSD or depression, and about 73% of those who screened positive received one or more mental health diagnoses. As the DoD phases in its primary care model of the patient-centered medical home—that is, a health care setting model with goals of providing comprehensive primary care for all family members and facilitating partnerships between the patient, his or her physician, and members of his or her family (if appropriate) (Patient-Centered Primary Care Collaborative, 2007)—it plans to use RESPECT-Mil as the basis of its mental health care delivery (DoD, 2011b).
The Air Force has developed the Behavioral Health Optimization Program (BHOP), which integrates mental health and primary care services (U.S. Air Force, 2011). That has resulted in increased availability of mental health services for service members and their families, and the program has reduced stigma by making mental health care a routine part of primary medical care. In surveys of BHOP patients, 97% indicated that they were satisfied or very satisfied with their care. In addition to substantial reductions in psychologic distress, fewer than 10% of the patients had to be referred to more intensive, specialty care services, and this suggests that
integrated providers are able to manage the needs of most mental health patients within the primary care setting (U.S. Air Force, 2011). A small study by Cigrang et al. (2011) found that evidence-based treatments can be delivered successfully in military primary care settings using the behavioral health consultant model developed by the Air Force. Patients were referred to the psychologist by primary care providers in an integrated primary care and mental health clinic.
The Navy has also integrated mental health and primary care services through deployment health clinics. Staff at the clinics include primary care providers, psychologists, psychiatrists, social workers, and certified medical assistants (Koffman, 2007). The clinics have been implemented at several installations and provide several deployment-related services, including care for PTSD and other mental health problems (Tanielian and Jaycox, 2008). The Navy has also piloted the Behavioral Health Integration Project, whose purpose is to ensure continuity of care by placing mental health service providers in primary care facilities. Mental health service providers work as consultants to the primary care providers and “provide sailors with short, focused assessments, brief interventions, skill training, and behavioral change plans” (Meredith et al., 2011).
Mental health practitioners. Service members who screen positive for PTSD symptoms on the PDHA or the PDHRA are referred to mental health practitioners after a health assessment interview with a DoD health care professional (GAO, 2006). The DoD employs psychiatrists, psychologists, social workers, and other mental health professionals to diagnose conditions in and treat service members who receive mental health referrals. Service members can also be referred to services through case managers, mental health triage, or buddy referral or by seeking care at the on-base military behavioral health care clinic.
As previously mentioned, a recommended treatment algorithm is detailed in the Clinical Practice Guideline for Management of Post-Traumatic Stress (VA and DoD, 2010). Once treatment options have been discussed and the patient and provider agree upon goals and expectations for treatment, the mental health professional should determine the optimal setting for the care and treatment plan. Beginning with the first-line treatment of psychotherapeutic interventions, pharmacotherapy, or both, the clinician is directed by the treatment algorithm to reassess the patient’s symptoms in order to appropriately modulate the level of care being provided based on symptom severity. Qualified mental health professionals are encouraged to adhere to evidence-based treatment guidelines such as CBT. For a detailed description of psychotherapy treatment options, see Chapter 7. Personal specialization and training often dictate the treatment options provided by each clinician. Psychiatrists are incorporated into the treatment plan when
psychiatric medications are a part of the treatment plan, though they too are capable of delivering psychotherapy and counseling as part of a service member’s treatment plan. Social workers also provide treatment through individual, group, and family counseling; triage of symptom severity; and fit-for-duty assessments of service members.
Specialized PTSD treatment programs. On some bases, service members may be referred to specialized PTSD programs. These programs include inpatient and outpatient services, depending on severity of the case. Hospitals with psychiatric wards are able to provide inpatient psychiatric acute treatment to patients not on active duty and patients who have TRICARE Prime coverage. That is accomplished through teams of psychiatrists, nurses, case managers, and other relevant professionals who provide counseling and pharmacotherapy to stabilize the patient’s condition. At Fort Hood, for example, services include diagnostic evaluations, psychotherapy, phar-macotherapy, occupational and physical training, and medical referrals as needed (U.S. Army, 2012b).
For service members who need longer-term facilitated medical support in an inpatient setting, the Warrior Transition Unit was created by the Army in 2007 to help transition the service member either back to active duty or out of the military. Nurse case managers coordinate medical appointments and treatment, including pharmacotherapy, cognitive therapy, and CAM treatments (Saito, 2011).
Several other treatment programs are available on base or on an installation. The National Intrepid Center of Excellence, a clinic on the campus of the Naval Support Activity in Bethesda, Maryland, supports patients who have traumatic brain injury and associated psychologic health conditions such as PTSD (Miller, 2011). It uses an interdisciplinary approach that includes several types of services, such as counseling, medication, physical rehabilitation, CAM treatments, nutrition, art therapy, and spiritual consultation. Specialized care programs for PTSD and trauma spectrum symptoms are offered through the Deployment Health Clinical Center and consist of a 3-week, intensive, integrative program that uses CBT and iRest yoga nidra meditation techniques—a manualized multistage treatment protocol developed specifically for combat veterans (Carnes, 2011). The restoration and resilience program at Fort Bliss is a 6-month program that focuses on retaining soldiers who would otherwise receive medical discharges (TRICARE, 2008). Because it is a 6-month program, it has been both criticized for its length and applauded for its comprehensiveness, but it has proved very hard to export to other installations. The South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR)—funded by the DoD’s Psychological Health and Traumatic Brain Injury Research Program—is working toward early
interventions that can be used for the detection and prevention or treatment for PTSD (STRONG STAR, 2012a). The consortium of STRONG STAR experts is using clinical trials, exploratory and preclinical studies, and two evidence-based therapies (prolonged exposure [PE] and cognitive processing therapy [CPT]) to treat people for PTSD. The studies are being carried out in several locations, primarily in San Antonio and Fort Hood (STRONG STAR, 2012b).
Military bases may also offer outpatient treatment facilities that specialize in PTSD care with a focus on diverse kinds of treatments. Many programs use aspects of the evidence-based psychotherapy treatments recommended by an established clinical guideline (VA and DoD, 2010), but many integrate CAM. Anecdotal evidence is often supportive; however, few programs are consistent among service branches or at military bases of the same branch and many lack evaluation or grounding in randomized controlled trials. During a site visit to Fort Hood in September 2011, the committee learned that the waiting lists for on-base specialized treatment programs can be long; this indicates a need for these programs to meet the treatment preferences for service members and an imperative to assess the programs in an effort to ensure the treatment regimens are evidence based and effective.
Off-base treatment for PTSD is usually coordinated by on-base case managers. The managers ensure a continuum of care by providing oversight of off-base appointments and by keeping informed of treatments that a service member receives from contracted TRICARE providers or at VA facilities. Service members may also seek care through mental health practitioners in a private practice setting or through Military OneSource, but these services are not reported to the case managers and do not become a part of the DoD mental health record.
TRICARE network providers. TRICARE network providers include psychologists, psychiatrists, counselors, and social workers. Treatment availability depends on the population of mental health professionals who are practicing in the area around each military base. Service members must receive a referral from their primary care manager or behavioral health care clinic for approval to receive treatment from network providers. Care and appointments are organized by the network case managers. TRICARE reimburses providers for a variety of treatment options that are consistent with the VA/DoD guideline (VA and DoD, 2010), including psychotherapy and medication management; however, the treatment options provided to the service member depend on the individual practice and experience of
the providers. Thus, it is difficult to establish whether the clinicians are practicing evidence-based treatment, and, if they are, whether the treatment is effective. Communication between on-base case managers and off-base TRICARE providers is limited by patient confidentiality concerns and the reporting habits of individual providers, and this makes it difficult to coordinate care between the two treatment sites and to ensure patients receive the best available care.
Treatment for service members in VA facilities. In some cases, active-duty service members are referred to VA treatment facilities for their PTSD care. These facilities generally provide a focus that local DoD facilities lack. For example, the Women’s Trauma Recovery Program in Palo Alto, California, is a resource for women who have experienced military sexual trauma and have PTSD. An active-duty service member may also use a VA facility if the facility has available bed space in specialized intensive PTSD programs to handle DoD overflow. TRICARE pays for treatment of active-duty service members at these facilities.
Military OneSource. Military OneSource is an Internet-based and inperson resource that offers assistance with a broad array of issues, such as money management, employment, education, child care, family relationships, relocation, and deployment. For active-duty service members who do not wish to receive counseling from military mental health professionals or TRICARE contractors, Military OneSource can provide up to 12 complimentary face-to-face counseling sessions for each service member per specific problem. Counseling options are also available online and by telephone. Because this is a confidential service, care coordination between Military OneSource and other off-base or on-base providers depends on the information shared by the service member.
Private practitioners. Another option for service members who do not wish to receive treatment from DoD-affiliated programs or clinicians is to seek mental health care from private practitioners. As civilians who are not contracted by TRICARE or employed by the DoD, these mental health practitioners are not bound by the established VA and DoD guideline (VA and DoD, 2010). TRICARE will not cover treatment by private practitioners, and the practitioners are not expected to report diagnosis or treatment progress to the DoD.
In the Theater of War
A stakeholder report from the MHS states that “each quarter, approximately 5,000 deployed service members receive about 14,000 mental health
encounters while in the theater of operations” (MHS, 2012). Mental health care in each of the services is provided in the combat theater by embedded psychiatrists, psychologists, social workers, mental health specialists, psychiatric nurse practitioners, occupational therapists and technicians, and general-practice doctors and clinicians. Chaplains are unique in that they train and deploy with the military unit to which they are assigned; they may provide informal counseling and routinely refer service members to more formal mental health resources and treatment facilities in deployed settings (Tanielian and Jaycox, 2008).
Most embedded mental health providers are deployed as part of COSC teams. For the Navy and Marine Corps, mental health teams are integrated at the regiment level as part of the OSCAR program. The Army uses a dualprovider structure; each division has a psychiatrist and a senior noncommissioned officer, supported by a unit-embedded behavioral health officer and an enlisted mental health specialist (Tanielian and Jaycox, 2008). Air Force behavioral health personnel may attach to and deploy with Army units to supplement and support personnel. In support of OEF in-theater mental health services, the Air Force provided 62% of mental health assets and the Army and the Navy 35% and 3%, respectively (MHAT VII, 2011). A combined total of 147 mental health providers from all services were deployed during the joint-MHAT VII assessment, for an overall staffing ratio of one mental health provider to 646 service members (MHAT VII, 2011). Although the ratio varied by service—for example, the Army mental health care model indicated the ratio was about one mental health provider to every 700–800 soldiers—this staffing ratio was found to be adequate. Findings from the latest joint MHAT indicate mental health personnel have provided more mental health services to service members outside the combat-stress control unit location than in previous years, but substantial barriers remain for both providers and users regarding acceptance and implementation of telehealth technologies (MHAT VII, 2011). Research is ongoing to improve understanding of the characteristics of mental health encounters in the theater of war.
Theater Mental Health Encounter Data is a pilot program developed and implemented by the integrated mental health practitioners who were part of the 1st Marine Division OSCAR team deployed in Iraq from January 2006 to January 2007. Overall, the 9 psychiatrists and 10 psychologists in the embedded team documented 3,180 encounters with 1,336 service members (Conway et al., 2011). Larson et al. (2011) used Theater Mental Health Encounter Data to investigate the incidence and types of mental disorders that service members presented with in theater. They found that 82 of the 1,078 service members who had been seen by a division psychiatrist or one of the mental health providers were given an initial diagnosis of PTSD while in theater.
Training military and civilian mental health care providers to give excellent PTSD care is an important goal of the DoD. Training includes educating providers in the nuances of military terminology and culture so treatment is oriented toward the experiences of service members and their families. Below are some examples of training opportunities in the DoD. Some of the barriers to training are discussed in Chapter 9.
In 2010, the Office of the Assistant Secretary of Defense issued a memorandum to the surgeons general of the Army, Navy, and Air Force, the director of the Marine Corps Staff, and the director of Health and Safety of the U.S. Coast Guard (DoD, 2010). The memorandum provided guidance on training regarding PTSD and acute stress disorders. The key recommendation is that all mental health providers have formal training in evidence-based psychotherapies that is consistent with the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress (2010); however, no instructions were provided on how to track the training or to whom this would be reported. It also suggested objectives for the implementation of treatment and guidance for achieving military culture competence, for obtaining clinical consultation after training, and for continuing education opportunities (for example, through training events offered by DCoE).
Specific training in evidence-based care for PTSD is available through several sources. The USUHS Center for Deployment Psychology conducts workshops and courses and issues certifications to military and civilian health care providers. Training modules include the assessment of PTSD, the etiology of PTSD, and an overview of evidence-based treatments for PTSD. In collaboration with Widener University, they also offer a 6- to 12-month post-master’s degree certificate program that aims to give health care providers knowledge of best clinical practices for addressing the behavioral health needs of service members, veterans, and their families. Training seminars and courses are provided through other platforms. The DCoE posts information on training events for specific PTSD therapies (such as PE, CPT, and virtual reality exposure therapy) that are geared to mental health care providers (DCoE, 2012c). DoD providers can access an Internet-based curriculum offered by the VA called PTSD 101 (VA, 2012b). This online course covers such topics as background and assessment of PTSD, clinical practice guidelines, treatments, specific traumas that increase risk of PTSD and other mental health problems, consideration of special populations, and general health care information. DoD and VA health care providers can earn continuing education credits for several of these modules. A series of training conferences that are geared specifically to chaplains and clergy have been developed. The goal of these conferences is to train chaplains and clergy to recognize PTSD symptoms and other service-related
mental health conditions so they can refer personnel to appropriate care (GAO, 2011a).
Training for TRICARE contractors is variable. There are optional conferences, workshops, and Internet-based training options, but none is mandated. A recent Institute of Medicine (IOM, 2010a) report, Provision of Mental Health Counseling Services Under TRICARE, recommended that TRICARE implement a mental health quality monitoring and management system. The system would require TRICARE mental health counselors to meet several criteria—including minimum education, licensure, and clinical experience requirements—and would involve “a systematic process for continued professional education and training to ensure continuing improvement in the clinical evidence base and accommodation of the changing needs of the TRICARE population” (IOM, 2010a).
An estimated 2.6 million service members were deployed in OEF and OIF from October 2001 through September 20, 2011 (GAO, 2011a); as of 2008, at least 868,000 OEF and OIF service members (including National Guard and reservists) had left active duty (IOM, 2010b). Generally, those who are eligible to receive care through the VA have either been discharged from active duty in the armed forces (see Box 4-1 for eligibility) and transition
Eligibility for Department of Veterans Affairs Health Care
Veterans who may qualify for health care benefits offered through the VA include those who served under active-duty military service in the Army, Navy, Air Force, Marines, or Coast Guard (or Merchant Marines during World War II) and reservists and National Guard members who were called to active duty by a Federal Executive Order. Benefits depend on the veteran’s priority status, which is based on a number of factors including service-connected disability, income, or other special status. All veterans who have served in a theater of combat operations within the past 5 years from the date they apply for VA health care are eligible. Other factors that qualify include separation from the service for medical reasons or hardship, discharge from the service due to disability, former prisoners of war, Purple Heart Medal recipient, receiving a VA pension or disability benefits, and receiving state Medicaid benefits. A person who has been discharged under dishonorable conditions is not eligible for benefits through the VA.
SOURCE: VA, 2012b.
to the VA only once, or return from activated deployment with the National Guard or reserves and are immediately eligible for VA care. In select cases multiple transitions between DoD and VA health care occur. That particularly affects National Guard and reserve members who have been activated and deactivated more than once. Some retirees may also choose to receive portions of their care from the DoD (through purchased TRICARE services), from the VA, or in the private sector if they have other medical coverage with Medicare or employer-provided plans.
Veterans who are enrolled in the VA have access to a comprehensive medical benefits package that includes a range of outpatient and inpatient services. Once enrolled, the veteran remains enrolled and is able to access health care at any VA facility in the United States.
A service member’s transition from active duty to the VA is supported in several ways. In recent years, the VA has expanded its efforts to reach out to veterans transitioning from service in OIF and OEF. Special OIF and OEF outreach teams have been funded and established in every VA facility. The teams work with staff from VA’s community-based readjustment counseling service centers (usually called Vet Centers) to seek out veterans recently discharged from active-duty status, including those in reserve components. A VA facility near a military base may also assign VA staff at an MTF to facilitate the transfer of injured service members to VA care as they are discharged.
VA personnel are present during the administration of the PDHRA to National Guard and reserve service members so that the service members can get information about eligibility for VA benefits and make follow-up appointments at VA facilities. The VA coordinates with the DoD to receive dates and locations of PDHRA administration, the number of service members referred to VA facilities, and copies of the PDHRA for people who access VA health care (GAO, 2008b). If a service member completes the PDHRA through a telephone interview, a VA benefits brochure, a copy of the PDRHA, and contact information of a VA liaison is mailed out after the interview (GAO, 2008b).
The Federal Recovery Coordination Program was originally conceived as an effort to ensure care coordination for severely wounded and ill OEF and OIF service members, who will most likely be separated from the military because of their conditions (including PTSD). The program, housed in the VA, has provided services to only a very small number of separating service members and veterans (about 2,000), but its goal is to use federal recovery coordinators as the points of contact for patient case managers in the DoD, the VA, and any other case management programs to monitor and coordinate both the clinical and nonclinical services needed by program enrollees (GAO, 2011b). Two Government Accountability Office (GAO) reports (2011c, d) cited challenges in program enrollment, staffing
needs, caseloads, and placement locations. The reports indicated there were substantial coordination problems with other DoD and VA programs that could result in duplication of effort, inefficiency, and confusion of enrollees. A third GAO report (2011c) on integrating DoD and VA care coordination programs was also critical of the lack of collaboration between the two departments in terms of case management and care coordination. The committee notes that the Federal Recovery Coordination Program only serves a very small number of service members and veterans. Such efforts need to be carefully scrutinized as to their effectiveness before they are more widely implemented; the lack of such effective programs means that many service members and veterans are underserved.
Treatment for PTSD and other mental health conditions is an important part of the VA’s mission of providing medical care to eligible veterans. In FY 2010, an estimated 790,000 veterans were identified as having a service-connected mental health disorder (GAO, 2011a). During FY 2010, 438,091 veterans (includes those service-connected for PTSD and those not service-connected for PTSD) were treated for the disorder in the VA health care system (NEPEC, 2011a). The latter made up 8.4% of all users of VA health care services, and the number was more than double the number treated for PTSD in FY 2002 (NEPEC, 2011a). That increase is directly related to the influx of veterans returning from deployments in OIF and OEF. During FY 2010, 82,239 veterans of OIF and OEF are known to have received PTSD services through the VA health care system; they amounted to 24.6% of all OIF and OEF veterans using the system (NEPEC, 2011a), although this underestimates the actual number because reporting from the Vet Centers is incomplete. Many of the 191,501 veterans who were reported to have used the Vet Centers received care for PTSD, but many of them are not included in the previously cited figures (see the discussion of Vet Centers later in this chapter). Data are not available on the number of people who use Vet Center services and have received a diagnosis of PTSD. Although the VA has built a system of specialized programs focused on treatment for PTSD, most of PTSD-related services are offered in general mental health and medical settings.
The VA is the second largest cabinet-level department in the federal government (the DoD is the largest) and has, in the aggregate, the largest health care system in the United States. Like other federal departments,
the VA accomplishes its mission through subcabinet agencies. The three primary subcabinet agencies in the VA are the Veterans Health Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery Administration (see Figure 4-4).
The VHA has about 239,000 full-time employees—more than 80% of the VA’s staff—and 53,000 independent licensed health care practitioners (VA, 2012c). The VHA accounts for about half of VA expenditures. The VHA provides health care services for enrolled eligible veterans through a fully integrated system of health care delivery assets. Those assets include 152 VA medical centers that typically are composed of an acute-care hospital,
FIGURE 4-4 A partial representation of the Department of Veterans Affairs organization (only selected offices and services are depicted).
an array of hospital-based clinics, a community living center (a skilled nursing facility), and various rehabilitation or other specialized treatment facilities (VA, 2012d). The VHA also manages more than 40 domiciliaries (residential care facilities) for veterans who have mental health or other long-term care needs, nearly 1,400 associated community-based outpatient clinics (VA, 2012d), and about 300 Vet Centers (VA, 2012e). A substantial amount of mental health care is provided in hospital-based primary care clinics and the community-based outpatient clinics, as well as the Vet Centers.
The VBA manages an array of programs that provide financial, educational, and employment assistance, and other services, such as compensation, pension, and survivors’ benefits, home loan guaranties, and life insurance coverage. The National Cemetery Administration is responsible for operating the 131 national cemeteries and providing oversight and management of the 33 soldiers’ lots, confederate cemeteries, and monument sites in the United States (VA, 2010a).
The VA health care system is organized into 21 veterans integrated service networks (VISNs) (Kizer and Dudley, 2009). The VISNs are the system’s basic operating units. Each VISN is responsible for the care of the population of veterans living in a defined geographic area of the United States and its possessions. The VISNs provide health services through their component VA medical centers, community-based outpatient clinics, and other care delivery assets, including an array of contractual relationships and partnership with private health care providers. Administrative and budgetary authority for the provision of services in the VHA rests with the VISN directors. The medical centers also oversee and distribute payments for contractual health care services provided to veterans.
An initiative to establish the community-based outpatient clinics was launched in the middle 1990s to increase access to care by establishing clinics in locations that were more geographically convenient for veterans than the large VA medical centers. The community-based outpatient clinics now provide both primary care and mental health care in most locations. Each community-based outpatient clinic is administratively and financially linked to a VA medical center where there is generally an integrated mental health care service or a set of clinical services (for example, psychiatry, psychology, social work, and nursing) that collaborate to provide and manage mental health services. The local mental health service manages and provides most of the treatment services for PTSD. The VA health care system uses a system-wide electronic health record, the VistA–Computerized Patient Record System, and a common comprehensive administrative database in which all medical contacts are documented (for example, outpatient encounters, inpatient stays, and residential stays).
As of September 30, 2011, there were about 22.2 million living U.S.
veterans, 8.3 million (37%) of whom were enrolled in the VA health care system (VA, 2011a); of these, about 5.2 million were treated by the VA during FY 2010 (GAO, 2011a). More than 80% of enrolled veterans over 65 years old are Medicare beneficiaries, and more than 25% of VA health care enrollees are beneficiaries of two or more non-VA federal health plans (such as Medicare, Medicaid, TRICARE, and the Indian Health Service) (Kizer, 2012). Relatively few VA health care beneficiaries are also enrolled in employer-provided health plans or have other private health insurance coverage. Thus, not every VA health care enrollee receives treatment in a VA facility every year, but over the course of 3 years, most do use VA services at some point. Unlike TRICARE for military retirees, spouses, and dependents, any dependents of veterans are not covered for health care services by the VA health care system except when services (such as marriage and family counseling) are a necessary part of treatment for a veteran and in a few other special situations (for example, spina bifida care for children of Vietnam veterans exposed to Agent Orange). The VHA’s Vet Centers provide some care for PTSD, but other mental health services are generally not provided in these counseling centers, although a VA staff psychiatrist may go to the center to see patients. VA medical center clinical staff who see patients at the Vet Center enter data on the encounters into the VA medical record.
As previously discussed, the VHA provides services through about 300 Vet Centers located throughout the United States and its possessions. The Vet Centers were formally established by an act of Congress in 1979, and were, by design, not aligned under the management of local VA medical centers (as shown in Figure 4-4). The intent was that they would be perceived as community centers where veterans could get “help without hassles” and not be stigmatized by receiving counseling or behavioral health services. They were originally targeted to serve only Vietnam veterans, many of whom had PTSD or other readjustment issues, but they have expanded their mission to include veterans of all conflicts.
Vet Centers are designed to assist in the continuing and successful readjustment of veterans to civilian life. That includes counseling, assessment, and rehabilitation services for veterans and, in some cases, family members. Vet Centers maintain records that are different from those of the medical system, and data cannot be combined across the VA medical and Vet Center systems. A separate Vet Center central office is responsible for oversight and evaluation, which includes developing policy and planning, and has administrative and budgetary authority over the Vet Centers. During FY 2010, 191,508 veterans and family members made 1,273,035 visits to Vet
Centers (VA, 2012e). Reportedly, 39% of Vet Center service recipients do not use VA medical services (Batres, 2011).
The VHA and Vet Centers have different policies with regard to PTSD treatment. Although VHA mental health services are seldom carried out in Vet Centers, each Vet Center must have an external clinical consultant who is required to perform at least 4 hours of clinical consultation each month. Providers in Vet Centers include social workers, clinical psychologists, mental health counselors, professionally trained counselors, and counseling therapists (VA, 2011b). Counseling services provided in these venues focus on assisting combat veterans in readjusting from military to civilian life (GAO, 2011a). Specifically, to ensure that providers are performing high-quality counseling, it is Vet Center policy for team leaders or clinical coordinators to conduct monthly reviews of randomly selected patient clinical records for each full-time provider (VA, 2002b). Vet Center policy also requires providers to review patient treatment plans (including type and estimated duration of counseling or therapy and expected outcomes) during the first five visits and then at least once every 6 months thereafter (VA, 2002a). Of the randomized sample, nearly 90% of records had a current treatment plan.
Most Vet Centers reported using the DSM or a combination of the DSM and validated instruments such as the PC-PTSD screen and the PTSD Checklist, to screen for PTSD. Although VHA policy mandates that all veterans who have PTSD must have access to CPT or PE in VHA facilities (VA, 2008), Vet Centers are not required to have these therapies available, although many of them do. In a survey of 27 Vet Centers, 21 had provided one or more forms of evidence-based therapy (VA, 2011b).
In FY 2010, an estimated 41% of veterans who were enrolled in the VA health care system were living in rural areas (GAO, 2011a). To support veterans and their families who live in these areas in the contiguous 48 states, Hawaii, and Puerto Rico, the VA has a fleet of 70 mobile Vet Centers. The mobile units increase access to readjustment counseling and other services and are equipped with satellite dishes, audio-visual equipment, multiple telephone lines, dedicated fax lines, laptop computers, encrypted computer lines, and wireless Internet (Tyson and VA, 2009). The interior of a mobile unit is divided into private counseling rooms that can be used for individual or small-group counseling sessions (VA, 2012f).
In FY 2011, the VA employed an estimated 21,000 mental health care providers (GAO, 2011a). The VHA offers a broad array of services, including all the primary and specialized medical and mental health services that
are commonly offered through comprehensive health care systems in the United States. It also offers vocational rehabilitation services; services that address homelessness; prevention, screening, diagnosis, treatment, and rehabilitation services for veterans who have PTSD; and comprehensive evaluations of veterans who are applying for compensation because of PTSD that was caused or aggravated by their time in service. The comprehensive PTSD evaluations are used to support the efforts of the VBA to adjudicate claims for service connection of veterans’ PTSD. Most of these services are provided by VHA staff, but occasionally local VA medical centers contract with community providers to provide services. In 2007, to increase the availability of mental health services, the VA required its mental health clinics to provide information about regular hours of service, such as early morning, evening, and weekend appointments.
From 2006 through 2010, an estimated 2.1 million veterans received mental health care from the VA, 10% of whom were OEF and OIF veterans (GAO, 2011a); of all OEF and OIF veterans receiving any health care during this 5-year period, 38% received mental health care (GAO, 2011a). In FY 2010, the five most common mental health diagnostic categories were adjustment reaction (including PTSD), depressive disorder, episodic mood disorder, neurotic disorder, and substance abuse disorder. Some veterans may have received a diagnosis of more than one mental health disorder.
Policy expectations for PTSD services are detailed in the VHA handbook Programs for Veterans with Post-Traumatic Stress Disorder (PTSD) (VA, 2010b). The VA funds several national evaluation centers that are responsible for, among other tasks, evaluations for specific categories of mental health services and programs, including some PTSD programs. In addition, the VA National Center for PTSD (discussed below) sponsors and promotes research on associated factors and treatments, training, and education; participates in the development of clinical practice guidelines; and disseminates information to the public on PTSD. Vet Center representatives collaborate with the National Center for PTSD and have participated in the development of clinical practice guidelines.
Whereas the VHA is responsible for providing care and services to veterans for PTSD, the VBA evaluates and adjudicates all claims for PTSD service connection and pays pensions awarded to veterans whose PTSD is found to be service connected. The VBA also provides rehabilitation services for those who are substantially impaired by PTSD that is service connected. That includes evaluation services, educational and vocational training services, vocational rehabilitation services, and other supportive services necessary to rehabilitate veterans who have service-connected PTSD and maintain them at the highest possible functional level. VBA staff provides some of the initial evaluation services and act as case managers in the rehabilitation process. Most services are provided through payments
by the VBA to educational, vocational, and rehabilitation institutions or service providers. The VBA also provides additional services for patients who have PTSD, such as loans, non–service-connected pensions, and GI Bill educational benefits. Those services are available for all veterans with PTSD, regardless of whether their PTSD has been adjudicated as being service-connected.
In July 2011, the VHA announced a reorganization of mental health support in the VHA Central Office in Washington, DC. The VA realigned the VHA to enhance effective oversight and to improve support of the VA’s health care programs, including mental health programs (Schoenhard, 2011). The Office of Mental Health Operations (OMHO) in the Office of the Deputy Undersecretary for Health for Operations and Management was established to ensure there is a structure for implementing mental health policies developed by the VHA. The OMHO reports directly to the deputy undersecretary for operations and management who is also the direct supervisor of all the VISN directors (see Figure 4-4). That makes one administrative entity responsible for ensuring that organizational priorities related to mental health care are met. In the reorganization, the OMHO will be responsible for monitoring compliance and providing technical assistance to networks to support implementation of national policies. Priorities related to mental health treatment, services, and policies will continue to be guided by the Office of Mental Health Services, which will work closely with OMHO to support common efforts. The realignment is expected to reduce variation in the delivery of mental health services throughout the system. The Office of Mental Health Services will also take the lead in the VHA’s joint participation with the DoD in the development and dissemination of evidence-based practice guidelines for the screening and diagnosis of and treatment for PTSD.
PTSD Services and Programs
After the Vietnam War, a small number of medical centers developed local specialized treatment programs for PTSD. In the mid 1980s, congressional funding spurred the expansion of the number of such programs throughout the VA health care system. The programs were locally developed and were largely distinct from one another in organizational structure and treatment approach. They were predominantly residential or inpatient programs that drew patients from large geographic areas. During the 1990s, centralized seed money and local initiatives led to an expansion of outpatient PTSD programs. PTSD outpatient clinical teams that had uniform staffing patterns and expectations were established. However, the deployment of specialized PTSD programs in the VHA health care system was uneven and varied among the VISNs; some VISNs had established
specialized programs, but others had done little specialized programming. Box 4-2 provides a selected list of programs and services offered by the VA. Many of the programs and services—especially those that are not specialized treatment programs—are not PTSD specific, but provide benefits and services that may be applicable to persons who have PTSD or other mental disorders.
Selected Examples of VA Programs and Services for PTSDa
Families OverComing Under Stress (FOCUS)
FOCUS (couples version)
Moving Forward: A Problem-Solving Approach to Achieving Life’s Goals
Psychological First Aid Manual for Direct Care Staff
Specialized Outpatient Treatment:
PTSD Clinical Teams
Substance Use PTSD Program
Women’s Stress Disorder Treatment Team
Specialized Intensive Treatment:
Evaluation and Brief Treatment PTSD Unit
PTSD Day Hospital
PTSD Residential Rehabilitation Program
Specialized Inpatient PTSD Unit
Women’s Trauma Recovery Program
Rehabilitation, Readjustment, and Disabilityb:
Vocational Rehabilitation and Employment Program
Compensated Work Therapy
Individual Placement and Support
Specialized Homelessness Services
Strength at Home
Supportive Housing Services
Community-Supported Homeless Prevention Programs
aThis is not a comprehensive list of programs offered by the VA, and not all those listed are exclusively for persons who have PTSD.
During FY 2010, the VA provided medical care to 5,232,182 veterans, of whom 438,091 (8.4%) received care for a diagnosis of PTSD (NEPEC, 2011a). Spurred by the return of large numbers of veterans from OIF and OEF, the VA has substantially increased the number of services for veterans who have PTSD and worked to improve the consistency of access to such services. Every medical center and at least the largest community-based outpatient clinics are expected to have specialized PTSD services available on site. Mental health staff members devoted to the treatment of OIF and OEF veterans have also been deployed throughout the system (Zeiss, 2011).
The National Center for PTSD is a VA-funded center of excellence for PTSD (VA, 2012h). Created in response to a congressional mandate in 1989, the center is made up of seven divisions around the United States—the Executive Division, the Behavioral Science Division, the Clinical Neurosci-ences Division, the Dissemination and Training Division, the Pacific Islands Division, and the Women’s Health Sciences Division (VA, 2012i)—which “provide a unique infrastructure within which to implement multidisci-plinary initiatives regarding the etiology, pathophysiology, diagnosis, and treatment of PTSD” (VA, 2012j). The center is at the forefront of research and education on PTSD.
Resilience services provided by the VHA are designed to improve the readjustment of veterans to civilian life, to reduce the number and intensity of stress reactions to levels below those required for a diagnosis of PTSD, and to prevent comorbidities. Several joint VA and DoD initiatives are being developed and piloted. For example, the goal of the Integrated Mental Health Strategy is to focus on broad psychological prevention and resilience activities. Although not related specifically to PTSD, the goal of Action 24 of the Integrated Mental Health Strategy is to “ensure that emerging resilience and prevention programs being developed and implemented in VA are informed by lessons learned from DoD’s resilience and prevention programs.” In addition, the VA and the DoD have been developing national inventories of their resilience and prevention programs for mental health to identify and share best practices throughout the two departments (Schiffner, 2011).
As previously discussed, a robust resilience program is an integral part of the Vet Center program. Services targeted to improving readjustment include individual, group, and family counseling; employment counseling; counseling related to military sexual trauma (MST), a term used in the VA for “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of the victim, or the
relationship to the perpetrator” (VA, 2012k); outreach; substance abuse assessment and referral; bereavement counseling; referral for other mental health, substance abuse, and medical problems; and guidance on VA benefits (VA, 2009).
Several other VA programs and services are specific to resilience, including LifeGuard, which aims to promote psychological resilience on the basis of acceptance and commitment; FOCUS, a family-centered preventive intervention program; and Moving Forward, a group-based program focused on early intervention and prevention of mental health problems. The VA has also implemented programs and services that are not specific to prevention of PTSD, but instead aim to prevent comorbidities that tend to co-occur with PTSD (see Chapter 8 for a more complete discussion of comorbidities).
Screening and Diagnosis
It is VA policy to screen every patient seen in primary care in VA medical settings for PTSD, MST, depression, and problem drinking. It takes place during a patient’s first appointment. Screenings for depression and problem drinking are repeated annually for as long as the veteran uses services. PTSD screening is repeated annually for the first 5 years and every 5 years thereafter (Schoenhard, 2011; VA, 2008). To screen for PTSD, the VA generally uses the four-item PC-PTSD screen. In 2005, the definition of a positive screen changed from at least two affirmative responses to at least three affirmative responses to the four questions (VA, 2005). A positive screen for PTSD or depression (using the two-item Patient Health Questionnaire) results in an additional screening for suicide. MST is screened for only once, generally at the first appointment, unless new data entered into the record indicate the need for additional screenings. Every veteran who receives services at a Vet Center is screened for PTSD and MST. Screening for PTSD is also available for all veterans through the VA’s My HealtheVet website (VA, 2012l). It is VA policy that all veterans who are given mental health referrals are contacted within 24 hours to evaluate any immediate medical needs they may have. If the situation is not an emergency, veterans are required to receive follow-up care within 14 days after the referral (GAO, 2011a). Of the 5,372,354 veterans who used VA services in FY 2011, 12% of those screened for PTSD had a positive screen (a screen is considered positive if a score of three or more is obtained on the PC-PTSD assessment instrument) (Schiffner, 2012). The numbers of referrals to diagnosis and referrals to treatment could not be determined because such referrals are not coded in a consistent way in the administrative medical record.
Every VA medical facility provides a full array of treatment services for PTSD, including pharmacotherapy, face-to-face mental health screening and assessment, group and individual therapy, and psychotherapy. The VA tracks where the treatment is given by assigning a code to every inpatient or residential bed setting and every outpatient clinic; this permits uniform definitions for the nature of the beds or clinics throughout the system. Services vary in frequency and intensity among treatment venues. The VA encourages the use of evidence-based treatments such as CPT and PE, although CAM treatment approaches are also common in the VA specialized treatment programs. A recent VA survey found that 96% of 125 PTSD programs surveyed used some type of CAM (Schiffner, 2011). Of those programs, about 77% offered mindfulness, 72% offered stress management or relaxation, 66% offered progressive muscle relaxation, and 59% offered guided imagery; almost one-third of the PTSD programs offered yoga and one-third offered art therapy. The VA is piloting and researching expanded use of CAM approaches that are the most promising (Schiffner, 2011). The committee will consider this topic in more detail during phase 2 of its study.
Table 4-2 provides data for FY 2010 on PTSD treatment venues in the VHA for 350,629 veterans who were given a primary diagnosis of PTSD. They constitute a substantial subset of the total of 438,091 veterans who received care for PTSD during that year. Some veterans received care in more than one venue, so the total in the table is greater than 350,629. The most common outpatient treatment venue for PTSD is in general mental health outpatient clinics. Treatment in those settings is usually provided by mental health practitioners who also provide services for other mental disorders. Each VA medical center has at least one “PTSD specialist” (VA, 2012a) who is expected to have expertise in treatment for PTSD. The mental health
TABLE 4-2 Care Setting in the VA for Veterans with a Primary Diagnosis of PTSD, FY 2010a
|General mental health clinics||275,838|
|Nonmental health clinics||67,871|
|PTSD clinical teams||117,313|
|a The data do not include patients seen in Vet Centers.
SOURCE: NEPEC, 2011b.
providers enter their PTSD treatment data into the electronic medical record by using a specialized PTSD encounter code; however, because PTSD specialists are not part of designated specialized PTSD treatment programs, their actions and qualifications are not monitored.
Much outpatient PTSD treatment for veterans occurs in clinics that are not specifically designated as mental health clinics, such as primary care. Treatment includes medication prescribed by non-psychiatrists for PTSD and care given by some mental health professionals who work outside mental health clinics. A substantial portion of the workload would be assigned to staff in the new OIF and OEF outreach teams. Because there is no centralized monitoring of the PTSD treatment workload provided outside of specialized PTSD programs, no additional data on the patients treated outside the programs or on the nature or intensity of their care are available, although it appears that such data could be developed.
Readjustment counseling is offered through community-based Vet Centers. Any veteran or family member of a veteran who served in a combat zone is eligible for this service, which includes individual and group counseling, family counseling for military-related issues, MST counseling and referral, and substance abuse assessment and referral (VA, 2012m). If a veteran needs medications or immediate care, then staff can make a referral to a VA medical center (VA, 2009). If a veteran receives treatment through a Vet Center, then no information about that treatment will be released to any person or agency (including the VA) without the veteran’s consent (VA, 2012n).
Primary Care in the Department of Veterans Affairs
The Primary Care Program Office is housed within the VHA and, similar to the DoD, is implementing a patient-centered medical home model at all VHA primary care sites. The Patient Aligned Care Teams are managed by primary care providers with support from other clinical and nonclinical staff to provide accessible, coordinated, comprehensive, patient-centered care to veterans. This model of health care has been associated with increased quality improvement, patient satisfaction, and fewer hospital visits and readmissions. To support the Patient Aligned Care Teams, the Primary Care Program Office has developed a variety of tools to assist primary care staff with implementing the patient-centered medical home model (VA, 2011c).
Like the DoD, the VA in recent years has substantially expanded the embedding of mental health providers (primarily psychologists) in primary care clinics. That facilitates the immediate assessment and treatment of patients who are identified by primary care providers as being in need of mental health services, including patients who screen positive for PTSD or
are otherwise identified as having PTSD or other stress-related disorders. Beginning in 2008, the VA has been employing mental health professionals to work as an integral part of primary care teams (GAO, 2011a). In FY 2010, at least 155,554 veterans were seen by mental health staff deployed in primary care clinics (Schoenhard, 2011). VA policy requires mental health staff to be available for consultation to VA emergency departments and urgent care centers during all hours of operation (GAO, 2011a).
Primary Care for Veterans Outside the Department of Veterans Affairs
About 60% of veterans do not receive care in the VA system (VA, 2011a). Thus, primary care clinicians in the non-DoD, non-VA sector are likely to see a considerable portion of the OEF and OIF veterans who are living with PTSD. As these engagements wind down, the number of veterans who have PTSD is likely to increase. Many of the clinicians probably have little knowledge of PTSD, little understanding of the DoD and VA medical resources that might be available for a veteran or military family, and limited familiarity of military culture (Boscarino et al., 2010).
Non-VA, non-DoD primary care providers constitute a heterogeneous group, and this results in variation in the types of care they provide to veterans who have PTSD—variation in the types of practice and the geographic locations; in the psychiatric, psychologic, social services, and financial resources that are available; in the providers’ training and expertise related to PTSD care; and in the providers’ level of involvement in the care of the spouses and children of veterans. These primary care providers include physicians, nurse practitioners, and physician assistants who are employed in large health systems, public clinics, rural health centers, and solo private practices. The resources and financial support they can access for their PTSD patients vary commensurately from extensive resources in some health systems and communities to very few in others. The presentation of veterans who have PTSD will also vary. In the VA, the established screening programs may bring patients of concern to the attention of clinicians who are generally attentive to the possibility of PTSD and other underlying clinical presentations. In contrast, nonmilitary primary care practices do not typically screen for such conditions as PTSD, given the small proportion of the U.S. population that has served in the military.
The evolution of primary practices in recent years has included, and over the next several years will probably include, a transition that embraces patient-centered medical home concepts, electronic medical records, advances in information technology, and the active use of registry and case management systems to promote adequate follow-up and treatment adjustment for those with mental health and chronic medical conditions.
The VA provides almost 200 specialized PTSD treatment programs (VA, 2012n), mainly through specialized outpatient and intensive PTSD programs. There are three types of specialized outpatient PTSD programs in the total of 127 throughout the VA system: 119 PTSD clinical teams, 4 substance-use PTSD teams, and 4 women’s stress-disorder treatment teams. The teams are interdisciplinary and are structured according to centralized staffing protocols. There is no uniform, national policy on admission criteria for specialized PTSD treatment programs. Individual programs may have specific inclusion or exclusion criteria, such as substance use disorder status or legal status (for example, not awaiting trial or sentencing), or in the case of specialized women’s programs, gender. In general, referral processes to specialized programs are very liberal; programs generally accept self-referrals and referrals from other health care providers and community resources. Services provided by PTSD clinical teams may include assessment and diagnosis; individual, group, and family therapy; psychoeducation; pharmacotherapy and medication management; supportive therapy; CBT, PE, and CPT; and referrals to other services or clinics. It is important to note that the provision of treatment by the staff on the specialized outpatient PTSD program teams is not standardized and may not be consistent among programs. Substance use PTSD teams provide assessment, symptom management (for example, in the form of pharmacotherapy, anger management, and counseling), and group and individual psychotherapy to treat co-occurring substance abuse and PTSD symptoms. Women’s stress disorder treatment teams are similar in structure to the PTSD clinical teams and provide face-to-face and group treatment to female veterans who have PTSD. Treatment options—such as psychologic assessment and consultation, psychiatric and medication services, and psychotherapy—do not vary markedly from those of VA-wide programs, but the teams target only female veterans, and their goal is for patients to feel more comfortable and thus improve treatment outcomes.
The 117,313 veterans treated in the specialized outpatient PTSD programs during FY 2010 were tracked in a centralized program evaluation system in the VHA, so more is known about the characteristics of this population than about characteristics of patients who are treated outside the specialized programs (NEPEC, 2011b). On the average, patients seen in the specialized outpatient PTSD programs made 7.8 visits during FY 2010 at a direct cost of $1,066 per person (this includes only the cost of the salaries of the program staff, not such indirect costs as facility and administrative overhead and supplies) (NEPEC, 2012a, b). According to intake forms filled out by the 21,104 new veterans who entered the programs during FY 2010, most had served in the Persian Gulf (includes the 1990–1991 Gulf
War, OIF, and OEF; 51%), were male (91%), were adjudicated as having their PTSD related to their time in service and were receiving compensation (62%), had been exposed to enemy or friendly fire (85%), and were prescribed psychotropic medications (63%) (NEPEC, 2011c).
Among veterans in outpatient services, comorbidities were high; 33% had a concurrent diagnosis of substance use disorder, 54% had a non-psychotic axis I diagnosis,1 4% had a psychotic axis I diagnosis, and 68% had a current chronic medical problem (NEPEC, 2011c). Most (64%) were not currently working, including 25% who were looking for but were unable to find work (NEPEC, 2011c). Only 2% were currently on active duty, but 13% were still active in the reserves or National Guard (NEPEC, 2011c). MST during time in service was reported by 9%, and an equal percentage reported sexual trauma either before or after their time in service (NEPEC, 2011c).
In addition to outpatient programs, the VA maintains 41 specialized intensive PTSD programs of six types: evaluation and brief treatment PTSD units, PTSD residential rehabilitation programs, PTSD domiciliary programs, PTSD day hospitals, specialized PTSD inpatient programs, and female trauma recovery programs. In FY 2010, specialized intensive PTSD programs had 3,967 admissions.
The specialized inpatient and outpatient settings seek to create a “therapeutic community” as a part of the treatment program and include counseling and social, recreation, and vocational training (VA, 2012n). The programs were locally developed, and therefore are different from each other in structure (for example, residential vs. day hospital), length of stay (average 43.9 days), and treatment approach. Most programs are comprehensive, offering a variety of interventions and treatment options. The VA monitors patients in the programs through a more robust national evaluation effort. Consequently, much is known because patient characteristics and outcome data are collected.
PTSD day hospitals provide intensive outpatient care for 3–6 weeks in individual or group settings (VA, 2010c). Evaluation and brief treatment PTSD units provide 14–28 days of care for acute cases of PTSD in inpatient psychiatric units with mandatory follow-up care after a stay. Specialized inpatient PTSD units provide trauma-focused care for 28–90 days for veterans who require more intense and monitored care. PTSD residential rehabilitation programs and PTSD domiciliary programs also
1 The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders uses a five-axis system to diagnose mental health disorders (APA, 2000): axis I includes clinical disorders, axis II includes personality disorders and mental retardation, axis III includes general medical conditions, axis IV includes psychosocial and environmental problems, and axis V includes global assessment of functioning.
provide longer-term care, generally 28–90 days, in a residential therapeutic environment to prepare veterans to re-enter the civilian community with better “self care and self control capabilities” (VA, 2010c). Some specialized services for women are met through women’s trauma recovery programs, 60-day live-in rehabilitation programs that include PTSD treatment and coping skills for re-entering the community. There are only two of these programs in the VA, and they served fewer than 60 patients during FY 2009. Overall, about 5% of participants in all VA specialized intensive PTSD programs and 8% of all patients in specialized outpatient PTSD programs are female (NEPEC, 2011c, d).
Most patients treated in specialized intensive PTSD programs (75%) had PTSD that was connected to their service and were receiving compensation, almost all (91%) of these patients were prescribed psychotropic medication, 49% had served in the Persian Gulf (including the 1990–1991 Persian Gulf War, OEF, and OIF), 47% had a concurrent substance abuse diagnosis, and 45% had another axis I disorder. Almost all (96%) patients had some type of prior treatment for PTSD. At admission, 83% were not working, including 18% who reported that they were looking for and not able to find work (NEPEC, 2011d). A robust program evaluation effort tracked the progress of these patients through treatment.
An attempt was made to follow up with patients 4 months after discharge from the specialized intensive PTSD programs. Two-thirds were contacted and completed follow-up evaluations. The VA provided the committee with only overall combined data from all the programs. There was a modest improvement on measures of PTSD symptoms and substance abuse and a stronger improvement for PTSD symptoms and violence. It must be noted that there was no control group, and the programs that were combined to yield overall results are very different from one another (NEPEC, 2011b).
The VA has implemented a national initiative to train providers in evidence-based psychotherapies for PTSD (Schiffner, 2011). National experts have been employed to train a cadre of VA staff in both CPT and PE. The training includes an initial intensive experientially based workshop (3–5 days long) and weekly telephone-based consultations with an expert in the therapy for about 6 months. At of the end of FY 2011, about 3,300 VA clinicians had been trained in CPT, 1,500 in PE, and 800 in both (Schiffner, 2011). Recently, the VA announced that it plans to hire about 1,600 nurses, psychiatrists, psychologists, social workers, and other mental health staff and about 300 administrative support staff. This is in addition to the VA’s current mental health staff of about 20,590 employees (VA, 2012g).
The emphasis has been on training clinicians who have large caseloads of patients who have PTSD. About one-third of those who are trained work in specialized PTSD programs, and about one-third work in general outpatient mental health settings, in which PTSD patients are also seen. There are plans to train an additional 400 clinicians in FY 2012 (Schiffner, 2011). Rates of participation in the consultation process after training workshops are very high (88%) for PE (Karlin et al., 2010). Master trainers are to be trained for each of the VISNs and for the Vet Centers to expand the training of clinicians closer to their work sites. The VA also continues to develop tools to enhance the delivery of the therapies, such as motivational educational videos for patients and supplemental training materials. The VA has reported good results from initial evaluations of the acceptance and impact of the program (Karlin et al., 2010). The VHA has also reported that the system has adequate staffing capacity to provide CPT or PE for PTSD to all OEF and OIF veterans in the VHA and is close to having full capacity to provide these therapies to VHA users of all combat eras (Schiffner, 2011).
The VHA has reported that barriers to the full implementation of treatment regimes remain (Schiffner, 2011). Most notable is the amount of time that clinicians have to provide a particular intervention in the time frame that is desirable for each patient. There are also problems with giving clinicians time to participate in post-workshop consultations and accessing the supplies and resources required to implement the evidence-based care. The VHA reports that it is attempting to address those barriers by implementing policies that make the requirements for the full implementation of evidence-based care at the local-facility level explicit. It also reports that it has developed a national performance measure that requires OEF and OIF veterans with a primary diagnosis of PTSD to receive at least eight sessions of psychotherapy within a 14-week period. And it has developed metrics for tracking psychotherapy delivery for all veterans who have PTSD that will be part of a comprehensive national dashboard of performance metrics. It has developed an initiative to expand the delivery of evidence-based therapies through telemental health modalities (Schiffner, 2011).
There is no mechanism for tracking the delivery of evidence-based therapies in the VA centralized databases. The VHA is developing progress note templates for CPT and PE that will allow documentation of the care in the computerized record in a manner that will facilitate the collection of centralized aggregate data (Desai, 2011).
VA clinicians also participate in seminars, courses, workshops, and other continuing education efforts that are not part of the new centralized VA initiative in evidence-based care for PTSD. These offerings may be sponsored by professional groups, educational institutions, local VA facilities, or a national VA educational center. Internet-based educational programs in PTSD are offered by the VA National PTSD Center and professional
organizations such as the International Society for Traumatic Stress Studies. No centralized tracking is conducted on how many PTSD-related educational efforts are attended by local VA clinical staff. The currently untracked training encounters would include attendance at seminars and workshops on pharmacotherapy for PTSD attended by VHA prescribers of medication. Specific training in screening of veterans for mental health conditions and in discussing treatment options is in place for primary care physicians (GAO, 2011a).
All VA-independent professional mental health staff (including psychiatrists, psychologists, social workers, and advanced practice nurses) are credentialed and privileged at the local-facility level. There are broad guidelines for the process, but local professional standards boards and cre-dentialing bodies are given latitude to delineate special competences and to grant privileges to engage in a particular therapeutic activity or treatment for specific disorders.
Among providers at 27 randomly selected Vet Centers, 98% of those who had been employed at a Vet Center for at least a year had attended mandatory training for PTSD assessment and counseling through the Readjustment Counseling Service. Nearly half had also attended VHA-sponsored training for PTSD; 37% reported receiving supplemental training in cognitive behavioral therapy, and 12% and 5% reported receiving supplemental training in cognitive exposure therapy and PE, respectively (VA, 2011a).
The committee was asked in its charge to identify collaborative activities between the DoD and the VA with respect to the prevention, screening, diagnosis, and treatment of PTSD. Some of these efforts, such as the original development of the joint VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress in 2004 and updated in 2010 (VA and DoD, 2010), are required to be used by VA and DoD mental health providers. The VA and the DoD have also issued joint guidelines for other medical conditions that are frequently comorbid with PTSD, such as post-deployment health, concussion and mild traumatic brain injury, substance use disorder, major depressive disorder, and several types of pain.
Other collaborative efforts between the DoD and the VA include multiple joint executive councils, coordinating offices, working groups, and direct sharing agreements between VA medical centers and DoD medical facilities (VA and DoD, 2011). There have also been a number of conferences on military health issues sponsored and attended by staff from both departments. For example, the 2009 Report of (VA) Consensus Conference: Practice Recommendations for Treatment of Veterans with Comorbid TBI,
Pain, and PTSD was produced by participants from both the VA and the DCoE (VA and DCoE, 2009). In 2009, the National Institutes of Health (NIH), the DCoE, the VA, and other federal agencies held the Second Annual Trauma Spectrum Disorders Conference: A Scientific Conference on the Impact of Military Service on Families and Caregivers; it focused on the impact of trauma spectrum disorders on military and veteran families and caregivers across deployment, homecoming, and reintegration. Trauma spectrum disorder encompasses injury or illness that occurs as a result of combat or an unexpected traumatic event, and covers a broad range of psychological health and traumatic brain injury issues.
The VA and the DoD have recently released the VA/DoD Collaboration Guidebook to Healthcare Research (2011) as part of the VA/DoD Joint Strategic Plan for 2009–2011. Although this research guide is not PTSD-specific, both departments allocate millions of research dollars for PTSD research, and this guide is intended to help facilitate collaborations in human subject health care research between the two departments.
The DoD and the VA also collaborate to transition service members from active duty to the VA, as discussed in detail in the earlier section on transitioning in this chapter. VA facilities near military bases may assign VA staff at an MTF to facilitate the transfer of injured service members to VA care as they are discharged. VA personnel coordinate with DoD personnel to receive dates and locations of PDHRA administration and are present during the administration of the PDHRA to National Guard and reserve service members to inform them of eligibility for VA benefits and services.
There appear to be several other VA and DoD collaborative efforts, but these seem to focus on working groups, such as those that issue clinical practice guidelines, and hosting joint conferences. The committee asked the DoD and the VA to provide information on PTSD-related programs and services for screening, diagnosis, prevention, treatment, or rehabilitation, including information on eligibility, setting, treatments used, costs per participant, and outcomes to identify areas where there may be overlap or duplication. However, such a list was not provided by the DoD, and the RAND Corporation report on DoD psychological health programs (Weinick et al., 2011) does not include this level of detail. The committee hopes to have this information for phase 2. Given the lack of information on program specifics from the DoD for this Phase 1 report, the committee is unable to comment on issues such as collaboration or duplication of programs between the VA and the DoD. However, the committee is able to note that there is one program that is used by both the DoD, specifically the Navy and Marine Corps, and the VA. This program, FOCUS, is a family-centered program discussed earlier. Because the VA and the DoD service different populations, some duplication of programs is expected and
appropriate as it may help with continuity as service members, including National Guard and reservists, move from active duty to veteran status.
Numerous research efforts are under way in the DoD and the VA to develop a better understanding of all aspects of PTSD, including causes, treatments, prevention, barriers to care, and comorbidities. For example, since FY 1992, the DoD has funded numerous extramural and intramural health-related studies through the Office of the Congressionally Directed Medical Research Programs and through the service branches. (For a listing of PTSD research projects up through 2009 see the DoD Biomedical Research Database at http://brd.dtic.mil/). The studies cover various topics, including PTSD, and are of various types, such as experimental animal models, epidemiologic studies, studies of behavioral and cognitive therapies, and studies of resilience interventions. For example, the Air Force Research Laboratory is conducting a study to determine the role of genetic susceptibility in the development of PTSD.
Funding for congressionally directed PTSD-related studies has increased substantially in recent years. One research effort that has benefited the understanding of PTSD barriers is that of the MHATs (U.S. Army, 2012c). As previously discussed, these teams have been assembled and sent to Iraq since 2003 and to Afghanistan since 2007 to obtain information on symptoms of anxiety and depression, barriers to care (including stigma), symptoms of anxiety and depression, PTSD, and other mental health care issues (see Chapter 9 for more information on barriers identified through MHAT survey collections).
Several other PTSD research efforts are going on in the DoD. For example, the Center for the Study of Traumatic Stress, which was established in 1987, is part of the USUHS Department of Psychiatry and is partnering with DCoE. Its work was started to investigate the physical and psychologic effects of traumatic events. The work has since grown beyond service members to research on the impact of war, deployments, and injuries on children and families (Center for the Study of Traumatic Stress, 2012). The Army and the DoD have supported the work of the Walter Reed Army Institute of Research for over 100 years (U.S. Army, 2012d). The institute aims to be at the forefront of biomedical research, including deployment psychology and the psychologic impacts of the recent conflicts in Iraq and Afghanistan (Hoge et al., 2011). The Army has partnered with the National Institute of Mental Health (NIMH) to investigate risk and protective factors associated with service members’ mental health symptoms and illness (NIMH, 2011). Mental health research is also carried out in the U.S. Army
Medical Research and Material Command, which is headquartered at Fort Detrick, Maryland. Psychologic health research managed by the Medical Research and Material Command totaled $524 million in FY 2006–2011 (255 projects); 57% of that research ($297 million, 162 projects) pertained to PTSD, 21% ($110 million, 24 projects) pertained to suicide, and 10% ($53 million, 25 projects) pertained to resilience (Hoover, 2011).
The VA has a separate line-item appropriation for research and development. During FY 2010, the VA research and development budget was $581 million (OMB, 2010), which supported more than 2,000 studies at VA facilities (U.S. Congress, 2011). The research portfolio is broad—from preclinical studies that use animal models or human biologic specimens, to health services and translational research—and includes large cooperative studies. VA researchers collaborate closely with academic affiliates and also receive funding from sources outside VA, including the NIH, nonprofit associations, and industry. Many VA medical centers have established VA-affiliated nonprofit research foundations that facilitate collaboration and that leverage VA research funding.
A recent GAO report noted that during FY 2009, VA research funding for PTSD totaled $24.5 million (4.8% of the VA research budget, an increase from 2.5% in FY 2005) (GAO, 2011e). The funding supported 96 intramural research studies in PTSD. VA research funding ($6.6 million) for one of the largest randomized controlled trials of PE in female veterans has recently concluded. The study provided a foundation for the VA’s initiative to expand evidence-based treatment for PTSD throughout the system.
The VHA Office of Research and Development has focused its efforts on prevention and diagnosis of, and treatment for, PTSD using many approaches. Research related to psychotherapy has included virtual reality simulations and guided imagery, and on the basis of strong positive research findings, the VA has systematically adopted PE. Other research has focused on pharmacotherapy, determining the biologic basis of PTSD (by eliciting the role of stress-related hormones and examining functional brain images), and examining clinical and lifestyle factors that may increase or decrease a person’s risk of PTSD. Additional research initiatives include collaborating with the DoD to create a PTSD registry and developing and improving telehealth models to improve PTSD care, especially for veterans in rural areas (VA, 2010b).
With clinical-care appropriations, the VA funds 10 mental illness research, education, and clinical centers that are located throughout the system. The centers were established to research the causes and treatments of mental disorders and to apply new knowledge to the VA’s routine clinical practice. Four of the centers have at least a partial emphasis on PTSD and postdeployment issues, and all may conduct studies relevant to PTSD and its comorbidities. Two new VA PTSD centers of excellence focus on
TABLE 4-3 Current Clinical Trials on PTSD Funded by the DoD, the VA, and the NIH by Topic Areaa
|a This list reflects the number of studies that were found on Clinicaltrials.gov on April 4, 2012.
b Primary focus of study is not PTSD.
c This sum denotes the total number of studies identified on the website. Studies were classified under multiple categories, so the sum of studies for each organization may exceed the total.
coordinated care for veterans returning from OIF and OEF, including coordination of care for those who have PTSD. The VA’s strategic plans for PTSD research include increased cooperation with DoD, the NIMH, the Centers for Disease Control and Prevention, and the Substance Abuse and Mental Health Services Administration.
Clinical trials on PTSD that are sponsored by the DoD, the VA, and the NIH are shown in Table 4-3. The committee categorized these studies by topic area. The number of studies on the Clinicaltrials.gov website changes frequently as studies are funded, completed, or discontinued. As can be seen from the table, the VA funds about four times as many studies on PTSD as does the DoD. Most of the studies funded by the NIH might be considered basic research on PTSD.
It is difficult to estimate the costs of screening and treating for PTSD in DoD and VA settings. Screening for PTSD in civilian primary care settings is likely to be similar in cost to screening for depression, which cost $23 per patient in 2004 (National Business Group on Health, 2011). However, that is unlikely to reflect the costs of screening in VA or DoD settings because of differences in how care is organized and delivered. In addition to the cost of resources directly involved in screening (which
primarily involve caregiver time), false positive results increase the cost of screening by leading to further testing and inconvenience. For people who screen positive, adequate resources need to be in place to cover the costs of treatment. Finally, in addition to the direct benefits of treatment to people, screening and early intervention may lead to economic benefits in averting productivity loss associated with PTSD. Not factored into the cost projections are substantial administrative expenditures associated with managing and overseeing the screening and general and specialized mental health treatment programs.
To the committee’s knowledge, there have been only two studies of the costs associated with PTSD. The first, originally published in a RAND report (Eibner, 2008) and later updated by Kilmer et al. (2011), used a microsimulation model to estimate the burden of PTSD from a societal perspective. The second was a naval postgraduate school master of science thesis (Kwan and Tan, 2008) that used administrative data from MTFs and TRICARE to estimate costs of PTSD treatment.
In the RAND microsimulation model (Eibner, 2008; Kilmer et al., 2011), future costs of PTSD in a hypothetical group of simulated people were computed. The group was based on the 261,827 soldiers who were deployed as part of OEF or OIF on June 30, 2008, and their health care trajectories and costs were modeled over a 2-year period. As part of the simulation, the hypothetical people were allowed to experience comorbid conditions, health care treatments, and secondary outcomes, such as unemployment. An advantage of that approach is that PTSD could be treated as a chronic condition with episodes of remission and relapse. Probabilities associated with the course of disease (for example, receipt of evidence-based treatment, remission, and relapse) were based on published studies. Costs of health care services were based on published TRICARE and Medicare reimbursement rates, and pharmaceutical costs were based on average wholesale prices. Costs of secondary outcomes, such as unemployment and suicide, were gathered from published studies. The studies estimated that costs associated with PTSD for service members returning from Iraq and Afghanistan ranged from $708 million to $1.2 billion, which translated into a cost per patient of $5,904–$10,298 in the 2 years after discharge from the military. The majority of the costs were due to productivity loss, which accounted for 55.3–94.5% of total costs (Eibner, 2008). Only 4% of the cost was attributable to treatment (Kilmer et al., 2011).
The Kwan and Tan study (2008) took a different approach, using administrative data from FY 2001–2006 to estimate costs from the perspective of the military health care system of treatment for PTSD. The analyses examined officers and enlisted personnel separately and estimated costs by branch of service. Overall, the authors found that costs varied considerably by location of care (MTF versus TRICARE) and branch of service. Among
officers, inpatient costs per patient ranged from $7,027 to $12,954 for PTSD treatment among the four military services, outpatient costs from $1,812 to $3,514, and pharmacy costs from $125 to $238. TRICARE inpatient costs ranged from $2,917 to $28,986, and outpatient costs from $976 to $1,106; no pharmacy costs under TRICARE were reported. Costs among enlisted personnel were similar, ranging from $10,723 to $12,954 for inpatient care in an MTF and from $684 to $1,130 for outpatient care received from TRICARE providers. It was not clear whether these were annual costs or costs over the entire study period (FY 2001–2006). Another limitation was the small sample sizes for some types of care in some of the services and outliers, which can have a considerable effect on the mean. For example, only two people who served in the Marine Corps received inpatient services from a TRICARE provider.
In addition to those published studies, there are some data from the VA on the costs of specialized PTSD programs, which treat about 25% of veterans who have PTSD. In FY 2010, the VA spent $112,460,032 on specialized outpatient PTSD programs that served 105,531 veterans, for an average cost of $1,066 per veteran. Veterans averaged 10.2 visits per year in those programs, for a cost of $105 per visit (NEPEC, 2012b). The VA also spent $42,716,581 on specialized intensive PTSD programs in FY 2010 (NEPEC, 2012c); the 5,128 admissions during the year cost an average of $8,330. Cost data on PTSD services delivered outside the specialized programs have not been reported (NEPEC, 2012c).
Thus, it is difficult to monetize the costs of PTSD treatment. Although the microsimulation model estimated societal costs associated with PTSD, few details were given about the costs of treatment. The Kwan and Tan study also lacked the detail needed for a thorough assessment of PTSD treatment costs. Although some data are available from the VA, they are limited to specialized programs, which treat a minority of PTSD patients. Finally, no data on costs of PTSD services have been reported by the DoD.
The DoD and the VA have played an active and pivotal role in the prevention of, screening for, diagnosis of, and treatment for PTSD. This chapter has sought to describe what is known about mental health care, specifically care for PTSD, in the DoD and the VA. Both organizations have contributed much time, funding, and effort to PTSD health care and research. The foundational information provided in this chapter has set the stage for further discussion of PTSD prevention and prophylaxis, screening, diagnosis, treatment, co-occurring medical conditions and psychosocial complexities, and barriers to, facilitators of, and access to care.
In phase 2 of this study, the committee will gather data from the DoD
and the VA and from visits to bases and medical centers to gain a better understanding of the success of different PTSD services and programs. The committee will also take a deeper look at costs associated with treatment and rehabilitation for PTSD.
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