Posttraumatic stress disorder (PTSD) is one of the signature injuries of the U.S. conflicts in Afghanistan and Iraq, but it affects veterans of all eras. It is estimated that 7–20% of service members and veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) may have the disorder. PTSD is characterized by a combination of mental health symptoms—reexperiencing of a traumatic event, avoidance of trauma-associated stimuli, adverse alterations in thoughts and mood, and hyperarousal—that last at least 1 month and impair functioning.
PTSD can be lifelong and pervade all aspects of a service member’s or veteran’s life, including mental and physical health, family and social relationships, and employment. It is often concurrent with other health problems, such as depression, traumatic brain injury (TBI), chronic pain, substance use disorder, and intimate partner violence.
COMMITTEE’S STATEMENT OF TASK AND APPROACH
The Department of Defense (DoD) and the Department of Veterans Affairs (VA) provide a spectrum of programs and services to screen for, diagnose, treat for, and rehabilitate service members and veterans who have or are at risk for PTSD. The 2010 National Defense Authorization Act asked the Institute of Medicine (IOM) to assess those PTSD programs and services in two phases. The committee’s statement of task is in Box S-1. In phase 1, the committee requested extensive data from DoD and VA on their PTSD programs and services; in addition, it looked at collaborative efforts of the two departments; provided a scientific overview of the neurobiology
BOX S-1
Statement of Taska
The Institute of Medicine will convene a committee to conduct a study of ongoing efforts in the treatment of PTSD. The study will be conducted in two phases: the focus in phase 1 will be on data gathering and will result in the initial study as noted in the congressional legislation; the focus in phase 2 will be on the analysis of data and result in the updated study. The work of the committee is dependent upon the timely delivery of data, in a usable format, from the DoD and the VA on their current PTSD programs.
Phase 1 (initial report):
In phase 1 of the study, the committee will collect data from the Department of Defense (DoD) and the Department of Veterans Affairs (VA) on programs and methods available for the prevention, screening, diagnosis, treatment, and rehabilitation of post-traumatic stress disorder. The committee will highlight collaborative efforts between DoD and the VA in those areas. Additionally, the committee will consider the status of studies and clinical trials involving innovative treatments of post-traumatic stress disorder that are conducted by the DoD, the VA, or the private sector.
Phase 2 (updated report):
In phase 2 of the study, the committee will analyze the data received in phase 1 specifically to determine the rates of success for each program or method; and an estimate of the number of members of the Armed Forces and veterans diagnosed by the DoD or the VA as having post-traumatic stress disorder and the number of such veterans who have been successfully treated.
In addition, the committee will focus on targeted interventions at Fort Hood, TX; Fort Bliss, TX; Fort Campbell, TN; and any other locations the committee deems necessary, including VA facilities. The committee will also examine gender-specific and racial and ethnic group-specific mental health treatment services available for members of the Armed Forces, including: the availability of such treatment and services; the access to such treatment and services; the need for such treatment and services; and the efficacy and adequacy of such treatment and services.
Finally, the committee will examine the current and projected future annual expenditures by the DoD and the VA for the treatment and rehabilitation of PTSD; and provide recommendations for areas for future research with respect to posttraumatic stress disorder.
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a This is an abridged version. The full Statement of Task is found in Chapter 1.
of PTSD; assessed the evidence base on PTSD prevention and treatment approaches, including both evidence-based treatments and complementary and alternative therapies; and described barriers to accessing PTSD services in the departments. The phase 1 report was published in June 2012.
In phase 2, the committee considers what a successful PTSD management system is and whether and how such a system is being implemented in each department. This includes an assessment of what care is given and to whom, how effectiveness is measured, what types of mental health care providers are available, what influences whether a service member or veteran seeks care, and what are the costs associated with that care. The committee was also tasked with assessing PTSD-related research efforts that are being undertaken by DoD, VA, and other organizations, including the National Institutes of Health. To address these tasks, further requests for data were made of DoD and VA, database and literature searches were conducted, and nine military medical facilities and six VA medical facilities were visited.
PREVALENCE OF PTSD IN MILITARY AND VETERAN POPULATIONS
Symptoms of PTSD may occur soon after exposure to a traumatic event or be delayed, sometimes for years. Many people will never have all the symptoms or the right combination of them to meet the criteria for a full diagnosis of PTSD but may suffer with many symptoms nonetheless.
Since October 2001, more than 2.6 million U.S. military personnel have been deployed to Afghanistan in support of OEF and to Iraq in support of OIF and Operation New Dawn. Increased exposure to combat-related trauma is associated with an increased risk for PTSD. The proportion of service members who have PTSD has increased dramatically since the beginning of those conflicts, from less than 1% in 2004 to more than 5% in 2012. In 2012, 13.5% of soldiers had a diagnosis of PTSD, as did 10% of marines, 4.5% of Navy personnel, and 4% of Air Force personnel. More military women than men had a diagnosis of PTSD (13% vs 9%), as did more nonwhites than whites (11% vs 8.5%).
In 2012, about 502,000 veterans made at least two visits to VA for PTSD outpatient care; they make up 9% of all users of VA health care services, up from 4% in 2002. Of veterans entering specialized outpatient PTSD programs (SOPPs) in 2012, 47% were OEF and OIF era, 20% were 1990–1991 Gulf War era, and 34% were Vietnam era. As in the case of service members, more female veterans than male veterans had a diagnosis of PTSD in 2013 (29.4% vs 24.5%). In 2012, 23.6% (119,500) of all OEF and OIF veterans who used VA health care services had a diagnosis of PTSD.
PTSD PROGRAMS AND SERVICES
Department of Defense
In DoD, PTSD management programs and services are implemented by the individual service branches and by the Defense Health Agency through its management of the TRICARE contract programs. Each service branch has developed and implemented training, services, and programs intended to foster mental resilience, preserve mission readiness, and mitigate adverse consequences of exposure to stress, although none of these resilience or prevention programs is PTSD-specific.
DoD screens all deployed service members for symptoms of PTSD at 30 days and again at 3–6 months after return from deployment. On the basis of the screening results, service members may be referred for further evaluation and, if appropriate, treatment.
Most psychotherapy or pharmacotherapy treatments for PTSD in DoD are provided on an outpatient basis and occur in general mental health clinics, primary care settings, or specialized PTSD programs. All service branches are embedding mental health care providers in primary care clinics to reduce barriers to care. Some military installations also have intensive outpatient PTSD treatment programs that not only offer evidence-based treatments (psychotherapy and pharmacotherapy) but include complementary therapies, such as acupuncture, art therapy, and biofeedback. DoD also offers inpatient PTSD treatment programs, but these are not as widely available. Outcome data on which to determine the effectiveness of these programs in either the short term or the long term are not available. One exception to this lack of data is the National Intrepid Center of Excellence, which has some limited, short-term outcome data on service members with severe PTSD and TBI.
Department of Veterans Affairs
The VA health care system offers a full array of treatment services for PTSD, including face-to-face mental health screening and assessment, psychotherapy (individual and group), pharmacotherapy, and adjunct services, such as employment counseling. VA uses its Uniform Mental Health Services in VA Medical Centers and Clinics handbook to specify the minimum clinical services that must be provided at each VA medical center and community-based outpatient clinic (CBOC). VA requires annual screening for PTSD for the first 5 years of care. It also requires that two evidence-based PTSD treatments—prolonged exposure (PE) therapy and cognitive processing therapy (CPT)—be available to all veterans who need them.
Other evidence-based and complementary therapies, as adjunctive treatments, are also offered in many medical centers.
In 2012, 29% of veterans who had a diagnosis of PTSD were seen in one of 127 SOPPs, and about 1% were seen in one of 39 specialized intensive PTSD programs (SIPPs); other veterans who have PTSD were seen in general mental health or primary care clinics. Some veterans may seek readjustment counseling in VA Vet Centers. In 2012, 216,090 OEF and OIF veterans who had PTSD were seen only in a VA medical center, 24,136 were seen only in a Vet Center, and 45,908 received care in both kinds of facilities. No treatment outcome data are collected in any general mental health clinic, Vet Center, or SOPP. Outcome data are collected for the SIPPs but suggest that there are only modest improvements in PTSD symptoms after treatment in these programs. VA is modifying the electronic health record system to capture the psychotherapy that each patient receives in addition to the record already captures pharmacotherapy data.
FINDINGS AND RECOMMENDATIONS
PTSD Management Strategies
PTSD management in DoD appears to be local, ad hoc, incremental, and crisis-driven with little planning devoted to the development of a long-range, population-based approach for the disorder by either the Office of the Assistant Secretary of Defense for Health Affairs or any of the service branches. Each service branch has established its own prevention programs, trains its own mental health staff, and has its own programs and services for PTSD treatment.
VA has a more unified organizational structure than DoD and, therefore, is able to ensure a more consistent approach to the management of PTSD in its medical facilities. Its strategic plans (2011–2015 and 2016–2020) include improving the quality and accessibility of mental health care, in part, by increasing capacity and outreach to veterans and their families and expanding care for both new and aging veterans. However, there are few data to indicate that PTSD-related performance measures are being met. Although improving mental health is one of VA’s 16 major initiatives in the strategic plan, highlighting improved PTSD care as a specific major initiative might help to focus attention on the needs of the growing population of veterans, including women, who have PTSD.
Although the DoD and VA are coordinating strategic efforts such as the DoD/VA Integrated Mental Health Strategy and the National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families, these activities have not proven to
be sufficient to determine whether PTSD management is improving or that a population-based approach is being used to reach and treat all service members and veterans in need of care for PTSD. Furthermore, current DoD and VA strategic efforts do not necessarily encourage the use of best practices for preventing, screening for, diagnosing, and treating for PTSD and its comorbidities, and they do not extend to ensuring continuity of care as service members transition from active duty to veteran status.
Recommendation A: DoD and VA should develop an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veterans, and their families, including female veterans and minority group members.
Leadership and Communication
Many military installations and VA medical facilities have engaged leaders who are actively working to encourage the use of best practices for PTSD. The installations and medical centers that had the most coordinated PTSD treatment and the most options for their patients appeared to be the ones that have strong, effective, and knowledgeable leaders and good communication among leaders, providers, and support staff.
In DoD and each service branch, leaders at all levels of the chain of command are not consistently held accountable for implementing policies and programs to manage PTSD effectively, including those aimed at reducing stigma and overcoming barriers to accessing care. In each service branch, there is no overarching authority to establish and enforce policies for the entire spectrum of PTSD management activities. A lack of communication among mental health leaders and clinicians in DoD can lead to the use of redundant, expensive, and perhaps ineffective programs and services while other programs, may be more effective, languish or disappear.
VA leadership engagement in PTSD management varies among sites, resulting in different types and quality of PTSD programs and services. Although the VA central office has established policies on minimum care requirements and guidance on PTSD treatment, it is unclear whether VA leaders adhere to the policies, encourage staff to follow the guidance, or use the limited outcome data available from the SIPPs to improve PTSD management.
DoD and VA leaders at the national and local levels set the priorities for PTSD care for their respective organizations. Authority, responsibility, and accountability for PTSD management need to begin at the central office level—at the level of the assistant secretary of defense for health affairs and the VA under secretary for health—and extend down to facility leaders and unit leaders. Leadership accountability can help ensure that information on
PTSD programs and services is collected and that their success is measured and reported. Effective leadership extends to supporting innovation in new processes and approaches for treatment for PTSD.
Recommendation B: DoD and VA leaders, who are accountable for the delivery of high-quality health care for their populations, should communicate a clear mandate through their chain of command that PTSD management, using best practices, has high priority.
Performance Measurement
DoD and VA do not collect data to identify best practices throughout the spectrum of their PTSD programs and services, although there are some initiatives to do so. Given that DoD and VA are responsible for serving millions of service members, families, and veterans, it is surprising that no PTSD outcome measures of any type for psychotherapy or pharmacotherapy are consistently used or tracked in the short or long term (with the exception of the VA SIPPs). Without tracking outcomes, neither department knows whether it is providing effective, appropriate, or adequate care for PTSD. Reliable and valid self-report measures are available and could be used to monitor progress, provide real-time response information to providers and patients, and guide modifications of individual treatment plans. For example, DoD is moving toward the use of a measurement-based PTSD management system through the use of the Behavioral Health Data Portal, but it has yet to be fully implemented throughout the service branches.
VA is also in the process of expanding its electronic health record to capture the types of psychotherapy that veterans are receiving, but the revised record still will not include regularly administered outcome measures. Although VA has been collecting data on its SOPPs and SIPPs for many years and publishes the compiled data in an annual internal publication, useful outcome data are scarce and available only for SIPPs. Furthermore, most veterans who have PTSD do not receive care in VA specialized PTSD programs, so their treatments and outcomes are unknown.
To better assess the success of their PTSD programs and services, DoD and VA should have a performance management system that includes
- The use of standard metrics to screen for, measure, and track PTSD symptoms and outcomes throughout DoD and VA. The departments should work with the National Quality Forum to endorse consensus performance measures for both clinical measures and quality indicators.
- Health information technology that documents a patient’s PTSD treatments and progress such that the data can be aggregated at the provider, program, facility, service, regional, and national levels.
- Performance measures to inform and improve the system via integrated feedback loops, which should be used by leaders at all levels to evaluate and improve PTSD management.
Recommendation C: DoD and VA should develop, coordinate, and implement a measurement-based PTSD management system that documents patients’ progress over the course of treatment and long-term follow-up with standardized and validated instruments.
Workforce and Access to Care
DoD and VA have substantially increased their mental health staffing—both direct care and purchased care. However, staffing increases do not appear to have kept pace with the demand for PTSD services, including specialized programs. DoD and VA acknowledge that it can be difficult to hire and retain staff in underserved areas in spite of targeted efforts to do so.
Staffing shortages can result in clinicians’ not having sufficient time to provide evidence-based psychotherapies readily and with fidelity to the treatment protocols. The lack of time to deliver psychotherapy with fidelity is reflected in the fact that in 2013 only 53% of OEF and OIF veterans who had a primary diagnosis of PTSD and sought care in the VA received the recommended eight sessions within 14 weeks. Provision of evidence-based treatments also implies refraining from providing services or programs that lack an evidence base or whose evidence base has been deemed ineffective by recent research. The size of the VA and DoD workforces will be influenced by how efficiently and effectively staff use their time to deliver the most effective assessments and treatments. Although expanding the number of staff to meet needs may be necessary, it may also be possible to achieve equal or better results with more efficient use of existing staff and by having existing staff use the most effective programs and services.
Neither department appears to have formal procedures for evaluating the qualifications of purchased care providers, mechanisms to determine the best purchased care provider for an individual patient, or a requirement that those providers give referring providers updates on patients’ progress. Having standards, procedures, and requirements for direct care and purchased care providers will help to ensure that they are trained in evidence-based treatments that are consistent with VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress, understand military culture, continuously measure patients’ progress, and, in the case of purchased care providers, coordinate with patients’ DoD or VA refer-
ring providers regularly. DoD and VA have expanded training in evidence-based psychotherapies, particularly PE and CPT, for all mental health staff. However, this training is not required for purchased care providers in either department. VA is working to coordinate and standardize the use of purchased care providers through the Patient-Centered Community Care initiative, which will require that these providers be screened to ensure that they meet or exceed VA standards for credentialing, licensing, and specialty care requirements and that they share patient records with VA providers. DoD does not appear to have a similar mechanism for ensuring that its purchased care providers are trained in and using evidence-based treatments.
Recommendation D: DoD and VA should have available an adequate workforce of mental health care providers—both direct care and purchased care—and ancillary staff to meet the growing demand for PTSD services. DoD and VA should develop and implement clear training standards, referral procedures, and patient monitoring and reporting requirements for all their mental health care providers. Resources need to be available to facilitate access to mental health programs and services.
Evidence-Based Treatment
DoD and VA have expended considerable effort to develop, update, and disseminate the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. The guideline provides algorithms for choosing an evidence-based treatment for PTSD, addresses comorbidities, describes approaches for engaging patients in treatment, and discusses the evidence on first-line and other psychotherapies and pharmacotherapies.
However, mental health care providers in both departments do not consistently provide evidence-based treatment in spite of policies that require that all service members and veterans who have PTSD receive first-line treatments, such as CPT and PE. It is unclear what PTSD therapies most service members or veterans receive in any treatment setting and whether their symptoms improve as a result. DoD and VA are also integrating complementary and alternative therapies into some of their specialized PTSD programs, but the interventions need to be studied to establish their evidence base and to ensure that their use does not deter patients from receiving first-line, evidence-based treatments.
DoD and VA are exploring approaches to deliver treatment more expeditiously, including the use of technological applications that extend the reach of clinical care and service delivery, such as virtual reality, videoconferencing, patient avatars, and mobile applications for patients and providers. The use of telehealth may improve access to care for service members
and veterans, but pilot programs and studies need to be conducted to support their effectiveness and optimal use.
Recommendation E: Both DoD and VA should use evidence-based treatments as the treatment of choice for PTSD, and these treatments should be delivered with fidelity to their established protocols. As innovative programs and services are developed and piloted, they should include an evaluation process to establish the evidence base on their efficacy and effectiveness.
Central Database of Programs and Services
DoD does not have a central database of PTSD programs and services that are available throughout the service branches. Without such a database, it is impossible to compare programs and services, to identify the ones that are effective and use best practices, and to recognize the ones that need improvement or should be eliminated.
Although the VA prepares an annual report on its specialized PTSD programs, that report does not include all PTSD treatment settings, such as general mental health clinics and women’s health clinics. Furthermore, the report does not contain any descriptive information on program elements and does not appear to be widely used. Most of the specialized PTSD programs in the service branches and VA medical facilities were developed and implemented locally. As a result, clinicians and other mental health care providers have no resource that provides information on programs (for example, type, location, admission criteria, and treatment modalities) to which they might refer service members who need specialized PTSD care, or that might serve as models for new programs at their facility.
All stakeholders, including families and direct and purchased care providers, would benefit from ready access to a routinely updated database in which programs are described and evaluated according to standardized measures. Existing resources, such as the National Center for PTSD, could be leveraged to develop more comprehensive information about VA-wide PTSD programs and services (not just specialized ones) and, in a collaborative effort, include those of DoD.
Recommendation F: DoD and VA should establish a central database or other directory for programs and services that are available to service members and veterans who have PTSD.
Family Involvement
DoD has a variety of resources to assist service members and their families and others in learning about PTSD, its diagnosis and treatment, and its impact on family and friends. Many support services are available to service members and their family members in military installations and personnel in those programs and services are trained to recognize early symptoms of PTSD, provide nonclinical supportive care, and refer service members and their families to appropriate professional care.
VA also has resources for families of veterans who have PTSD, such as the National Center for PTSD. Some veterans have expressed their interest in and preference for having their partners involved in their PTSD treatment and the need for support groups for those partners. However, there is no formal VA-wide program for engaging family members in the veterans’ treatments, for providing psychoeducation in a facility, or for establishing support groups for family members. In several VA mental health programs, veterans who have PTSD and their partners and children receive couple or family therapy from professional clinicians. VA, including Vet Centers, provides peer counselors and peer support groups that help to engage veterans in treatment, reduce stigma, and promote empathy, but data on the number of veterans who seek treatment as a result of peer counseling or who participate in support groups are not available. Vet Centers also provide counseling services for family members.
Recommendation G: DoD and VA should increase engagement of family members in the PTSD management process for service members and veterans.
Research Priorities
There can be substantial barriers to conducting PTSD research within and between DoD and VA and in collaboration with academic and government organizations, and private partners. To date, there does not appear to have been a systematic effort by either department to identify those barriers and mechanisms to overcome them. Nevertheless, DoD and VA are funding broad PTSD research portfolios and are working collaboratively with the National Institutes of Health and other organizations to fill research gaps (for example, developing the joint National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families for improving access to mental-health services), but much work remains to be done. The committee identified the following as major foci of future PTSD-related research:
- Increasing knowledge of how to overcome barriers to implementation, dissemination, and use of evidence-based treatments to improve their accessibility, availability, and acceptability for patients and their families.
- Increasing understanding of basic biological, physiological, psychological, and psychosocial processes that lead to the development of more and better treatments for PTSD.
- Developing markers to identify better approaches for PTSD prevention, diagnosis, and treatment.
- Understanding the heterogeneity of PTSD presentations and predicting responses to treatment for them in different populations and at different times in the course of the disorder.
- Preventing the development of PTSD before and after trauma exposure.
- Developing and rigorously assessing new interventions and delivery methods (pharmacological, psychological, somatic, technological, and psychosocial) for both PTSD and comorbidities.
- Identifying effective care models, establishing evidence-based practice competences, and developing methods to enhance effective training in and implementation and dissemination of them.
Recommendation H: PTSD research priorities in DoD and VA should reflect the current and future needs of service members, veterans, and their families. Both departments should continue to develop and implement a comprehensive plan to promote a collaborative, prospective PTSD research agenda.
DoD and VA are spending substantial time, money, and effort on the management of PTSD in service members and veterans. Those efforts have resulted in a variety of programs and services for the prevention and diagnosis of, treatment for, rehabilitation of, and research on PTSD and its comorbidities. Nevertheless, neither department knows with certainty whether those many programs and services are actually successful in reducing the prevalence of PTSD in service members or veterans and in improving their lives.
