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Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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10

Findings and Recommendations

Posttraumatic stress disorder (PTSD) has entered the national consciousness as one of the signature injuries of the conflicts in Afghanistan and Iraq. Almost daily newspaper accounts document the travails faced by service members and veterans as they attempt to deal with the nightmares, flashbacks, and isolation that PTSD can cause. Although many service members and veterans seek help for their symptoms, many do not, because they do not believe that they have a problem, they do not see their symptoms as something that can be treated, or they are reluctant to be labeled as having a mental health problem. It is clear that the number of service members and veterans who have symptoms of PTSD and the number in the subset who seek treatment in the Department of Defense (DoD) military health system and the Department of Veterans Affairs (VA) health care system have dramatically increased since the start of the conflicts in Afghanistan and Iraq. DoD and VA each have a responsibility to provide the best possible care for PTSD and to reach out to all who might need and benefit from it.

In its phase 1 report, the committee offered five overarching recommendations and seven more detailed recommendations for improving DoD and VA programs, services, and facilities for the prevention and diagnosis of and treatment for PTSD (see Chapter 1). The committee continues to believe that those recommendations are appropriate and supported by this phase 2 report and that their implementation would result in improvements in the PTSD management systems in both departments.

In the following sections, the committee presents its findings and recommendations, which build on those in its phase 1 report. The recommen-

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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dations in this report are informed by the committee’s fact-finding efforts conducted during both phases of the study.

FINDINGS AND RECOMMENDATIONS

PTSD Management Strategies

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.

The departments should coordinate their strategies and activities to encourage the use of best practices for preventing, screening for, diagnosing, and treating for PTSD and its comorbidities. The coordination should extend to ensuring continuity of care as service members transition from active duty to veteran status. This strategy should embrace a population-based approach to PTSD and be applicable to all service members and eligible veterans in a catchment area, not only those now receiving treatment in DoD and VA facilities.

Through its review, the committee found that 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 this disorder by either the Office of the Assistant Secretary of Defense for Health Affairs [OASD(HA)] 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. The under secretary of defense for personnel and readiness and the assistant secretary of defense for health affairs (ASD[HA]) have not developed a comprehensive plan for mental health generally or PTSD specifically. Although the ASD(HA) has issued some directives and instructions that apply to all service branches, implementation typically is at the discretion of each service branch’s surgeon general, installation commander, or even military treatment facility (MTF) leaders. The committee recognizes that, in part, such stovepiping of responsibility is inherent in the organizational structure of DoD and serves a purpose, given the different mission and culture of each service branch, but these differences do not preclude a more systematic and integrated approach to PTSD management. Standardization and consistency of PTSD programs and services among facilities and service branches are not evident, and they often appear to have been developed and sustained at the local level without coordination with similar programs on other installations. Although the Defense Centers of Excel-

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

lence for Psychological Health and Traumatic Brain Injury should have a major role in cataloging and coordinating PTSD programs and services and in developing a comprehensive strategy for PTSD management among the service branches and at the OASD(HA), this has not been the case, and its effect on PTSD management in DoD appears to be minor.

The committee found that VA has a more unified organizational structure than DoD and is able to ensure a more consistent approach to PTSD management among all the veterans integrated service networks (VISNs) and down to the medical center level. VA uses its Uniform Mental Health Services in VA Medical Centers and Clinics handbook as a strategy document, but the handbook contains primarily program-specific requirements. The handbook does not address the need for new or expanded programs, such as those for female veterans.

VA does have 5-year strategic plans (2011–2015 and 2014–2020) to improve the quality and accessibility of its health care, and specifically mental health, in part by increasing capacity and outreach to veterans and their families and expanding care for both new and aging veterans. There are few data, however, to indicate that the five performance measures for mental health in the 2011–2015 plan are being met 4 years into the plan. 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 increase the visibility of this high-priority disorder and help to focus attention on the growing population of veterans who have it.

DoD and VA have been working together to improve integration and coordination of their mental health efforts, but much work remains to be done. One result of this collaboration is the 2011 DoD/VA Integrated Mental Health Strategy (IMHS), which has four strategic goals and 28 strategic actions; the latter include operating plans and performance metrics. Addressing these goals and actions may alleviate some of the communication and coordination issues between the departments. Although the IMHS was developed to provide a comprehensive public health approach to mental health management in DoD and VA, it is not PTSD-specific and the committee found little information and no formal reports on the status of the strategy’s implementation.

DoD, VA, and other federal departments are also coordinating and collaborating on such other efforts as the National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families. The plan, discussed in Chapter 9, focuses on enhancing scientific research on mental health, fostering effective treatments, and reducing the incidence and prevalence of PTSD and other mental health disorders. Other coordinated activities include the development and updating of the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress and locating VA liaisons on military installations to

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

assist service members as they transition from active-duty to veteran status. The committee acknowledges those efforts but finds that they fall short of an integrated, coordinated, and collaborative approach to PTSD management. The committee expects that the development and implementation of a DoD and VA comprehensive strategy for PTSD management will need to begin with and be sustained by the highest administrative levels in each department.

Leadership and Communication

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.

DoD and VA leaders set the priorities for PTSD care. If it does not have high priority for executive leadership, it will not have high priority for DoD and VA line staff. Authority, responsibility, and accountability for PTSD management should begin at the central office level (that is, at least at the level of the DoD ASD(HA) and the VA under secretary for health) and extend down to facility leaders and unit leaders. Only if local leaders are empowered can effective change occur, but the organizational environment embodied by executive leaders needs to encourage and reward such change. Leaders also should be responsible for all service members or eligible veterans in their catchment areas, not only those who are receiving treatment for PTSD in their facilities.

In DoD, and in each service branch, unit commanders and leaders at all levels of the chain of command are not consistently held accountable for implementing policies and programs to manage PTSD effectively. Furthermore, in each service branch, there is no overarching authority to establish and enforce policies for the entire spectrum of PTSD management activities (prevention, screening, treatment, and rehabilitation). Instead, prevention programs belong to the under secretary of defense for manpower and readiness. Mental health care belongs to medical commands under the office of the surgeon general in each service branch or the ASD(HA). Despite the recent creation of the Defense Health Agency to consolidate responsibility for health care, prevention programs remain under a different line of authority.

Leadership accountability encompasses both personnel and responsibilities. For example, in VA, leadership accountability includes the actions of PTSD program managers, directors of mental health departments, and facility, VISN, and central office leaders. In this capacity, leaders are responsible for diverse activities—from plans for managing the comorbidities of

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

aging veterans who have PTSD to establishing and maintaining standards of care from purchased care providers, using outcome data to improve care, and ensuring that PTSD management is population based.

The committee found that lack of communication among mental health leaders and clinicians in DoD and VA can lead to duplicative, expensive, ad hoc, and perhaps ineffective programs and services while other programs, that may be effective, languish or disappear. Variability in leadership engagement in PTSD management in both DoD and VA can result in similar variability in the types and quality of the PTSD programs and services that are available to service members and veterans. The committee found in its site visits that 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 had strong leadership and excellent communication among providers and support staff.

Finally, effective leadership extends to supporting innovation in processes and approaches to treatment for PTSD. Results of such innovations should be measured and evaluated. Leaders (and their staffs) should not be penalized if well-designed and well-executed programs, services, and processes are not successful; however, if they are successful, leaders should be responsible for disseminating them.

Performance Measurement

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.

The system should collect data to identify best practices along the spectrum of DoD and VA PTSD programs and services. Elements of this management system include:

  • Use of standard metrics to screen for, measure, and track PTSD symptoms and outcomes throughout DoD and VA. The departments together should work with the National Quality Forum to endorse consensus clinical measures and quality indicators.
  • Health information technology that documents all the PTSD treatments that a patient receives and his or her progress in such a way that collected data are available in real time to the provider and can be aggregated at the provider (whether direct care or purchased care provider), program, facility, service, regional, and national levels.
Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×
  • Performance measures to inform and improve the system via integrated feedback loops, which should be used by leaders at the local level (installation, MTF, medical center or community-based outpatient clinic [CBOC]), the regional level (service branch or VISN), and the national level (DoD and VA) to evaluate and improve PTSD management continuously.

Given that DoD and VA are responsible for serving millions of service members, families, and veterans, the committee found it surprising that no PTSD outcome measures of any type are consistently used or tracked in the short or long term (with the exception in the specialized intensive PTSD programs [SIPPs] in VA). That is even more problematic inasmuch as both departments have expanded their provider workforce, begun to give priority to patient-centered and evidence-based treatments, and expanded access to care by using telehealth and other approaches. Without tracking outcomes, however, neither department will be able to ascertain the value of those actions or whether they are effective in providing appropriate or adequate care for PTSD. Furthermore, neither department currently uses continuous measurements of patient progress to guide and manage patient treatment. Reliable and valid self-report measures, such as the PTSD Checklist (PCL), are available and could be used to monitor patient progress, provide real-time response information to clinicians and patients, and guide modifications of individual treatment plans.

DoD is moving toward the use of a measurement-based PTSD management system, but progress has been slow, and implementation throughout the service branches is incomplete. The Army has developed and rolled out its Behavioral Health Data Portal (BHDP) in its MTFs, and the Air Force and Navy will also be using the portal to standardize data collection. One advantage of the BHDP is that service members will complete a PTSD assessment before each mental health appointment, and their responses will be available to their clinician during their appointments. The BHDP will provide real-time and aggregate data to clinicians and leaders; however, the system is in its infancy and no information on outcomes or provider and patient satisfaction has been reported. Moreover, no outcome data are available for any of the DoD specialized PTSD programs with the exception of a small amount of short-term outcome data from the National Intrepid Center of Excellence, which treats service members who have severe PTSD and traumatic brain injury.

VA is also expanding the PTSD treatment data that are captured in veterans’ electronic health records. It is modifying the records so that clinicians are able to enter the types of psychotherapy that patients are receiving, but the committee is aware of no plans to include regularly administered outcome measures, such as PCL scores. The committee notes that through-

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

out the almost 4 years of its deliberations, implementation of the revised electronic health record system was reported by VA to be imminent but it had not occurred at the time of this report’s publication. Although the committee was not asked to review or comment on the funding available for the technological improvements suggested in this recommendation, it recognizes that the costs of integrating, or even modifying, the DoD and the VA electronic health records are substantial. Both the President and Congress need to be aware of those costs as DoD and VA move forward with their efforts to manage PTSD. An integrated, comprehensive strategy promulgated by senior DoD and VA leaders regarding institutional priorities would help to address such issues.

Vet Center providers do not enter information to a veteran’s electronic health records, although some providers are able to see sections of the veteran’s VA record. The committee does not specifically include Vet Centers in this recommendation, but it hopes that this issue will be discussed by VA (with input from veterans) because approximately 46,000 veterans who have PTSD receive care in both a Vet Center and a VA medical facility.

VA has been collecting information on its specialized outpatient PTSD programs (SOPPs) and SIPPs for many years and compiles the data in its annual internal publication The Long Journey Home. Outcome data (such as PCL scores) are collected before and 4 months after treatment only for veterans in a SIPP, and it appears that on the basis of those data, many of the patients in those programs show little improvement after treatment. The committee does not endorse the continued use of these specialized programs without additional data on their effectiveness and sees no reason why such outcome data should not be collected.

Finally, most veterans who have PTSD receive care in generalized mental health clinic or primary care clinics. Data are lacking on how many of those patients receive the recommended course of an evidence-based treatment; whether patients can choose a preferred evidence-based treatment; whether the treatments are effective in the long term; or whether there are benefits to using other treatments, such as complementary and alternative therapies. That lack of information raises concerns inasmuch as VA reported that in 2013 only 53% of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans who had a primary diagnosis of PTSD received at least eight psychotherapy sessions within a 14-week period—far short of the target of 67%.

Workforce and Access to Care

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

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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 provide the necessary infrastructure to facilitate access to mental health programs and services.

Such standards, procedures, and requirements will help to ensure that providers are trained in evidence-based treatments that are consistent with the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress understand military culture, measure the progress of patients on a continuing basis, and, in the case of purchased care providers, coordinate with patients’ DoD or VA referring providers regularly. DoD and VA should establish procedures, based on clinical status and patient preference, for referring patients to the most appropriate available purchased care providers. Activities to bolster the current mental health workforce might include:

  • Providing sufficient mentoring and supervision to trained staff to ensure that evidence-based treatments are delivered with fidelity to their manuals.
  • Evaluating and improving incentives for recruiting and retaining mental health care workers—both direct care and purchased care providers—in an increasingly competitive hiring environment.
  • Ensuring that DoD and VA staff have sufficient resources (such as space, time, equipment, and incentives) to provide high-quality PTSD care. That might mean expanded facilities, reduced provider workloads, and recruitment and retention incentives and benefits.

DoD and VA have greatly increased the number of mental health care providers in their departments, including those who have been trained in evidence-based psychotherapies, typically prolonged exposure (PE) therapy and cognitive processing therapy (CPT). As of 2013, almost 5,000 VA providers had been trained in CPT, more than 1,800 in PE, and 1,200 in both. Despite these increases, DoD and VA data and the committee’s site visits indicate that mental health staffing has not kept pace with the growing demand for PTSD services. Such staffing shortages can result in clinicians’ not having sufficient time to provide the evidence-based psychotherapies readily and with fidelity.

Staffing shortages in DoD and VA have also resulted in increased use of purchased care providers. However, neither department appears to have formal procedures for evaluating the qualifications of those providers, mechanisms for determining the best purchased care provider for an indi-

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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vidual patient, or requirements that such a provider inform the referring provider about a patient’s progress. The committee found this lack of oversight and standards of care for purchased care providers to be particularly problematic.

Efforts are under way in VA to coordinate and standardize the use of purchased care providers via the Patient-Centered Community Care initiative, which has been piloted for 4 years in four VISNs. The initiative requires that purchased care providers be screened to ensure that they meet or exceed VA standards for credentialing, licensing, and specialty care. It also requires that purchased care providers share their patient files with VA providers to ensure continuity of care. The program is in its initial implementation phase, so its impact on improving the quality of purchased care cannot yet be assessed. DoD does not appear to have a similar mechanism for ensuring that its purchased care providers are trained in and using evidence-based treatments or that service members are accessing the most appropriate providers.

Both departments offer training in military culture to direct care providers. DoD has recently issued guidance that requires all new hires, both direct care and purchased care providers, to be trained or have experience in military culture and terminology. VA does not have a similar requirement.

Recruiting and retaining mental health care providers can be challenging, especially in less than desirable areas and where there is competition from other health organizations. Both DoD and VA acknowledge that it can be difficult to hire and retain staff in underserved areas, despite targeted efforts to do so. DoD and VA can help to ensure a supply of providers through expanded formal training programs with academic institutions, whereby students train at the medical facilities and then may be recruited for permanent positions.

Mental health staff in the PTSD management system should be given appropriate recognition and rewards on the basis of identified goals (such as decreasing wait times, using evidence-based treatments, or being trained in a preferred modalities) to reinforce desired behaviors and outcomes. The corollary to such a reward system is the need to discourage the use of services or programs that lack an evidence base or whose evidence base has been eclipsed by research. Although the committee understands that it is difficult to change practice patterns, it believes that there are opportunities and strategies that DoD and VA can use to encourage and promote such changes.

The committee believes that each department can determine its own staffing needs—including how to allocate current and future staff, whether to hire more or different providers, whether to expand the use of purchased care providers, and how to determine training needs—to meet the goal of providing high-quality, evidence-based care to service members and vet-

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

erans who have PTSD. Therefore, it has not given specific staff-to-patient ratios or other metrics inasmuch as these may be interpreted as prescriptive and not simply as examples. Although it may be necessary to expand the number of staff to meet needs, it may be possible to achieve equal or better results with more efficient use of existing staff and with the use of more effective programs and services by that staff.

Evidence-Based Treatment

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. If innovative programs and services are being developed and piloted, they should include an evaluation process to establish the evidence base on their efficacy and effectiveness.

DoD and VA should use their VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress to inform the delivery of all PTSD treatments. Existing programs and services that lack an evidence base should also be evaluated along with new programs.

The best available evidence should guide all DoD and VA PTSD treatment programs. The departments have expended considerable effort to develop, update, and disseminate the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress. The guideline presents algorithms for choosing an evidence-based treatment for PTSD, addresses the treatment of comorbidities, and discusses the evidence or lack thereof for psychosocial therapies and pharmacotherapies that do not rise to the level of a first-line treatment. The committee was concerned to learn that mental health care providers in both departments do not consistently provide evidence-based treatment at levels that would be expected in a high-performing PTSD management system. DoD and VA have policies that recommend that all service members and veterans who have PTSD receive PE and CPT (first-line treatments in the guideline).

There are many reasons why a service member or veteran might not receive a first-line psychotherapy including heavy workloads (both number of patients and ancillary duties), lack of time to schedule patients for the requisite number of visits in the recommended time, and patients’ not being ready to engage in trauma-focused therapy. To help engage patients in treatment, DoD and VA are also integrating complementary and alternative therapies into some of their specialized PTSD programs. The effectiveness of these adjunctive treatments needs to be studied to ensure that their use does not deter patients from receiving first-line treatments.

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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In many cases, the committee was unable to determine what, if any, therapies most service members or veterans who have PTSD receive in any care setting and whether the care they receive results in improvements. Treatment options are not always consistent in installations within or among the service branches or in all VA medical centers, and it is not clear that treatment plans are based on patients’ preferences. For example, although each VA medical center and large CBOC is required to offer PE and CPT, in 24 of 166 specialized outpatient programs only 10–30% of veterans who had PTSD received any type of treatment in 2012. Strategies for transitioning patients who have more severe PTSD from primary care or general mental health care to specialty care and back once treatment in specialty care has effectively intervened are also necessary.

Delivery of evidence-based treatment for PTSD is a concern for DoD and VA, and they are exploring approaches to deliver them more expeditiously. In some cases, that includes the use of technological applications that extend the reach of clinical care and service delivery. Some of the technologies being used include virtual reality PE, treatment sessions via videoconferencing, patient avatars for training clinicians, and mobile applications for patients and providers. The use of telehealth is expanding, but the committee cautions that pilot programs and studies need to be conducted to build the evidence base on their effectiveness.

Central Database of Programs and Services

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.

Programs in the directory should be described (including current contact information), evaluated according to standardized measures, and updated routinely. This programmatic information should be readily available and easy to navigate for all stakeholders, including direct care and purchased care providers and families.

Currently, there is no single, central resource of PTSD programs and services that are available throughout DoD and only a limited directory of programs available in VA. In the absence of a central directory of programs and services, the committee found it 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. The committee and other organizations have found the lack of a central resource to identify PTSD programs and services in DoD and, to a smaller extent, in VA to be frustrating. The frustration stems from an inability to identify

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

what PTSD programs and services are available in DoD and the service branches and, in VA, what resources each program has and whom it treats, and the goals of the programs and how they determine success.

DoD has a variety of PTSD programs in the service branches. However, many of the clinicians and other mental health care providers with whom the committee spoke seemed to be unaware of the range of programs to which they might refer service members who needed more PTSD care than they were able to provide. VA maintains a catalog of specialized PTSD programs with its The Long Journey Home annual report, but the report does not include all PTSD treatment settings, such as general mental health clinics and women’s health clinics, and it does not contain descriptive information on any of the programs. 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 include those of DoD.

The lack of information on existing programs and services and whether they are effective has led many caring and thoughtful clinicians to develop their own PTSD programs. In the absence of information on whether those programs are successful in treating for PTSD and of dissemination of that information outside a single location, best practices cannot be identified and communicated to a wider audience. For example, each service branch has developed and implemented a service-wide combat and operational stress control program without first piloting the program to determine whether it is effective in reducing stress reactions.

Family Involvement

Recommendation G: DoD and VA should increase engagement of family members in the PTSD management process for service members and veterans.

The DoD has a variety of resources to assist service members, their families, and others in their support networks to learn about PTSD, its diagnosis and treatment, and its impact on family and friends. Many support and prevention services are available to service members and their family members in military installations, such as chaplains, military and family life counselors, family advocacy programs, Marine Corps community services, Families OverComing Under Stress, Military OneSource, and peer support groups. 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. They can also deliver psychoeducation, training, screening, counseling, and social support for service members and their families as an adjunct to professional

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

mental health treatment. In many DoD mental health settings, couple or family therapy for service members who have PTSD and the family members they designate is provided by professional mental health care providers. These providers include clinical social workers, counseling and clinical psychologists, and marriage and family therapists. In spite of the variety of support services available on installations or in the community, family members—including spouses, partners, children, and parents—are often unsure of where to get information about PTSD, how to encourage a service member to seek treatment, and how to assist them with their treatments.

VA also has resources for families of veterans who have PTSD, such as the National Center for PTSD, but it does not provide health care for veterans’ dependents. Some veterans have expressed great interest in having their partners involved in their PTSD treatment and the need for support groups for their partners. However, there is no formal VA-wide program for engaging family members in veterans’ treatment, for providing psychoeducation in a facility, or for establishing support groups. In several VA mental health programs, veterans who have PTSD, their partners, and their children receive couple or family therapy from professional clinicians. In addition, VA provides peer support in its facilities and through the Make the Connection website. Peer counselors and peer support groups appear to be helpful in engaging veterans in treatment, reducing stigma, and promoting 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. Finally, the committee learned that some VA facilities have too little space for support group meetings, potentially limiting the number of these programs that exist or could be created.

During site visits, service members and veterans stated that their spouses would benefit from PTSD education programs. They often expressed a preference for family-based PTSD interventions over individual treatment that excluded their family members. Only a few studies have examined whether family therapy improves PTSD outcomes in service members or veterans, but studies of couple therapy and family therapy are building the evidence base for their efficacy. Several studies on couple therapy for treating PTSD have found it to be effective in reducing PTSD symptoms and enhancing relationship satisfaction.

Research Priorities

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.

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

Given the high prevalence of PTSD in service member and veteran populations, both DoD and VA need to ensure that they are investing an appropriate portion of their research efforts in PTSD. The following should be major foci of PTSD-related research:

  • Increasing knowledge of how to overcome barriers to implementation, dissemination, and use of evidence-based treatments to improve the accessibility, availability, and acceptability of effective PTSD treatments for patients and their families.
  • Increasing knowledge of basic biological, physiological, psychological, and psychosocial processes that lead to the development of more and better treatments for PTSD.
  • Developing markers—biological, physiological, and psychological—to identify better approaches for PTSD prevention, diagnosis, and treatment.
  • 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 PTSD and comorbidities.
  • Understanding the heterogeneity of PTSD presentations and predicting responses to treatment for them in different populations (such as populations that differ in sex, race, ethnic group, age, or cohort of service) and at different times in the course of the disorder.
  • Improving the quality of mental health services, identifying effective care models, establishing evidence-based practice competences, and developing methods to enhance effective training in and implementation and dissemination of those competencies.

There can be substantial barriers to conducting PTSD research within and between the departments and in collaboration with academic and government organizations and private partners. There does not appear to have been a systematic effort by either department to identify those barriers or identify mechanisms to overcome them. Nevertheless, DoD and VA are funding broad PTSD research portfolios and are working collaboratively with the National Institutes of Health (NIH), other organizations, and academe 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 conducted an in-depth review of the research being conducted by DoD, VA, and NIH, but it did not conduct a formal gap

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

analysis, nor did it seek to determine the quality and details of the research, for example, whether one drug should be studied more than another. In particular, research on treatment and technology is advancing rapidly and numerous studies are being conducted to identify new treatment modalities, new delivery methods, and mechanisms to reach a larger number of patients who might benefit from the treatments.

Although basic biological research will inform an understanding of the underlying mechanisms of PTSD development and response to treatment, it may take decades to translate the findings to clinical practice. Given the current and growing number of service members and veterans who have PTSD and the availability of effective treatments for it, a more immediate research effort that may prove to be beneficial in the short term is identifying methods for overcoming the barriers that prevent the wide use of those treatments in DoD and VA.

CONCLUSIONS

DoD and VA are focusing substantial efforts on addressing PTSD in service members and veterans. Those efforts have resulted in numerous programs and services and much research support in both departments for the prevention and diagnosis of, treatment for, and rehabilitation of PTSD and its comorbidities. However, in spite of well-intentioned and often innovative efforts to provide high-quality PTSD management, the committee found that neither department knows whether its many programs and services are effective in reducing the prevalence of PTSD in service members or veterans. It may be that current efforts are beneficial in the long term or that new approaches are necessary, but the committee believes that, until prevention and treatment outcome data are collected, analyzed, and evaluated at all organizational levels, it will be impossible to determine the success of any of those efforts.

The committee recognizes that DoD and VA are enormous, complex, and dynamic government organizations that have numerous responsibilities and obligations not only to service members and veterans—and in many cases, their families—but also to the President, who establishes their budgets; to Congress, which funds them and provides oversight; and to the American public. Both departments are capable of dramatic, and in some cases rapid change, but most changes must go through long, involved approval processes. Therefore, the committee tried to avoid being overly prescriptive in its recommendations in the belief that both DoD and VA should have flexibility in implementing them. Many of the administrative, technical, and scientific challenges that DoD and VA face in providing population health–based, high-quality PTSD management are not specific to them and may be found in other large health care systems, but that

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

does not mean that the departments cannot lead the way with regard to providing the best possible PTSD care. None of the challenges described in this report is insurmountable; in fact, both DoD and VA are working to overcome them. But gaps remain, and current efforts to address them can be confusing, cumbersome, and disjointed and can fall short of what would be expected of a high-performing PTSD management system. If the many dedicated and thoughtful mental health care providers and leaders that the committee spoke with during its site visits and open sessions are representative of the talent available in each department, improving short-term and long-term PTSD management for service members and veterans should be not only possible but probable.

The occurrence and impact of PTSD are not diminishing. On the contrary, PTSD prevalence is growing among the nation’s service members and veterans. The committee hopes that leaders in Congress and throughout DoD and VA will consider the findings and recommendations in this report as part of an overall effort to make positive changes in the management of PTSD in both departments. Acting on the committee’s recommendations can help ensure that the United States will be better prepared for the next generation of men and women who serve our country.

Suggested Citation:"10 Findings and Recommendations." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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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 and Operation Iraqi Freedom may have the disorder. PTSD is characterized by a combination of mental health symptoms - re-experiencing 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, chronic pain, substance abuse disorder, and intimate partner violence.

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 to assess those PTSD programs and services in two phases. The Phase 1 study, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment, focused on data gathering. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment is the report of the second phase of the study. This report analyzes the data received in Phase 1 specifically to determine the rates of success for each program or method.

Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment considers what a successful PTSD management system is and whether and how such a system is being implemented by DoD and VA. 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. This report focuses on the opportunities and challenges that DoD and VA face in developing, implementing, and evaluating services and programs in the context of achieving a high-performing system to care for service members and veterans who have PTSD. The report also identifies where gaps or new emphases might be addressed to improve prevention of, screening for, diagnosis of, and treatment and rehabilitation for the disorder. The findings and recommendations of Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment will encourage DoD and VA to increase their efforts in moving toward a high-performing, comprehensive, integrated PTSD management strategy that addresses the needs of current and future service members, veterans, and their families.

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