The current and future costs of the conflicts in and around Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF] and Operation New Dawn1), and the full magnitude of their long-term effects on those who served, will not be known for many years. Posttraumatic stress disorder (PTSD) and blast injuries, including traumatic brain injury (TBI), are the signature wounds of these conflicts and their effects can be lifelong.
As was demonstrated after World War II, Korea, Vietnam, and the 1990–1991 Gulf War conflicts, public memory is short; the needs of our returning warriors fade from the headlines. As the conflicts in Afghanistan and Iraq wind down, the public may believe that service members and veterans will no longer experience PTSD or other mental health problems, such as depression or substance use disorder. That belief is faulty: Many service members and veterans may have symptoms now or will develop them, and the risk of recurrence is ever present.
Exposure to any potentially traumatic event—such as physical or sexual abuse, natural disaster, being threatened with death, observing death,
1 In this report, the committee uses the term OIF to include both OIF, which began on March 9, 2003, and ended on September 1, 2010, and Operation New Dawn, which began on September 1, 2010, and ended on December 31, 2012. These terms also include service members deployed to countries near Afghanistan and Iraq, such as Kuwait and Qatar.
or taking someone else’s life—may trigger the symptoms that characterize PTSD. Those symptoms occur in four clusters2:
- intrusive re-experiencing of the traumatic event, such as recurrent nightmares or flashbacks;
- avoidance of reminders of the traumatic event;
- distortions of thinking and memory or emotional numbing; and
- persistently high physiologic arousal and reactivity.
Combat exposure is a well-known risk factor for PTSD, and the greater the number of combat-related traumas experienced during deployment, the greater the risk of developing postdeployment PTSD (Schnell and Marshall, 2008, in Tanielian and Jaycox, 2008). Many service members who deploy to a combat zone experience a combat-related trauma (Gates et al., 2012; Hoge et al., 2004; Tanielian and Jaycox, 2008), but the majority of them do not develop PTSD and are able to complete their deployments and reintegrate into military or civilian life without substantial distress or alteration in functioning. But for the estimated 7–20% of OEF and OIF service members who have clinical PTSD (Hoge et al., 2004; Seal et al., 2007; Smith et al., 2008; Tanielian and Jaycox, 2008; Vasterling et al., 2010), readjustment from combat zone deployments and reintegration into their families and communities may be severely affected by chronic distress and disability in their physical, psychological, social, and occupational functioning.
The Department of Defense (DoD) and the Department of Veterans Affairs (VA) offer a variety of programs and services to prevent PTSD and to identify and treat service members and veterans who have symptoms of PTSD, depression, substance use disorder, and other common mental health disorders.3 The National Defense Authorization Act (NDAA) for FY 2010 required the secretary of defense, in consultation with the secretary of
2 Although the American Psychiatric Association revised the diagnostic criteria for PTSD in the 2013Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), the committee uses the DMS-IV-TR criteria in this report as those are the criteria used in the studies cited in this report. More discussion of the differences between the two sets of criteria may be found in Chapter 2.
3 In the DoD, the terms behavioral health and mental health are used interchangeably, and the VA uses the term mental health; the committee has chosen to use the term mental health throughout this report, unless the term behavioral health is in a name.
veterans affairs, to enter into an agreement with the Institute of Medicine (IOM) of the National Academies to assess PTSD treatment programs and services in DoD and VA. The statement of task is shown in Box 1-1, and the legislative language calling for the study is in Appendix B.
In response to the NDAA, IOM convened a committee that included not only psychologists, psychiatrists, and other mental health professionals but also several members who have served in the military and others who had been employed by VA. Thus, committee members had substantial expertise in mental health needs, programs, and services in both DoD and VA; this expertise helped to inform the committee’s report. Short biographies of all committee members may be found in Appendix A. This phase 2 report is the committee’s final report.
Prior IOM reports that have addressed PTSD directly or indirectly were helpful in the preparation of this report:Posttraumatic Stress Disorder: Diagnosis and Assessment (NRC, 2006), Improving the Quality of Health Care for Mental and Substance-Use Conditions (IOM, 2006), Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (IOM, 2008), Provision of Mental Health Counseling Services Under TRICARE (IOM, 2010), and Substance Use Disorders in the U.S. Armed Forces (IOM, 2013). The two reports that pertain to PTSD treatment were discussed in the phase 1 report and are not discussed further in this report.
The remainder of this chapter summarizes the phase 1 approach, findings, and recommendations, followed by the committee’s approach to its charge for phase 2.
PHASE 1 REPORT
The phase 1 report Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment described current approaches to PTSD prevention and treatment, neurobiologic research being conducted on PTSD in the government and private sectors, and DoD and VA programs and services for PTSD. It also considered comorbidities that are common with PTSD as well as some barriers to care.
DoD and VA each provide an array of prevention, assessment, screening, diagnosis, treatment, and rehabilitation programs and services for PTSD. Their goals are to maintain force readiness and to enable veterans to function well in daily life, respectively. DoD programs and services vary by service branch and include outpatient care, inpatient care, complementary
Statement of Task
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, with regard to:
- efforts to identify physiological markers of post-traumatic stress disorder;
- efforts to determine causation of post-traumatic stress disorder, using brain imaging studies and studies looking at the correlation between brain region physiology and post-traumatic stress disorder diagnoses and the results (including any interim results) of such efforts;
- the effectiveness of alternative therapies in the treatment of post-traumatic stress disorder, including the therapeutic use of animals;
- the effectiveness of administering pharmaceutical agents before, during, or after a traumatic event in the prevention and treatment of post-traumatic stress disorder; and
- identification of areas in which the DoD and the VA may be duplicating studies, programs, or research with respect to post-traumatic stress disorder.
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.
and alternative4 therapies, and telehealth. The VA health care system has a number of specialized treatment programs for PTSD but offers most of its care for PTSD in general mental health and primary care settings.
DoD and VA issued an updated joint clinical practice guideline for management of PTSD in 2010 and have also issued joint guidelines for medical conditions that frequently co-occur with PTSD—such as TBI, substance use disorders, depression, and chronic pain. However, there is no guideline on how to integrate treatment for PTSD with treatment for these co-occurring conditions. Further, there are no data on whether mental health care providers in either department use the PTSD guideline or whether they offer evidence-based treatments5—such as prolonged exposure therapy or cognitive processing therapy, or selected serotonin reuptake inhibitors—to their patients.
Complementary and alternative treatments for PTSD—such as yoga, acupuncture, and animal-assisted therapy—received particular consideration as required by the legislation, but the lack of evidence on their effectiveness made them difficult to assess. The same was true of new techniques to deliver established, evidence-based treatments, such as telehealth and virtual reality, although studies of these are under way and some promising preliminary results have been reported.
DoD has spent millions of dollars on programs to build psychological resilience and prevent the adverse effects of military operational stress. These programs include the Army’s Comprehensive Soldier and Family Fitness, the Navy and the Marine Corps Combat and Operational Stress Control programs, and the Marine Corps Operational Stress Control and Readiness program.
Many service members and veterans do not seek a diagnosis of their symptoms or seek treatment should they receive a PTSD diagnosis. The reasons for the treatment gaps are many and include patients’ concerns about their careers, not getting a security clearance in the future, loss of coworker confidence, side effects from medications, and the belief that family and friends would be more helpful than a mental health professional. Additional
4 The committee uses the National Center for Complementary and Alternative Medicine’s definitions of “complementary medicine” (a non-mainstream approach plus conventional medicine) and “alternative medicine” (a non-mainstream approach instead of conventional medicine) in this report (http://nccam.nih.gov/health/whatiscam, accessed April 7, 2014).
5 In this phase 2 report, evidence-based treatments are considered to be ones “that are most strongly supported by randomized controlled trials” (VA/DoD, 2010). That definition aligns with the Substance Abuse and Mental Health Services Administration’s definition of evidence-based interventions: “strong evidence means that the evaluation of an intervention generates consistently positive results for the outcomes targeted under conditions that rule out competing explanations for effects achieved (e.g., population and contextual differences)” (Center for Substance Abuse Prevention, 2009).
barriers to care include the difficulty of getting appointments with mental health care providers and restrictions on medications that can be used to treat for PTSD when a service member is in a combat zone. For veterans, barriers to care include lack of available providers, logistic challenges, and lack of knowledge of available services.
Based on its findings, the committee grouped its phase 1 recommendations into five action items that are applicable to both DoD and VA: analyze, implement, innovate, overcome, and integrate, as described below. During phase 2, the committee confirmed that these findings and recommendations continue to be appropriate and necessary for improving PTSD management in DoD and VA.
- A1. Study the efficacy of treatment. To move toward measurement-based PTSD care in DoD and VA, assessment data should be collected before, during, and after treatment and should be entered into patients’ medical records. Such information should be made accessible to researchers with appropriate safeguards to ensure patient confidentiality.
- A2. Institute programs of research to evaluate the efficacy, effectiveness, and implementation of all PTSD screening, treatment, and rehabilitation services, including research in different populations of active-duty personnel and veterans; the effectiveness of DoD prevention services should also be assessed. DoD and VA should coordinate, evaluate, and review these efforts continually and routinely and should disseminate the findings widely.
- B1. Conduct PTSD screening at least once a year when primary care providers see service members at DoD military treatment facilities or at any TRICARE provider locations, as is currently done when veterans are seen in VA facilities.
- C1. Rigorously evaluate specialized intensive PTSD programs for the delivery of PTSD care, including combining different treatment approaches. Such emerging treatments as complementary and alternative medicine and couple and family therapy, need to
be evaluated throughout DoD facilities (including TRICARE providers) and VA facilities for efficacy, effectiveness, and cost. More rigorous assessment of symptom improvements (e.g., such outcome metrics as follow-up rates) and of functional improvements (e.g., improvements in physical comorbidities, and memory and return to duty) is needed. The evaluations of these programs should be made publicly available.
- C2. Support neurobiology research that might help translate current knowledge of the neurobiology of PTSD to screening, diagnosis, and treatment approaches and might increase understanding of the biologic basis of evidence-based therapies.
- D1. Support research in both DoD and VA that investigates emerging technologic approaches (mobile, telehealth, Internet-based, and virtual reality) that may help to overcome barriers to awareness and to the accessibility, availability, and acceptability of and adherence to evidence-based treatments; disseminate the outcomes to a wide audience.
- E1. Encourage research to create an evidence base to guide the integration of treatment for comorbidities with treatment for PTSD. PTSD treatment trials should incorporate assessment of comorbid conditions and the value of concurrent and sequential care. Effective treatments should be included in updates of the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress.
APPROACH TO PHASE 2
This phase 2 report is a more in-depth evaluation of the DoD and VA PTSD services and research described in phase 1. To meet its charge, the committee undertook the following activities:
- Identify prior DoD and VA PTSD program evaluation efforts.
- Submit data requests to DoD and VA.
- Conduct database searches and literature searches.
- Visit the military installations specified in the 2010 NDAA and other sites deemed important by the committee.
- Hold open sessions to hear from representatives from DoD, VA, and other organizations.
It is important to note which populations were considered in phase 2 of this study and which were deemed outside of scope. This report focuses on service members and veterans who have PTSD as a result of their time in service. Although PTSD in military and veteran populations may also affect family members and caregivers, these populations do not fall within the purview of this report. Coast Guard members or never-activated National Guard members also were not considered in this report because the Coast Guard is under the jurisdiction of the Department of Homeland Security and never-activated National Guard members are not eligible for DoD or VA care.
On the basis of discussions with DoD and VA, it was obvious that a comprehensive survey and assessment of all PTSD treatment programs and services throughout the departments was not feasible because a survey would duplicate efforts already in progress; very few programs in DoD or VA collect data on outcomes, and many DoD and VA specialized PTSD programs were conceptualized and implemented individually or are new.
Finally, the lack of data meant that it would be impossible to determine the success rates or effectiveness of DoD and VA PTSD programs and services. Consequently, the committee believed that it could contribute to PTSD management in DoD and VA by examining where and how in the system PTSD prevention, screening, diagnosis, treatment, and rehabilitation services and programs exist, what resources, such as workforce and technology, need to be available to support these services and programs, and what challenges and successes the departments have had in implementing or sustaining them.
The committee used several mechanisms to provide both quantitative and qualitative information: detailed requests for DoD and VA data and program evaluation documentation, literature and database searches, site visits, and open sessions. Each of those mechanisms is discussed below.
In both phase 1 and phase 2, a number of requests for data were made to DoD, the service branches, and to VA. The data requests asked for the number of service members and veterans who had received diagnoses of PTSD, types of treatments they received, where treatment was given, the duration and frequency of treatment, the comorbidities most frequently associated with PTSD, and the costs associated with PTSD treatment. Data were also requested on mental health care provider training, staffing levels, wait times for appointments, data collection efforts, and disposition
of patients. Each department was asked for information on the need for, availability of, access to, and effectiveness of PTSD treatments that are sex-specific, racial-, cultural-, or ethnic-group-specific, or specific to other factors such as service era or branch of service. The requests were made for information from 2004 to 2012. Each service branch was also asked for information on their specialized PTSD treatment programs or prevention efforts. Responses from the service branches are included in this report, where appropriate. The DoD Office of Strategic Management, which maintains oversight of the many DoD health care system databases, including those for TRICARE, provided more detailed demographic information and information on medication use, comorbidities, and treatment costs, through its database contractor, Kennell and Associates.
Data requests were also made of the VA Office of Mental Health Operations (including the Northeast Program Evaluation Center), the Office of Mental Health Services, and the Office of Research and Development, all in the Veterans Health Administration, and to the Veterans Benefits Administration (VBA). Data requested included the VA strategy for coping with the growing veteran population, staffing plans, no-show rates for appointments, and efforts to track PTSD treatments and outcomes in patients’ health records. A separate data request was sent to the VA Readjustment Counseling Service (Vet Centers) for an update of information received in phase 1. VBA was also asked to provide information on veterans who have service-connected PTSD disability.
The data requests to both departments for cost information were specific to those associated with treating PTSD and its comorbidities. Information on the costs of administering PTSD programs, salaries, equipment, information technology, performance incentives and bonuses, and facilities were not requested for this report, although the committee recognizes these can add substantially to the costs of managing PTSD. All DoD, service branch, and VA responses to requests for data are included in the project’s public access file.
Database and Literature Searches
To identify ongoing PTSD research projects being conducted or funded by DoD, VA, National Institutes of Health (NIH), other government agencies, and if possible, the private sector, three publicly available databases were used—the VA Health Services Research and Development database, the NIH Research Portfolio Online Reporting Tools database, and ClinicalTrials.gov. DoD also provided a list of DoD-funded PTSD studies because the department does not have a publicly available database of studies that parallels NIH and VA. The specific methods used for each database and a summary of the reviewed research are described in Chapter 9.
Databases and Websites
|PILOTS||Government Accountability Office|
|Congressional Budget Office||National Institute of Mental Health|
|Armed Forces Health Surveillance Center||PsychInfo|
|Congressional Research Service||PubMed|
|DCoE (PTSD Treatment Options)||RAND Corporation|
|Defense Technical Information Center||Scopus|
|Embase (OVID)||Web of Science|
Several literature searches were conducted in October 2013 to identify new programs, services, policies, or outcomes related to PTSD in DoD and VA. The search was limited to papers in English published since 2011 (policies published since 2005), and studies had to be conducted in military or veteran populations. Search categories for PTSD included physiological biomarkers, alternative therapies, prevention and resilience, treatment and diagnosis, rehabilitation and related topics, and policy reports. Box 1-2 lists the databases and websites used for the literature searches.
Several site visits (see Box 1-3) informed the committee’s approach, including those to the three Army bases (Fort Hood and Fort Bliss in Texas and Fort Campbell in Kentucky), as required by its charge. The visits were an opportunity to see what is available, what works, and what could be improved with regard to PTSD care. The visits were intended to be information-gathering sessions for the committee, not fault-finding exercises, and were not intended to be focus groups, surveys, or structured interviews. It was not possible, given time and resource constraints, to conduct a thorough review or even representative sampling of all military installations or of all VA facilities that provide treatment for PTSD.
During each visit, the committee asked the following open-ended questions:
- What is your facility’s, service’s, or department’s current approach to providing PTSD care now and in the future?
- What are your successes and challenges in providing PTSD care?
- What might this committee’s report say that would help you to improve PTSD care?
- What programs or services do you have or see a need for with regard to treating women and members of ethnic, racial, or cultural minorities who have PTSD?
- What treatment (or prevention) outcome data are being collected and how they are used?
Military Installations During phase 2, the committee visited two Army bases—Fort Bliss, Texas, and Fort Campbell, Kentucky—and two Marine Corps bases—Camp Lejeune, North Carolina, and Camp Pendleton, California—inasmuch as the marines had been deployed as often as, if not more often than, Army soldiers and had been engaged in substantial combat activities. Naval Medical Center San Diego and Naval Base Point Loma in California were also visited to coincide with the Camp Pendleton visit and because these naval facilities have special programs for treating PTSD and are available to members of all service branches. Joint Base Langley-Eustis (specifically Langley Air Force Base) in Virginia was visited after discussions with the Air Force Office of the Surgeon General. Of particular interest were the Warrior Combat Stress Reset Program at Fort Hood, the Warrior Resilience Center at Fort Bliss, and the intensive outpatient program at Fort Campbell.
At all the military installations, discussion participants included hospital and mental health department leaders and mental health care providers
DoD and VA Site Visits
Fort Hood, TX (Army)
Fort Bliss, TX (Army)
Fort Campbell, KY (Army)
Camp Lejeune, NC (Marine Corps)
Camp Pendleton, CA (Marine Corps)
Naval Medical Center
San Diego, CA (Navy)
Naval Base Point Loma, CA (Navy)
Joint Base Langley-Eustis, VA (Air Force)
National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, MD
VA Medical Facilities
James J. Peters VA Medical Center, Bronx, NY
Roseburg Health Care System, OR
Palo Alto Health Care System,
Menlo Park, CA
San Francisco VA Medical Center, CA
Edward Hines, Jr. VA Hospital,
Hampton VA Medical Center, VA
from inpatient, outpatient, primary care, embedded mental health clinics, and specialized PTSD programs; primary care providers also participated in the discussions. Some of the providers had deployed to combat zones, and a number of them used complementary and alternative therapies for PTSD. Other participants included trainers in resilience and prevention programs; researchers; local community mental health care providers; leadership and case managers for the wounded warrior transition units; providers of family counseling services; administrators for the Medical Examination Board and the DoD/VA Integrated Disability Evaluation System; VA liaisons located on military bases; and service members who had received treatment for PTSD. Virtually all the service members who met with the committee were active-duty and had had at least one deployment to Afghanistan or Iraq; many of them were in Wounded Warrior programs.
Department of Veterans Affairs Medical Facilities VA medical center or health care system sites were selected to capture the heterogeneity among them and to see centers that were in different geographic locations and that served different veteran populations. Thus, the Bronx VA Medical Center serves an urban veteran population that is socioeconomically diverse and consists largely of minority-group members; the Roseburg VA Health Care System serves a rural veteran population, has an inpatient mental health facility, does not have a mental health outpatient clinic, and is in a state that does not have any military bases; the San Francisco VA Medical Center conducts extensive research on PTSD treatments and services and serves a socioeconomically diverse population; the Palo Alto Health Care System serves a geographically diverse population, has men’s and women’s trauma recovery programs, has a women’s counseling center, has a division of the National Center for PTSD, and is considered a flagship facility for VA; and the Hines VA Medical Center serves a large suburban population and has had an influx of veterans from OEF and OIF. The Hampton VA Medical Center, in eastern Virginia, serves a large veteran population and is near several military installations.
At the visits, discussion participants included senior VA medical facility leaders and representatives of the veterans integrated service networks; inpatient, outpatient, and specialized PTSD program providers and providers at community-based outpatient clinics; complementary and alternative therapy providers; researchers; Vet Center providers; specialized providers who treat for PTSD and co-occurring conditions, such as substance use disorders and TBI; social support and rehabilitation case managers who help veterans who have PTSD with employment and family and relationship issues and who in some cases provide counseling to homeless veterans; and personnel who handle veterans’ compensation and benefits examinations
for PTSD. The committee also met with groups of veterans at each VA facility. The veterans represented different eras of conflict and were asked many of the same questions that were asked of the active-duty service members.
Several open sessions were held to hear from representatives of both DoD and VA with regard to the departments’ strategies and activities for PTSD, and from others who were familiar with DoD and VA PTSD management efforts. The sessions supplemented the site visits and allowed more detailed discussions of DoD and VA policies and procedures with senior administrators as well as a representative from the National Guard. Finally, the director of the National Institute of Mental Health discussed PTSD research at the institute. The complete list of open session agendas, including site visits, is in Appendix C.
ORGANIZATION OF THIS REPORT
In the following chapters, DoD and VA approaches to PTSD management are considered. Chapter 2 contains a short discussion of the diagnostic criteria for PTSD, and the various outcomes that may be expected with or without treatment, as well as information on the prevalence and incidence of PTSD in service members and veterans. Chapter 3 highlights the PTSD programs and services that are available in DoD and VA and what can be ascertained about their effectiveness. A brief overview of the organization of each department’s health care system is also given.
Chapters 4–8 assess important attributes of a high-performing PTSD management system. Each chapter discusses what activities in DoD and VA help them provide the best care for PTSD and where there are gaps that could be addressed. First, Chapter 4 discusses performance management requirements with a focus on performance measures that are necessary to determine whether the management of PTSD is effective. Chapter 5 identifies the current costs associated with PTSD treatment in both departments and how to determine if the care is high-value; it also discusses the information that is required to project such costs in the future. Next, Chapter 6 looks at workforce to emphasize the role of leaders in developing and sustaining a high-performing system; to determine whether sufficient DoD and VA staff are available to treat service members and veterans effectively; and to determine how training and retaining such staff are integral aspects of a high-performing workforce. Chapter 7 discusses the use of effective programs for PTSD prevention and treatment in both departments and ends with a short section on safety considerations for all treatment modalities. The focus of Chapter 8 is access to care and encompasses the acceptability,
accessibility, and availability of PTSD care in both departments as well as efforts to facilitate service members, and veterans receiving that care. This chapter also looks at aspects of patient-centered care that may encourage a patient to seek treatment for PTSD and the availability of programs for populations with specific needs.
Chapter 9 provides an in-depth examination of PTSD research being conducted by DoD, VA, and other organizations, including NIH. This chapter evaluates current research efforts and identifies gaps that might be addressed to develop new treatments and approaches to managing PTSD. Basic science, neurobiology, and new technology are all considered, as are specific treatments and the need to address comorbidities. Finally, Chapter 10 presents the committee’s findings, recommendations, and conclusions.
The appendixes present short biographic sketches of the committee members (Appendix A); the 2010 NDAA language that called for this study (Appendix B); the open session agendas, including invited presenters and site visits (Appendix C); a compilation of selected PTSD centers, consortiums, and collaborations for PTSD research (Appendix D); and detailed descriptions of current PTSD research in DoD, VA, and NIH that supplement Chapter 9 (Appendix E).
Center for Substance Abuse Prevention. 2009. Identifying and selecting evidence-based interventions: Revised guidance document for the strategic prevention framework state incentive grant program. Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration.
Gates, M. A., D. W. Holowka, J. J. Vasterling, T. M. Keane, B. P. Marx, and R. C. Rosen. 2012. Posttraumatic stress disorder in veterans and military personnel: Epidemiology, screening, and case recognition. Psychological Services 9:361-382.
Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351(1):13-22.
IOM (Institute of Medicine). 2006. Improving the quality of health care for mental and substance-use conditions. Quality chasm series. Washington, DC: The National Academies Press.
IOM. 2008. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.
IOM. 2010. Provision of mental health counseling services under TRICARE. Washington, DC: The National Academies Press.
IOM. 2013. Substance use disorders in the U.S. Armed Forces. Washington, DC: The National Academies Press.
NRC (National Research Council). 2006. Posttraumatic stress disorder: Diagnosis and assessment. Washington, DC: The National Academies Press.
Seal, K. H., D. Bertenthal, C. R. Miner, S. Sen, and C. Marmar. 2007. Bringing the war back home: Mental health disorders among 103,788 U.S. veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine 167(5):476-482.
Smith, T. C., D. L. Wingard, M. A. Ryan, D. Kritz-Silverstein, D. J. Slymen, and J. F. Sallis. 2008. Prior assault and posttraumatic stress disorder after combat deployment. Epidemiology 19(3):505-512.
Tanielian, T., and L. H. Jaycox (Eds.). 2008. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.
VA/DoD (Department of Veterans Affairs/Department of Defense). 2010. VA/DoD clinical practice guideline for management of post-traumatic stress. Washington, DC: Department of Veterans Affairs and Department of Defense.
Vasterling, J. J., S. P. Proctor, M. J. Friedman, C. W. Hoge, T. Heeren, L. A. King, and D. W. King. 2010. PTSD symptom increases in Iraq-deployed soldiers: Comparison with non-deployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. Journal of Traumatic Stress 23(1):41-51.