Treatment for
POSTTRAUMATIC STRESS DISORDER
in Military and Veteran Populations
Final Assessment
Committee on the Assessment of Ongoing Efforts in the
Treatment of Posttraumatic Stress Disorder
Board on the Health of Select Populations
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. W81XWH-10-C-0290 between the National Academy of Sciences and the Department of Defense. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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International Standard Book Number-10: 0-309-30173-4
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Suggested citation: IOM (Institute of Medicine). 2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON THE ASSESSMENT OF ONGOING EFFORTS IN THE TREATMENT OF POSTTRAUMATIC STRESS DISORDER
Sandro Galea (Chair), Professor and Chair of the Department of Epidemiology, Mailman School of Public Health, Columbia University
Kathryn K. Basham, Professor, Codirector of the Ph.D. Program, and Editor of Smith College Studies in Social Work, Smith College
Larry Culpepper, Professor, Department of Family Medicine, Boston University School of Medicine
Jonathan R. Davidson, Emeritus Professor, Department of Psychiatry, Duke University Medical Center
Edna B. Foa, Professor, Department of Psychiatry; Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine
Kenneth W. Kizer, Distinguished Professor, Department of Emergency Medicine, University of California, Davis, School of Medicine and Betty Irene Moore School of Nursing; Director, Institute for Population Health Improvement, Davis Health System
Karestan C. Koenen, Associate Professor, Department of Epidemiology, Mailman School of Public Health, Columbia University
Douglas L. Leslie, Professor, Department of Public Health Sciences and Department of Psychiatry, The Pennsylvania State University
Richard A. McCormick, Senior Scholar, Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center
Mohammed R. Milad, Associate Professor, Department of Psychiatry, Harvard Medical School; Director of Behavioral Neuroscience Laboratory and Associate in Research Psychiatry, Massachussets General Hospital
William P. Nash, University of California, San Diego, and Virginia Commonwealth University
Elizabeth A. Phelps, Silver Professor of Psychology and Neural Science, Department of Psychology and Center for Neural Science, New York University
Elspeth Cameron Ritchie, District of Columbia Department of Behavioral Health; Clinical Professor of Psychiatry, Georgetown University
Albert “Skip” Rizzo, Associate Director, Institute for Creative Technologies; Research Professor, Department of Psychiatry and School of Gerontology, University of Southern California
Barbara O. Rothbaum, Associate Vice Chair of Clinical Research, Professor in Psychiatry, and Director, Trauma and Anxiety Recovery Program, Emory University School of Medicine
Douglas F. Zatzick, Professor, and Associate Vice Chair for Health Services Research, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
Study Staff
Roberta Wedge, Study Director
Anne Styka, Program Officer
Heidi Murray-Smith, Program Officer, Board on Environmental Studies and Toxicology
Heather Chiarello, Senior Program Assistant (from April 2013)
Emily Morden, Associate Program Officer (until November 2013)
Joi Washington, Senior Program Assistant (until March 2013)
Norman Grossblatt, Senior Editor
Frederick Erdtmann, Director, Board on the Health of Select Populations
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Christopher K. Cain, Nathan Kline Institute for Psychiatric Research
Peter Chiarelli, One Mind for Research
Colleen Conway-Welch, Vanderbilt University
Terri DeRoon-Cassini, Medical College of Wisconsin
David Gustafson, University of Wisconsin–Madison
Anand Kumar, University of Illinois at Chicago
Thomas G. McGuire, Harvard Medical School
Alan Peterson, University of Texas Health Science Center at San Antonio
Harold Pincus, Columbia University/RAND Corporation
Terri Tanielian, RAND Corporation
Shelley MacDermid Wadsworth, Purdue University
Stephen Xenakis, Uniformed Services University of the Health Sciences
Antonette Zeiss, Consultant
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Ellen Wright Clayton, Vanderbilt University, and Kristine M. Gebbie, Flinders University of South Australia. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Posttraumatic stress disorder (PTSD) remains one of the signature injuries of the U.S. engagements in Afghanistan and Iraq. The burden of PTSD in service members who have been deployed in support of Operation Enduring Freedom in Afghanistan since 2001 and Operation Iraqi Freedom since 2003 is staggering. Fortunately, national awareness of the toll that PTSD has had on the health and well-being of service members, veterans, their families, and their communities has been increasing. Both the Department of Defense (DoD) and the Department of Veterans Affairs (VA) have, in a variety of reports and activities, demonstrated keen understanding of the challenges posed by PTSD. Each department has responded to the challenges with substantial funding to foster research, develop programs, and initiate services to combat PTSD. Although both departments are making strides in identifying and treating people who have PTSD symptoms, many obstacles remain before they will have a comprehensive, integrated, and high-performing approach to managing PTSD.
The 2010 National Defense Authorization Act asked the Institute of Medicine (IOM) to look at the effectiveness of the growing number of PTSD programs and services that are available for service members and veterans in DoD and VA, respectively. The present report is the second of a two-phase study. In this phase, the committee focused on the opportunities and challenges that each department faces 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 committee also conducted a focused review of DoD, VA, and other organizations’ portfolios of PTSD-related research to identify where
gaps or new emphases might be addressed to improve prevention of, screening for, diagnosis of, and treatment and rehabilitation for the disorder. During its review of the literature and ongoing research and preparation of this report, it was obvious to the committee that although there is a wealth of information on PTSD, there are also substantial gaps in our knowledge of how best to manage PTSD in service members and veterans who have it. This report attempts to recognize both progress and stasis in improving care for PTSD in DoD and VA.
The committee gratefully acknowledges the many individuals and groups that generously shared their time, expertise, and insights with the committee. They provided valuable information on particular aspects of PTSD, including reports and data, and answered committee queries about their work and experience in dealing, personally and professionally, with PTSD. Among the numerous people who helped the committee are those who worked tirelessly on the committee’s data requests, specifically Keith Hoffman and Wendy Funk, of Kennell and Associates; Mary Schohn, of the VA Office of Mental Health Operations; Rani Hoff, of the VA Northeast Program Evaluation Center; and many others in the Army, Navy, Marine Corps, and Air Force. The committee also visited many DoD and VA facilities and expresses its appreciation for the time, insights, and personal stories offered by a variety of leaders, mental health providers, primary care providers, specialty program directors, researchers, and purchased care providers. The committee appreciates especially the many service members and veterans who were receiving or had received treatment for PTSD and who took time to share their experiences with the committee. The committee is grateful to Roberta Wedge, who served as study director for this project, and to the IOM staff members who contributed to the project: Heather Chiarello, Emily Morden, Heidi Murray-Smith, and Anne Styka. A thank you is also extended to Daniel Bearss and Ellen Kimmel, who conducted the literature searches.
Sandro Galea, Chair
Committee on the Assessment of Ongoing Efforts
in the Treatment of Posttraumatic Stress Disorder
APA | American Psychiatric Association |
Army STARRS | Army Study to Assess Risk and Resilience in Service Members |
BDNF | brain-derived neurotrophic factor |
BHDP | Behavioral Health Data Portal |
C5 | Comprehensive Combat and Complex Casualty Care |
CBOC | community-based outpatient clinic |
CBT | cognitive behavioral therapy |
CDP | Center for Deployment Psychology |
COSC | combat and operational stress control |
CPT | cognitive processing therapy |
CSF2 | Comprehensive Soldier and Family Fitness |
DCoE | Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury |
DCS | D-cycloserine |
DoD | Department of Defense |
DSM-IV-TR | Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, Text Revision |
DSM-5 | Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition |
EMDR | eye movement desensitization and reprocessing |
fMRI | functional magnetic resonance imaging |
FY | fiscal year |
GAO | Government Accountability Office |
ICD | International Classification of Diseases |
IDES | Integrated Disability Evaluation System |
IMHS | DoD/VA Integrated Mental Health Strategy |
INTRuST | Injury and Traumatic Stress consortium |
IOM | Institute of Medicine |
MDMA | 3,4-methylenedioxy-N-methylamphetamine |
MFLC | military and family life counselor |
MHAT | mental health advisory team |
MHS | military health system |
MIRECC | Mental Illness Research, Education, and Clinical Center |
MST | military sexual trauma |
MTF | military treatment facility |
NDAA | National Defense Authorization Act |
NEPEC | Northeast Program Evaluation Center |
NICoE | National Intrepid Center of Excellence |
NIH | National Institutes of Health |
NIMH | National Institute of Mental Health |
NQF | National Quality Forum |
OASD(HA) | Office of the Assistant Secretary of Defense for Health Affairs |
OASIS | Overcoming Adversity and Stress Injury Support |
OEF | Operation Enduring Freedom |
OIF | Operation Iraqi Freedom |
OMHO | Office of Mental Health Operations (VA) |
OSCAR | Operational Stress Control and Readiness |
PACT | patient-aligned care team |
PCL | PTSD Checklist |
PCL-M | PTSD Checklist-Military Version |
PCMH | patient-centered medical home |
PDHA | Post-Deployment Health Assessment |
PDHRA | Post-Deployment Health Reassessment |
PE | prolonged exposure therapy |
PHRAMS | Psychological Health Risk Adjusted Model for Staffing |
PTSD | posttraumatic stress disorder |
RePORT | Research Portfolio Online Reporting Tools database |
RESPECT-Mil | Re-engineering Systems for Primary Care Treatment of Depression and PTSD in the Military |
rTMS | repetitive transcranial magnetic stimulation |
SIPP | specialized intensive PTSD program |
SNRI | serotonin norepinephrine reuptake inhibitor |
SOPP | specialized outpatient PTSD program |
SSRI | selective serotonin reuptake inhibitor |
STRONG STAR | South Texas Research Organizational Network Guiding Studies on Trauma and Resilience |
T2 | National Center for Telehealth and Technology |
TBI | traumatic brain injury |
TMS | transcranial magnetic stimulation |
TrIOPS | Tri-service Integrator of Outpatient Programming Systems |
VA | Department of Veterans Affairs |
VBA | Veterans Benefits Administration |
VHA | Veterans Health Administration |
VISN | veterans integrated service network |
VLER | virtual lifetime electronic record |
WRC | Warrior Resilience Center |
WSDTT | Women’s Stress Disorder Treatment Team |
WTRP | Women’s Trauma Recovery Program |