Institute of Medicine: DOD, VA Fail at Tracking Outcomes of PTSD Treatments

By Annette M. Boyle

WASHINGTON – One of the signature injuries of the wars in Iraq and Afghanistan, post-traumatic stress disorder (PTSD), affected 13.5% of soldiers and caused 502,000 veterans to seek treatment in 2012. Despite the ubiquity of the disorder, DOD and VA employ no consistent measures to determine the effectiveness of the treatments received by millions of servicemembers and veterans, according to the Institute of Medicine (IoM).

As a result, neither the DOD nor the VA can determine which treatments work best or whether some treatments work at all. Yet, in 2012, DOD spent $294 million and the VA spent more than $3 billion on PTSD treatments.

“Given that the DOD and VA are responsible for serving millions of servicemembers, families, and veterans, we found it surprising that no PTSD outcome measures are used consistently to know if these treatments are working or not,” said IoM committee chair Sandro Galea, professor and chair of the department of epidemiology, Mailman School of Public Health at Columbia University in New York. “They could be highly effective, but we won’t know unless outcomes are tracked and evaluated.”

The current IoM report, “Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment,” is the second in a two-phase study authorized by Congress in 2010 to look at the effectiveness of PTSD programs and services offered by the DOD and VA.

Lack of Coordination

The committee found that DOD’s PTSD treatments tend to be “local, ad hoc, incremental and crisis-driven, with little planning devoted to the development of a long-range approach to this disorder.” Each branch has its own programs for prevention, screening and treatment and its own training for mental health professionals. Implementation is left to the service branch’s surgeon general, installation commander or military treatment facility (MTF) leader.

Treatment outcomes have not been tracked for most specialized PTSD programs by the services, according to the findings. One exception noted by the committee is the National Intrepid Center of Excellence, which has a small amount of short-term outcome data. The center treats servicemembers with severe PTSD and traumatic brain injury.

More outcomes data may be available shortly, however. The Army has rolled out the Behavioral Health Data Portal (BHDP) in its MTFs, and the Air Force and Navy plan to use the portal to standardize data collection. With the portal, servicemembers will complete a PTSD assessment prior to each mental health appointment, and clinicians will have access to their responses during each appointment. While promising, the BHDP is still in its early stages and no information on outcomes or patient or provider satisfaction have been reported yet.

The VA’s PTSD treatment programs have a more unified structure and use a more consistent approach based on the Uniform Mental Health Services handbook. Yet, even in the VA, outcome measures are not consistently used or tracked, except in the specialized intensive PTSD programs, according to the report. The committee noted that during the nearly four years that it researched and deliberated, the VA repeatedly announced that modification of electronic health records to permit clinicians to enter the types of psychotherapy patients are receiving was “imminent” but that the modification had not occurred as of June.

Where the VA does collect outcomes data, including scores on the PTSD checklist, Northeast Program Evaluation Center PTSD scale, and Mississippi short form, from its specialized inpatient PTSD programs (SIPPs), “it appears that at on the basis of those data, many of the patients in those programs show little improvement after treatment,” according to the authors.

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