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.
The issues are far from new, according to the IoM study. The authors cited a 1997 study that compared outcomes for long-stay SIPPs with short-stay specialized PTSD programs and general psychiatric units and found patients in all three showed improvements at discharge that disappeared over the course of a year, particularly among veterans who participated in the longer and substantially more expensive programs. “It is unclear why, after more than 15 years of poorly sustained outcomes and high costs, the VA has not used these findings on the SIPPs to improve care for veterans who are being treated for PTSD,” the authors question.
The committee did not tackle what outcome measures the VA and DOD should use to assess treatment effectiveness.
“We don’t recommend specific measures and, in fact, defer to the National Quality Forum, but the PTSD checklist is certainly one that is used frequently by clinicians and researchers alike,” explained committee member Barbara O. Rothbaum, PhD, associate vice chair of clinical research, professor in psychiatry, and director of the trauma and anxiety recovery program at Emory University School of Medicine in Atlanta.
No Evidence Basis
In specialized and primary care settings, treatment should be guided by the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress, which provides guidelines for selecting an evidence-based treatment, managing comorbidities and using psychosocial treatments and pharmacotherapies that do not meet the requirements for first-line recommendations, according to the report. “The committee was concerned to learn that mental healthcare providers in both departments do not consistently provide evidence-based treatment at levels that would be expected in a high-performing PTSD management system,” and many patients do not receive the first-line treatments of prolonged exposure (PE) and cognitive processing therapy (CPT).
The IoM committee’s first report noted that PE, CPT, eye movement desensitization and reprocessing (EMDR) and stress inoculation training (SIT) are evidence-based treatments for PTSD, and they are recommended in the VA/DoD clinical practice guidance, Rothbaum noted.
Besides these recommended therapies, many other treatments are used that have not been validated by randomized clinical trials, Rothbaum told U.S. Medicine. Those treatments include “other types of cognitive behavioral therapy, in particular, and also group therapies and what are known as CAM — complementary and alternative medicine, such as yoga,” she said.
The authors wrote that servicemembers or veterans may not receive first-line psychotherapy because providers have heavy workloads and may lack time to schedule patients for the requisite number of visits in the recommended time frame or because patients are not prepared to enter trauma-focused therapy. In these instances, complementary and alternative therapies may engage patients in specialized PTSD programs. The authors expressed concern that the VA and DOD ensure that the adjunctive treatments did not deter patients from receiving first-line treatments.
Overview of IoM Committee Recommendations
- DoD and VA should develop an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for servicemembers, veterans, and their families, including female veterans and minority group members.
- DoD and VA leaders should communicate a clear mandate through their chain of command that PTSD management, using best practices, has high priority.
- 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.
- DoD and VA should have available an adequate workforce of mental healthcare providers—both direct care and purchased care—ancillary staff, and resources to meet the growing demand for PTSD services. This includes clear training standards, referral procedures, and patient monitoring and reporting requirements for all their mental healthcare providers.
- Both departments should use evidence-based treatments as the treatment of choice for PTSD, and these treatments should be delivered with fidelity to their established protocols. Any new programs and services should be piloted and include an evaluation process to establish the evidence base on their efficacy and effectiveness.
- DoD and VA should establish a central database or other directory for programs and services that are available to servicemembers and veterans who have PTSD.
- DoD and VA should increase engagement of family members in the PTSD management process for servicemembers and veterans.
- PTSD research priorities in DoD and VA should reflect the current and future needs of servicemembers, veterans, and their families. Both departments should continue to develop and implement a comprehensive plan to promote a collaborative, prospective PTSD research agenda