National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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Treatment for

POSTTRAUMATIC STRESS DISORDER

in Military and Vetern Populations

Initial 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.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

THE NATIONAL ACADEMIES PRESS      500 Fifth Street, N.W.      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.

International Standard Book Number-13: 978-0-309-25421-2

International Standard Book Number-10: 0-309-25421-3

Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2012 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2012. Treatment for posttraumatic stress disorder in military and veteran populations: Initial assessment. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

Knowing is not enough; we must apply.
Willing is not enough; we must do.

—Goethe

image

INSTITITE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

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. Charles M. Vest 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. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.

www.nationalacademies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

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, New York, NY

Kathryn Basham, Professor and Editor, Co-Director of the PhD Program, College of Social Work, Smith College, Northampton, MA

Larry Culpepper, Professor and Chairman of the Department of Family Medicine, Boston University School of Medicine; Chief of Family Medicine, Boston Medical Center, MA

Jonathan Davidson, Emeritus Professor, Department of Psychiatry, Duke University Medical Center, Durham, NC

Edna Foa, Professor, Department of Psychiatry; Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania School of Medicine, Philadelphia

Kenneth Kizer, Director, Institute for Population Health Improvement; Professor, School of Medicine and Nursing, University of California, Davis

Karestan Koenen, Associate Professor, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY

Douglas Leslie, Professor, Department of Public Health Sciences and Department of Psychiatry, Pennsylvania State University, State College

Richard McCormick, Senior Scholar, Center for Health Care Research and Policy, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH

Mohammed Milad, Associate Professor, Department of Psychiatry, Harvard Medical School; Director of Behavioral Neuroscience Laboratory, Associate in Research Psychiatry, Massachussets General Hospital, Boston

Elspeth Cameron Ritchie, Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences; Chief Clinical Officer, Washington, DC, Department of Mental Health

Albert “Skip” Rizzo, Associate Director, Institute for Creative Technologies; Research Professor, Department of Psychiatry and School of Gerontology, University of Southern California, Los Angeles

Barbara O. Rothbaum, Associate Vice Chair of Clinical Research, Department of Psychiatry; Director, Trauma and Anxiety Recovery Program, Emory University School of Medicine, Atlanta, GA

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

Douglas Zatzick, Professor, University of Washington School of Medicine; Associate Vice Chair for Health Services Research, Medical Director of the Inpatient Consultation Liaison Service, University of Washington Harborview Level I Trauma Center, Seattle

Consultant

Carol Tamminga, Professor, Chairman, University of Texas Southwestern Medical Center, Dallas

Study Staff

Roberta Wedge, Study Director

Margot Iverson, Program Officer (through January 2012)

Anne Styka, Associate Program Officer

Rebecca Hebner, Senior Program Assistant (through March 2012)

Joi Washington, Senior Program Assistant (since April 2012)

Heidi Murray-Smith, Program Officer, Board on Environmental Studies and Toxicology

Norman Grossblatt, Senior Editor

Frederick Erdtmann, Director, Board on the Health of Select Populations vi

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

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

Joseph T. Coyle, Harvard Medical School

Johanna T. Dwyer, Tufts Medical Center

Mardi J. Horowitz, University of California, San Francisco

Israel Liberzon, University of Michigan

John Parrish, Massachusetts General Hospital

Alan Peterson, University of Texas Health Science Center at San Antonio

Gale S. Pollock, Pollock Associates, LLC

William E. Schlenger, Abt Associates Inc.

Murray Stein, University of California, San Diego

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Floyd E. Bloom, The Scripps Research Institute, and Jacquelyn C. Campbell, The Johns Hopkins University School of Nursing. Appointed by the National Research Council and 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.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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Preface

Posttraumatic stress disorder (PTSD) is one of the signature injuries of the U.S. engagements in Iraq and Afghanistan. Of the more than 2.6 million active-duty, National Guard, and reserve service members who have been deployed to Operation Enduring Freedom (OEF) in Afghanistan since 2001 and Operation Iraqi Freedom (OIF) since 2003, an estimated 13–20% of them have or may develop PTSD. Managing PTSD in those populations is a huge task for the Department of Defense (DoD) and the Department of Veterans Affairs (VA). The DoD and the VA have responded with substantial funding to foster research, develop programs, and initiate services to combat PTSD. Both departments are making strides in identifying and treating people who have PTSD, but there are many obstacles to the achievement of effective and timely treatments, from identifying those at risk for PTSD to using the best evidence-based treatments—psychotherapy, pharmacotherapy, or some combination. Diagnostic procedures and treatment options are not standardized with respect to who uses which approach and when. There is a need to ensure that service members and veterans who seek treatment receive it in a timely and thorough manner, and to make treatments available to those who are in remote locations or for whom access to treatment is difficult. Research is being conducted to identify the physiologic bases of reactions to trauma and to identify biomarkers for preventing and diagnosing PTSD, and for treating it.

The present two-phase Institute of Medicine (IOM) study is particularly timely, given the recent conclusion of OIF and the expectation that OEF will be winding down in the next few years. The charge given to this committee represents a serious commitment of the DoD and the VA to address health

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

care issues surrounding service members and veterans who have PTSD. This phase 1 report summarizes much of the literature on the burden of PTSD in service members and veterans, including National Guard and reservists, and explores the options available in the DoD and the VA for the prevention of, diagnosis of, and treatment for PTSD. In the second phase of its work, the committee will focus on the evaluation of data provided by the DoD and the VA and will investigate cost considerations, new neurobiologic findings, and the use of complementary and alternative treatments. Although the committee did visit one congressionally mandated site for this report (Fort Hood, Texas), in phase 2 it will undertake visits to at least two other Army sites—Fort Bliss, Texas, and Fort Campbell, Tennessee—and it hopes to visit other military bases and VA medical facilities to gain an appreciation of real-world successes and problems related to the diagnosis of and treatment for PTSD in these settings. The committee recognizes the burden that PTSD poses for many service members, veterans, and their families, and the pressing need to prevent it, diagnosis it, and treat for it in those who have given so much for this country.

The committee gratefully acknowledges the many individuals and groups who generously gave their time and expertise to share their insights on particular aspects of PTSD, who provided reports and data, and who answered queries about their work and experience in dealing, personally and professionally, with PTSD. Among the many people who helped the committee are staff of the DoD and the VA, researchers, staff of veteran and service member organizations, and members of the public who attended the committee’s open meetings. The committee also visited U.S. Army Garrison Fort Hood in Killeen, Texas, and expresses its appreciation for the time, insights, and personal stories offered by a variety of base staff, mental health providers, and service members who have PTSD and their families. The committee is also grateful to Roberta Wedge, who served as study director for this project, and to the IOM staff members who contributed to this project: Rebecca Hebner, Margot Iverson, Heidi Murray-Smith, Anne Styka, and Joi Washington. A thank you is also extended to William McLeod, who conducted database and literature searches.

Sandro Galea, Chair
Committee on the Assessment of Ongoing Efforts in the Treatment of
Posttraumatic Stress Disorder

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
×

Acronyms

ACT acceptance and commitment therapy
AFQ TArmed Forces Qualification Test
APA American Psychiatric Association
ASD acute stress disorder
BDN Fbrain-derived neurotrophic factor
BHOP Behavioral Health Optimization Program
BICEPS brevity, immediacy, centrality or contract, expectancy, proximity, and simplicity
CAM complementary and alternative medicine
CAPS Clinician-Administered PTSD Scale
CBCT cognitive-behavioral conjoint therapy
CBT cognitive behavioral therapy
CBT-MVA cognitive behavioral therapy–motor vehicle accident
CI confidence interval
CIDI Composite International Diagnostic Interview
CISD critical incident stress debriefing
COSC combat and operational stress control
COSR combat and operational stress reaction
CPT cognitive processing therapy
CRT cognitive rehabilitation therapy
CSC combat stress control
CSF Comprehensive Soldier Fitness
CT cognitive therapy
Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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CWT compensated work therapy
DART deployment anxiety reduction training
DCoE Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury
DCS D-cycloserine
DIS-IV Diagnostic Interview Schedule
DNA deoxyribonucleic acid
DoD Department of Defense
DSM-IV Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition
EFT emotional freedom technique
EMDR eye movement and desensitization reprocessing
FOCUS Families OverComing Under Stress
FORT functional and occupational rehabilitation treatment
FY fiscal year
GABA gamma-aminobutyric acid
GAF global assessment of function
GAO Government Accountability Office
GAT global assessment tool
HBOT hyperbaric oxygen therapy
HOPE Helping to Overcome PTSD with Empowerment
HPA hypothalamic-pituitary-adrenal
HT hydroxytryptamine
IED improvised explosive device
IOM Institute of Medicine
IPAP International Psychopharmacology Algorithm Project
IPT interpersonal therapy
IPV intimate partner violence
IQ intelligence quotient
IRT imagery rehearsal therapy
ISTSS International Society for Traumatic Stress Studies
MANSA Manchester Short Assessment of Quality of Life
MAO monoamine oxidase
MAOI monoamine oxidase inhibitor
MHAT Mental Health Advisory Team
MHS military health system
Page xvii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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MINI Mini-International Neuropsychiatric Interview
MRI magnetic resonance imaging
MST military sexual trauma
mTBI mild traumatic brain injury
MTF military treatment facility
NCS National Comorbidity Study
NCS-R National Comorbidity Study-Replication
NHMRC National Health and Medical Research Council
NICE National Institute for Health and Clinical Excellence
NIH National Institutes of Health
NIMH National Institute of Mental Health
NMDA n-methyl-d-aspartate
NVVRS National Vietnam Veterans Readjustment Study
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OMHO Office of Mental Health Operations (VA)
OND Operation New Dawn
OR odds ratio
OSCAR operational stress control and readiness
PCL PTSD Checklist
PC-PTSD Primary Care PTSD screen
PDHA Post-Deployment Health Assessment
PDHRA Post-Deployment Health Reassessment
PE prolonged exposure
PHA Periodic Health Assessment
PSS-I PTSD Symptom Scale—Interview Version
PTSD posttraummatic stress disorder
RAS reticular activating system
RCT randomized controlled trial
REACH Reaching Out to Educate and Assist Caring, HealthyFamilies
REM rapid eye movement
RESPECT-Mil Re-Engineering Systems for Primary Care Treatmentof Depression and PTSD in the Military
RNA ribonucleic acid
rTMS repetitive transcranial magnetic stimulation
SCCIP-ND Surviving Cancer Completely Intervention Program–Newly Diagnosed
SIP Structured Interview for PTSD
Page xviii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2012. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Washington, DC: The National Academies Press. doi: 10.17226/13364.
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SIT stress inoculation training
SKY Sudarshan Kriya yoga
SNRI serotonin norepinephrine reuptake inhibitor
SPRINT Short Post-Traumatic Stress Disorder RatingInterview
SRI serotonin reuptake inhibitor
SSRI selective serotonin reuptake inhibitor
STAIR Skills Training in Affect and Interpersonal Regulation
STRONG STAR South Texas Research Organizational NetworkGuiding Studies on Trauma and Resilience
TBI traumatic brain injury
TMH telemental health
USUHS Uniformed Services University of the Health Sciences
VA Department of Veterans Affairs
VBA Veterans Benefit Administration
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
VR virtual reality
VRE virtual reality exposure therapy
WHOQOL-100 World Health Organization Quality of LifeAssessment
WL wait list
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Prior to the military conflicts in Iraq and Afghanistan, wars and conflicts have been characterized by such injuries as infectious diseases and catastrophic gunshot wounds. However, the signature injuries sustained by United States military personnel in these most recent conflicts are blast wounds and the psychiatric consequences to combat, particularly posttraumatic stress disorder (PTSD), which affects an estimated 13 to 20 percent of U.S. service members who have fought in Iraq or Afghanistan since 2001. PTSD is triggered by a specific traumatic event - including combat - which leads to symptoms such as persistent re-experiencing of the event; emotional numbing or avoidance of thoughts, feelings, conversations, or places associated with the trauma; and hyperarousal, such as exaggerated startle responses or difficulty concentrating.

As the U.S. reduces its military involvement in the Middle East, the Departments of Defense (DoD) and Veterans Affairs (VA) anticipate that increasing numbers of returning veterans will need PTSD services. As a result, Congress asked the DoD, in consultation with the VA, to sponsor an IOM study to assess both departments' PTSD treatment programs and services. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment is the first of two mandated reports examines some of the available programs to prevent, diagnose, treat, and rehabilitate those who have PTSD and encourages further research that can help to improve PTSD care.

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