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Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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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.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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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.

International Standard Book Number-13: 978-0-309-30173-2

International Standard Book Number-10: 0-309-30173-4

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 2014 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). 2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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

                                                —Goethe

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INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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.

www.nationalacademies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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.

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

Preface

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

Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

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

Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×

Abbreviations and Acronyms

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
 
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
×
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
 
Suggested Citation:"Front Matter." Institute of Medicine. 2014. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Washington, DC: The National Academies Press. doi: 10.17226/18724.
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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
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Posttraumatic stress disorder (PTSD) is one of the signature injuries of the U.S. conflicts in Afghanistan and Iraq, but it affects veterans of all eras. It is estimated that 7-20% of service members and veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom may have the disorder. PTSD is characterized by a combination of mental health symptoms - re-experiencing of a traumatic event, avoidance of trauma-associated stimuli, adverse alterations in thoughts and mood, and hyperarousal - that last at least 1 month and impair functioning. PTSD can be lifelong and pervade all aspects of a service member's or veteran's life, including mental and physical health, family and social relationships, and employment. It is often concurrent with other health problems, such as depression, traumatic brain injury, chronic pain, substance abuse disorder, and intimate partner violence.

The Department of Defense (DoD) and the Department of Veterans Affairs (VA) provide a spectrum of programs and services to screen for, diagnose, treat for, and rehabilitate service members and veterans who have or are at risk for PTSD. The 2010 National Defense Authorization Act asked the Institute of Medicine to assess those PTSD programs and services in two phases. The Phase 1 study, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment, focused on data gathering. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment is the report of the second phase of the study. This report analyzes the data received in Phase 1 specifically to determine the rates of success for each program or method.

Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment considers what a successful PTSD management system is and whether and how such a system is being implemented by DoD and VA. This includes an assessment of what care is given and to whom, how effectiveness is measured, what types of mental health care providers are available, what influences whether a service member or veteran seeks care, and what are the costs associated with that care. This report focuses on the opportunities and challenges that DoD and VA face 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 report also identifies where gaps or new emphases might be addressed to improve prevention of, screening for, diagnosis of, and treatment and rehabilitation for the disorder. The findings and recommendations of Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment will encourage DoD and VA to increase their efforts in moving toward a high-performing, comprehensive, integrated PTSD management strategy that addresses the needs of current and future service members, veterans, and their families.

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