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

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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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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.

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OF THE NATIONAL ACADEMIES

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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

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

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

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.

Contents

Preface

Acronyms

Summary

1 Introduction

Committee’s Charge

Committee’s Approach

Organization of the Report

References

2 History, Diagnostic Criteria, and Epidemiology

History of PTSD

Diagnostic Criteria for PTSD

Epidemiology of PTSD in the General Population

Epidemiology of PTSD in Military and Veteran Populations

Summary

References

3 Neurobiology

Adaptive and Maladaptive Stress Responses

Models for the Development of PTSD

Factors That Influence the Development of PTSD

Implications for PTSD Prevention, Diagnosis, and Treatment

Biomarkers

Summary

References

4 Programs and Services for PTSD in the Department of Defense and the Department of Veterans Affairs

The Department of Defense Health Care System

Mental Health Care in the Department of Defense

Transitioning Between the Department of Defense and the Department of Veterans Affairs Health Care Systems

The Department of Veterans Affairs Health Care System

Mental Health Care in the Department of Veterans Affairs

Collaborative Efforts Between the Department of Defense and the Department of Veterans Affairs

Research in the Department of Defense and the Department of Veterans Affairs

Cost Considerations

Summary

References

5 Prevention

Overview of PTSD Prevention

Pretrauma Prevention Efforts

Interventions for Trauma-Exposed People

Prevention in the Department of Defense

Prevention in the Department of Veterans Affairs

Summary

References

6 Screening and Diagnosis

Screening

Considerations Regarding Screening in the Department of Defense and the Department of Veterans Affairs

Screening in Primary Care

Screening Tools

Diagnosis

Quality of Life, Disability, and Resilience Measures

Summary

References

7 Treatment

Psychosocial Treatments for Chronic PTSD

Pharmacotherapy

Combined Psychotherapy and Pharmacotherapy Approaches

Integrative Collaborative Care

Emerging Therapies for PTSD

Guidelines for Treatment of PTSD

Summary

References

8 Co-Occurring Psychiatric and Medical Conditions and Psychosocial Complexities

Co-Occurring Psychiatric Conditions and PTSD

Co-Occurring Medical Conditions and PTSD

Co-Occurring Psychosocial Problems and PTSD

Summary

References

9 Access to Care

Barriers to Care

Barriers to Delivery of Evidence-Based Care

Facilitators of Care for PTSD

Summary

References

10 Findings and Recommendations

Analyze

Implement

Innovate

Overcome

Integrate

Phase 2

References

Appendixes

A Committee Member Biographies

B Congressional Legislation

C Posttraumatic Stress Disorder Programs in the Department of Defense

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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

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

Acronyms