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.

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

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

                                                —Goethe

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

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.

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

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

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

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.

Contents

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

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