Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment
In response to the attacks of September 11, 2001, the United States entered
into military conflicts in Iraq and Afghanistan. While prior wars and conflicts
have been characterized by such injuries as infectious diseases and catastrophic
gunshot wounds, the signature injuries suffered by U.S. military personnel
involved in these conflicts are blast wounds and the psychiatric consequences
of exposure to combat, particularly posttraumatic stress disorder (PTSD).
PTSD is triggered by a specific traumatic event, which can include
combat. The cluster of symptoms that characterize it include persistent reexperiencing
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.
An estimated 13 to 20 percent of the 2.6 million U.S. service members
who have fought in Iraq or Afghanistan since 2001 may have PTSD.
As the United States 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. Congress,
concerned by the number of service members and veterans at risk for, or
already diagnosed with, PTSD asked the DoD, in consultation with the VA,
to sponsor an Institute of Medicine (IOM) study to assess both departments’
PTSD treatment programs and services. This report, Treatment for Posttraumatic
Stress Disorder in Military and Veteran Populations: Initial Assessment, is
the first of two mandated in the National Defense Authorization Act for Fiscal
PTSD Risk, Resilience
Risk factors for military personnel developing
PTSD include combat experience, being
wounded, witnessing death, serving on graves
registration duty or handling human remains,
being captured or tortured, being exposed to
unpredictable and uncontrollable stress, and
experiencing sexual harassment or assault.
Higher rates of PTSD and depression are associated
with longer deployments, multiple deployments,
and greater time away from base camp. Car
and suicide bombs, improvised explosive devices,
and rocket-propelled grenades—all elements of
the recent Iraq and Afghanistan conflicts—can
exacerbate the already severe stress of combat,
according to the IOM committee’s report.
However, good leadership, support of others
in the unit, and training—which may bolster
positive mental health and well-being
during deployment—are protective factors
that can reduce the risk of developing PTSD.
Both the DoD and the VA provide an array of
prevention, screening, diagnosis, treatment, and
rehabilitation options with the respective aims of
maintaining force readiness and enabling veterans
to function well in daily life. The DoD has a number
of PTSD programs and services that can vary by
service branch. These programs and services provide
a range of PTSD management including outpatient
care, inpatient care, complementary and
alternative medicine therapies, and telemedicine.
In 2010, the VA medical system treated 438,091
veterans who had PTSD through specialized
treatment programs and in general mental health
and medical settings, including primary care.
(These veterans may have served in previous U.S.
military missions, not only in Afghanistan or Iraq.)
Working collaboratively, the DoD and the
VA in 2004 issued a joint guideline for managing
PTSD and revised the guideline in 2010, but it is
unknown whether their mental health providers
adhere to it. The DoD and the VA have issued
other joint guidelines for medical conditions that
military personnel can experience along with
PTSD, such as traumatic brain injury, substance
use disorders, depression, and chronic pain.
Analyze, Implement, Innovate, Overcome, and Integrate
To treat PTSD, the committee recommends the
use of treatments and therapies supported by
robust evidence, such as cognitive behavioral therapy.
However, the committee’s analysis of innovative
treatments—including yoga, acupuncture,
and animal-assisted therapy—was hampered by a
lack of empirical evidence on their effectiveness.
PTSD screening should be done at least once a
year, when DoD or its contract primary care providers
see service members, as is currently done
for veterans in the VA. The committee notes that
many validated instruments can be used to screen
service members and veterans for PTSD, but there
is insufficient evidence to recommend one screening
tool over another. Moreover, even a validated
screening tool is not sufficient to actually diagnose
PTSD. A diagnosis of PTSD requires a careful
and comprehensive clinical evaluation performed
by a qualified psychologist, social worker,
psychiatrist, or psychiatric nurse practitioner.
Of the U.S. service members who deployed to
Iraq and Afghanistan, only slightly more than half
of those diagnosed with PTSD actually received
treatment for it. The reasons for that treatment
gap may include patients’ concerns that the
stigma of PTSD may jeopardize their careers and
difficulties they may have getting to appointments
with mental health providers, particularly in
combat zones. Additional barriers to care include
providers who lack the necessary training to treat
PTSD and restrictions on PTSD medications
that can be used by active-duty service members
during deployment. One promising method
of increasing access to PTSD care is telemental
health, which delivers the expertise of trained
therapists to service members in remote locations
and to veterans who live in rural areas, allowing
patients to better manage their mental health
while reducing the time and expense of travel.
The DoD and the VA should build on their
efforts in early identification of service members
and veterans who have PTSD by providing timely
access to the best evidence-based care, the committee
recommends. To that end, the DoD and the
VA also should support research that investigates
emerging techniques and technology, including
telemedicine, Internet-based approaches, and
virtual reality, that may help to overcome barriers
to awareness, accessibility, availability, and adherence
to evidence-based treatments. Treatment
for PTSD should be integrated into the treatment
of other physical and mental health conditions
affecting service members and veterans.