There needs to be better systems for the prevention of posttraumatic stress disorder (PTSD) in military personnel and for screening, diagnosis, and treatment when it does occur, according to a new report from the Institute of Medicine (IOM).
Although the Department of Defense (DOD) and the Department of Veterans Affairs (VA) offer many programs for PTSD, “treatment isn’t reaching everyone who needs it, and the departments aren’t tracking which treatments are being used or evaluating how well they work in the long term,” Sandro Galea, MD, DrPH, chair of the IOM committee that produced the consensus report, said in a press release issued Friday.
“In addition, DOD has no information on the effectiveness of its programs to prevent PTSD,” added Galea, who is professor and chair of the department of epidemiology at Columbia University in New York City.
PTSD – which is characterized by persistent re-experiencing of trauma, avoidance of trauma-related stimuli, and persistent hyperarousal – is occurring in an estimated 13% to 20% of veterans who have returned from Iraq or Afghanistan since 2001, according to the report.
The authors list several known risk factors for the disorder in military populations, including:
Experiencing combat
Being wounded
Witnessing death
Serving on graves registration duty or handling remains
Being taken captive or tortured
Experiencing unpredictable and uncontrollable stressful exposure
Experiencing sexual harassment or assault
To further explore the issue of how veterans with PTSD are cared for, the IOM’s Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder was convened with the purpose of gathering data from the DOD and VA on their programs for an initial report on PTSD prevention, screening, diagnosis, treatment, and rehabilitation. The committee’s second report, to be issued later, will focus on the success rates of the programs and make recommendations for areas of future PTSD research.
Some of the committee’s findings included:
Prevention: The DOD is addressing prevention of PTSD in two ways, the committee found: by educating troops before they deploy on ways of dealing with deployment-related stressors, and by intervening as soon as possible after a service member is exposed to trauma.
Many predeployment programs “[have] several layers of training for enlisted service members and officers and [include] concepts of positive psychology and individual hardiness, and factors such as a positive command climate, unit cohesion, social support, and confidence in the military mission and training,” the authors noted. “At present, however, there is no empirical evidence regarding the effectiveness of these approaches.”
Screening: Although there are many different tools available to screen for PTSD, “the evidence is insufficient to support recommending one tool over another,” according to the committee. However, the committee did note that “service members who received care in an integrated mental health and primary care setting had significantly reduced psychologic distress and improved clinical outcomes.”
In particular, the report cited the Army’s RESPECT-Mil (Re-Engineering Systems for Primary Care Treatment of Depression and PTSD in the Military) program, as an example of a successful screening approach. In RESPCT-Mil, primary care providers are trained to screen and treat soldiers for PTSD and depression at every visit.
Treatment: The committee found that although all branches of the military “have some type of PTSD treatment program,” there is no central place at the DOD or at any branch of the service that maintains a complete listing of them or that could direct military personnel to the programs best suited to them.
The PTSD therapies that had the strongest evidence of effectiveness included exposure therapy – in which patients are exposed to and confront trauma-related memories and stimuli – and cognitive behavioral therapy. Eye movement desensitization and reprocessing (EMDR) therapy, in which patients get access to and then reprocess traumatic memories – also has been shown to be effective, according to the report.
As to pharmacologic therapies, PTSD treatment guidelines generally recommend the use of “antidepressants, specifically, a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI), as a first-line treatment,” the report noted. “However, although two studies of Bosnian and Iranian veterans demonstrated the efficacy of SSRI treatment for PTSD, no positive trials have been conducted in U.S. veterans.”
Access to Care: Just slightly more than half of service members and veterans who served in Iraq and Afghanistan and have screened positive for PTSD have received treatment, the authors wrote. They listed several patient barriers to treatment, including concerns that seeking treatment may affect the service member’s military career, the perception that mental healthcare is not effective, lack of information on ways to get care, and financial concerns.
“For providers, barriers to treating patients with PTSD might include lack of training, lack of time, and treatment location issues, such as transportation in the theater of war,” they said.
Overall, “the DOD and the VA have made progress in early identification of service members and veterans who have PTSD,” the report concluded. “This progress needs to be followed by timely access to the best evidence-based care.”
###
By Joyce Frieden, News Editor, MedPage Today