WASHINGTON -- The U.S. Department of Defense and U.S. Department of Veterans Affairs should track the outcomes of treatment for post-traumatic stress disorder (PTSD) provided to service members and veterans and develop a coordinated and comprehensive strategy to do so, says a new congressionally mandated report from the Institute of Medicine. Without tracking outcomes, neither DOD nor VA knows whether it is providing effective or adequate PTSD care, for which they spent $294 million and more than $3 billion, respectively, in 2012. The report is the second of a two-phase assessment of PTSD services for service members and veterans and echoes the findings of the first report, issued in 2012.
An estimated 5 percent of all service members in the military health system have been diagnosed with PTSD, and the prevalence is 8 percent for those who have served in Iraq and Afghanistan, the report notes. The number of veterans of all eras who sought care for PTSD from the VA more than doubled from 2003 to 2012 -- from approximately 190,000 veterans (4.3 percent of all VA users) in 2003 to more than a half million veterans (9.2 percent of all VA users) in 2012. For those treated for PTSD in the VA system in 2012, 23.6 percent (119,500) were veterans of the Iraq and Afghanistan wars.
DOD and VA have a multitude of programs and services that range in their intensity to prevent, screen for, diagnose, and treat current and former service members who have PTSD or who are at risk for it. Right now, DOD's PTSD treatment programs appear to be local, ad hoc, incremental, and crisis-driven, with little planning devoted to the development of a long-range approach to obtaining desired outcomes, the report says. VA's PTSD programs have a more unified organizational structure, and the agency is able to ensure more consistency of treatment. However, without data on which treatments patients are receiving and whether they are improving as a result of their treatment, the departments have no way of knowing whether the care they are providing is effective or whether DOD and VA's expenditures are resulting in high-value health care, said the committee that wrote the report.
"Given that the DOD and VA are responsible for serving millions of service members, families, and veterans, we found it surprising that no PTSD outcome measures are used consistently to know if these treatments are working or not," said committee chair Sandro Galea, professor and chair of the department of epidemiology, Mailman School of Public Health, Columbia University, New York City. "They could be highly effective, but we won't know unless outcomes are tracked and evaluated." An exception, the committee noted, are VA's specialized intensive PTSD programs, which are collecting outcomes data. Nevertheless, these programs serve only 1 percent of veterans who have PTSD, and the data suggest the programs yield only modest improvements in symptoms.
The report recommends that DOD and VA develop, coordinate, and implement a measurement-based PTSD management system that documents patients' progress over the course of treatment, regardless of where they receive treatment, and does long-term follow-up using standardized and validated instruments. Reliable and valid self-report measures, such as the PTSD Checklist, are available and could be used to monitor patient progress and guide modifications of individual treatment plans.
Current DOD and VA strategic efforts do not necessarily encourage the use of best practices for preventing, screening for, diagnosing, and treating PTSD, the committee observed. In DOD and the service branches, leaders at all levels are not consistently held accountable for implementing policies and programs to manage PTSD effectively. And although the VA's central office has established policies on minimum care requirements and guidance on PTSD treatment, it is unclear whether VA leaders adhere to the policies, encourage staff to follow the guidance, or use the data available from its specialized PTSD programs to improve the way they manage the disorder.
DOD and VA leaders, who are responsible for delivering high-quality care for their populations, should communicate a clear mandate through their chain of command that PTSD management, using best practices, has high priority, the report says. Leadership accountability can also help ensure that information on PTSD programs and services is collected and that their success is measured and reported.
The report also recommends that DOD and VA have an adequate workforce of mental health care providers to meet the growing demand for PTSD services. While the departments have substantially increased their mental health staffing, the increases do not appear to have kept pace with the demand for PTSD services. Staffing shortages can result in clinicians not having time to provide evidence-based psychotherapies readily. In 2013, only 53 percent of veterans of the Iraq and Afghanistan wars who had a primary diagnosis of PTSD and sought care in the VA had received the recommended eight sessions within 14 weeks.
The report contains additional noteworthy findings, including:
- PTSD has also increased among veterans of other eras of conflict. In 2013, 62,536 new cases of PTSD in the VA were diagnosed in veterans who did not serve in the Iraq and Afghanistan wars, and 34 percent of new admissions to VA specialized PTSD programs in 2012 were Vietnam-era veterans.
- Veterans of the Iraq and Afghanistan wars use the VA at rates double those of other veterans -- 54 percent of Iraq and Afghanistan war veterans use the VA versus 27 percent of all veterans.
- PTSD is the third most common major service-connected disability after hearing loss and tinnitus.
- In 2012, 13.5 percent of soldiers in the U.S. Army had a diagnosis of PTSD, as did 10 percent of Marines, 4.5 percent of Navy personnel, and 4.4 percent of Air Force personnel.
The study was sponsored by the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.
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Pre-publication copies of Treatment for Post-traumatic Stress Disorder in Military and Veteran Populations: Final Assessment are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.
INSTITUTE OF MEDICINE Board on the Health of Select Populations
Committee on the Assessment of Ongoing Efforts in the Treatment of Post-traumatic Stress Disorder
Sandro Galea, M.D., Dr.P.H., M.P.H. (chair) Anna Cheskis Gelman and Murray Charles Gelman Professor and Chair Department of Epidemiology Mailman School of Public Health Columbia University New York City
Kathryn Karusaitis Basham, Ph.D., M.S.W. Professor and Co-Director of Ph.D. Program School for Social Work Smith College Northhampton, Mass.
Larry Culpepper, M.D., M.P.H Professor of Family Medicine Boston University Medical Center Boston
Jonathan R. Davidson, M.D. Emeritus Professor Department of Psychiatry Duke University Medical Center Seabrook Island, S.C.
Edna B. Foa, Ph.D. Professor Department of Psychiatry, and Director Center for the Treatment and Study of Anxiety School of Medicine University of Pennsylvania Philadelphia
Kenneth W. Kizer, M.D., M.P.H. Distinguished Professor School of Medicine and Betty Irene Moore School of Nursing University of California Davis, and Director Institute for Population Health Improvement UC Davis Health System Sacramento
Karestan C. Koenen, Ph.D. Associate Professor Department of Epidemiology Mailman School of Public Health Columbia University New York City
Douglas L. Leslie, Ph.D. Professor Department of Psychiatry and Department of Public Health Services Pennsylvania State University Hershey
Richard A. McCormick, Ph.D. Senior Scholar Center for Health Care Research and Policy Case Western Reserve University MetroHealth Medical Center Cleveland
Mohammed R. Milad, Ph.D. Assistant Professor Department of Psychiatry, Director Behavioral Neuroscience Laboratory, and Associate in Research Psychiatry Massachusetts General Hospital Charlestown
William P. Nash, M.D. Adjunct Assistant Professor University of California, San Diego, and Virginia Commonwealth University Vienna
Elizabeth A. Phelps, Ph.D. Silver Professor of Psychology and Neural Science Department of Psychology and Center for Neural Science New York University New York City
Elspeth C. Ritchie, M.D. Clinical Professor of Psychiatry Georgetown University; and Chief Clinical Officer District of Columbia Department of Behavioral Health Washington, D.C.
Albert Rizzo, Ph.D. Professor and Associate Director Institute for Creative Technologies Research University of Southern California Playa Vista
Barbara O. Rothbaum, Ph.D. Associate Vice Chair for Clinical Research, Professor in Psychiatry, and Director, Trauma and Anxiety Recovery School of Medicine Emory University Atlanta
Douglas F. Zatzick, M.D. Professor Associate Vice Chair for Health Services Research Department of Psychiatry and Behavioral Sciences School of Medicine University of Washington Seattle
Roberta Wedge Study Director