IOM Assesses Efforts to Prevent and Treat PTSD Among Service Members and Veterans

A new Institute of Medicine (IOM) report describes efforts by the U.S. Department of Defense (DoD) and the Department of Veterans Affairs (VA) to combat posttraumatic stress disorder (PTSD). The report commends both departments for offering an array of prevention, screening, diagnosis, treatment, and rehabilitation options and for investing in research, programs, and services, including joint development of a clinical practice guideline for PTSD. However, improvements are needed in several areas, according to the report.

“DOD and VA offer many programs for PTSD, but 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,” said IOM panel chair Sandro Galea, M.D., Dr.P.H., of Columbia University. The report also noted that neither the DoD nor the VA is doing enough to integrate PTSD treatments into care that is provided for common comorbid conditions, such as substance use disorders.

A total of 2.6 million U.S. military personnel have served in Iraq or Afghanistan since 2001, including those who are currently there. It is estimated that from 13% to 20% already have or will develop PTSD. In 2010, concerned by the rising incidence of PTSD among active service members and veterans, Congress asked the DoD, in consultation with the VA, to fund a study of PTSD programs in both departments. At the Pentagon's request, the IOM convened a 14-member panel of experts in the fields of psychiatry, social work, family medicine, and public health.

The 396-page report, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment, is the first of two studies mandated by Congress. It is based on an extensive literature search; two public information-gathering sessions; and meetings with mental health providers and with patients and their families. Separate chapters provide overviews of the epidemiology and neurobiology of PTSD and common comorbid conditions; best practices in prevention, screening, and treatment; descriptions of promising DoD and VA programs; and recommendations for addressing the panel's concerns. In the second report, due out in 2014, the panel hopes to refine its findings and recommendations by analyzing more detailed data now being gathered by the DoD and VA.

The panel grouped its current recommendations into five action areas: analyze, implement, innovate, overcome, and integrate. To better analyze effectiveness and move toward measurement-based PTSD care, both the DoD and the VA should be collecting data before, during, and after treatment; entering these data into patients' medical records; and making deidentified data accessible to researchers. Specific research programs should be instituted, especially on the effectiveness of DoD's prevention programs to promote resilience and train troops in the rigors of deployment.

In the area of implementation, the panel recommends that DoD follow the lead of the VA and institute annual PTSD screening of service members when they are seen by primary care providers at DoD military treatment facilities or at TRICARE provider locations. In the area of innovation, the DoD and VA should conduct more research on the specialized intensive PTSD programs that they offer, including emerging treatments in complementary and alternative medicine. Because innovative treatment approaches will emerge from a better understanding of the neurobiology of PTSD, the panel recommends that both departments make greater investments in this area.

Barriers to awareness, accessibility, availability, acceptability, and adherence are common and need to be overcome. In this area, the panel strongly recommends research on emerging technologic approaches—mobile, telemedicine, Internet-based, and virtual reality. In the final recommendation area, the panel found three types of integration that are needed. First, PTSD screening, diagnosis, and treatment must be integrated into a variety of clinical settings. Second, PTSD treatment should be integrated with treatments for common comorbid conditions, such as traumatic brain injury and intimate partner violence. Third, various treatment options should be integrated and combined.

The report is available on the IOM Web site at books.nap.edu/catalog.php?record_id=13364. Shortly before the report's release the National Alliance on Mental Illness published a 14-page issue brief, Parity for Patriots: The Mental Health Needs of Military Personnel, Veterans and Their Families, calling for Purple Heart medals to be awarded for psychological wounds such as PTSD (www.nami.org).