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Damn Interesting Reading
National Academies of
Science | Engineering | Medicine

Key Information from Institute of Medicine – the following is taken from the document below. Also note the press release that National Academies put out – it is where the Institute of Medicine resides.

Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment June 20, 2014 http://www.iom.edu/Reports/2014/Treatment-for-Posttraumatic-Stress-Disorder-in-Military-and-Veteran-Populations-Final-Assessment.aspx

This report was requested by congress via the 2010 National Defense Authorization Act to look at the effectiveness of the growing number of PTSD programs and services that are available for service members and veterans in the DoD and VA, respectively. (Note – is report does focus on those diagnosed with PTSD which does not cover everyone dealing with readjustment issues only, those not diagnosed with PTSD and the more than 40% who have not sought care by through the DoD and or VA).

Press release

Date: June 20, 2014
http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=18724

FOR IMMEDIATE RELEASE

Effectiveness of PTSD Treatment Provided by Defense Department and VA Unknown;
Tracking of Outcomes Needed to Manage Growing Burden

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. …more

Excerpts from IOM Report:

(Page 1 Summary) – thought helpful to put in their definition of PTSD.
PTSD is characterized by a combination of mental health symptoms—re-experiencing of a traumatic event, avoidance of trauma-associated stimuli, adverse alterations in thoughts and mood, and hyper-arousal—that last at least 1 month and impair functioning.

PTSD can be lifelong and pervade all aspects of a service member’s or veterans life, including mental and physical health, family and social relationships, and employment. It is often concurrent with other health problems, such as depression, traumatic brain injury (TBI), chronic pain, substance use disorder, and intimate partner violence.

(Page 3 Prevalence)

In 2012, 13.5% of soldiers (ARMY) had a diagnosis of PTSD, as did 10% of Marines, 4.5% of Navy personnel and 4% of Air Force personnel.
More military women than men (13% vs 9%) as did nonwhites than whites (11% vs 8.5%)
In 2012 about 502,000 veterans made at least two visits to the VA for PTSD outpatient care; they make up 9% of all users of the VA health services. Of all entering specialized outpatient PTSD programs – 47% were OIF/OEF, 20% were Gulf War era and 34% Vietnam era.

In 2012 of the OIF/OEF veterans that use the VA health care – 23.6% had a diagnosis of PTSD.

The report does note that the numbers have grown over the years and they expect they will continue to grow

(Page 4 & 5 Programs/Services)

In the DoD, programs and services are implemented by individual service branches and Tricare – programs are intended to “foster mental resilience, preserved mission readiness, and mitigate adverse consequences of exposure to stress – non are PTSD specific”. They offer complementary treatments and also inpatient PTSD programs.
Outcome data on which to determine the effectiveness of these programs in either the short term or long term are not available.

The VA offers a full array of services; other evidence based complementary therapies are offered as an adjunct as well as services via the Vet Centers. No treatment outcome data are collected in any general mental health clinic, Vet Center or specialized outpatient PTSD programs (SOPP). Outcome data is being collected at the Specialized Intensive PTSD program (SIPP) but suggest that there are only modest improvements in PTSD symptoms after treatment in these programs.


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(Page 5 & 6 Findings/Recommendations)

PTSD management in DoD appears bot be local ad hoc, incremental and crisis driven with little planning developed to the development of a long-range, population based approach for the disorder.

Each branch of service establishes its own prevention programs, trains its own mental health staff, had has its own programs and services for PTSD treatment.

VA has a more unified organizational structure than the DoD and is able to ensure a more consistent approach…its plans include improving quality and accessibility of mental health care, in part, by increasing capacity and outreach to veterans and their families…However, there are few data to indicate that the PTSD-related performance measures are being met.

Although the DoD and VA are coordinating strategic efforts…these efforts have not proven to be sufficient to determine whether PTSD management is improving or that a population based approach is being used to reach and treat all service members and veterans in need of care for PTSD. Furthermore, current DoD and VA strategic efforts do not necessarily encourage the use of best practices for preventing, screening for and diagnosing, and treating PTSD and its co-morbidities, and they do not extend to ensuring continuity of care for service members as they transition from active duty to veteran status.

Recommendation A: DoD and VA should develop an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veteran, and their families, including female veterans and minority group members.

(page 6 Leadership)

A lack of communication among the mental health leaders and clinicians in the DOD can lead to use of redundant, expensive and perhaps ineffective programs and services while other programs, may be more effective, languish or disappear.

(Page 7, 8 & 9 Performance Measurement)

Given the DoD and VA are responsible for serving millions of service members, families and veterans, it is surprising that no PTSD outcome measures of any type for psychotherapy or pharmacological-therapy are consistently used or tracked in the short or long term with the exception of the VA SIPPs.

Recommendation C: DoD and VA should develop, coordinate and implement a measurement-based PTSD system that document patients’ progress over the course of treatment and long-term follow-up with standardized and validated instruments.

(page 8 Workforce/Access to Care)

DoD and VA have substantially increased their mental health staffing – both direct care and purchased care. However, staffing increases do not appear to have kept pace with the demand for PTSD services, including specialized programs. DoD and VA acknowledge that it can be difficult to hire and retain staff in underserved areas in spite of targeted efforts to do so.

In 2013, on 53% of the OEF and OIF veterans who had a primary diagnosis of PTSD and sought care in the VA received the recommend 8 sessions within 14 weeks.

Although expanding the number of staff to meet the needs may be necessary, it may also be possible to achieve equal or better results with more efficient use of existing staff and by having existing staff use the most effective programs and services.

Recommendation D: DoD and VA should have available an adequate workforce of mental health providers both direct care and purchased care- and ancillary staff to meet the growing demand forPTSD services. DoD and VA should develop and implement clear training standards, referral procedures, and patient monitoring and reporting requirements for all their mental health care providers. Resources need to be available to facilitate access to mental health programs and services.

(Page 10)

Recommendation E. Both DoD and VA should use evidence-based treatments of choice for PTSD, and these treatments should be delivered with fidelity to their established protocols. As innovative programs and services are developed and piloted, they should include and evaluation process to establish the evidence base on their efficacy and effectiveness.
Recommendation F: DoD and VA should establish a central data base or other directory for programs and services that are available to service members and veterans who have PTSD.

(Page 11 Family)

Recommendation G: DoD and VA should increase engagement of family members in the PTSD management process for service members and veterans.

Note our yellow ribbon programs with the PA National Guard “the family” was incorporated in the curriculum.

(Page 12 Research Priorities)

Increasing knowledge of how to overcome barriers to implementation, dissemination, and use of evidence-based treatments to improve their accessibility, dissemination, and use of evidence-based treatments to improve their accessibility, availability, and acceptability for patients and their families.

Preventing the development of PTSD before and after the trauma exposure.
Developing and rigorously assessing new interventions and delivery methods (pharmacological, psychological, somatic, technological, and psychosocial) for both PTSD and co-morbidities.

Identifying effective care models, establishing evidence-based practice competences, and developing methods to enhance effective training in and implementation and dissemination of them.

(close of Summary)

DoD and VA are spending substantial time, money and effort on the management of PTSD in service members and veterans. Those efforts have resulted in a variety of programs and series for the prevention, diagnosis of, treatment for, rehabilitation of, and research on PTSD and its co-morbidities. Nevertheless, neither department knows with certainty whether those many programs and service are actually successful in reduction in the prevalence of PTSD in service members or veterans an in improvement in their lives.

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