Section 4: Evidence Based Approaches for Prevention, Outreach, Assessment, Diagnosis, and Treatment
The goal of PTSD interventions is to address the prevention, diagnosis, and treatment of PTSD. In terms of prevention, emphasis must be placed both on minimizing combat stress reactions, and, when they do occur, preventing normal stress reaction from developing into chronic PTSD. Preventing all cases of PTSD, however, is impossible. When cases do arise, assessment and diagnosis leading to timely treatment is crucial. The goal of treatment is not merely to reduce service members’ symptoms, but to help them regain the capacity to lead complete lives as full members of their community – to work, to partake in leisure and civic activities, and to form and maintain healthy relationships with their family and friends.
In an attempt to maximize the effectiveness of their treatment programs, DoD, VA, and the broader psychological community have undertaken studies to identify the best practices for treating PTSD. The “gold standards” for identifying best practices are randomized controlled trials (RCT), which are designed to ensure that any changes in the outcome measure can be attributed to the intervention rather than to extraneous factors. Unfortunately, many promising interventions have not been subjected to RCT studies. In this section, we describe best practices based on theoretical frameworks and medical research in addition to evidence from RCTs.
Cognitive fitness and psychological resilience can serve as barriers to developing PTSD. Although no RCT studies exist that indicate how to increase this resilience among service members, VA and DoD developed the following general guidelines based on theoretical frameworks (US Department of Veterans Affairs and Department of Defense 2004):
- Provide realistic training that includes vicarious, simulated, or actual exposure to traumatic stimuli that may be encountered;
- Strengthen perceived ability to cope by providing instruction in coping skills;
- Create supportive interpersonal work environments; and,
- Develop and maintain adaptive beliefs such as confidence in leadership, confidence in the meaningfulness of the work, and knowledge about the transitory nature of most acute stress reactions.
Preliminary evidence suggests that psychological preparation enhances resilience. For example, in a 2007 survey of deployed soldiers, those who received pre-deployment “Battlemind” training described in Section 5 reported fewer mental health problems in Iraq than those who did not receive the training (US Army Surgeon General 2008).
Screening: Early identification of PTSD and other stress reactions is critical. Quickly referring people to treatment can shorten their suffering and lessen the severity of their functional impairment.
The effectiveness of screening remains controversial for two reasons. First, screening troops immediately upon return from combat yields false positives, meaning that screening misidentifies cases that are normal combat stress reactions. Medicalizing and pathologizing these reactions may cause the individual to take on a patient role and symptoms that may normally dissipate over time with rest, relaxation, and social support may persist. (DoD response in US Government Accountability Office May 2006).
Second, people may misrepresent their symptoms based on the situation. For example, service members may not admit to symptoms when they are screened immediately upon return from Iraq because they are eager to get back to their families and know that any indication that they need psychiatric help will delay that process. Service members who plan to remain in the military may hide symptoms so that they can stay with their unit. The benefits of PTSD screening 3-6 months after return from combat clearly outweigh the risks. However, the screening does not identify all cases.
Integrate mental health screening and diagnosis into primary care: Because veterans are likely to seek care for a general medical ailment, the primary care physician (PCP) may be the first health-care professional to engage an individual with PTSD. In a study of 103,788 OEF/OIF veterans seen in VA health care facilities between 2001 and 2005, almost one-quarter received a mental health diagnosis and most initial mental health diagnoses (60 percent) were made in non-mental-health clinics, mostly primary care settings (US Department of Veterans Affairs, Office of Inspector General 2007).
The PCP can play a critical role in referring someone to care, but the client may not follow through with the recommendations. There are two models for integrating mental health into primary care that can address this problem. The first is a model of co-located collaborative care between a mental health provider and primary care physician. In this model, if the primary care physician believes the patient has PTSD, that same day she or he can refer the patient to a mental health clinician located in the same building. The second approach is a case management model, in which a primary care physician can refer patients to a mental health provider, and a case manager will conduct ongoing phone follow-up to encourage continued engagement in the treatment process and to assist in negotiating needed adjustments in the treatment plan (US Department of Veterans Affairs, Office of Inspector General 2007).
The best time to assess the impact of TBI is immediately after the injury. For severe TBIs, the impact is obvious and the individual is removed from combat as soon as possible. For mild TBI, many soldiers just “shake it off” but may encounter problems later. Of the three approaches to diagnosing mild TBI, all have limitations. For example:
- Cognitive Evaluations—TBI may cause cognitive impairments. Thus, it is useful to measure changes in cognitive functioning. A baseline cognitive assessment is needed so that in the event of exposure to an IED or other types of blasts, service members' cognitive functioning right after the injury can be compared to their baseline functioning prior to deployment.
- Neuroimaging—For most mild TBI patients, magnetic resonance imaging (MRI) and computed tomography (CT) scans are inconclusive or difficult to interpret (Belanger et al. 2007, Hoge 2008). Other imaging techniques such as functional Magnetic Resonance Imaging (fMRI), Positron Emission Tomography (PET), and Single Photon Emission Computed Tomography (SPECT) show some promise in detecting mild TBI, but these findings are preliminary (Belanger et al. 2007). Because of their cost, brain scans are not a viable alternative for large scale screenings, but can be useful in some cases.
- Self-reported History—Self-reported history of mild TBI/concussion is not well correlated with post-deployment symptoms. Using self reports for screening is likely to result in mislabeling service members as “brain injured” when there are other reasons for their symptoms that may require different treatment (Hoge 2008).
Available PTSD treatment can address the primary symptoms of PTSD by helping clients bring under control the vivid re-experiencing of the trauma and the continual re-appraisal of the event so that they can feel better about themselves and their actions. (Brewin 2007). In addition to addressing the symptoms, treatment addresses functional limitations such as relationship and trust issues, anger management, feelings of alienation, sleep disturbances, and other limitations.
In 2004 VA and DoD jointly released a set of clinical guidelines for treating PTSD. The guidelines included individual psychotherapy, group therapy, and pharmacotherapy recommendations based on a review of efficacy studies (US Department of Veterans Affairs and Department of Defense 2004).
1. Individual Psychotherapy
The aforementioned guidelines recommend that the therapist explain to the client the range of available and effective therapeutic options and then the therapist and client should jointly agree on an approach. The guidelines strongly recommend the following four evidence-based practices:
Exposure therapy: The client repeatedly confronts feared situations, sensations, memories, or thoughts in a planned, often step-by-step manner. With repeated, prolonged exposure to previously feared situations, the fear tends to dissipate. ET usually lasts from 8 to 12 sessions depending on the trauma and treatment protocol.
Exposure therapy may be very intimidating for clients to contemplate and can be time consuming and emotionally wrenching for them to complete. The client may have homework in which they write down a nightmare, script a new ending and read the script repeatedly. During the therapy, the client may begin to have more symptoms before the symptoms begin to subside. Thus, it is important to have a strategy to ensure that the client will continue through the entire therapeutic protocol.
In addition, although exposure therapy is highly successful in reducing the key symptoms associated with PTSD, such as intrusive memories, it does not address other issues such as feelings of detachment from others, excessive anger and feelings of alienation. To treat these, the therapist must draw on other therapeutic approaches.
Cognitive restructuring: The client identifies upsetting thoughts about the traumatic event, particularly thoughts that are distorted and irrational, and learns to replace them with more accurate, balanced views. For example, veterans may feel they are to blame for failing to save a fallen comrade even if they did everything they could. Cognitive restructuring helps them look at what happened in a healthier way.
Stress Inoculation Training: This treatment includes a variety of approaches to manage anxiety and stress and to develop coping skills. The client is taught deep muscle relaxation, breathing control, assertiveness, role playing, thought stopping, positive thinking and self-talk.
EMDR (Eye Movement Desensitization and Reprocessing): EMDR incorporates elements of exposure therapy with eye movements or other forms of rhythmic, left-right stimulation, such as hand taps or sounds. For example, in EMDR the client talks about the traumatic event while visually following the therapist’s finger back and forth. Eye movements and other bilateral forms of stimulation are thought to work by “unfreezing” the brain’s information processing system and allowing the individual to reprocess the memory.
In 2006, the Institute of Medicine (IOM) concluded that, based on results from RCT, the only proven effective intervention is exposure therapy (Institute of Medicine and National Research 2007). The IOM committee noted that this finding does not mean that exposure therapy is the only therapy that should be used. The committee used very strict criteria for evaluating the studies and recognizes that some interventions may be useful but have not been tested. Additional research on evidence-based interventions clearly is needed.
2. Group Therapy
In group therapy, four to twelve clients are led by a mental health professional and can share their thoughts, find comfort in knowing they are not alone, and gain confidence by helping others resolve their issues. Little research has been done to validate its effectiveness, or to delineate those characteristics of group therapy that lead to improved clinical outcomes. The VA/DoD guidelines recommend that this therapy be done in conjunction with individual therapy (US Department of Veterans Affairs and Department of Defense 2004).
In terms of pharmacotherapy, evidence indicates that certain medications, especially selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft, are effective at relieving core symptoms of PTSD. The VA/DoD guidelines recommend the use of these and several other medications that have shown some efficacy. They recommend against the use of benzodiazepine and typical antipsychotic drugs such as Chlorpromazine, Haloperidol, and Thioridazine.
According to the Centers for Disease Control and Prevention (CDC), treatment for individuals who have sustained mild TBI may include increased rest, refraining from participation in activities that are likely to result in additional head injury, management of existing symptoms, and education about mild TBI symptoms and what to expect during recovery. For some cases, rehabilitative or cognitive therapies, counseling, or medications might be used. Currently, there are no evidence-based clinical practice guidelines that address treatment of mild TBI (US Government Accountability Office Feb 2008).
A. Family Support
Family support is fundamental to a service member’s recovery from PTSD. According to a 2005 DoD survey, 74 percent of DoD active-duty personnel cope with stress by talking to a friend or family member (Bray et al., 2006). While there are no randomized controlled studies documenting the value of this informal support, the evidence that does exist suggests this support is extremely important. Spouses and family members are often the first to recognize when service members require professional assistance and often play a key role in influencing service members to seek help (US DoD Task Force on Mental Health 2007).
Unfortunately, this support is not always available. In fact, the very nature of PTSD works to drive this support away. One of the classic symptoms of PTSD is withdrawal, leading veterans to try to shut out the very family members and friends who could help them alleviate their pain. Veterans may be reluctant to open up because they worry that what they say will upset the family. Sometimes when they do turn to their family members, they find that those relatives are under a lot of stress as well, and may not be able to offer needed support.
Providing support and education to the whole family can go a long way toward effective treatment. Family members must be equipped with the ability to recognize distress, and the knowledge of how and where to refer loved ones for assistance (US DoD Task Force on Mental Health 2007).
Family and relationship problems are a serious concern. For example, in a recent anonymous survey of 532 National Guard members, 292 of whom had recently returned from deployment in Iraq, 36% of the deployed acknowledged relationship problems with spouse, 26% relationship problems with children, and 31% emotional numbness that interferes with their relationships. Rates of problems for those deployed were three times greater than for those not deployed. The Army’s Mental Health Advisory Team’s 2007 surveys indicated that up to 30% of Soldiers and Marines are considering divorce by the midpoint of their deployment, with rates highest for those in their fourth or fifth deployment (US Army Surgeon General 2008). Furthermore relationship problems are a key factor in the majority of suicidal behaviors among active duty service members (US DoD Task Force on Mental Health 2007).
After returning home, relationship problems are often the first symptoms to come to the fore. It is therefore crucial that access to marital and relationship counseling be free of barriers. Early intervention with relationship problems can reduce the long term social costs for veterans and can serve as a means to bring veterans with more severe problems such as PTSD to the attention of healthcare providers.
DoD and VA might consider developing a formal training course for families similar to the Family to Family Education program hosted by the National Alliance on Mental Illness and should continue to utilize the effectiveness of the Chaplaincy Corps.
B. Peer Support
Empirical evidence and theories of PTSD suggest the importance of social support as a moderator of the effects of trauma. Support from peers who have shared the experience is particularly important. Peers can provide information, offer support and encouragement, provide assistance with skill building, and provide a social network to lessen isolation.
Researchers divide peer support models into three categories: 1) naturally occurring mutual support groups; 2) consumer-run services; and 3) the employment of consumers as providers within clinical and rehabilitative settings (Davidson 1999).
Naturally occurring mutual support groups: Service members who return to garrison after their deployment are naturally surrounded by peers. However, this community of peers may not exist to the same degree for National Guard members and Reservists. They receive a short homecoming briefing and usually have 90 days at home before they report back for weekend training. This separation from other soldiers comes at a time when support and connections with others who are going through the same emotional adjustments is critical. This separation may account for some of the increased prevalence of PTSD among the Guard and Reserve.
Consumer-run services: A variety of peer consumer run models exist in the community and in the VA system such as: support groups, drop-in centers, consumer-run organizations; warm lines (peer run telephone call-in service for support and information), and internet support groups and message boards. Research on consumer-run services has consistently yielded positive results. For example, participants of self help groups have increased social networks and quality of life, improved coping skills, greater acceptance of mental illness, improved medication adherence, lower levels of worry, and higher satisfaction with health (Solomon 2004).
Consumers as employees: In a peer employee model, individuals with mental illnesses are trained and certified and then hired into positions that are adjunct to traditional mental health services. These positions include peer companion, peer advocate, consumer case manager, peer specialist, and peer counselor. Although these models are relatively new, emerging evidence suggests that adding peer services improves the effectiveness of traditional mental health services (Solomon 2004). In addition, the peer provider can alter the negative attitudes of many mental health consumers toward mental health providers, and of some providers toward consumers. In recent years, the evidence for the efficacy and cost-effectiveness of this practice has grown to the point that the Centers for Medicare and Medicaid Services (CMS) has recently allowed Medicaid reimbursement for services provided by peer specialists, and the military in Canada has recently established the Operational Stress Injury Social Support Program based on a peer support model (Veterans Affairs Canada 2006).
Peers may also be used as outreach workers. Service members or veterans who have been deployed during war need not have PTSD or TBI themselves to understand the barriers to seeking services created by stigma and military culture. These peers can help identify people who need professional interventions and facilitate their entry into treatment.
Peer support services should be part of the array of services available. However, if should not be used as a cost-saving substitute for clinical services. As a means of insuring quality care, peer services should implement a credentialing process similar to that of clinical services. Both Georgia and New Jersey have been successful in developing credentialing programs for peer support workers.
Consumers aiding in the development and deployment of services: In order for DoD and VA to develop and deploy services that are responsive to the needs of the consumers, consumers with PTSD and TBI must be included in the planning processes. There are many possible mechanisms. VA has initiated a program for local Mental Health Consumer Councils through which veteran consumers of care, their families and representatives meet with local professional and administrative leaders and assist in identifying problems or gaps in service and brainstorming ways to overcome barriers to care. This program is currently operating only in selected medical centers, and is a local option.
C. Web-based Education and Support
The Internet has become a vital resource for information and interventions. It allows service members, veterans, and their families to access resources immediately and anonymously.
Afterdeployment.org: In response to a 2006 Congressional mandate to develop a website for service members, veterans and their families, DoD has recently unveiled www.afterdeployment.org. The site has 12 modules, each of which address a post deployment issue including adjusting to war memories, dealing with depression, handling stress, improving relationships, succeeding at work, overcoming anger, sleeping better, controlling alcohol and drugs, helping kids deal with deployment, seeking spiritual fitness, living with physical injuries, and balancing your life.
DE-STRESS: VA is exploring the effectiveness of melding an internet-based intervention with professional therapy. In the DE-STRESS program (DElivery of Self-TRaining and Education for Stressful Situations), veterans use a web site to access information and complete a series of homework assignments that monitor, manage and treat PTSD symptoms. The work done on the Web site is self-paced and self-directed and takes approximately eight weeks to complete. The web activities are complemented by either face-to-face meetings or telephone conversations with professional therapists. (Litz et al. 2007).
Other web resources: Websites hosted by a variety of private, nonprofit, and governmental organizations offer easily accessible educational materials such as fact sheets, academic articles, and links to other sources. Two particularly informative sites are VA’s National Center for PTSD (http://www.ncptsd.va.gov) and Mental Health America’s “Operation Healthy Reunion” (http://www.nmha.org/reunions/info.cfm).
Online support groups offer veterans a relatively anonymous place to share their questions, concerns, frustrations, and fears and hear reactions from people in similar situations. Several MSN groups have emerged such as Iraq War Wives, Aftermath of War: Coping with PTSD, and Iraq War Veterans.
D. Other Nonmedical Interventions
A variety of other nonmedical interventions have shown some promise, but their efficacy is not fully established. These interventions include acupuncture, exercise, and mindful meditation (Hollifield et al. 2007, Stathopoulou et al. 2006, Chartier 2007).
E. Employment and Housing
Veterans with psychological health issues such as PTSD and TBI are at elevated risk of unemployment and homelessness. In addition, evidence suggests that stable housing and supported employment are effective interventions for mental health rehabilitation (Martinez and Burt 2006, Bond 2004). However, availability of housing and employment supports for veterans with mental health issues is limited.
Employment: Individuals with PTSD and mild TBI may have difficulty holding a job. They may, for example, have difficulty concentrating on job tasks, coping with stress, exhibiting appropriate emotions, or controlling anger. In some cases, the employer can make accommodations such as reducing distractions in the workplace, allowing the employee to play soothing music, and allowing flexible scheduling (Artman and Duckworth 2007). In an effort to increase employment options for veterans, the Department of Labor has initiated the "America's Heroes at Work" campaign to educate employers on the issues surrounding the employment of veterans with PTSD and TBI and strategies to accommodate their needs (DOL 2008).
In other cases, the employee may need additional support. Although no employment-related interventions have been developed and tested specifically for veterans with PTSD and mild TBI, promising strategies have been established for people with mental illnesses. For example, substantial evidence indicates that supported employment integrated with mental health treatment is effective in placing and maintaining people with mental health issues in competitive employment (Cook et al. 2005). NCD reviewed strategies for increasing employment among people with disabilities in Empowerment for Americans with Disabilities: Breaking Barriers to Careers and Full Employment (National Council on Disability 2007).
Housing: VA has multiple programs that provide short-term housing and treatment for homeless veterans including: the Compensated Work Therapy/Transitional Residence Program; the Homeless Veterans Reintegration Program; the Domiciliary Care for Homeless Veterans Program; the Homeless Providers Grant and Per Diem (GPD) Program. The Department of Housing and Urban Development (HUD) also assists homeless veterans through a Supported Housing Program funded jointly by HUD and VA and HUD's Section 8 Voucher Program, which specially designates vouchers for veterans with chronic mental illnesses. VA centers also coordinate with local government and nonprofit agencies to assist homeless veterans (US Department of Veterans Affairs 2008).
In 2007, VA estimated that it had served approximately 300 OEF/OIF veterans in its homeless programs and has identified 1,049 more as being at risk of becoming homeless. The experience of Vietnam veterans indicates that the risk of homelessness increases over time. In a survey conducted in the mid-1980’s, more than three-quarters of Vietnam-era combat troops and 50 percent of noncombat troops who eventually became homeless reported that at least ten years passed between the time they left military service and the time they became homeless (Perl 2007).
The Restoration and Resilience Center at Fort Bliss, Texas integrates many techniques described above into one program. The participants are in treatment 35 hours per week for 6-9 months. The treatment includes daily psychotherapy and daily group therapy combined with holistic approaches such as yoga, massage therapy and other nontraditional approaches.
The program also includes a physical component. Participants are required to walk at least 10,000 steps per day, which includes a 45-minute power walk. They also play water polo three times per week, which facilitates their interaction with other people. Throughout the program, the soldiers are also involved in field trips to public places that they might otherwise avoid because they perceive those places as too big, too crowded and too noisy. The soldiers are taught ways to regulate their stress level, so that they can handle the stress of the crowds and noise in these environments.
The program was established in 2007, so its success has not been firmly established. However, early indications are very promising. Among the first set of participants, one-third have graduated and returned to their units, while only two have dropped out and been medically discharged from the Army ("A Soldier’s Mind" 2008).