Clinicians Urged to Heed Guidelines in Treating Troops for PTSD

The U.S. Army issued a new policy memorandum in April seeking to ensure consistent diagnosis and treatment of posttraumatic stress disorder (PTSD) among its soldiers.

The directive was based on 2010 clinical practice guidelines developed by the Department of Veterans Affairs and the Department of Defense (VA/DoD) and supported by a recent study carried out jointly by the American Psychiatric Institute for Research and Education (APIRE) and the Walter Reed Army Institute for Research (WRAIR).

“The APIRE/WRAIR study provides compelling and empirical support for this policy, especially since a significant percentage of patients are not being treated according to guidelines,” said Joyce West, Ph.D., M.P.P., the study’s principal investigator and the policy research director of APIRE, in an interview.

Stigma and barriers to care within the military health system remain high, according to the memo.

Often service members who have PTSD and are being treated for it do not have an appropriate ICD-9 diagnosis recorded for an office visit. Soldiers fearing the stigma of a PTSD label or worrying about their career prospects may prefer that some other term be entered in their medical records.

This “reflects a current standard of practice within military treatment settings,” according to the memo.

“This part of the policy memo serves to reinforce the notion that the lack of a documented history of PTSD does not necessarily mean that a patient does not have PTSD,” said Army Col. David Benedek, M.C., a professor and deputy chair of psychiatry and associate director of the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences in Bethesda, Md.

“A PTSD diagnosis should be considered in all patients reporting emotional and behavioral changes in the aftermath of deployment, combat, or other potentially traumatic exposure, regardless of diagnoses previously recorded in medical records,” Benedek told Psychiatric News.

The new policy seeks to bring reality in closer touch with the medical record to improve the care soldiers receive.

“The memo was designed to encourage a shift in policy and in culture and get clinicians to report the actual diagnosis or document why another conclusion should be drawn from the symptoms,” said West.

The document noted the value of screening tools but said that nothing could replace a comprehensive differential clinical interview for diagnosing PTSD. It added that the A2 criterion for PTSD—“fear, helplessness, or horror”—generally did not apply to the experience of well-trained troops, and it would likely be removed in DSM-5, which is scheduled to be published next May.

Diagnostic labels, which become part of a soldier’s permanent record, should be used to facilitate patient care. Clinicians were cautioned about associating symptoms of prior traumatic experience or PTSD with a personality disorder, adjustment disorder, or malingering.

Treatment for PTSD should follow the 2010 VA/DoD clinical practice guidelines, beginning by offering patients a recommended, evidence-based option, the memo pointed out. That can be either trauma-focused psychotherapy or pharmacotherapy using SSRI or SNRI medications, depending on patient preferences and comorbidities.

The APIRE/WRAIR study developed measures of fidelity to exposure-based psychotherapy, but also found that therapy provided to a significant number of patients did not meet manualized standards.

“The memo sets out the key components of treatment fidelity, but it allows clinicians to vary such treatment as long as they fully document reasons for nonadherence,” said West.

The memo is the latest attempt by the armed forces to encourage treatment seeking and improve care for PTSD. How it will work in practice remains to be seen, according to Benedek.

“It would seem that any widely disseminated message encouraging the use of evidence-based practices and reminding clinicians to stay alert to potential changes in diagnostic criteria should promote quality care within the Department of Defense,” he said. “However, the actual impact of any policy memorandum would be hard to measure.”

(Initial results from the APIRE/WRAIR study were presented at the 2011 APA annual meeting and are now being prepared for publication.)