The time, money, and effort expended for managing posttraumatic stress disorder (PTSD) among U.S. veterans and service members may or may not be working, but it is almost impossible to make that determination, according to a report from the Institute of Medicine (IOM) released June 20.
An IOM committee spent two years gathering evidence from the departments of Defense (DoD) and Veterans Affairs (VA), following up on an earlier report by the same group (Psychiatric News, August 17, 2012).
“Neither department knows with certainty whether those many programs and services are actually successful in reducing the prevalence of PTSD in service members or veterans and in improving their lives,” concluded the IOM committee, chaired by Sandro Galea, M.D., Dr.P.H., a professor and chair of the Department of Epidemiology at the Mailman School of Public Health at Columbia University.
The DoD could supply almost no data on outcomes of either short- or long-term treatment care, which it mainly provides on an outpatient basis, the committee noted in its report.
Even when a specific program appears to work well, it is hard know if that is actually the case without good data, said committee member Elspeth Cameron Ritchie, M.D., M.P.H., chief medical officer of the District of Columbia Department of Behavioral Health and a former Army psychiatrist. “So you get a good local effort but without the top leadership support to track it.”
The Pentagon’s primary job is preparing for and fighting wars, but the VA is in part intended to be a health care system. The VA offers a wider array of screening, therapeutic, and ancillary services (such as job counseling) than the military, but has collected no data about results in its general mental health clinics, Vet Centers, or outpatient PTSD programs. Only the 39 specialized intensive PTSD programs could provide outcome information, and the data they provided showed just modest improvements following treatment.
Neither department has used standard tracking measures to determine whether the PTSD care it provides is “effective, appropriate, or adequate,” said the committee.
Both departments are large, centrally controlled bureaucracies, but nevertheless they have produced fragmented systems on the ground. “DoD’s PTSD management appears to be local, ad hoc, incremental, and crisis-driven, with little planning devoted to development of a long-range, population-based approach,” the IOM committee concluded.
“The DoD is and is not a centralized bureaucracy,” said psychiatrist Stephen Xenakis, M.D., a retired Army brigadier general who served as a reviewer for the IOM report. “There’s a real tension between the [Pentagon’s] Health Affairs office and the surgeons general in each of the service branches. No one wants to be subordinated to someone else, so things are not well coordinated.”
The committee raised other issues as well in its report: the continuity of care as troops make the transition from active military service to care in the VA’s health system, the need for standardized tracking measures, and the creation of a central database to catalog programs and services.
The report, however, did not address other conditions that are relevant to people with PTSD, such as traumatic brain injury, sleep problems, or chronic pain, said Xenakis. “These confound symptoms and the effectiveness of treatments.”
Both departments have expanded their workforces in recent years, but they also need to know more about what therapies those clinicians and outside contractors are using and how patients are faring in response. “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,” the IOM committee stated.
Finally, the DoD and the VA would do well to retain some of the lessons learned over the years from the wars in Iraq and Afghanistan, said committee member Douglas Zatzick M.D., a professor and associate vice chair for health services research in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle.
“There’s a national amnesia for the health care system that is part of fallout of military downsizing,” said Zatzick in an interview with Psychiatric News. “With all the military rev ups and downs, you need someone who can look at these issues longitudinally and understand what we’ve learned from these wars.” ■