June 21, 2014
Questions Surround Effectiveness Of Veteran PTSD Treatment
April Flowers for redOrbit.com – Your Universe Online
PTSD is one of the biggest problems facing our returning veterans. Time Magazine's Battleland Blog asserts that 21 percent of the 500,000 post-9/11 troops treated by the VA are being treated for PTSD, not counting veterans of the Vietnam or Korean wars. With so many vets under treatment for PTSD, you would think the US Department of Defense (DOD) and the US Department of Veterans Affairs (VA) would have a firm grip on which of their treatments are working the best.[ Watch the Video: PTSD Treatment Going Unmeasured By VA And DOD ]
A recent report from the Institute of Medicine (IOM), however, reveals that this is not the case. The report, the second in a two-phase assessment of PTSD services for the military, determined that the DOD and the VA do not measure the effectiveness of treatment for PTSD, nor have they kept pace with the growing demand for PTSD treatment. These findings call into question the millions of dollars spent to improve the mental health of returning servicemen.
"Both departments lack a coordinated, consistent, and well-developed evidence-based system of treatment for PTSD and need to do a better job tracking outcomes," said Sandro Galea, MD, DrPH, chair of the IOM committee, and chair of the Department of Epidemiology at Columbia University's Mailman School of Public Health. "Mental health is among the most important factors behind successful re-entry after military service, and we don't know if treatments are working."
This report follows a recent scandal at the VA that resulted in the resignation of VA Secretary Eric Shinseki on May 30. Federal investigators found that in a network of more than 1,700 healthcare facilities, veterans were being systematically denied timely care. The facilities, according to the investigation, suffered from inefficiency and bureaucracy.
The IOM report has more comprehensive tallies for the number of veterans being treated for PTSD. According to the results, an estimated five percent of all being treated in the military health system suffer from PTSD, with a higher eight percent seen among those who served in Iraq and Afghanistan. Between 2003 and 2013, the number of veterans from all eras seeking help with PTSD more than doubled -- going from approximately 190,000 (4.3 percent of total VA users) to more than half a million (9.2 percent). Of all the PTSD sufferers treated by the VA in 2012, 23.6 percent were veterans of the Iraq and Afghanistan wars. The VA spent $294 million in 2012 alone to treat PTSD. That number is expected to reach $500 million by 2017 if the treatment demands continue to rise at the current rate.
The VA and the DOD already have a host of programs and services in place to help. These range in intensity to prevent, screen for, diagnose, and treat current and former service members who have PTSD or who are at risk for it. The report finds that the current efforts of the DOD are local, ad hoc, incremental, and crisis-driven, with little planning devoted to the development of a long-range approach to obtaining desired outcomes. The VA's programs, in contrast, have a more unified organizational structure, ensuring more consistency of treatment. Without data analysis to determine which treatments are the most effective, neither department has any ways of measuring whether the care they provide is effective, or whether the money they spend is resulting in high-quality healthcare.
"Given that the DOD and VA are responsible for serving millions of service members, families, and veterans, we found it surprising that no PTSD outcome measures are used consistently to know if these treatments are working or not," said Galea. "They could be highly effective, but we won't know unless outcomes are tracked and evaluated."
The IOM committee noted an exception: the VA's specialized intensive PTSD programs. These programs are collecting outcome data, but they only serve one percent of PTSD-suffering veterans. Moreover, the data collected suggests that these programs are only moderately successful in improving the symptoms of the patients.
The IOM report strongly suggests that both departments develop, coordinate and implement a measurement-based PTSD management system. This system should document patients' progress over the course of treatment, regardless of where they receive treatment, and continue with long-term follow-up using standardized and validated instruments. One example of such validated instruments would be the PTSD checklist, which is one of several reliable and valid self-report measures that could be used to monitor patient progress and guide modification of individual treatment plans.
The report also found that neither department's strategic efforts necessarily encourage the use of best practices for preventing, screening for, diagnosing, and treating PTSD. Leaders at all levels within the DOD and service branches were found to not be consistently held accountable for implementing policies and programs to manage PTSD effectively. The VA's central office has established policies for minimum care and PTSD treatment, yet it is unclear if the VA leaders adhere to those policies, encourage staff to follow the guidance, or use the data available from its specialized PTSD programs to improve the way they manage the disorder, according to the IOM.
The committee suggests that both VA and DOD leaders should communicate a strong mandate through their chain of command regarding the high priority that PTSD management and using best practices should have. Holding those leaders, who are responsible for delivering high-quality care for their populations, accountable can also help ensure that information on PTSD programs and services is gathered, measured and reported.
The committee also recommends that both agencies maintain an adequate workforce of mental health professionals. Although both have substantially increased their workforce, they have not kept pace with demand for services. Such shortages of staff could result in clinicians not having adequate time to provide evidence-based psychotherapies.
"There is generally good will and spikes of excellence in both departments. Substantial effort has been made toward providing service members excellent PTSD care. However, there is tremendous variability in how care is implemented and an absence of data that tell us if programs are working or not," Dr. Galea said.
"In many respects our findings that neither the DOD nor the VA has a system that documents patients' progress and uses standardized instruments to chart long-term treatment are not surprising," he added. "We are hopeful that the report will provide a blueprint for where we need to get to."