Benefits of PTSD treatment going unmeasured, says Institute of Medicine Report
A report from the Institute of Medicine (IOM) finds that the U.S. Department of Defense (DOD) and U.S. Department of Veterans Affairs (VA) do not measure the effectiveness of treatment of post-traumatic stress disorder (PTSD), calling into question millions of dollars spent to improve service members’ mental health. The report also found that neither agency has kept pace with growing demand for PTSD treatment.
“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.”
The IOM issued this report on the heels of a scandal at the Department of Veterans Affairs that led to the resignation of VA Secretary Eric Shinseki on May 30. Federal investigators determined that service members were systematically denied timely care in a network of more than 1,700 healthcare facilities that suffers from inefficiency and bureaucracy.
PTSD is diagnosed by combination of symptoms, including hypervigilence and sleeplessness, and can be treated pharmacologically and psychologically with cognitive behavioral therapies involving multiple sessions with trained counselors.
An estimated 5 percent of service members have been diagnosed with PTSD; for veterans who served in Iraq and Afghanistan conflicts, the number rises to 8 percent. In 2012, more than half a million sought care for PTSD in the VA - 9.2 percent of all VA users. In 2012 the DOD and VA spent $294 million for PTSD care. If treatment demands continue to climb, the total cost for PTSD could exceed $500 million by 2017.
How common is PTSD?
An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD. About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD during the course of a given year. This represents a small portion of those who have experienced at least one traumatic event; 60.7% of men and 51.2% of women reported at least one traumatic event. The traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse.
About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced “clinically serious stress reaction symptoms.” PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent.
Who is most likely to develop PTSD?
1. Those who experience greater stressor magnitude and intensity, unpredictability, uncontrollability, sexual (as opposed to nonsexual) victimization, real or perceived responsibility, and betrayal
2. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events
3. Those who report greater perceived threat or danger, suffering, upset, terror, and horror or fear
4. Those with a social environment that produces shame, guilt, stigmatization, or self-hatred
The report also recommends that the DOD and VA enlist a workforce of mental health care providers to meet the growing need for PTSD treatment. While the departments have substantially increased mental health staffing, these increases do not appear to have kept pace with the demand.
The most surprising outcome over four years of deliberation, according to Dr. Galea, is the dissonance between the intention of senior leadership and how a PTSD management system is implemented. “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.
After a traumatic experience, it’s normal to feel frightened, sad, anxious, and disconnected. But if the upset doesn’t fade and you feel stuck with a constant sense of danger and painful memories, you may be suffering from post-traumatic stress disorder (PTSD). It can seem like you’ll never get over what happened or feel normal again. But by seeking treatment, reaching out for support, and developing new coping skills, you can overcome PTSD and move on with your life.
What is post-traumatic stress disorder (PTSD)?
Post-traumatic stress disorder (PTSD) can develop following a traumatic event that threatens your safety or makes you feel helpless.
Most people associate PTSD with battle-scarred soldiers - and military combat is the most common cause in men - but any overwhelming life experience can trigger PTSD, especially if the event feels unpredictable and uncontrollable.
Post-traumatic stress disorder (PTSD) can affect those who personally experience the catastrophe, those who witness it, and those who pick up the pieces afterwards, including emergency workers and law enforcement officers. It can even occur in the friends or family members of those who went through the actual trauma.
PTSD develops differently from person to person. While the symptoms of PTSD most commonly develop in the hours or days following the traumatic event, it can sometimes take weeks, months, or even years before they appear.
“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.”
The report is the second of a two-phase assessment of PTSD services for the military. The first report of the committee, also chaired by Dr. Galea, was issued in July 2012.
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Interview with Columbia University’s Dr. Sandro Galea, IOM Committee Chair, on report findings.
About Columbia University’s Mailman School of Public Health
Founded in 1922, Columbia University’s Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 450 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,300 graduate students from more than 40 nations pursuing a variety of master’s and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including ICAP (formerly the International Center for AIDS Care and Treatment Programs) and the Center for Infection and Immunity.
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Stephanie Berger
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Columbia University’s Mailman School of Public Health