A lack of consistent outcome measures means there is no way to know whether the more than $3 billion spent on treating posttraumatic stress disorder by the Department of Defense and Veterans Affairs in 2012 yielded worthwhile results, according to a report released June 20.
"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," Dr. Sandro Galea, chair of the Institute of Medicine committee tasked by Congress to study PTSD treatment in military and veteran populations, said in a statement.
The report notes that currently, "neither the DOD nor the VA knows whether it is providing effective or adequate PTSD care, for which they spent $294 million and more than $3 billion, respectively, in 2012." Similar findings were reported by the IOM in 2012.
"What we found over and over again were really hardworking, well-intentioned people who wanted to do the best they could, but they either didn’t have an administrative structure to support them, or enough staff, or they had an overwhelming number of patients," committee member Dr. Elspeth Cameron Ritchie said during a press briefing.
In addition to better data collection and sharing, the report calls for the development of an adequate workforce to provide mental health care to this growing population.
Although tele-therapies and virtual reality therapies, for which the evidence base is growing, can provide some help, inadequate staffing still leads to a limitation in the number of evidence-based therapies available to patients, said Dr. Ritchie, a retired Army psychiatrist and current professor of psychiatry at Georgetown University in Washington. To wit, the report cited the VA’s failure in 2013 to provide the recommended eight sessions of psychotherapy within 14 weeks to nearly half of all Iraq and Afghanistan war veterans seeking care for a primary diagnosis of PTSD.
The report also calls for the development of evidenced-base treatments, including combination therapies of psychotherapies such as cognitive behavioral therapy, with medications such as SSRIs.
The report recommends that family members be involved in the treatment of PTSD; the recommendation was based on feedback from service members and veterans who said they wanted their loved ones to be actively included.
In addition, the report states that research into PTSD should be focused on current patient needs, and that both departments should actively collaborate with one another and with other government agencies, such as the National Institutes of Health, to fill knowledge gaps.
The number of veterans seeking care for PTSD from the VA has more than doubled from 190,000 (4.3% of all VA users) in 2003 to more than a half million (9.2%) in 2012. Although veterans of all eras are included in the increase, 23.6% (119,500) of those treated for PTSD by the VA in 2012 were veterans of the wars in Iraq and Afghanistan.
Dr. Sandro Galea
In 2013, 528,260 veterans made at least two visits to the VA for PTSD outpatient care; one-quarter were new patients. Although the overall incidence rate for PTSD across all service members is about 1%, the prevalence rose from 0.4% in 2004 to 5% in 2012, with an 8% increase in those who had been deployed previously, according to the report.
The committee said the DOD approach to PTSD treatment is "local, ad hoc, incremental, and crisis driven, with little planning." While VA programs benefits from better organization and consistency, the lack of data on either department’s delivery methods and outcomes means there is "no way of knowing whether the care they are providing is effective or whether DOD and VA’s expenditures are resulting in high-value health care," according to the report.
The report is based on 4 years of combing through data provided by the DOD and the VA, peer-reviewed literature, government documents, research databases, and testimonies from a variety of DOD and VA experts and providers at military bases and treatment facilities around the country, including six VA medical centers.
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