Samuel Kacew, Ph.D. University of Ottowa David Kalman, Ph.D. University of Washington Judy LaKind, Ph.D. University of Maryland, Pennsylvania State University,

Samuel Kacew, Ph.D.University of Ottowa

David Kalman, Ph.D.University of Washington

Judy LaKind, Ph.D.University of Maryland, Pennsylvania State University, LaKind Associates

Jose Sericano, Ph.D.Texas A&M University

Kenneth R. Still, Ph.D.Portland State University,Occupational Toxicology Associates Inc.

Committee on the Assessment of Ongoing Efforts in the

Treatment of PTSDFinal Report

June 24, 2014

• Analyze the data received in phase 1 to: • Determine the rates of success of DOD/VA PTSD programs

• Estimate of the number of service members and veterans diagnosed as having PTSD; and

• Estimate the number of veterans successfully treated.

• Focus on targeted interventions at Ft. Hood and Ft. Bliss, TX; Fort Campbell, TN; and any other DoD or VA sites deemed necessary.

• Examine gender-, racial-, and ethnic group-specific PTSD treatment services; specifically the availability of, access to, the need for, and the efficacy and adequacy of such treatment and services.

• Examine the current and projected annual expenditures by DoD and VA for the treatment and rehabilitation of PTSD.

• Provide recommendations for areas of future PTSD research.

Statement of Task: Phase 2

•Data requests to DoD and VA

• Peer-reviewed literature, government documents, other

• Research databases

• Open sessions to hear from DoD and VA experts

•Site visits to: •3 Army, 2 Marine Corps, 2 Navy, 1 Air Force, and 1 National

Capital Region military facilities

•6 VA medical centers or health care systems

Committee’s Approach

• PTSD prevalence in OEF/OIF service members is 13-20% (based on literature); civilian population 7% (lifetime) and 4% (12 month.)

• Incidence is ~1% for all service members; prevalence has increased from 0.4% in 2004 to 5% in 2012, 8% for previously deployed (OSM data); prevalence varies by service branch.

• In 2013, 528,260 veterans made at least two visits to VA for PTSD outpatient care, and 25% of these were new patients.

• 23.6% of all veterans using VA PTSD services in 2012 were OEF/OIF veterans.

• 47% of all veterans using VA specialized outpatient PTSD programs were OEF/OIF veterans.

Scope of the Problem

• Prevention programs are expensive, e.g., Army’s Comprehensive Soldier and Family Fitness program had initial implementation costs of $125 million and incurs annual costs of $50 million.

• In 2012

• total costs for PTSD care were $294 million.

• total health care costs/PTSD patient were $18,259, but $1,951/person without PTSD or other mental health disorders.

• 45% of PTSD care for service members provided via TRICARE purchased care at a cost of $131 million.

• If the trend continues, total costs for PTSD could exceed $500 million by 2017.

Cost of PTSD Care in DoD

• In 2012

• 9.2% of veterans using VA services had a diagnosis of PTSD; total annual costs for PTSD were about $3 billion.

• 23.6% of all OEF/OIF veterans using VA services had a diagnosis of PTSD for a total annual cost of $673 million.

• total annual VA health care costs/veteran with PTSD is >2x that of a veteran without PTSD; 73.1% of these costs were for non-mental health services.

• 108,745 veterans received care in specialized outpatient PTSD programs (total cost = ~$178 million or $1,638/patient);

• 4,275 veterans were admitted to specialized intensive PTSD programs (average cost = $20,497/patient).

• 653,249 veterans (all eras) have service-connected PTSD.

• Data on purchased care costs of PTSD were not included in VA’s response to the committee’s data requests.

Cost of PTSD Care in VA

Findings:• DoD has no long-range, population-based approach to PTSD.• VA has 5-year strategic plans to improve the quality and

accessibility of mental health care, but few data to indicate that performance measures are being met.

Recommendation ADoD and VA should develop an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veterans, and their families, including female veterans and minority group members.

PTSD Management Strategies

Findings:• DoD and VA leaders at all levels of the chain of authority are not

consistently held accountable for implementing policies and programs to manage PTSD effectively.

• Neither department has an overarching authority to establish and enforce policies for the entire spectrum of PTSD management activities from prevention, screening, and treatment, to rehabilitation (i.e., there is no PTSD “champion”).

Recommendation BDoD and VA leaders, who are accountable for the delivery of high-quality health care for their populations, should communicate a clear mandate through their chain of command that PTSD management, using best practices, has high priority.

Leadership and Communication

Findings: • No PTSD outcome measures of any type are consistently used or

tracked in the short- or long-term (with the exception in the specialized intensive PTSD programs in VA).

• Both departments are moving toward capturing more PTSD treatment data in electronic health record but no outcome data are available.

Recommendation CDoD and VA should develop, coordinate, and implement a measurement-based PTSD management system that documents patients’ progress over the course of treatment and long-term follow-up with standardized and validated instruments.

Performance Management

Findings:• DoD and VA have increased the number of mental health care

providers, including those trained in PE and CPT, but staffing has not kept pace with the growing demand for PTSD services.

• Both departments have increased use of purchased care providers, but have no formal procedures for evaluating those providers, determining the best purchased care provider for an individual patient, or tracking care given by those providers.

Recommendation D: DoD and VA should have available an adequate workforce of mental health care providers—both direct care and purchased care—and ancillary staff to meet the growing demand for PTSD services. 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. Resources need to be available to facilitate access to mental health programs and services.

Workforce and Access to Care

Findings:• DoD and VA have expended considerable effort to develop, update,

and disseminate the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress.

• But mental health care providers do not consistently provide evidence-based treatment.

Recommendation EBoth DoD and VA should use evidence-based treatments as the treatment of choice for PTSD, and these treatments should be delivered with fidelity to their established protocols. As innovative programs and services are developed and piloted, they should include an evaluation process to establish the evidence base on their efficacy and effectiveness.

Evidence-Based Treatment

Findings:• Neither DoD or VA have a central database to identify available

PTSD programs or services.

• Lack of such a resource makes it difficult to compare and evaluate programs and services, identify best practices, and make referrals to those determined to be effective.

Recommendation FDoD and VA should establish a central database or other directory for programs and services that are available to service members and veterans who have PTSD.

Central Database of Programs/Services

Findings:• DoD has numerous programs and services for families but gaps

remain; VA has fewer family resources and less responsibility for family members.

• DoD, and to a lesser extent VA, offers assistance to families including couple and family therapy.

• Both service members and veterans want more family engagement in their treatment process.

Recommendation GDoD and VA should increase engagement of family members in the PTSD management process for service members and veterans.

Family Involvement

Findings:• DoD and VA are funding broad PTSD research portfolios and are

working collaboratively with the National Institutes of Health, other organizations, and academe to fill research gaps.

• Substantial barriers exist to conducting PTSD research within and between the departments and in collaboration with other organizations; no systematic effort by either department to identify those barriers or identify mechanisms to overcome them.

Recommendation HPTSD research priorities in DoD and VA should reflect the current and future needs of service members, veterans, and their families. Both departments should continue to develop and implement a comprehensive plan to promote a collaborative, prospective PTSD research agenda.

Research Priorities

http://www.nap.edu/catalog.php?record_id=18724