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IOM Report Challenges DOD and the VA
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Demonstrate Effectiveness of Their PTSD Treatment Programs


The U.S. Department of Defense and the U.S. Department of Veterans Affairs should track the outcomes of treatment for posttraumatic stress disorder (PTSD) provided to service members and veterans and develop a coordinated and comprehensive strategy to do so, says a new congressionally mandated report from the Institute of Medicine (IOM). 

Without tracking outcomes, neither DOD nor 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. Issued in June, the report is the second of a two-phase assessment of PTSD services for service members and veterans, and it echoes the findings of the first report, issued in 2012.

An estimated 5 percent of all service members in the military health system have been diagnosed with PTSD, and the prevalence is 8 percent for those who have served in Iraq and Afghanistan, the report notes. The number of veterans of all eras who sought care for PTSD from the VA more than doubled from 2003 to 2012—from approximately 190,000 veterans (4.3 percent of all VA users) in 2003 to more than a half million veterans (9.2 percent of all VA users) in 2012. For those treated for PTSD in the VA system in 2012, 23.6 percent (119,500) were veterans of the Iraq and Afghanistan wars. 

DOD and VA have a multitude of programs and services that range in their intensity to prevent, screen for, diagnose, and treat current and former service members who have PTSD or who are at risk for it. Currently, DOD’s PTSD treatment programs appear to be local, ad hoc, incremental, and crisis-driven, with little planning devoted to the development of a long-range approach to obtaining desired outcomes, the report says. 

VA’s PTSD programs have a more unified organizational structure, and the agency is able to ensure more consistency of treatment. However, without data on which treatments patients are receiving and whether they are improving as a result of their treatment, the departments have no way of knowing whether the care they are providing is effective, said the committee that wrote the report.

An exception, the committee noted, are VA’s specialized intensive PTSD programs, which are collecting outcomes data. Nevertheless, these programs serve only 1 percent of veterans who have PTSD, and the data suggest the programs yield only modest improvements in symptoms.

Another problem is that current DOD and VA strategic efforts do not necessarily encourage the use of best practices for preventing, screening for, diagnosing, and treating PTSD, the committee observed. In DOD and the service branches, leaders at all levels are not consistently held accountable for implementing policies and programs to manage PTSD effectively. 

And though the VA’s central office has established policies on minimum-care requirements and guidance on PTSD treatment, it is unclear whether VA leaders adhere to the policies, en-courage staff to follow the guidance, or use data available from its specialized PTSD programs to improve the way they manage the disorder.

IOM Report Recommendations

  • New PTSD management system. DOD and the VA should develop, coordinate, and implement a measurement-based PTSD management system that documents patients’ progress over the course of treatment, regardless of where they receive treatment. The IOM also recommends that the DOD and VA do long-term follow-up using standardized and validated instruments. Reliable and valid self-report measures, such as the PTSD Checklist, are available and could be used to monitor patient progress and guide modifications of individual treatment plans. 
  • Mandate for PTSD management from leaders of DOD and VA. DOD and VA leaders, who are responsible for delivering high-quality care for their populations, should communicate a clear mandate through their chain of command that PTSD management, using best practices, has high priority, the report says. Leadership accountability can also help ensure that information on PTSD programs and services is collected and that their success is measured and reported.
  • Adequate workforce of mental healthcare providers. The report also recommends that DOD and VA have an adequate workforce of mental healthcare providers to meet the growing demand for PTSD services. While the departments have substantially increased their mental health staffing, the increases do not appear to have kept pace with the demand for PTSD services.

Staffing shortages can result in clinicians not having time to provide evidence-based psychotherapies readily. In 2013, according to the report, only 53 percent of veterans of the Iraq and Afghanistan wars who had a primary diagnosis of PTSD and sought care in the VA had received the recommended eight sessions within 14 weeks.
The study was sponsored by the U.S. Department of Defense. The National Academies comprises The Institute of Medicine—along with the National Academy of Sciences, National Academy of Engineering, and National Research Council. 

Source: The National Academies June 20, 2014, press release. The full report can be read online at no charge.

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