Is the $3B Paid by U.S. Government for Treating PTSD in Soldiers Well-Spent?

Though an estimated $3B U.S. is spent each year by the U.S. government for treatment programming to deal with PTSD in soldiers and veterans, a new Institute of Medicine report raises disturbing questions about the effectiveness of these programs.   The report, titled "Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations" was produced by a multidisciplinary committee formed to evaluate how the Department of Defense and Veterans Administration were handling the complex issues surrounding PTSD in the military.  Mandated by Congress, the report determined that, despite the billions spent on treatment programming, there was no way to evaluate the effectiveness of this treatment since long-term patient outcome was not being tracked. 

According to committee chair Sandro Galea of Columbia University's Mailman School of Public Health, the rising number of veterans requesting treatment for PTSD (having more than doubled between 2003 and 2012) means more treatment is being offered but with little real oversight to ensure proper quality.   "“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," Galea said in an interview with NextGov. “They could be highly effective, but we won't know unless outcomes are tracked and evaluated.”

Based on statistics provided in the report, of the 2.6 million U.S. military personnel deployed to Afghanistan and Iraq since 2001, the proportion who have since been diagnosed with PTSD has steadily risen from one percent in 2004 to more than 5 percent in 2012.   The proportion of soldiers being diagnosed varies across different branches of the armed forces with 13.5 percent of soldiers, 10 percent of marines, 4.5 percent of Navy personnel, and 4 percent of Air Force personnel.   Women in the military are more likely to be diagnosed than men (13 percent vs. 9 percent) and nonwhites more than whites (11 percent vs 8.5 percent).   To make sure PTSD cases don't go undiagnosed, the DOD routinely screens returning veterans 30 days after their return and again at three to six months. 

In 2012, about 502,000 veterans received outpatient care for PTSD-related issues and make up 9 percent of all VA health care users.  Of those veterans, 47 percent had served during Operation Enduring Freedom or Operation Iraqi Freedom.    Of the rest, 20 percent had served during the previous Gulf War and 34 percent were from the Vietnam era. 

While most of the treatment received by active military and veterans was conducted in general mental health clinics, primary care settings, or specialized PTSD programs in the community, some military bases also provide intensive PTSD programs to reduce barriers to care.   Along with evidence-based psychotherapy and pharmacotherapy, programs may also provide alternative treatment including art therapy, acupuncture, and biofeedback.    There appears to be little, if any, outcome statistics to evaluate how effective these programs are, either in terms of short-term or long-term benefit.

From 2010 to 2012, the VA spent $8.5 B on PTSD treatment while the DOD spent $789.1 million.   Much of the treatment programming provided by the DOD is described as crisis-driven with little emphasis on a long-term strategy for dealing with trauma issues.   Despite the obvious benefits, the DOD has devoted relatively few resources to PTSD prevention or implementing programs for managing traumatic stress in troops.   As for the VA, the report raises questions about whether the treatment veterans receive meets the guidelines for minimum care set by health agencies.  The VA is currently upgrading their electronic health care records to include information on psychotherapy treatment plans.    While this should make treatment evaluation easier, the report also calls for greater integration of PTSD treatment  between the DOD and VA to track the care soldiers receive and to make sure their health needs are met.

Another problem is that both the DOD and VA do not have enough trained mental health care workers to meet the soaring demand for treatment.   While more therapists have been hired over the past few years, staffing shortages mean that many soldiers are not getting the recommended amount of treatment.   In 2013 alone, only 53 percent of recent veterans with PTSD issues received adequate treatment without being placed on waiting lists.   Despite contracting out treatment services to therapists in the community to get more veterans into treatment,the report also raises questions about the credentials of many of these treatment providers and whether they can provide the best care for veterans asking for help. 

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