Date:  June 20, 2014




Effectiveness of PTSD Treatment Provided by Defense Department and VA Unknown;

Tracking of Outcomes Needed to Manage Growing Burden


WASHINGTON -- The U.S. Department of Defense and U.S. Department of Veterans Affairs should track the outcomes of treatment for post-traumatic 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. 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. The report is the second of a two-phase assessment of PTSD services for service members and veterans and 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. Right now, 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 or whether DOD and VA's expenditures are resulting in high-value health care, said the committee that wrote the report.


"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," said committee chair Sandro Galea, professor and chair of the department of epidemiology, Mailman School of Public Health, Columbia University, New York City. "They could be highly effective, but we won't know unless outcomes are tracked and evaluated." 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.


The report recommends that DOD and VA 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, and does 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.  


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 although 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, encourage staff to follow the guidance, or use the data available from its specialized PTSD programs to improve the way they manage the disorder.


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.


The report also recommends that DOD and VA have an adequate workforce of mental health care 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, 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 report contains additional noteworthy findings, including:

·         PTSD has also increased among veterans of other eras of conflict.  In 2013, 62,536 new cases of PTSD in the VA were diagnosed in veterans who did not serve in the Iraq and Afghanistan wars, and 34 percent of new admissions to VA specialized PTSD programs in 2012 were Vietnam-era veterans.

·         Veterans of the Iraq and Afghanistan wars use the VA at rates double those of other veterans -- 54 percent of Iraq and Afghanistan war veterans use the VA versus 27 percent of all veterans.

·         PTSD is the third most common major service-connected disability after hearing loss and tinnitus.

·         In 2012, 13.5 percent of soldiers in the U.S. Army had a diagnosis of PTSD, as did 10 percent of Marines, 4.5 percent of Navy personnel, and 4.4 percent of Air Force personnel. 


The study was sponsored by the U.S. Department of Defense. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.  The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.  A committee roster follows.



Jennifer Walsh, Senior Media Relations Officer

Chelsea Dickson, Media Relations Associate

Office of News and Public Information

202-334-2138; e-mail

Twitter: @NAS_news and @NASciences

RSS feed:



Pre-publication copies of Treatment for Post-traumatic Stress Disorder in Military and Veteran Populations: Final Assessment are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at  Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).



#       #       #


Board on the Health of Select Populations


Committee on the Assessment of Ongoing Efforts

in the Treatment of Post-traumatic Stress Disorder

Sandro Galea, M.D., Dr.P.H., M.P.H.

Anna Cheskis Gelman and Murray Charles Gelman Professor and Chair

Department of Epidemiology

Mailman School of Public Health

Columbia University

New York City


Kathryn Karusaitis Basham, Ph.D., M.S.W.

Professor and Co-Director of Ph.D. Program
School for Social Work

Smith College
Northhampton, Mass.


Larry Culpepper, M.D., M.P.H

Professor of Family Medicine

Boston University Medical Center



Jonathan R. Davidson, M.D.

Emeritus Professor

Department of Psychiatry

Duke University Medical Center

Seabrook Island, S.C.


Edna B. Foa, Ph.D.


Department of Psychiatry, and


Center for the Treatment and Study of Anxiety
School of Medicine

University of Pennsylvania



Kenneth W. Kizer, M.D., M.P.H.

Distinguished Professor

School of Medicine and Betty Irene Moore School of Nursing

University of California Davis, and


Institute for Population Health Improvement

UC Davis Health System



Karestan C. Koenen, Ph.D.

Associate Professor

Department of Epidemiology

Mailman School of Public Health

Columbia University

New York City


Douglas L. Leslie, Ph.D.


Department of Psychiatry and Department of Public Health Services

Pennsylvania State University



Richard A. McCormick, Ph.D.

Senior Scholar

Center for Health Care Research and Policy

Case Western Reserve University

MetroHealth Medical Center



Mohammed R. Milad, Ph.D.

Assistant Professor

Department of Psychiatry,


Behavioral Neuroscience Laboratory, and

Associate in Research Psychiatry

Massachusetts General Hospital



William P. Nash, M.D.

Adjunct Assistant Professor

University of California, San Diego, and

Virginia Commonwealth University



Elizabeth A. Phelps, Ph.D.

Silver Professor of Psychology and Neural Science

Department of Psychology and Center for Neural Science

New York University

New York City


Elspeth C. Ritchie, M.D.

Clinical Professor of Psychiatry

Georgetown University; and

Chief Clinical Officer

District of Columbia Department of Behavioral Health

Washington, D.C.


Albert Rizzo, Ph.D.

Professor and Associate Director

Institute for Creative Technologies Research

University of Southern California

Playa Vista


Barbara O. Rothbaum, Ph.D.

Associate Vice Chair for Clinical Research,

Professor in Psychiatry, and

Director, Trauma and Anxiety Recovery

School of Medicine

Emory University



Douglas F. Zatzick, M.D.


Associate Vice Chair for Health Services Research

Department of Psychiatry and Behavioral Sciences

School of Medicine

University of Washington






Roberta Wedge

Study Director