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Wednesday, April 02, 2008

House Veterans Affairs Subcommittee Hears Testimony on PTSD Treatment and Research

Yesterday, the House Veterans Affairs Subcommittee on Health convened a long-anticipated hearing on Post Traumatic Stress Disorder (PTSD) Treatment and Research: Moving Ahead Toward Recovery. The hearing was the first to be telecast live from the House committee's website and can be viewed online in full today.

From Chairman Michael H. Michaud's opening statement:

Post-traumatic stress disorder is among the most common diagnoses made by the Veterans Health Administration. Of the approximately 300,000 veterans from Operations Enduring and Iraqi Freedom who have accessed VA health care, nearly 20 percent –60,000 veterans- have received a preliminary diagnosis of PTSD. The VA also continues to treat veterans from Vietnam and other conflicts who have PTSD.

With the release of the 2007 IOM report “Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence,” we learned that we still have much work to do in our understanding of how to best treat PTSD. I hope that my colleagues will continue to work with me in supporting VA’s PTSD research programs.

I look forward to hearing testimony today from several organizations that are working to provide comprehensive and cutting edge treatment to those with PTSD. The committee recognizes that this is an important issue and one that will be with us for a long time to come. We are committed to ensuring that all veterans receive the best treatment possible.

In educational interest, article(s) quoted from extensively.

Colonel Charles W. Hoge, M.D., Director, Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research:

I would like to briefly discuss the findings of three studies published since my last testimony to this committee in September 2006, which highlight both the successes and challenges in addressing the mental health needs of our service members.

The first is a study reported this past November in the Journal of the American Medical Association (JAMA) involving nearly 90,000 Soldiers who completed both the post-deployment health assessment (PDHA) and the post-deployment health reassessment (PDHRA) after return from deployment to Iraq. Soldiers completed the PDHA immediately upon their return and they completed the PDHRA six months later. The study confirmed that many mental health concerns do not emerge until several months after return from deployment, highlighting the importance of the timing of the PDHRA, particularly for Reserve Component Soldiers.

20% of Active Component and 42% of Reserve Component Soldiers were identified as needing mental health referral or treatment, most often for PTSD symptoms, depression, or interpersonal conflict. About half of Soldiers with PTSD symptoms identified on the PDHA showed improvement by the time of the PDHRA, often without treatment. However, more than twice as many Soldiers who did not have PTSD symptoms initially became symptomatic during this same period.

One counterintuitive finding was that we could not demonstrate any direct relationship between referral or treatment for PTSD as identified on the PDHA and symptom improvement six months later on the PDHRA. The difficulty in demonstrating the effectiveness of the PDHA assessment may reflect, in part, the inherent limitations in screening or the fact that mental health services remain overburdened with the current operational tempo, despite the extensive efforts to bolster services and training.

An encouraging finding was that many Soldiers sought care within 30 days of the PDHA and PDHRA even if they were not referred, which suggests these assessments may be encouraging individuals to seek help on their own following discussion of mental health issues with a health professional or participation in concurrent Battlemind education.

The second study I’ll discuss is the recently released Mental Health Advisory Team 5 (MHAT-V) report. We have conducted MHAT evaluations every year in Iraq since the start of the war, and twice in Afghanistan. The MHATs have shown that longer deployments, multiple deployments, greater time away from base camps, and combat intensity all contribute to higher rates of PTSD, depression, and marital problems.

The MHAT-V included for the first time a sizable number of Soldiers on their 3rd rotation to Iraq. The study showed that with each deployment there is an increased risk; 27% of Soldiers on their third deployment reported serious combat stress or depression symptoms, compared with 19% on their second, and 12% on their first deployment. The MHAT-V also showed that Soldiers in brigade combat teams deployed to Afghanistan are now experiencing levels of combat exposure and mental health rates equivalent to those experienced by Soldiers deployed to Iraq.

Soldiers encounter a variety of traumatic experiences and stresses as part of their professional duties. The majority cope extraordinarily well and transition home successfully. However, surveys in the post-deployment period have shown that rates of mental health problems, particularly PTSD, remain elevated and even increase during the first 12 months after return home, indicating that 12 months is insufficient time to reset the mental health of Soldiers after a year-plus combat tour. Many of the reactions that we label as “symptoms” of PTSD when Soldiers come home are, in fact, adaptive skills necessary in combat that Soldiers must turn on again when they return for their next deployment.

The 3rd study I’ll discuss is one that we just published in the New England Journal of Medicine pertaining to the relationship of PTSD to mild traumatic brain injury (or “mild TBI”). It is important to clarify terminology. Reports have indicated that as many as 20% of troops returning from Iraq and Afghanistan have had traumatic brain injuries, but what is not always made explicit is that the vast majority of these are concussions. “Mild TBI” means exactly the same thing as “concussion,” which athletes or Soldiers also refer to as getting their “bell rung” or being “knocked out.” I advocate using the term “concussion” because it is less stigmatizing than the term “brain injury,” is better understood by Soldiers and Families, and is less likely to be confused with moderate or severe TBI.

A concussion is a blow or jolt to the head that causes a brief loss of consciousness or change in consciousness, such as disorientation or confusion. Full recovery is expected, usually within a few hours or days. This is very different from moderate or severe TBI, where there is an obvious injury to the brain that almost always requires evacuation from theater.

Although most Soldiers are able to go back to duty quickly after concussions, there has been concern that concussions in combat, particularly from blasts, may have lasting effects that are not immediately visible
. Some Soldiers report persistent symptoms (termed “post-concussive symptoms”), such as headaches, irritability, fatigue, dizziness, problems concentrating, sleep disturbance, balance problems, and cognitive or memory difficulties. Our study involving 2,500 infantry Soldiers was one of the first to look at the relationship between concussions Soldiers sustained while deployed to Iraq and these types of physical and mental health outcomes three months after their return.

There were three key conclusions from this study:

First, the study highlighted a problem that we face with not having an accurate diagnostic tool in the post-deployment period. We are not aware of any questionnaire or test that can accurately tell us who had a concussion while deployed, or which symptoms were caused by a concussion that occurred months earlier, as we are attempting to do with post-deployment screening. In our study sample, 15% of Soldiers reported a concussion while deployed based on the questions currently being used on the post-deployment assessment forms. However, only one-third of these, or 5% of the Soldiers, reported an injury in which they were knocked unconscious, usually for just a few seconds or minutes. The rest had injuries that only involved being briefly “dazed or confused” without loss of consciousness, and it was not clear how many of these were true concussions. We found that this type of injury did not confer much excess risk of adverse health effects after redeployment.

The second important finding was that having a concussion was strongly associated with PTSD. 44% of Soldiers who lost consciousness met the criteria for PTSD, compared with 16% of those who had other types of injuries and 9% who had no injury.

Third, and the most important finding, was that the symptoms that we thought were due to the concussions were actually attributed to PTSD or depression. If a concussion was the cause of the post-concussive symptoms we should have been able to confirm an association of these symptoms with a concussion, both in those Soldiers who had PTSD and in the larger group of Soldiers who did not. We did not see this in either group. Instead, all the physical health outcomes and symptoms were associated with PTSD or depression. Both PTSD and depression are biological disorders that are associated with a host of chemical changes in the body’s hormonal system, immune system, and autonomic nervous system. Many studies have shown that PTSD and depression are linked to physical health symptoms, including all of the symptoms in the “post-concussion” category, to include cognitive and memory problems.

This study allowed us to refine our knowledge about what distinguishes concussions in combat from concussions in other settings. Concussions on the football field, for example, are not known to be associated with PTSD. It is possible that there is an additive effect in the brain when a Soldier who is already seriously stressed in combat sustains a blow to the head, or there may be something unique about blast exposure, as many people are speculating. However, a hypothesis that is better supported by our data as well as other medical literature is the life threatening context in which the concussion occurs. Being knocked unconscious from a blast during combat is about as close a call as one can get to losing one’s life. There are frequently other traumatic events that occur at the same time, such as a team member being seriously injured or killed, all of which can precipitate PTSD or depression.

The most important implication of this study is that current post-deployment TBI screening efforts may lead to a large number of service members being mislabeled as “brain injured” when there are other reasons for their symptoms that require different treatment. The optimal time to evaluate and treat concussion is at the time of injury, and it is my opinion that post-deployment screening efforts months after injury may actually lead to unintended harmful effects. As a result, my research group has provided recommendations to medical leaders at Army and DoD to refine the post-deployment screening efforts to assure that all health concerns are addressed in a way that minimizes potential risks. These recommendations are now under consideration. In addition to screening and treatment, our study has important implications for educating Soldiers and Families about mild TBI (i.e. concussion).

Carolyn M. Baum, PhD, OTR/L, FAOTA, Immediate Past President
American Occupational Therapy Association and Professor, Occupational Therapy and Neurology, Elias Michael Director of the Program in Occupational Therapy, Washington University School of Medicine , St. Louis, MO:

The VA has made significant strides in preparing to meet the needs of returning OIF/OEF veterans but work remains to be done. AOTA urges Congress to continue to monitor how the VA uses occupational therapists and other professionals to assure that quality care is provided and that the full scopes of practice of all professions are brought to bear to meet veterans’ needs. Veterans deserve every service and intervention that professionals have been trained to provide. But they should receive services only from qualified professionals.

Throughout the VA system, but particularly within the Polytrauma Rehabilitation Centers, there should be a special focus on appropriate training and on evidence-based practice. Monitoring how each profession is integrated into the team should be done to provide for continuous quality improvement in these facilities.

Additionally, AOTA is concerned about the fragmented way the VA integrates or more problematically, does not integrate occupational therapists and other professionals into multidisciplinary teams for assessment and treatment of PTSD. While VA and Department of Defense (DoD) treatment guidelines for PTSD exist and include occupational therapy, it is the experience of our members that the inclusion of occupational therapists varies from site to site. This variation does not ensure full access to effective treatments and AOTA encourages the committee to look at this issue in detail.

It is also our concern that because of the primary role occupational therapy plays in the assessment and treatment of other conditions like TBI, low-vision and traumatic amputations, veterans with PTSD are not getting the access to occupational therapy they need. Occupational therapists are simply not as readily available as they need to be to address PTSD because their workload is so high in other areas. Additional therapists are needed to address PTSD because the unique, activity-based focus of occupational therapy is so critical to recovery from PTSD, particularly during the community reintegration phase of recovery.

It is possible for the private sector to supplement the Veteran’s Administration. Occupational Therapists at Washington University School of Medicine in St. Louis are currently contracted to provide services with three of our community based programs.

Veteran’s referred to us are evaluated by the Community Practice Program in their home to determine the issues that may be limiting their ability to care for themselves or others, get in and out of their homes if they are using mobility devices; and to determine if their home arrangements support them in daily tasks like toileting, bathing, preparing meals and maintaining the household. Their needs and goals are determined based on real life needs. If they have unmet mobility or work needs they are referred to either the Washington University Enabling Mobility Center (EMC) where they are evaluated and receive mobility and other equipment that will maximize their independence. If needed, they begin a program of post rehabilitation fitness (similar to what is provided at the Intrepid Center at Fort Sam Houston).

It is in the fitness program where the veteran can re-build their strength and endurance while socializing with other persons with mobility limitations on equipment designed for people in wheelchairs. If the veteran has a cognitive impairment and needs additional rehabilitation to be able to work or return to school they are referred to our Occupational Performance Center (OPC) where they learn strategies to perform work tasks and are assisted in maximizing their work potential using both simulated and then actual work tasks. The OPC team works with employers to create the right environmental fit to use the capacities of the worker. In this program people have gone back to complex jobs like nursing, teaching and the law in addition to trade jobs. ...

Roughly 750 occupational therapists are currently employed by the VA, but many more will be necessary to meet the needs of the new generation of veterans. Occupational therapy allows veterans with PTSD to return to activities of meaning that deliver a sense of normalcy and belonging to veterans and their families.

David Matchar, M.D., Member, Committee on Treatment of Posttraumatic Stress Disorder
Board on Population Health and Public Health Practice, Institute of Medicine The National Academies:

The Department of Veterans’ Affairs charged the Institute of Medicine committee with several specific tasks. We were asked to: (1) review the evidence and make conclusions regarding the efficacy of available treatment modalities; (2) note restrictions of the conclusions to certain populations; (3) answer questions related to treatment goals, timing and length; (4) note areas where evidence is limited by insufficient research attention or poorly conducted studies; and (5) comment on gaps and future research. ...

VA asked the committee to comment on what the literature tells us about the meaning of recovery, the effect of early intervention, and the impact of treatment length (e.g., brief vs. prolonged therapy). The committee found no generally accepted and used definition of recovery in PTSD. We recommend that clinicians and researchers work toward common outcome measure that are valid in research, allow comparability between studies, and are useful to clinicians.

We interpreted early intervention to mean keeping cases of PTSD from becoming chronic. Intervention before the diagnosis of PTSD or before the possibility of meeting the definition of PTSD (generally, early intervention in the literature occurs immediately post-trauma, referring to a condition that’s a precursor to PTSD, such as Acute Stress Disorder) was not part of our scope, because it refers to people who do not yet have or may never develop PTSD. We could not reach a conclusion on the value of early intervention, and recommended that further research specify time since trauma and duration of PTSD diagnosis. Interventions should be tested for efficacy at clinically meaningful intervals.

On length of treatment the committee found that the research varied widely in length of treatment even for a single modality, and was not able to reach a general conclusion. We recommend that trials focus on optimal length of given treatments, and that trials of comparative effectiveness between treatments should follow. There is also a need for longer-term follow-up studies after treatment concludes.

Our last two tasks were to address areas inadequately studied, and recommendations for further research. Our overall message here is that PTSD needs more attention from high-quality research, including in veterans. The committee highlighted several research-related issues in the report, including internal validity (for example, was there blinding in the study, was there adequate follow-up of patients, were missing data handled with appropriate analyses?), investigator independence, and special populations.

As outlined in our methods and in a technical appendix, the committee found much of the research on PTSD to have major limitations when judged against contemporary standards in conducting randomized controlled trials. While recognizing that PTSD research perhaps presents special challenges, we know that high quality studies are possible because we found them in our search, and there are authorities in the field of PTSD research who have called for more attention to methodologic quality. We recommend that funders of PTSD research take steps to insure that investigators use methods to improve the internal validity of research.

The committee also noted that the majority of drug studies have been funded by the pharmaceutical manufacturers, and the majority of psychotherapy studies have been conducted by the individuals who developed the techniques or their close collaborators. The committee recommends that a broad range of investigators be supported to conduct replication and confirmation studies.

The committee recognized that PTSD is usually associated with other problems such as comorbid substance abuse, depression, and other anxiety disorders. More recently, there’s been growing concern about people with PTSD and traumatic brain injury. The research literature is not informative on this issue of patients who have PTSD and other disorders. It also does not address PTSD in special veteran populations such as ethnic and cultural minorities, women, and people with physical impairments. We recommend that the most important such subpopulations be defined to design research around interventions tailored to their special needs.

Finally, the committee made two general recommendations about research in veterans. First, the committee found that research on veterans with PTSD is inadequate to answer questions about interventions, settings, and length of treatment. We recommend that Congress require and insure that resources are available to fund quality research on the treatment of veterans with PTSD, with involvement of all relevant stakeholders. Second, the committee found that the available research is not focused on actual practice. We recommend that the VA take an active leadership role in identifying the high impact studies that will most efficiently provide clinically useful information.

In closing, I would like to highlight the three key messages of this report.

1. Many of the studies that have looked into the effectiveness of PTSD therapies have methodological flaws and therefore do not provide a clear picture of what works and what does not work.

2. Various pharmaceuticals and psychotherapies may or may not be effective in helping patients with PTSD; we simply do not know in the absence of good data in most cases. To strengthen study quality, we need: larger studies, longer and more complete follow-up of all participants (including those who discontinue treatment before the study is over), and better selection of which treatments to study and which to compare to each other, with priority given to the most widely used therapies. Also, greater focus on veteran populations and special subpopulations (e.g. those with traumatic brain injury, substance abuse).

3. Given the growing number of veterans with PTSD and the seriousness of this disorder, the VA, Congress, and the research community urgently need to take steps to ensure that the right studies are undertaken to yield scientifically valid and generally applicable data that would help clinicians most effectively treat PTSD sufferers.

Additional written testimonies.

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