Department of defense ptsd/tbi research program

If you are a Veteran in crisis or concerned about one, connect with our caring, qualified responders for confidential help. Many of them are Veterans themselves. Get more resources at VeteransCrisisLine. In earlier wars, it was called "soldier's hearat," "shell shock," or "combat fatigue.

PTSD can occur after a traumatic event such as military combat, a physical assault, or a natural disaster. While stress is common after a trauma, people with PTSD often relive a traumatic event in their minds. They may also feel distant from friends and family and experience anger that does not go away over time, or may even get worse.

PTSD can affect individuals who have experienced a wide range of life-threatening events. It has taken a significant toll on many Veterans who currently use VA health care.

People with PTSD can experience a number of distressing and persistent symptoms, including re-experiencing trauma through flashbacks or nightmares, emotional numbness, sleep problems, difficulties in relationships, sudden anger, and drug and alcohol misuse. Recently, reckless and self-destructive behavior has been added as a PTSD symptom.

VA research has led the way in developing effective psychotherapies for PTSD and exploring other approaches such as medications, behavioral interventions, and therapeutic devices. VA researchers are working to better understand the underlying biology of PTSD, advance new treatments, and refine diagnostic approaches. Ongoing studies range from investigations of genetic or biochemical foundations of PTSD to evaluating new treatments and drugs. Veterans of all eras are included in these studies.

The brain bank is responsible for tissue acquisition and preparation, diagnostic assessment, and storage. Most of the brains stored in the bank are from people once diagnosed with PTSD. Others are from donors who had major depressive disorders. Other brains are from healthy individuals who serve as controls. The goal is to help pinpoint how PTSD affects changes in brain structure and function.

With medication alone, 42 of will achieve remission. VA conducted a head-to-head comparison of prolonged exposure and CPT. Currently, study results are pending. Cognitive processing therapy— In the s, Dr. Patricia Resick developed CPT, a session cognitive behavioral treatment originally designed to help victims overcome symptoms of sexual trauma. It is a specific type of cognitive behavioral therapy CBT , a form of psychological treatment that involves efforts to change thinking patterns.

People undergoing CPT therapy are helped to understand and change how they think about their trauma and its aftermath. The goal is to understand how certain thoughts about the trauma cause stress and make symptoms worse. In prolonged exposure therapy, the goal is to make memories of traumatic events less fearful. Patients talk about their traumas with therapists in a safe, gradual way and listen to recordings of their trauma narratives in between sessions, in hopes of gaining control of thoughts and feelings about these difficult experiences.

While thinking of or talking about their memories, people undergoing EMDR therapy focus on other stimuli like eye movements, hand taps, and sounds. No other psychotherapies were found to be effective.

In a study published in , a team led by researchers from the VA San Diego Healthcare System found that women Veterans with PTSD whose symptoms of depression were reduced were most likely to see improvements in their quality of life. For men, however, reducing symptoms of anger had a greater effect on improving the quality of their lives.

The researchers believe that the effectiveness of PTSD treatment should be evaluated within the context of gender. Some clinicians are reluctant to use these therapies for patients with both PTSD and TBI because they fear patients would be less able to tolerate therapy, or that cognitive limitations would make the therapy less effective.

The researchers noted that their study had some limitations, because it was not a randomized trial, and the sample size was small. Combination of therapies may be effective— Dialectical behavior therapy DBT utilizes individual psychotherapy and group skills training classes to help people learn and use new skills and strategies to develop a personally meaningful life. DBT teaches skills to foster mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

In their study, 22 Veterans underwent a week intensive outpatient program combining the two treatments. It does not directly confront trauma memories as CBT does. Theta-burst transcranial magnetic stimulation— Transcranial magnetic stimulation TMS is a medical treatment that uses an electromagnetic coil to produce a magnetic field that is applied to specific points on the skull to stimulate areas of the brain. Theta-burst stimulation TBS is a newer form of TMS in which magnetic pulses are applied in a certain pattern, called bursts.

They applied the technique intermittently to the right dorsolateral prefrontal cortex an area in the front of the brain in hopes of reducing activity in areas involved in PTSD. Prazosin and sleep disorders— In , researchers from the VA Puget Sound Health Care System in Seattle and the University of Washington demonstrated that an inexpensive generic drug called prazosin, used by millions of Americans for high blood pressure and prostate problems, could also be used to reduce nightmares in Veterans with PTSD.

The researchers found that patients taking prazosin got an average of 94 minutes of additional sleep a night, increased the time and duration of their rapid eye movement sleep cycles, had fewer trauma-related nightmares, woke up less in the middle of the night in distress, and appeared to have more normal dreams.

However, in a large multisite clinical trial involving more than combat Veterans whose results were published in , the drug did no better than placebo pills in reducing nightmares. VA now believes the decision to use prazosin should be made by Veterans and their medical providers.

Not every Veteran who subjectively reports nightmares in the context of a PTSD diagnosis is going to respond to prazosin, said the study authors, but there is clearly a subgroup of people who do respond. Individual placement and support helps Veterans find employment— Individual placement and support IPS , a person-centered model to help Veterans find and keep jobs, is more effective than older methods of vocational rehabilitation, according to a multi-site VA study published in IPS helped nearly twice as many participants in the study to get steady jobs as a program using transitional work.

Veterans with PTSD are more likely to be unemployed than those without the disorder. The outreach and support are more intensive during the first few months after a Veteran is placed in a job, then tapers off as the Veteran gets stabilized in the work setting. Long-term career development continues afterwards.

Mantram therapy may reduce hyperarousal— Hyperarousal, a common symptom of PTSD, is a heightened state of anxiety that is more difficult to treat using common treatments than other PTSD symptoms.

In a study published in , researchers with the San Diego VA Healthcare System asked Veterans to practice mantram repetition to deal with hyperarousal. Mantram is a simple meditation technique in which Veterans silently repeat a word or phrase that holds personal meaning for them. The team found that Veterans using the technique had greater reductions in hyperarousal, compared with those using standard psychotherapy only.

The results show that mantram treatment focused specifically on hyperarousal could lead to lower levels of PTSD symptoms, according to the study authors. Stellate ganglion block— A procedure called stellate ganglion block, which involves injecting a local anesthetic into the neck, is used to treat certain pain conditions.

The procedure may also be able to stop nerve impulses to the brain that trigger anxiety in patients with PTSD. A VA evidence review urged further study of this possible treatment. The VA Long Beach Healthcare System initiated a stellate ganglion block clinical program in and now has treated more than 60 Veterans using this procedure. Effective solutions to support relationships and parenting, prepare families for potential secondary trauma exposure, and empower families to access tailored support and resources.

Solutions to address aspects of workplace culture and climate e. Research of interest includes but is not limited to solutions to provide and incentivize positive options and substitutes for alcohol and substance use and promote pro-social behavioral norms.

Treat: Research will address immediate and long-term treatments and improvements in systems of care, including access to and delivery of health care services.

Treatment topics may include novel treatments and interventions, personalized medicine approaches, length and durability of treatment, rehabilitation, relapse, and relapse prevention. Interventions that promote sustained functional recovery, including interventions administered acutely, during the post-acute phase, or during the chronic phase of injury.

Research of interest includes, but is not limited to: Interventions focused on sensory and locomotor dysfunction after brain injury. Interventions that address cognitive functioning and reserve. Personalized medicine approaches to treatment that may include tailoring treatment to the biological and endophenotypic elements present. Rapid assessments and treatments for psychological health conditions. Effective assessments and interventions for delivery in rural or other resource-limited environments e.

Considerations for sequencing and optimal combinations of pharmacologic and non-pharmacologic interventions. Treatments that promote recovery and improving long-term outcomes. Studies may include, but are not limited to, one or more of the following: Responders versus non-responders to treatment and rehabilitation. Implementation, follow-up, and services research to increase provider adoption and availability of evidence-based treatments, as well as treatment engagement, follow-up care, and understanding of long-term outcomes.

Optimized messaging for successful dissemination and implementation of interventions. Understanding mechanisms of action for existing evidence-based treatments is also of interest. Effective community-level postvention strategies to address social connectedness during reintegration of individuals into teams following a sexual assault or suicide event.

Proposed research should prevent subsequent suicides or other counterproductive behaviors among individuals and community members. Supports planning and development activities necessary to initiate a future clinical study.

Recipients are expected to be ready to apply for advancing funding in the year following completion of the award; recipients are in no way assured of future funding.

Submission of a Letter of Intent is required prior to full application submission. Maximum period of performance is 2 years. Clinical Trial Award Extramural applicants only. Investigators at the level of Assistant Professor and above or equivalent.

Supports clinical trials for pharmacological e. Submission of a preproposal is required; application submission is by invitation only. Different funding levels, based on the scope of research, are available. It is the responsibility of the Principal Investigator PI to select the funding level that is most appropriate for the research proposed.

The funding level should be selected based on the scope of the research project, rather than the amount of the budget.

The following are general descriptions, although not all-inclusive, of the scope of research projects that would be appropriate to propose under each funding level: Funding Level 1: Proof-of-principle pilot trials, correlative studies, and other innovative, exploratory clinical trials.

Funding Level 2: Clinical trials for promising treatments or interventions that have already demonstrated acceptable safety in human subjects. The strategy uses a public health model to improve DoD and VA mental health care for all active-duty service members, National Guard and reserve component members, veterans, and their families.

The IMHS has four strategic goals: expand access to mental health care in DoD and VA; ensure quality and continuity of care across the departments; advance care through community partnership, education, and successful public communication; and promote resilience and build better mental health care systems.

According to the strategy, these goals are to be achieved within 3 years by developing and implementing 28 strategic actions. The strategic goals will include both operating plans and performance metrics.

There is also a lack of information on whether the strategy has been implemented across DoD and VA and what progress has been made on achieving the goals and the strategic actions, to date. In this chapter, the organizational structure of the mental health care systems in DoD and VA are briefly described. Where data are available on the effectiveness of a program, this information is noted. The chapter concludes with a summary of DoD and VA PTSD or mental health program evaluations that are being, or have recently been, conducted by the departments or by other organizations.

PTSD-related or -focused services are offered at military treatment facilities MTFs , embedded mental health clinics, and primary care clinics. Responsibility for developing, implementing, and evaluating PTSD programs and services resides in several offices in DoD and the service branches.

The next section provides an overview of the organization of the DoD health care system followed by a description of the prevention programs, screening and diagnostic assessments, and treatment and rehabilitation programs that are available to service members.

This section also includes descriptions of PTSD programs that are available in the community if they treat a large number of service members or provide a service that is not available on the military installation. Overseen by the Office of the Assistant Secretary of Defense for Health Affairs [OASD HA ], the military health system MHS is responsible for maintaining the readiness of military personnel by promoting physical and mental fitness, providing emergency and long-term casualty care, and ensuring the delivery of health care to all service members, retirees, and their families.

MHS coordinates efforts of the medical departments of the Army, Navy includes the Marine Corps , and Air Force; the joint chiefs of staff; the combatant command surgeons; and private-sector health care providers, hospitals, and pharmacies.

Figure shows the organizational structure of the major health care components in DoD. Organization of health care services provided by DoD in the continental United States. Health care in theater is under a different command structure from that in garrison and is not included in this figure. How mental health care is provided within DoD varies greatly among its service branches.

Mental health care is provided to service members in garrison primarily in MTFs and affiliated mental health clinics that are on or near military bases. The affiliated mental health clinics operate under the direction of regional Army or Navy medical commands of the military departments or Air Force air-base wing commanders. The Navy provides the majority of mental health service to the Marine Corps.

Because each installation has its own unique arrangement of medical facilities—including hospitals, clinics, dispensaries, and aid stations—it is not possible to make generalizations regarding the availability of facilities on each installation.

Although TRICARE is sometimes used to describe only purchased care, the committee uses the term in a broader sense: as a wide-reaching health care provider for DoD beneficiaries that includes service members, retirees, and their families and delivers direct care through MTFs and purchased care through network and non-network civilian health professionals, hospitals, and pharmacies TRICARE Management Activity, In , it is estimated that about 9.

The organization of health care services, as depicted in Figure , provides a sense of where PTSD management services reside in the department and the service branches. Many of these policies have been implemented recently or are in the process of being implemented, so compliance with them and their effects on improving PTSD management have not yet been assessed.

Each service branch has developed and implemented training, services, and programs intended to foster mental resilience and to preserve mission readiness and effectiveness, and mitigate adverse consequences of exposure to stress DoD, b , but none is PTSD-specific.

While there is overlap in the goals of these programs, the content of each one is tailored to a particular service branch. Comprehensive Soldier and Family Fitness CSF2 is a resilience-building program designed to enhance the performance of soldiers, their families, and Army civilians. CSF2 has five dimensions—physical, emotional, social, family, and spiritual—and consists of four components: master resilience training, comprehensive resilience modules, the global assessment tool, and the Army Center for Enhanced Performance U.

Army, b ; Weinick et al. The effectiveness of this program is discussed in Chapter 7. The foundation for psychological health promotion and mental disorder prevention in both the Navy and Marine Corps is their Combat and Operational Stress Control COSC Program, in which unit leaders are directly responsible for protecting the mental health of their service members and families Marine Corps Combat Development Command and Navy Warfare Development Command, ; Nash, OSCAR is intended to prevent, identify, and manage stress reactions at the level of operational units through two simultaneous efforts: training OSCAR mentors small-unit leaders and extenders chaplains, corpsmen, and non-mental-health medical providers.

OSCAR mentors and extenders monitor and manage the stress of unit members by using the COSC tools and embedding OSCAR providers mental health professionals directly in combat units throughout their deployment cycles to provide clinical support Nash, In , the Air Force began Airmen Resilience Training to enhance resilience, increase recognition of stress symptoms, and connect airmen with information on when, how, and where to access mental health and other support services.

Air Force, a ; Weinick et al. The Air Force requires that all its installations have traumatic stress response teams to offer resilience education for those likely to experience traumatic events, followed by education, intervention, screening, psychological first aid, and referral as necessary U.

Air Force, Exposed airmen can seek up to four one-on-one education and consultation meetings with a team member. The meetings, however, are not considered to be treatment for exposure to a traumatic event and, therefore, often are not documented.

DoD has a series of screenings and assessments for mental health during the deployment cycle for all service members—the pre-deployment health assessment, the post-deployment health assessment PDHA , and the post-deployment health reassessment PDHRA DoD, a. The predeployment health assessment is administered within 60 days before deployment and documents general health information on each service member. An affirmative response to the question may result in referral to a medical provider for further assessment for deployment.

The PDHA is given to service members within 30 days after they leave their assigned posts or after their return from deployment and the PDHRA is administered 3—6 months after return from deployment. On the basis of responses to the questions, a service member may be referred for further evaluation GAO, Each service has its own process for administering the assessments.

For example, the Marine Corps administers the PDHA and the PDHRA in deployment health clinics along with other screening tools, such as automated neuropsychological assessment metrics for traumatic brain injury. Updated information on the number of mental health referrals that get activated was requested from DoD but was not received for this report.

Although early interventions for stress management may occur while a service member is serving in theater, most PTSD treatment is delivered in garrison, on and off base. In addition, most treatment for PTSD is outpatient and occurs in general mental health clinics or primary care settings. Figure illustrates the treatment pathways available to service members who have PTSD.

For example, service members who have mild symptoms or subsyndromal PTSD may be treated in primary care clinics.

DoD has adopted the patient-centered medical home model PCMH to provide mental health services in primary care settings to improve patient access to mental health care, provide coordinated care for comorbidities, and decrease overall health costs DoD, a ; TRICARE Management Activity, The PCMH also provides a mechanism for primary care sites to receive patients back from specialty mental health care and to coordinate maintenance treatment with mental health and rehabilitative services.

Case facilitators assist primary care clinicians with follow-up, symptom monitoring, and treatment adjustment medication, counseling, or both Engel et al. Dotted line between primary care and general mental health denotes that many service branches are moving to the PCMH model in which mental health practitioners are embedded in primary care teams. On-base providers more The Army, Air Force, and Marines are all implementing some form of integrated mental health care. Army, b. The Air Force Behavioral Health Optimization Program also integrates mental health and primary care services to reduce stigma and enhance access to mental health care DoD, b ; U.

The Navy is integrating mental health personnel within its Medical Home Port programs, and the Marine-Centered Medical Home is currently under development with collaboration from the Navy and the Marine Corps deployment health clinics DoD, b. In the Army, mental health care providers are in both MTFs and mental health clinics embedded in brigades 3,—4, soldiers. MTFs provide both outpatient and inpatient treatment, whereas embedded clinics are limited to outpatient care.

Embedded mental health care providers also serve as advisers to the commanders of their operational units. The Army has established 44 embedded clinics in brigades and plans to establish them service-wide U. Army, a. Embedded health teams consist of 13 providers and staff, including at least one uniformed officer who is a mental health care provider Blakeley and Jansen, Outpatient care for marines and Navy personnel is provided mainly through mental health clinics close to the units, but MTFs also provide some PTSD treatment.

As full members of the operational units to which they are assigned, OSCAR providers increase access to mental health services in garrison, during training, and during deployment. Marine Corps deployment health clinics also have embedded providers to treat for mild to moderate mental health conditions in a timely manner and thus reduce the need for referrals.

During —, 5, marines had PTSD encounters in primary care clinics, 16, had encounters in mental health settings, and 1, had encounters in other clinics.

Of Navy personnel, 2, had PTSD encounters in primary care clinics during —, 13, had encounters in mental health clinics, and 1, had encounters in other clinics U.

Navy, For many years, the Navy has stationed a full-time clinical psychologist on each of its aircraft carriers for the duration of their overseas deployments. During —, 7, Air Force personnel who had PTSD were treated in outpatient clinics, 6, in specialty mental health clinics, and 3, in primary care clinics. Those in the outpatient clinics received an average of 9. Air Force, b. The Air Force has mental health care providers in its intelligence and remotely piloted aircraft units as well U.

Each service branch also embeds mental health care providers in especially high-risk units, such as special operations units and units in which personnel are involved in intelligence, surveillance, and reconnaissance. Although the goals of embedding are to shorten the physical distance between patients and providers, to enhance mutual trust and understanding, and potentially to decrease barriers to care for PTSD, no studies have confirmed the efficacy or effectiveness of the embedded mental health programs in the service branches.

Service members in need of more intensive PTSD treatment may be referred to a specialized program. There are 21 such programs in DoD: six intensive outpatient programs, eleven partial hospitalization or day treatment programs, and four residential treatment facilities. Intensive outpatient programs operate 3—4 hours per day and 3—5 days per week, and generally run 4—6 weeks.

Criteria for admission to these programs are variable; for example, some programs accept patients who have substance use disorder in addition to PTSD and others do not. Participation in the program is voluntary but the soldiers must be willing to try all therapies offered in the program. Every soldier has at least one complementary and alternative therapy session daily to calm down and relax after psychotherapy.

WRC also offers family and partner support groups. WRC offers aftercare services for soldiers who need additional individual or group therapy and has drop-in yoga, art, and meditation classes and spousal support activities. Although the WRC staff reported that they collect data on patient outcomes, they had not published any results. The program consists of 3 weeks of intensive daily treatment for groups of 12 soldiers that uses evidence-based individual therapy; group therapy; acupuncture; relaxation techniques; a variety of complementary and alternative interventions, such as yoga, meditation, neurofeedback, and cranial electrical stimulation; and occupational therapy.

That treatment regimen can be followed by 8 additional weeks of therapy if necessary. The current wait list for the program is about a year, and priority is given to soldiers who want to remain on active duty.

Soldiers who have substance use disorders are not eligible for the program and are referred to a dual-diagnosis intensive outpatient program. The PCL-M and depression and anxiety measures are given before and after the program along with patient satisfaction surveys, to measure outcomes and changes in PTSD symptoms Wesch, , but results have not been published.

Although the Reset leaders would like to expand the program to accommodate more soldiers, there is no space available at Fort Hood for them to do so. Partial hospitalization programs associated with a hospital and day treatment programs programs that are usually outpatient for PTSD are similar to intensive outpatient programs.

They have highly structured environments and activities—similar to residential settings, but without crisis stabilization or acute detoxification services—and generally operate a minimum of 6 hours per day, 5 days per week. Treatments promote functioning in home and work and typically include peer socialization, group support, psychoeducation, life skills training, medication management, individual and family therapy, and complementary and alternative therapies.

Although the Army, the Navy, and the Marine Corps have partial hospitalization programs for PTSD, the Air Force does not have any specialized residential, partial hospitalization, or day treatment programs for PTSD and it refers its personnel to other programs if necessary U. Freedom Care treats active-duty service members from Fort Bliss and elsewhere who have combat PTSD, addiction, or a dual diagnosis of PTSD with addiction, military sexual trauma, or other psychiatric diagnoses.

The program runs 6 hours per day, 5 days per week; the average stay is 2 weeks. The program offers evidence-based treatments, process and educational group therapy, and other interventions such as art therapy, pet therapy, aquatics, and rock climbing, as well as family therapy and individual therapy for spouses and children, which are offered after hours.

On the average, 20 service members participate in the program at any time. At any time, there are two groups of 10 participants in the week program. The 23 program staff members, including a chaplain, offer a broad array of evidence-based and complementary and alternative therapies in both individual and group formats.

OASIS also offers posttraumatic growth classes, couples counseling, and canine therapy, in which service members help to train service dogs for others. Participants who have PTSD and an alcohol problem have daily Alcoholics Anonymous sessions and receive treatment for compulsive behavior.

Most inpatient mental health treatment in DoD focuses on stabilizing a service member in the acute or crisis phase for example, when people are expressing suicidal or homicidal ideation or attempts.

The MTF psychiatric wards visited by the committee generally had fewer than 15 beds. The average number of inpatient bed days per soldier admitted for PTSD was Army, a and Many service members in these programs have received a diagnosis of PTSD and many have comorbidities, such as TBI, although precise numbers are not available. As noted in Chapter 2 , PTSD is often accompanied by other psychiatric, medical, or psychosocial conditions, such as alcohol dependence, anxiety, obstructive sleep apnea, lumbago, depression, and rehabilitation procedures that require treatment Kennell and Associates, Although treatment of comorbidities is vital for the effective management of PTSD, there is a lack of evidence on how best to treat for PTSD and comorbid conditions.

NICoE offers both evidence-based psychotherapy and pharmacotherapy and such complementary and alternative therapies as animal-assisted therapy, biofeedback, journaling, recreation therapy, and mind—body skill building.