Vast Majority of Veterans With PTSD Do Not Receive Sufficient Treatment

Caroline Cassels

March 19, 2010

March 19, 2010 — Fewer than 10% of Iraq and Afghanistan veterans with new posttraumatic stress disorder (PTSD) diagnoses receive the recommended number and intensity of mental health treatment sessions within the first year of diagnosis, new research shows.

A study conducted by investigators at the San Francisco Veterans Affairs (VA) Medical Center in California shows that of 49,425 veterans who received a new diagnosis of PTSD between 2002 and 2008 only 9.5% completed the recommended 10 to 12 weekly treatment sessions.

Further, researchers found that compared with their female counterparts, male veterans were less likely to receive adequate care. In addition, veterans younger than 25 years, those who received their PTSD diagnosis from primary care clinics, and veterans living in rural areas were also less likely to receive the recommended amount of care.

"We found that less than 10% of Iraq and Afghanistan veterans who received a new PTSD diagnosis had 9 or more sessions in the first year of diagnosis within a 15-week period. Put another way, more than 90% of veterans with a new PTSD diagnosis did not receive a treatment dose adequate enough to cause their symptoms to remit," principal investigator Karen H. Seal, MD, MPH, told Medscape Psychiatry.

The study was published online February 9 in the Journal of Traumatic Stress.

Barriers to Care

According to the study, the Department of Veterans Affairs is the single largest provider of healthcare services for separated Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans in the United States.

However, the researchers point out that despite the mounting cases of mental health disorders in this population little is known about veterans' use of VA mental health services.

"Our previous research has focused on charting the epidemic of mental health problems, the most common being PTSD, among returning Iraq and Afghanistan veterans.

"We found that there is a growing proportion of veterans nationwide presenting to the VA with [mental health] problems, but we really didn't know what type of mental health services utilization they were getting. However, anecdotally, it has always been our impression that these veterans have numerous barriers to care. So the aim of the study was to look at national level data and the actual utilization of mental health services in this population," said Dr. Seal.

The study population included 238,098 OIF and OEF veterans who enrolled in the VA between 2002 and 2009. Of these individuals, 84,972 (35%) received one or more mental health diagnoses. A total of 49,425 (58.2%) received new PTSD diagnoses, 76.5% of which were comorbid with other mental health diagnoses.

Among veterans with PTSD, only 9.5% attended 9 or more VA mental health sessions in 15 weeks or less in the first year of diagnosis. Dr. Seal said investigators chose the study cut point of 9 to 12 sessions during 15 weeks or less as the primary outcome measure because it reflects the recommended number and intensity of treatment sessions within the first year of diagnosis.

However, the study authors note that when the interval was "liberalized" to 1 year after the first PTSD diagnosis more than one-quarter (27%) attended 9 or more VA treatment sessions.

The investigators found that veterans who received a PTSD diagnosis were less likely to attend an adequate amount of mental health treatment sessions if they received their diagnosis from a primary care or non–mental health specialty clinic.

The researchers also found that being male, being younger than 25 years, and living a significant distance from a VA facility were all significantly associated with a decreased likelihood of receiving sustained mental health treatment.

Falling Through the Cracks

Although the study did not investigate the underlying reasons veterans received suboptimal doses of mental healthcare, Dr. Seal said it was no surprise that receiving a diagnosis of PTSD in a non–mental health setting was associated with a lower likelihood of receiving an adequate "dose" of mental health treatment.

"Any time you require a referral you risk losing that patient, and this is where a lot of our patients really fall through the cracks. Patients will accept a referral but then for numerous reasons don't show up for these appointments, and the reasons for this are multifactorial," said Dr. Seal.

Despite what Dr. Seal described as the US military's "significant" efforts to boost access to mental health services and take the stigma out of seeking mental healthcare, it still exists.

Many veterans, she said, are reluctant to seek mental healthcare because they view it as a sign of "weakness." One possible solution is to integrate mental health services into the primary care setting.

This approach, she said, bypasses the perceived stigma of attending a specialty mental health clinic and provides patients with a "one-stop shop" for healthcare. In fact, said Dr. Seal, her center at the San Francisco VA has adopted this approach for returning OEF/OIF veterans as part of a growing national movement led by Stephen Hunt, MD, at the VA Puget Sound Health Care Systems in Seattle, Washington.

"If you think about it, this really is quite an obvious and simple solution — if people are reluctant to go to a psychiatrist, you bring the psychiatrist to them," she said.

The potential consequences of untreated PTSD are significant and far-reaching, with implications for affected individuals and their families, as well as society as a whole.

"PTSD can have a significant impact on the family — there are high rates of divorce and interpersonal violence. In addition, this population has high rates of comorbid mental health disorders, including depression, anxiety, alcohol and substance use disorders," said Dr. Seal.

Dr. Seal added that the "VA has already done a tremendous amount, and I think the challenge now is finding innovative ways of getting veterans to engage with the system."

Enormous Problem

Commenting on the study for Medscape Psychiatry, Sidney Weissman, MD, professor of clinical psychiatry, Northwestern University School of Medicine in Chicago, Illinois, said he was concerned about the accuracy of the rates of PTSD diagnoses.

"The primary value of this study is that it highlights the fact that there are a significant number of men and women returning from Iraq and Afghanistan with PTSD," said Dr. Weissman.

"I can't comment on the quality of treatment they received nor can I comment on the reliability of the diagnostic process, particularly in the primary care setting, where physicians are often pushed for time; nevertheless, the numbers are so high that I think you can safely say this is an enormous problem," said Dr. Weissman.

A former US Air Force psychiatrist, in 2008 Dr. Weissman testified before the House Committee on Veterans' Affairs Subcommittee on Disability Assistance and Memorial Affairs, where he called for standardization of diagnosis and treatment in VA centers across the country.

It is a problem that persists, said Dr. Weissman. "There is a real challenge to make sure people are treated fairly so that whether you are in Chicago or New York or Boise, Idaho, you are fairly assessed in terms of help [and] financial support and that the element of [PTSD] severity be assessed in the same way," he said.

Like Dr. Seal, Dr. Weissman pointed out that the consequences of untreated PTSD are "wide-ranging and severe."

"With untreated PTSD you have a dysfunctional individual that has the potential to have an extremely adverse impact on themselves and others so that the cost of treatment is relatively inexpensive compared to the potential societal cost of not treating these individuals."

Dr. Seal and coauthors have disclosed no relevant financial relationships.

J Traum Stress. Published online February 9, 2010.

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