Billions spent treating vets with PTSD, but is it working?

In ten years, the number of service members and veterans seeking treatment for post-traumatic stress from the Veterans Administration has doubled. A Seattle doctor is among the authors of a new, national report that outlines failures and shortcomings in the way the military handles those cases.

The report from the Institute of Medicine concludes that only about half of veterans diagnosed last year with Post-Traumatic Stress Disorder, after serving in Iraq and Afghanistan, received the recommended therapy. And for those that do, there is no assurance that it’s the best, most effective therapy.

“What we couldn’t find in the report was evidence that in the Defense Department or even in the VA (Department of Veteran’s Affairs,) clinicians were regularly reassessing patients who were coming in for care to follow longitudinally their PTSD, or other symptoms,” said University of Washington professor Dr. Douglas Zatzick. The Harborview Medical Center psychiatrist and trauma specialist calls that lack of assessment a significant failure in the treatment process.

“It needs to be prioritized,” he said.

The report calls the VA’s PTSD treatment programs “ad hoc, incremental and crisis-driven.” It also finds that while the VA has increased staffing, the work force is still not adequate to meet demand.

“Even if you don’t have the staffing or resources to deliver the best psychotherapy care, 12 weekly sessions, or even if you can’t see every patient at the exact time you’re supposed to see them, according to a manual, you can at least give assessments with structured instruments that have reliability and validity,” Zatzick asserted.

The report, sponsored by the Department of Defense, cites the PTSD checklist, for example, as a proven assessment tool. It’s a list of questions used to monitor patient progress that can be self-administered.

Dr. Zatzick is an advocate of alternate treatments for PTSD, driven by what works for the veteran.

“They’d come up with: ‘I’m doing yoga’ or ‘I’ve got this new phone app and it’s fantastic’ and these things have not been tested,” said Zatzick. “The way you do that, is you have this measurement-based approach and say, ‘OK, you hang out with your yoga teacher and you do whatever you’re doing in your yoga class for the next 30 days, and we’ll come back in in 30 days and we’ll work together and we’ll reassess your symptoms with one of these measurements, a PTSD checklist,'” he explained.

If the alternate treatments are no good, Zatzick said, the assessment tells you to move on.

“We’ll move from something you’re engaged in and activated by, with not the greatest evidence base, nobody’s done clinical trials of yoga or phone apps at this point, but we’ll go with your lead but the key is that you and I work collaboratively and we reassess how you’re doing.”

The report, commissioned by Congress, took four years to complete. Dr. Zatzick hopes it will make a difference.

“I think there really is policy momentum as this point, with everything the VA has been through.”

With all the well-publicized problems of diagnosis and treatment delays, the VA and the Defense Department spent more than $3 billion in 2012 to care for patients with PTSD, according to the report, uncertain if the treatments are working, or not.