Posttraumatic Stress Disorder, Depression, and Other Comorbidities: Clinical and Systems Approaches to Diagnostic Uncertainties

MHS Care Enhancements

Many of the innovations deployed throughout the U.S. Army system of behavioral health care have driven changes across the MHS as a whole. The DoD and the VA have made substantive systemwide policy and practice changes to improve care for beneficiaries with PTSD, depression, and comorbid PTSD and depression. In particular, significant implementation efforts have addressed population screening strategies, outcome monitoring to support measurement-based care, increased access to effective care, and revision of the disability evaluation system.

To improve the identification and referral of soldiers with deployment-related mental health concerns, the DoD implemented a comprehensive program that screens service members prior to deployment, immediately on redeployment, and then again 6 months after returning from deployment. Additionally, annual primary care- based screening requirements have been instituted as part of the DoD PCMH initiative. Both deployment-related and primary care-based screenings include an instrumentation to detect symptoms of PTSD and depression and extend the reach of mental health screening to the entire MHS population.

Building on the success of BHDP, former Assistant Secretary of Defense for Health Affairs Jonathan Woodson mandated BHDP use across the MHS for all patients in DoD behavioral health clinics and the use of outcome measures for the treatment of PTSD, anxiety, depression, and alcohol use disorders.⁵⁷ A DoD-wide requirement to use the PTSD checklist and patient health questionnaire to monitor PTSD and depression symptoms at mental health intakes and regularly at follow-up visits is being implemented. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, through its Practice-Based Implementation Network (underwritten by a Joint Incentive Fund managed between DoD and VA), has worked across the MHS and the VA to facilitate the implementation, uptake, and adoption of this initiative.

The DoD established the Center for Deployment Psychology (CDP) in 2006 to promote clinician training in EBTs with the aim of increasing service members’ access to effective psychological treatments. Since its inception, the CDP has provided EBT training to more than 40,000 behavioral health providers. Although the impact of these and other efforts on improving the quality of care that patients receive is unknown, a recent study documented widespread self-reported usage of EBT components in U.S. Army clinics and that providers formally trained in EBTs were more likely to deliver EBTs.⁵⁸

Finally, systemwide changes to the VA Schedule of Ratings for Disability (VASRD) and integration of DoD and VA disability evaluation systems have led to shifts in diagnosis toward PTSD that usually merit a minimum 50% disability rating. Mandates in law require military clinicians to evaluate patients who have deployed for PTSD and TBI prior to taking any actions associated with administrative separation. The practice of attributing PTSD symptoms to character pathology or personality disorders, even when these symptoms did not clearly manifest or worsen with military service, has likely been eliminated from practice in military and veteran populations.

Robust policy changes to limit personality disorder discharges started in fiscal year 2007, when there were 4,127 personality disorder separations across DoD. This number was reduced to 300 within 5 years. Policy changes regarding separation not only seem to have affected discharges, but also may have shaped diagnostic practice. The incidence rate of personality disorder diagnoses declined from 513 per 100,000 person-years in 2007 to 284 per 100,000 person-years by 2011.⁵⁹ The VASRD recognizes chronic adjustment disorder as a disability, and the National Defense Authorization Act of 2008 mandated that DoD follow disability guidelines promulgated by VA.

As stated in the memorandum Clinical Policy Guidance for Assessment and Treatment of Post-Traumatic Stress Disorders (August 24, 2012), DoD recognizes chronic adjustment disorder as an unfitting condition that merits referral to its disability evaluation system.⁶⁰ Acute adjustment disorders may still lead to administrative separations, as many service members manifest emotional symptoms stemming from the failure to adjust to the routine vicissitudes of military life. Finally, many court jurisdictions, including veteran’s courts, military courts, and commanders empowered to adjudicate nonjudicial infractions under the Uniform Code of Military Justice, have recognized PTSD as grounds for the mitigation of penalties associated with a wide array of criminal and administrative infractions.

Conclusion

In response to the increased mental health burden following a decade of war and the associated pressures stemming from federal mandates, the MHS has invested unprecedented resources into improving care for military service members. The U.S. Army has played a prominent role in this endeavor by investing in clinical research efforts to accelerate discovery on the causes and cures for these conditions, enacting policies that mandate best practices, and implementing evidence-based care approaches across the system of care. Despite this progress, however, understanding and effectively treating the most prevalent mental health conditions remain a challenge across the DoD and VHA health care systems. Many service members and veterans still do not receive timely, high-quality care for PTSD, depression, and other common comorbidities associated with military experience, and controversies in diagnostic clarification abound.

In short, great strides have been made, yet there is still a large distance to go. The vision of an effective, efficient, comprehensive care system for mental health conditions will continue to be pursued and achieved through collaborations across key agencies and the scientific community, implementation of health system approaches that support population care, and the sustained efforts of dedicated clinicians, staff, and clinic leaders who deliver the care to our service members and veterans.