Clinical Treatment
Although the VA and DoD have codeveloped a PTSD clinical practice guideline (CPG) and are working closely to ensure seamless transition of care, their policy approaches to PTSD treatment have been quite different. 15 The VA has placed particular attention on training PTSD specialists in prolonged exposure (PE) and cognitive processing therapy (CPT) and ensuring that all veterans have access to one of these two “formulary,” trauma-focused psychotherapies. 16 U.S. Army and DoD policies have emphasized that PTSD treatment should be a core competency for all mental health providers and have interpreted the literature and CPG recommendations broadly, emphasizing the core components found in many different trauma-focused psychotherapies and encouraging use of a wide range of options. 16
One of the reasons for DoD’s approach has been the recognition that the most important threat to treatment efficacy is not the fidelity in which manualized treatments are delivered but the willingness of patients to engage in care and their rate of dropping out. 16,17 Several studies from VA health care settings have shown that only one-third of Operation Enduring Freedom/Operation Iraqi Freedom veterans diagnosed with PTSD end up receiving a minimally acceptable number of treatment sessions to have reasonable expectation of recovery. 18-20 One study suggested that treatment adequacy is somewhat higher in DoD among active-duty soldiers (41%-52%), though still far from optimal. 17
For treatment interventions, the VA/DoD CPG remains an authoritative guide, with A-level recommendations (strong evidence benefits outweigh harms)
assigned to a wide range of trauma-focused psychotherapies as well as medications in the serotonin reuptake inhibitor and serotonin-norepinephrine reuptake inhibitor classes. 15 However, despite a growing list of available pharmacologic choices, new developments in PTSD pharmacotherapy remain elusive. Prazosin, an alpha-1 receptor antagonist, has become widely used in service members and veterans, based on initial clinical trials, but release of findings from a recently completed VA multicenter cooperative clinical trial are still pending. 21,22
Pharmacologic enhancement of exposure treatment is an active area of research but has not yet produced sufficient evidence to change treatment recommendations. 23 Expensive clinical trials of hyperbaric oxygen for chronic postconcussive symptoms and PTSD in combat veterans have informed clinicians more about the nature of placebo responses than of anything else. 24 Benzodiazepines have received D-level recommendations (harm outweighs benefits) in the VA/DoD CPG yet continue to be prescribed relatively frequently to service members and veterans with PTSD. 15 Temporary relief of anxiety symptoms is offset by the propensity of benzodiazepines to worsen or impede PTSD recovery through tolerance and dependence, rebound sleep disturbance or anger, and they seem to enhance rather than alleviate fear conditioning. 15,16 Risperidone has received a D-level recommendation, based on the results of a large VA cooperative trial, and other atypical antipsychotics carry similar concerns, including metabolic and cardiovascular adverse effects. 25
Trauma-Focused Psychotherapy
For mental health professionals working with service members and veterans, the most important clinical strategy supported by strong evidence is to have a firm understanding of the core components of effective trauma-focused psychotherapy and deliver these in a patient-centered manner that fosters continued treatment engagement, which is the most important variable in predicting treatment effectiveness. 15-17 The core components are: