Showing papers by "Charles W. Hoge published in 2016"

Unintended Consequences of Changing the Definition of Posttraumatic Stress Disorder in DSM-5: Critique and Call for Action.

Abstract: T he 2013 DSM-5, the first major revision of US psychiatric nomenclature since 1994’s DSM-IV, was coordinated by the American Psychiatric Association in a manner to ensure revisions were empirically supported and maintained continuity with previous editions.1,2 Although many important evidence-based changes resulted, core criteria and diagnostic language for most common conditions affecting adults remained unchanged, safeguarding continued use of treatments validated over decades.1,3 A notable exception was posttraumatic stress disorder (PTSD). Criteria were added and major wording changes were made to symptoms that have been foundational clinical descriptors even before DSM-IV— revisions that workgroup members themselves acknowledged were controversial.4-6 Their rationale4-6 appeared to reflect selective interpretations of evidence (eg, based on nonsystematic literature review and overlooking complex neuroscience domains); cognitive theory influenced key changes, potentially lessening the emphasis of other wellestablished neurobiological models underlying evidence-based treatments.7,8 Emerging research has demonstrated that the revised definition offers no improvement in clinical utility, identifies different individuals,andexcludesmanyindividualsmeetingpreviouscriteria.9-11 This article details problematic changes, implications, and rationale for immediate action.

Transformation of mental health care for U.S. soldiers and families during the Iraq and Afghanistan wars: where science and politics intersect

Abstract: The cumulative strain of 14 years of war on service members, veterans, and their families, together with continuing global threats and the unique stresses of military service, are likely to be felt for years to come. Scientific as well as political factors have influenced how the military has addressed the mental health needs resulting from these wars. Two important differences between mental health care delivered during the Iraq and Afghanistan wars and previous wars are the degree to which research has directly informed care and the consolidated management of services. The U.S. Army Medical Command implemented programmatic changes to ensure delivery of high-quality standardized mental health services, including centralized workload management; consolidation of psychiatry, psychology, psychiatric nursing, and social work services under integrated behavioral health departments; creation of satellite mental health clinics embedded within brigade work areas; incorporation of mental health providers into pri...

Gender Differences in Posttraumatic Stress Disorder and Help Seeking in the U.S. Army

Abstract: Background: Inconsistent findings between studies of gender differences in mental health outcomes in military samples have left open questions of differential prevalence in posttraumatic stress disorder (PTSD) among all United States Army soldiers and in differential psychosocial and comorbid risk and protective factor profiles and their association with receipt of treatment. Methods: This study assesses the prevalence and risk factors of screening positive for PTSD for men and women based on two large, population-based Army samples obtained as part of the 2005 and 2008 U.S. Department of Defense Surveys of Health Related Behaviors among Active Duty Military Personnel. Results: The study showed that overall rates of PTSD, as measured by several cutoffs of the PTSD Checklist, are similar between active duty men and women, with rates increasing in both men and women between the two study time points. Depression and problem alcohol use were strongly associated with a positive PTSD screen in both gen...

The Meaning of Evidence-Based Treatments for Veterans With Posttraumatic Stress Disorder

Abstract: Steenkamp’s Viewpoint1 reminds us that “evidencebased” psychotherapy for posttraumatic stress disorder (PTSD) encompasses clinical judgment and patient preferences as much as it does evidence from randomized clinical trials. This is a welcome perspective for clinicians working in settings such as Veterans Affairs (VA), where they are mandated by policy to provide prolonged exposure or cognitive processing therapy (CPT) as first-line treatments for veterans with PTSD.2 The mandate to prioritize prolonged exposure and CPT is based on overly strict interpretations of clinical practice guidelines that in actuality include much broader, more clinically sensitive recommendations for a wide range of traumaand nontrauma-focused treatment options.3 These interpretations have become so influential that health policy makers and many clinicians have come to assume that unless prolonged exposure or CPT is prescribed and “delivered with fidelity to their established protocols,”4 veterans with PTSD are not receiving adequate care. Accordingly, health care professionals within VA and military treatment facilities are now highly trained to use prolonged exposure and CPT. These treatments are tracked with institutional performance measures and imparted to younger therapists under supervision. Furthermore, because a large proportion of funded research at academic VA and military facilities is aimed at optimizing the efficacy of prolonged exposure and CPT, recruitment of patients is incentivized toward these modalities, as opposed to other internationally accepted trauma-focused treatments, such as, for example, eye movement desensitization and reprocessing. Although health policies and institutional metrics have emphasized prolonged exposure and CPT, militaryrelated PTSD and disabling comorbidities remain intractable problems even for veterans receiving care. Moreover, engagement with these treatments remains low and drop-out rates are high,5 raising important questions concerning whether these treatments are as effective as claimed. Steenkamp points out that prolonged exposure and CPT trials involving veterans have not been definitive.1 Effect sizes are small, especially when compared with active control conditions (eg, presentcentered or interpersonal approaches), and chronic symptoms often persist.6 In many trials, a 12-point decrement on the Clinician-Administered PTSD Scale is considered a clinically meaningful response, yet is well within the range of variation for a chronic disorder. Veterans often have scores around 80 when treatment is initiated, and a 12-point decrease would still indicate severe disease.7 A bigger problem is that the population studied in randomized clinical trials is not always representative of individuals seeking treatment in VA and military settings due to restrictive inclusion criteria. Veterans with PTSD often present with severe symptoms related to suicidality, impulsivity, ongoing life stressors, or comorbid conditions (eg, traumatic brain injuries, substance use disorders, chronic pain, or medical illness). These are often explicit exclusions from the clinical trials upon which recommendations of evidence-based treatments are made. Thus, the mandate to use prolonged exposure and CPT in normative clinical settings is not, strictly speaking, based on evidence from comparable patients. In clinical practice, some veterans have adverse responses to prolonged exposure or CPT, such as worsening of symptoms, hospitalization, or disengagement from treatment. There is little discussion or surveillance of negative outcomes of trauma-focused treatments. However, even under the best scenarios, in which these treatments have resulted in significant symptom reduction, the veteran’s clinical status may not be one in which treatment is no longer required.6 Indeed, a veteran may achieve PTSD symptom improvement but still feel alienated from civilian life. Many veterans experience complex grief, loss, despair, or existential guilt due to events they have witnessed or participated in. As a result, their spiritual, moral, or interpersonal connections may be challenged. Processing traumatic events (one or several) does not necessarily achieve the veteran’s goals of meaningful integration of their experiences, reintegration into family or society, or projecting a positive future. It should also be noted that combat veterans may be reluctant to let go of their physiological hypervigilance or emotional detachment because these served them well during deployment (eg, in the form of situational awareness or emotional control under fire). The professional discipline of critical appraisal and not letting one’s guard down ensures mission effectiveness, minimizes mistakes, and promotes survival in the field. In contrast to victims of interpersonal violence, rape, torture, or natural disasters, combat veterans experience events within a context of occupational comradery and shared purpose and do not want to completely shed the experiences of their military service. They are defined by their deployment in positive and complex ways, and may not even wish to rid themselves of intrusive war memories. Thus, the perspective that combat-related PTSD requires an approach that targets extinction of fear memories is overly narrow. Moreover, it can feel disingenuous to veterans to conceptualize legitimate concerns (reinforced by training and experience) involving issues such as guilt, blame, mistrust, control, safety, or sense of self as maladaptive or problematic beliefs. Finally, treatment and health services outcomes for prolonged exposure and CPT focus largely on PTSD symptom reduction or fidelity to a 12-session treatVIEWPOINT

Diagnosis of PTSD by Army Behavioral Health Clinicians: Are Diagnoses Recorded in Electronic Health Records?

Abstract: Objective:The study sought to identify the extent to which posttraumatic stress disorder (PTSD) diagnoses are recorded in the electronic health record (EHR) in Army behavioral health clinics and to assess clinicians’ reasons for not recording them and treatment factors associated with recording or not recording the diagnosis.Methods:A total of 543 Army mental health providers completed the anonymous, Web-based survey. Clinicians reported clinical data for 399 service member patients, of whom 110 (28%) had a reported PTSD diagnosis. Data were weighted to account for sampling design and nonresponses.Results:Of those given a diagnosis of PTSD by their clinician, 59% were reported to have the diagnosis recorded in the EHR, and 41% did not. The most common reason for not recording was reducing stigma or protecting the service member’s career prospects. Psychiatrists were more likely than psychologists or social workers to record the diagnosis.Conclusions:Findings indicate that for many patients presenting with...

Assessment and Evidence-Based Treatments for Patients with Alcohol Use Disorders Treated in Army Behavioral Health Care Settings

Abstract: This study examines patterns and quality of care for alcohol use disorders (AUDs) provided by U.S. Army behavioral health clinicians (BHCs). Army BHCs (N = 399) completed a clinically detailed Web-based questionnaire on one systematically selected service member patient. Of 399 service member patients, 18% (n = 68) were diagnosed with AUD. Nearly two-thirds received evidence-based (EB) psychopharmacotherapy and/or any psychotherapy. Only 40%, however, received AUD-targeted psychotherapy (e.g., motivational interviewing/enhancement, 12-Step facilitation) and/or psychopharmacotherapy. Army BHCs commonly provide EB care for AUD. However, AUD-targeted psychotherapies are less common. Selected opportunities for improvement in provision of EB care for AUD have been identified.