Defense Department, VA Can Not Prove PTSD Treatment Works

A new report highlights something that those in the military community and veterans have known for a long time: the treatment that is currently used for those with PTSD often has little effect on the disorder. In addition, the Department of Defense and the VA don’t share information with one another, so if there are any successes, those findings are not communicated in a way that would help patients.

“PTSD management in DoD appears to be local, ad hoc, incremental, and crisis-driven with little planning devoted to the development of a long-range, population-based approach for this disorder,” A new report from the Institute of Medicine says. “The undersecretary of defense for personnel and readiness and the assistant secretary of defense for health affairs (ASD[HA]) have not developed a comprehensive plan for mental health generally or PTSD specifically.”

The report, which was mandated by Congress, also said that each service branch as well as the VA is currently responsible for creating their own prevention and treatment programs and training their own staff despite having a shared set of guidelines. Since they are just guidelines, they leave much room for variation.

The report also went on to say that it’s unclear whether or not the VA follows the minimum-care requirements set forth by the agency.

The current treatment protocol for PTSD within the DoD and VA is fairly basic and there is so much deviation between services and departments that doctors frequently will simply write a prescription and leave it at that. The goal is to get soldiers deployable or get them discharged and packed off to the VA.

The drugs that are prescribed are often not approved for the treatment of PTSD and have not been tested to determine how effective they truly are, or they have been tested and were shown to be ineffective. They simply provide a sedative effect and soldiers and veterans are sent on their way.

The use of this medication is actually contrary to the VA and DoD’s own Clinical Practice Guideline. However, since there is little coordination or oversight between and within the departments, their use continues.

One example of this is the drug Seroquel.

A 2007 study out of Penn State found that more than 740,000 prescriptions for the drug had been written that year for the treatment of PTSD in veterans — to the tune of $92 million. The problem is that Seroquel is a powerful anti-psychotic drug that is being prescribed “off-label” as a sleeping pill. There is no evidence that it is effective in the treatment of PTSD and has, in fact, caused several deaths by disrupting normal heart rhythms.

Within the last decade, the VA wrote more than 5 million prescriptions for another drug similar to Seroquel, called Risperdal — this to the tune of $717 million. Like Seroquel, Risperdal is not approved, recommended, or even effective for treating PTSD. It is approved for the treatment of schizophrenia and bipolar disorder.

There are two anti-depressant medications specifically approved by the FDA for first-line treatment of PTSD, Paxil and Zoloft. Other anti-depressants are not specifically approved for PTSD treatment, but have been shown to be effective when used “off-label.”

Medication alone is not an appropriate method of treating PTSD. It should always be used as part of a comprehensive treatment program that includes psychotherapy and other complimentary and supportive therapies.

According to Dr. David Reiss, M.D., part of the problem with the treatment of PTSD within the DoD and VA is something called, “Evidence-Based Medicine.” Reiss is a private practice psychiatrist providing treatment with the Uniformed Service Program at The Brattleboro Retreat in Vermont.

“The current medical system is intoxicated with the idea of ‘Evidence-Based Medicine’ based upon statistics and averages,” Reiss said in an interview. “The result of providing treatment geared toward the average [patient] is that it will work very well for some, partially for others, and not at all, or even be counter-productive, for a sizable minority of persons.”

The most important issue in evaluating the effectiveness of treatment for PTSD is realizing that you cannot just treat the symptoms or the disorder. You must treat the person.
Dr. David Reiss
He went on to say that the system of averages “avoids requiring a comprehensive evaluation of each person’s unique history and psychological make-up and an individualized treatment plan.”

“The result is often partial results that are frustrating for the patient,” Reiss added.

This frustration can make the situation worse by feelings of failure, and failure can lead to increased distrust —  one of the symptoms of PTSD — directed at the health care providers and treatment program itself. Combine that with “the ‘loading on’ of one psychotropic medication after another,” and the result is that all sense of treating the individual is lost and the problems snowball.

“The results can be positive, but more often are only temporarily effective as an intervention…but do not get to the ‘heart’ of the trauma, conflict, and pathology,” Reiss said. “The most important issue in evaluating the effectiveness of treatment for PTSD is realizing that you cannot just treat the symptoms or the disorder. You must treat the person.”

The IOM report detailed a number of recommended changes to the PTSD programs within the VA and DoD. Spokesman for both agencies praised the report for its thoroughness and said that they were working on improvements. It is unclear if or when any of the recommended changes will be implemented.

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