Treatment of posttraumatic stress disorder in military and veteran populations

While concerns about the psychological effects of war are not new, only recently has systematic attention been paid to such problems among past and present military personnel. There is increasing recognition that mental health has serious implications for operational performance, retention, and compensation. Although little controlled research exists with this population, preliminary evidence suggests that psychological treatments for posttraumatic stress disorder may be beneficial, albeit less so than for civilian populations. This article reviews evidence for each of several psychological treatment stages: stabilization and engagement, psychoeducation, symptom management, prolonged exposure, cognitive restructuring, and relapse prevention, with particular reference to the clinical issues raised by military personnel. Possible explanations for reduced treatment effects in this population compared with civilians are discussed. Departments of Veterans’ Affairs and, more recently, defense forces around the world have become increasingly concerned with the development of mental health problems, particularly posttraumatic stress disorder (PTSD) and related conditions, among past and present military personnel. The issue has serious implications for operational performance, retention rates, and subsequent compensation claims. Rates of PTSD following military service vary greatly across deployments and studies, with figures ranging from 8% of peacekeepers following Somalia (Litz, Orsillo, Friedman, Ehlich, & Batres, 1997) to 19% among veterans of the 1991 Gulf War (Sutker, Uddo, Brailey, & Allain, 1993). For at least half of those affected, the disorder shows a chronic course in veterans; the National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990), for example, reported a lifetime PTSD prevalence of 31%, with current rates of 15%. That is, half of those Vietnam veterans who had ever had PTSD still had it 20 or so years later. While there may be some debate about the validity of the various prevalence figures, the general principal remains: PTSD is a chronic and disabling condition that affects a significant proportion of veterans. In that context, it is somewhat surprising that little adequately controlled treatment research has been conducted with this population. The outcome data that do exist suggest that psychological and pharmacological treatments for militaryrelated PTSD may be beneficial, albeit perhaps less so than for some other populations. Following a brief discussion of treatment goals, this article reviews the major components of psychological treatment with particular reference to veteran and military populations. Possible explanations for the modest treatment effects with this population are discussed. Mark Creamer and David Forbes, Australian Centre for Posttraumatic Mental Health (ACPMH) and Department of Psychiatry, University of Melbourne, West Heidelberg, Victoria, Australia. Correspondence regarding this article should be addressed to Mark Creamer, ACPMH, ARMC Repat Campus, P.O. Box 5444, West Heidelberg, Victoria 3081, Australia. E-mail: markcc@unimelb.edu. au Psychotherapy: Theory, Research, Practice, Training Copyright 2004 by the Educational Publishing Foundation 2004, Vol. 41, No. 4, 388–398 0033-3204/04/$12.00 DOI 10.1037/0033-3204.41. 4.388