Interventions for war-related posttraumatic stress disorder: meeting veterans where they are.

A DECADE OF CONFLICT IN AFGHANISTAN AND IRAQ has caused a substantial mental health burden for war veterans and their families, particularly posttraumatic stress disorder (PTSD). (The term veterans in this article includes personnel still remaining in service.) The postdeployment PTSD prevalence in US infantry personnel has averaged 10% to 20%, often coexisting with depression, substance misuse, and other concerns. In response, the US Departments of Defense and Veterans Affairs (VA) have implemented numerous programs in the areas of population screening, education (eg, stigma reduction), and clinical care. The VA has mandated that all veterans treated for PTSD have access to either prolonged exposure therapy or cognitive processing therapy (CPT). However, veterans remain reluctant to seek care, with half of those in need not utilizing mental health services. Among veterans who begin PTSD treatment with psychotherapy or medication, a high percentage drop out, commonly 20% to 40% in randomized clinical trials (RCTs) but considerably higher in routine practice. The rate of recovery of 60% to 80% among treatment completers declines to around 40% when noncompleters are accounted for (using intentionto-treat analyses). With only 50% of veterans seeking care and a 40% recovery rate, current strategies will effectively reach no more than 20% of all veterans needing PTSD treatment. Thus, interventions that will have the greatest potential for improving care on a population level are those focused on enhancing the reach of treatment (eg, engagement, adherence, and acceptability). Enhancing treatment reach requires moving beyond screening and other stigma-reduction approaches. Postdeployment screening has never been demonstrated to be effective in improving mental health (one program evaluation found paradoxical opposite associations), and new research among veterans found negative perceptions of mental health care more important than stigma in predicting low service utilization. Examples of such perceptions include lack of trust in mental health professionals, thinking less of others who seek care, or considering treatment ineffective, unhealthy, or a “last resort. ” Therefore, a high priority is to understand the reasons for these perceptions and meet veterans where they are. Veterans frequently report dissatisfaction with care and disconnect between their experiences as warriors and perspectives they encounter trying to obtain the help they need. Conceptualizing PTSD within an occupational context that is much broader than the clinical definition can help bridge the gap. Military personnel are members of professional workgroups, similar to police and other first responders, trained to respond to multiple traumatic events; they do not normally perceive themselves as victims, nor their reactions as pathological. The paradox of war-related PTSD is that reactions labeled “symptoms” upon return home can be highly adaptive in combat, fostered through rigorous training and experience. For example, hyperarousal; hypervigilance; and the ability to channel anger, shut down (numb) other emotions even in the face of casualties, replay or rehearse responses to dangerous scenarios, and function on limited sleep are adaptive in war. Improving evidence-based treatments, therefore, must be paired with education in military cultural competency to help clinicians foster rapport and continued engagement with professional warriors. This includes sensitivity and knowledge in attending to difficult topics, such as grief and survivor’s guilt stemming from loss of team members, ethical dilemmas in combat, or situations associated with feelings of betrayal (eg, poor leadership, rape by fellow team member). Strict fidelity to treatment protocols may not always support these goals, and clinicians must know how to apply evidence-based techniques in a patient-centered manner. Fundamentally, all psychotherapies with an A-level recommendation for PTSD (good evidence that benefits outweigh harm by US Preventive Services Task Force criteria) involve 5 core components: (1) narration, (2) cognitive restructuring, (3) in vivo exposure, (4) stress inoculation (eg, relaxation) skills, and (5) psychoeducation. Evidence indicates that as long as these components are applied, how