Who Cares? Part I: Veterans Denied Access to Top PTSD Treatments

There has never been an investigation, ceremonial firings, media outrage, or congressional hearings as to "why" the nation has failed again to meet the mental health needs of the warrior class.
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Who cares? Or more appropriately, does the ruling elite and national media honestly give a damn about whether the warrior class receives the highest quality of treatment for war stress injuries available? Better yet, why should the 95.5 percent of the American public that has never deployed to a war zone, be the least bit concerned?

Aside from the obvious moral and ethical obligation to keep a sacred promise to care for those that we send to war, each year the number of veterans receiving mental health care has increased, from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year 2010 [1]. Research has consistently shown that after accounting for the intensity and duration of exposure to combat stress, the next best predictor of developing chronic war stress injuries such as PTSD, is the level of perceived social support [2]. Factor in the exorbitant individual and societal costs of untreated and inadequately treated war stress injuries, including the escalating rates of rage and despair directed inward (e.g., suicide), and outward (e.g., interpersonal violence), the hard truth after every war, is that one way or another, we all pay a very high cost, often decades after the war comes home.

In January 2004, the Department of Veterans Affairs (DVA) and Department of Defense (DoD), published the first-ever Clinical Practice Guideline for Management of Post-Traumatic Stress (DVA/DoD, 2004), listing Eye Movement Desensitization and Reprocessing (EMDR) therapy as one of only four, top-tier recommended evidence-based psychotherapies, concluding that:

• "Overall, argument can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD" (p. 5)
• "Foa et al (1995) note that exposure therapy may not be appropriate for use with clients whose primary symptoms include guilt, anger, or shame" (p. 4)
• "EMDR may be more easily tolerated for patients who have difficulties engaging in prolonged exposure therapy" (p. 2)
• "EMDR processing is internal to the patient, who does not have to reveal the traumatic event" (p. 1).

Justification for the DVA/DoD's designation of EMDR as a highly recommended treatment, included a randomized controlled trial of EMDR in 1998 with Vietnam combat veterans demonstrating that 77 percent of veterans no longer had PTSD diagnosis after 12 sessions and with no drop-outs [3]. Promising results; however, 1998 marked the last EMDR research trial the DVA has funded. Subsequently, in February, 2004, the American Psychiatric Association released their PTSD treatment guidelines -- similarly designating EMDR as evidence -- based practice (see the Practice Guideline section below for further evidence of the domestic and international scientific communities position on EMDR).

Restricting Veteran's Access to High Quality PTSD Treatments

However, in my last blog, "War Atrocities in Afghanistan: Who Is Blameworthy?," I reported that in January 2011, the Government Accountability Office (GAO) investigated the DVA's decision to severely restrict veterans' access to only two PTSD treatments, both homegrown by DVA researchers -- Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) -- while excluding external competitors such as top ranked evidence-based PTSD treatments like Eye Movement Desensitization and Reprocessing (EMDR), developed outside the DVA. Aggravating the injustice, in February 2012, the DVA informs the Congressional Budget Office that 60 percent of VA patients fail to complete their PTSD treatment. In a field where there are no panaceas, veterans deserve access to all of the best available treatments, as reflexively promised by DVA, DoD, and government leaders.

Unveiling the VA's Deception

Getting back to the 2011 GAO report, what I didn't mention is that the GAO actually commented on how VA officials attempted to lie and cover-up their harmful policy to limit veteran's access for PTSD treatment, by falsely stating their decisions were based on a 2008 DVA commissioned survey by the Institute of Medicine (IOM). The IOM report was uncharacteristically sloppy, and is the only domestic or international "expert panel" to ever deny EMDR's status as evidence-based. However, the GAO openly questioned VA officials about the truthfulness of their account, citing documents showing that long prior to the IOM report, VA had already begun to invest significant resources in training programs and manuals for its politically favored CPT and PE treatments, while completely excluding EMDR.

Verification of the VA's deception and playing politics with veteran's mental health care is publicly accessible. For example, in 2007, the DVA hired the IOM under the guise "to assess the scientific evidence on treatment modalities for Posttraumatic Stress Disorder (PTSD)" despite the fact that the DVA's and DoD's own panel of experts, along with the American Psychiatric Association, had already done the same in 2004. On October 18, 2007, the very day that the IOM released its preliminary draft, Dr. Antonette Zeiss, VA's Deputy Chief of Mental Health Services published an immediate News Release entitled, "VA Agrees with Key Points about PTSD Treatment In New Institute of Medicine Report." Swiftly reacting to the draft IOM report, Dr. Zeiss announced that, "The report released today by the IOM Committee on Treatment of PTSD concluded among its key findings that exposure-based therapies such as prolonged exposure therapy and cognitive processing therapy have proven to be effective treatments for PTSD, while more research is needed on pharmacotherapy to determine its effectiveness." The Deputy Chief adds that, "VA is pleased to see IOM agrees with us that exposure-based therapies are effective treatments for PTSD," and then goes onto explain the reason behind the DVA's satisfaction, is that the "VA has been making the therapies readily available, even before the IOM report was released."

Jumping ahead, in 2010, the DVA/DoD practice guideline was updated, and reaffirmed EMDR as a top-rated PTSD treatment, thereby contradicting the 2008 IOM report, as has every PTSD practice guideline since.

Impunity of Institutional Military Medicine Politics and Veteran's Mental Healthcare

On October 19, 2006, I testified on the "Status of DoD Mental Health Care: Carpe Diem," before the congressional DoD Task Force in San Diego, California (Transcript available on Defense Health Board website). Amongst other pressing issues related to the military mental health care debacle mentioned earlier, the military's institutional ban of EMDR training, treatment (TRICARE), and research was discussed, along with empirical evidence obtained from the field, clearly supporting EMDR's potential effectiveness as described earlier. The testimony was covered by local (i.e., San Diego Union Tribune - "Military's mental care ailing, panel is advised: Staff burnout, resource shortage cited by experts") and national press (i.e., USA Today, "Navy Psychologist: Navy faces crisis"), that set-off another firestorm. Unfortunately, media portrayals narrowly focused on broader deficits (i.e., staffing shortages, inadequate training, etc.), and failed to specifically address the status of EMDR, or the underlying causes for the current and past failures to meet military mental health needs.

Sadly, but not unexpectedly, after a year-long tour of military bases, the DoD Task Force released its report in June 2007, concluding that, "The system of care for psychological health that has evolved over recent decades is insufficient to meet the needs of today's forces and their beneficiaries, and will not be sufficient to meet their needs in the future," and that, "the immediacy of these needs imparts a sense of urgency to this report" (see An Achievable Vision: Report of the Department of Defense Task Force on Mental Health-June 2007). The Task Force report listed "99" recommendations to fix serious, chronic mental health care deficits posing imminent harm to war veterans and their families (i.e., increasing staff, training, research, access to care, etc.). Specifically, in regards to clinical trainings and compliance with DVA/DoD clinical practice guidelines, the Task Force offered, "Recommendation The Department of Defense should ensure that mental health professionals apply evidence-based clinical practice guidelines." As for clinical research, the Task Force reported that "innovations in care often arise through research to understand the processes that generate need and efforts to develop and test new interventions."

The Department of Defense (DoD) and EMDR Treatment Access

In comparison with the DVA, Military Medicine can claim the moral high ground, appearing considerably more enlightened with its decision to increase military patient access to all top rated PTSD treatments including EMDR, as it began to sponsor EMDR trainings in 2009, a mere eight years after the war started, and four years after I widely disseminated a 2005 clinical training survey. Knowing that military leaders respond best with data and proposed solutions versus a litany of complaints, and armed with the 2004 DVA/DoD PTSD treatment guidelines, I conducted what would become the first and only clinical training survey of military mental health clinicians. Tragically, the results of the convenience sample of 137 DoD mental health providers merely confirmed what every DoD clinician already instinctively knew-wherein 90 percent reported not receiving training or supervision on any of the four evidence-based PTSD treatments highly recommended by the DVA and DoD's own clinical practice guidelines, including EMDR [4]. All of this of course was communicated to the aforementioned DoD Task Force.

Furthermore, on December 9, 2010, TRICARE, the military's health care agency, quietly lifted its indefensible ban on covering EMDR therapy for military beneficiaries, posting, without explanation that "Eye Movement Desensitization and Reprocessing (EMDR) is now a TRICARE-covered benefit for the treatment of post-traumatic stress disorder (PTSD) in adults." Tricare Management Activity's decision to reverse its coverage of EMDR therapy represents Institutional Military Medicine's begrudging acknowledgment that its exclusionary policy has been out of sync with the global scientific community and its own expert consensus since 2004. Most importantly, TRICARE's course correction, finally grants access to an evidence-based treatment for military personnel, their family members, returning Reservists and National Guardsmen, and military retirees.

Despite significant evidence of leadership failures, public deception, and wrongful policies that potentially are harming thousands of veterans and their families, there has never been an investigation, ceremonial firings, media outrage, or congressional hearings as to "why" the nation has failed again to meet the mental health needs of the warrior class.

In Part-Two of this blog series, like a National Geographic exploration, we will uncover the amazingly bizarre, tragic, and mostly unknown world of PTSD research and military politics, and how both the DVA and DoD are engaging in a foolish conspiracy that will impact the future of military mental health care.

[1] Government Accountability Office. January 2011. VA Health Care: VA spends millions on post-traumatic stress disorder research and incorporates research outcomes into guidelines and policy for post-traumatic stress disorder services. Subcommittee on Health, Committee on Veterans' Affairs, House of Representatives. Report to the Ranking member, Report 11-32.
[2] Kulka, R.A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York, NY: Brunner/Mazel.
[3] (Carlson, et al. (1998). Eye movement desensitization and reprocessing for combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.
[4] Russell, M, & Silver, S. M. (2007). Training needs for the treatment of combat-related post-traumatic stress disorder: A survey of Department of Defense clinicians. Traumatology, 13(3), 4-10.

Practice Guidelines by Scientific Community and EMDR

Clinical Practice Guidelines for PTSD: EMDR is NOT Evidence-Based
1.Institute of Medicine (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. National Academies Press: Washington, DC

Domestic PTSD Clinical Practice Guidelines: EMDR IS Evidence-Based

1.American Psychiatric Association. (2004/2009). Practice Guideline for the Treatment of Patient with Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, VA: American Psychiatric Association Practice Guidelines

2.American Psychological Association (Division 12). Chambless, D. L., Baker, M. J., Baucom, D.H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., Daiuto, A., DeRubeis, R., Detweiler, J., Haaga, D.A.F., et al. (1998). Update of empirically validated therapies, II. The Clinical Psychologist, 51, 3-16

3.VA/DoD (2004/2010).Clinical Practice Guideline for the Management of Post-Traumatic Stress Washington, DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. Office of Quality and Performance publication 10Q-CPG/PTSD-04

4.International Society for Traumatic Stress Studies. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J.A. (2009). Effective treatments for PTSD: Practice Guidelines of the International Society for Traumatic Stress Studies. New York: Guilford Press

5.Substance Abuse and Mental Health Services Administration (SAMHSA). (2010). Eye movement desensitization and reprocessing. National Registry of Evidence-Based Programs and Practices, U.S. Department of Health and Human Services

6.Therapy Advisor (2004-7). National Institute of Mental Health -sponsored website listing empirically supported methods. http://www.therapyadvisor.com

International PTSD Clinical Practice Guidelines: EMDR IS Evidence-Based

1.Cochrane Database of Systematic Reviews. Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 3, Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub3

2.National Council for Mental Health: Bleich, A., Kotler, M., Kutz, L., Shaley, A. (2002). National Council for Mental Health: Guideline for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel

3.CREST (2003). The management of post-traumatic stress disorder in adults. Clinical Resource Efficiency Support Team, Northern Ireland, Department of Health, Social Services, and Public Safety. Belfast, Ireland

4.Dutch National Steering Committee Guidelines Mental Health Care (2003). Multidisciplinary Guideline Anxiety Disorders. Quality Institute Health Care CBO/Trimbos Institute. Utrecht, Netherlands

5.INSERM (2004). Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research. Paris, France

6.National Institute for Clinical Excellence (2005). Post-traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: NICE Guidelines

7.Stockholm: Medical Program Committee/Stockholm City Council. Sjöblom, P.O., Andréewitch, S. Bejerot, S., Mörtberg, E., Brinck, U., Ruck, C., & Körlin, D. (2003) Regional treatment recommendation for anxiety disorders. Stockholm: Medical Program Committee/Stockholm City Council

8.United Kingdom Department of Health (2001). Treatment choice in psychological therapies and counseling evidence based clinical practice guideline. London, England
Potential Advantages of EMDR Therapy with Military Personnel

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