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As of September 30, 2008 over 200,000 women were serving on active duty in the U.S. military, and women make up approximately 14% of deployed forces. While women are technically barred from serving in combat,they are serving in forward positions in greater numbers. Additionally, as of 2008, there were approximately 38,000 U.S. citizens serving as contractor personnel in Iraq– many of whom are women. These new role for women in military operations brings with it physical and mental health concerns, namely posttraumatic stress disorder or PTSD. PTSD affects approximately 2.6% of the U.S. population.Among military personnel serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), more than 17% percent of service members surveyed screened positive for PTSD.

Research has shown that there are significant sex differences in diagnosis and treatment of PTSD in the general public.However, much less is known about PTSD in women returning from combat. As the proportion of female veterans is projected to be 14% by the year 2010, it is critical that military, Department of Veterans Affairs (VA), and private sector providers are prepared to identify and care for the unique needs of female service members, veterans, and contractors with PTSD.

To assess the current state of the science, knowledge gaps, and research priorities on the issue, the Society for Women’s Health Researchconvened an expert workshop on December 8, 2008 in Washington, DC. Attendees discussed what is currently known about PTSD in women returning from combat and developed a roadmap for improving the diagnosis and treatment of PTSD in female service members. The following paper reflects a summary of the day’s discussions. It is not meant as a comprehensive review of the literature. A list of frequently used acronyms is available in Appendix I. Additional source information was used to supplement the discussion of the participants. References for these sources are given in the text. 

Background – What is PTSD and What Are Its Causes

According the National Institute of Mental Health, PTSD is a condition that develops after a distressing ordeal that involved physical harm or the threat of physical harm. This harm may have happened to the person who develops PTSD or to a friend or loved one or may have simply been witnessed by the person who developed PTSD. People with PTSD may suffer flashbacks to the traumatic event, become aggressive or withdrawn, have nightmares, and become emotionally numb or even violent. Symptoms of PTSD usually appear about three months after the traumatic event. PTSD generally affects twice as many women as men, and women with PTSD report having a lower quality of life than do men with PTSD. The time to remission of PTSD symptoms is longer in women than in men, and the rate of remission in women is half that

  • This workshop was cosponsored by the National Institute of Mental Health, DynCorp International, and Magellan Health Services in men.For more information regarding criteria for diagnosing PTSD, please refer to Figure I. For a discussion of the neurobiological pathways of PTSD, please refer to Appendix II.

What Causes Sex Differences in PTSD?

Workshop participants engaged in a detailed discussion of potential causes of sex differences in PTSD. Participants noted that animal models have shown that male and female rats process stress differently. They also noted that male rats tend to develop more acute reactions (i.e., they can respond quicker) to stressors while females exhibit greater object memory after a traumatic event, meaning they learn to recognize stressors in the future. While these behaviors may pose evolutionary advantages for each sex, in humans they lead to women “holding onto” negative memories more so than men, causing women to “relive” the traumatic event more than their male counterparts. Participants also shared that in general, males also exhibit a faulty memory during times of high stress, possibly protecting them from PTSD. Women react more negatively than men to interpersonal stressors and laboratory stressors. Women also show more ruminative coping. In general women have greater frequency and intensity of negative emotions. Women have more startle modulation and autonomic responses to aversive content – all of which can make women more susceptible to developing PTSD.

Workshop participants also theorized that sex difference in the hypothalamic-pituitary-adrenal (HPA) axis, a major part of the neuroendocrine system that controls reactions to stress and regulates many body processes, may also contribute to disproportionate rates of PTSD in women and men.

Figure I. Criteria used for diagnosing PTSD†

Criterion A1: A person is exposed to a life-threatening event either directly or through an experience happening to someone significant to him or her.

Criterion A2: The event results in an intense, overwhelming sense of fear or horror or the person becomes disorganized in their response to the trauma. This reflects a neurobiological response to stress. Men generally have a greater number of A1 events, while women have a greater overall exposure to both A1 exposures and A2 symptoms.

Criterion B: Re-experiencing the traumatic event. characterized by five symptoms: 1) recurrent, intrusive, distressing recollections including thoughts, images, and perceptions; 2) recurrent, distressing dreams; 3) acting or feeling as if the traumatic event were recurring (reliving, illusions, hallucinations, dissociative flashbacks); 4) experiencing psychological distress at exposure to internal or external reminders or cues; and 5) a physiologic reactivity at exposure to cues.

Criterion C: Symptoms of avoidance. These symptoms can manifest as avoiding thoughts, feelings, conversations, people, activities, or places related to the traumatic event. Persons exhibiting avoidance may also experience partial or total memory loss surrounding the traumatic event. The individual may also suffer from diminished interest in important activities or feel detached or estranged from others. They may also have a limited range of affect, meaning they are unable to experience loving feelings. They may also exhibit a foreshortened sense of future, e.g., one doesn’t expect to have a career, marriage, or normal lifespan.

Criterion D: Persistent symptoms of increased arousal. These symptoms of arousal (e.g., difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hyper-vigilance, and exaggerated startle response) were not present prior to the traumatic event.

Criterion E: The symptoms of criteria A, B, C and D must be present for at least one month.

Criterion F: The above symptoms must result in significant distress or impairment in social, occupational, or other important areas of functioning.

†From the Diagnostic and statistical manual of mental disorders DSM- IV-TR, Fourth Edition. American Psychiatric Association; 2000.

The HPA axis plays a major role in the body’s reaction to stress. A study by Uhart et al. found that men have a greater HPA axis response to psychological stressors than women while females have greater hormonal reactivity to chemical stressors such as naloxone. More research is needed into these sex differences as they relate to the development and treatment of PTSD. 

Sex and Gender Issues in Combat-Related PTSD

In considering the diagnosis, prevention, and treatment of PTSD, workshop participants noted that there are unique issues facing female active military personnel, veterans, and other women returning from combat. They are affected by a number of trauma-related conditions, including, but not limited to, PTSD, traumatic grief, unexplained somatic symptoms, depression, sleep disturbances, increased use of tobacco and alcohol, and increased family violence and conflict. A 2004 study found that returning OIF/OEF service members were significantly more likely to suffer from mental health problems, including PSTD, than those not exposed to combat. Of those reporting mental health issues, only 20-40% sought medical care. Perceived barriers to care included fear of stigmatization, lack of trust in the medical system, and lack of knowledge of how to access care. A study that estimated prevalence in the entire deployed force as of 2007 showed that the number of combat traumas experienced while deployed was the single best predictor of PTSD as well as of major depressive disorder (MDD), and that only half of those with a probable current disorder had sought any mental health treatment in the prior year. Perceived barriers to care included concerns about the effectiveness of treatment as well as institutional barriers such as lack of confidentiality and potential harm to the military career.

Traumatic brain injury is another contributing factor to PTSD in men and women returning from combat. A 2008 study of combat service members found that almost half of service members suffering from mild traumatic brain injuries also met the criteria for PTSD. Because diagnostic techniques and evidence-based treatment protocols for post-concussive symptoms for combat- related head injuries are lacking,more research is needed into the appropriate diagnosis and treatment of PTSD in service members with traumatic brain injury.

PTSD and Females Military Personnel

Because the female facing combat conditions is a relatively new phenomenon, little is known about the unique needs and issues facing the female service member and other women with combat-related PTSD. Workshop participants discussed a recent, informal survey of health care providers at Walter Reed Army Medical Hospital and Bethesda Naval Hospital that found that approximately 13% of active duty patients with PTSD were women.Of the responding clinicians, 35% stated that their female patients reported more depressive symptoms than did their male patients. Male patients reported more irritability and anger, nightmares, and flashbacks. The responding clinicians also stated female patients are more receptive to psychotherapy while men expressed a stronger preference for medication. An important sex difference in PTSD in combat troops is that almost 65% of the respondents said that sexual trauma (either childhood or in theater) was an in issue in the treatment of their female patients with PTSD. No respondents cited sexual trauma as an issue for male patients. For men, the traumatic event was related to killing or seeing people killed or injured.Workshop participants shared that army medical data demonstrate that about 11% of identified cases of PTSD from OIF/OEF are in females, which is similar to the proportions of women serving in those theaters.

Treatment of Combat-Related PTSD

Of interest to the workshop participants were possible new treatment modalities for PTSD. Discussion centered on the role of allopregnanolone (ALLO), a neurotransmitter that mediates the fear response, in the treatment of PTSD. The same enzyme that makes ALLO also converts testosterone to its inactive form. Studies in military trainees have demonstrated that testosterone levels actually fall during the military’s Survival, Evasion, Resistance, and Escape (SERE) training. Workshop participants remarked that when testosterone levels fall, ALLO is reduced, resulting in increased stress and aggression. This aggression can be blocked with the use of a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which normalize the brain’s ALLO levels. However, for individuals who do not respond to SSRIs, which is at least 50% of women in treatment studies, participants theorized that it is possible that a more effective medication would be ganaxalone, a synthetic form of ALLO, which has been shown to prevent fear conditioning and anxiety.

Progesterone may be another treatment modality for women with PTSD. As stated earlier, progesterone is a precursor of ALLO. Levels of progesterone fluctuate with a woman’s menstrual cycle and pregnancy. Higher levels of progesterone in the luteal phase of the menstrual cycle are associated with higher levels of ALLO and a suppression of the HPA and autonomic responses to stress. Workshop participants theorized that women on steroidal birth control might be at a higher risk for developing PTSD as they do not generally experience a luteal phase during their menstrual cycles. Participants agreed that more research is needed into the use of progesterone in the prevention and/or treatment of PTSD.

Dehydroepiandrosterone (DHEA), a precursor of the sex steroids, is another possible avenue of treatment for PTSD. Studies of DHEA in animals have shown DHEA to increase ALLO and decrease cortisol levels.Levels of dehydroepiandrosterone sulfate (DHEAS), the storage form of DHEA, are 50-70% lower in women.During the second half of the menstrual cycle, women metabolize DHEA faster than men, possibly resulting in lower levels of DHEA and leaving women more susceptible to PTSD.

Workshop participants also discussed sex differences in the role of catecholamines in memory retention as catecholamines seem to play a larger role in women’s memory retention as compared to men. High levels of catecholamines during stress promote the consolidation of emotionally significant memories.Beta-blockers such as propranolol, which prevent memory reconsolidation, are frequently given to patients who were exposed to traumatic events to prevent the development of PTSD. However, a recent study of OIF/OEF service members returning home with burn injuries found that propranolol did not prevent PTSD in burn patients. But, this study did not take into account any psychological counseling that may have been received or when that counseling may have occurred in relation to the propranolol administration. The authors concluded that the timing of propranolol administration and psychological counseling resulting in memory reactivation needs further investigation.

Lastly, workshops participants also discussed the potential role of neuropeptide-Y (NPY) in the treatment of PTSD. At high levels of stress, NPY makes norepinepherine more effective. In men with PTSD, levels of NPY are extremely low. Combat troops exposed to stress have been found to have lower levels of NPY. Normalizing the levels of NPY may improve the resiliency of the brain to the effects of trauma.

SSRIs have shown a positive effect in treating non-combat related PTSD. However, in combat-related PTSD, SSRIs were found to be ineffective.Workshop participants remarked that existing research on combat-related PTSD has been conducted primarily on men, and more research is needed to gauge the potential efficacy of SSRIs for women with combat-related PTSD. Research is also needed on the effectiveness of non-SSRI antidepressants for combat- related PTSD.

Cognitive processing therapy (CPT), which includes both cognitive and exposure components, is one of the more effective treatments for PTSD. CPT focuses not only on anxiety resulting from trauma, but also on a range of emotions including shame, sadness, and anger. Based on the results of a 2007 study published in the Journal of the American Medical Association, the VA is currently implementing a program of prolonged exposure therapy (a form of cognitive processing therapy to treat PTSD in female service members). The 2007 found that prolonged exposure therapy was effective in treating PTSD in female veterans and active duty personnel.

Cognitive processing therapy and exposure-therapy have shown promise in treating both combat and non-combat related PTSD. As the military and VA implement more programs to treat PTSD in female military personnel, resulting data will help to strengthen and refine the existing knowledge base regarding treatment guidelines.

Other Mental Health Issues Unique to Women in Combat Situations

Workshop participants discussed the fact that while all service members face stress when deployed to a combat area, female service members face unique stressors that may impact their mental health. Participants noted that serving in the military and/or as a military contractor is an atypical career path for women. As such, women in the military may experience feelings of isolation and lack of support from colleagues, friends, and family. Women also bear the stress of often being the primary caregiver for family members – not only for their children, but also for their aging parents. The stress of extended deployments for these women is compounded by the demands of caring for their families back home. Participants also remarked that the lack of adequate and safe hygiene facilities for women in combat can lead to both physical and mental health issues. For example, a lack of adequate facilities for urination can lead to an increase in bladder infection. As many latrines are somewhat isolated, women also face a threat (either real or perceived) to their personal safety when faced with the need to urinate. Stressors such as these can contribute to, compound, and/or complicate the diagnosis and treatment of PTSD in women.

Prevention and Treatment of PTSD in Theater

When a service member or contractor is diagnosed with PTSD, is it better for her to be medically discharged or to be treated in theater and returned to duty? Participants noted that when service members are discharged, they lose the support and structure of steady employment. According to workshop participants, the military has recognized that PTSD and mental health are significant issues for combat troops and has deployed over 200 mental health providers to Iraq. The purpose of these providers is to prevent mental health disorders, as well as to treat and restore affected service members to active duty. In 2006, the Department of Defense issued guidelines for deployment and continued service for military personnel who are suffering from psychiatric disorders or who are prescribed psychiatric medications.These guidelines allow for the use of SSRIs and other psychiatric medications in theater when appropriate, but codify the prohibition against the use of other psychiatric medications such as lithium and antipsychotics. The military has also developed web-based programs to help service members cope with the stressors of deployment and combat.

Despite these efforts, the military still faces significant challenges to providing appropriate mental health services to service personnel. Workshop participants identified these challenges as including a growing population of service members suffering from PTSD, a shortage or trained providers, multiple deployments, and traumatic brain injury. Upon being released from active duty, service members access services through the VA or private providers. More research is needed on how to best provide mental health services to both active duty personnel and veterans. There is ongoing research in VA on the provision of mental health services, and also on screening for PTSD. The military has also implemented various programs aimed at better screening. Workshop participants noted that there might be a need to collaborate with the private sector to improve the screening on veterans in the private health care sector.

Workshop participants also noted that consultants and military contractors exposed to combat situations face similar challenges and barriers to obtaining appropriate services to diagnose and treat PTSD. More research is needed to assess what services are available to these women, both in theater and when they return home.

Military Sexual Trauma and PTSD

Aside from trauma directly related to combat experiences, female service members face the risk of military sexual trauma (MST), the term that the Department of Veterans Affairs uses to refer to experiences of sexual assault or severe, repeated sexual harassment experienced during military service. As noted by workshop participants, MST is not a uniquely female problem. While the percentages differ, the absolute numbers for veterans – male and female – who have suffered MST are fairly comparable. Gender responses to MST may differ, and research in ongoing regarding this issue. According to the National Center for PTSD, there is almost no empirical data comparing MST to sexual trauma that occurs outside of military service, although there is anecdotal evidence the MST is unique from and has quantitative and qualitative psychological outcomes.

In a 2005 study of Gulf War veterans, Kang et al. found that exposure to sexual assault during deployment conferred a greater risk of developing PTSD than did combat exposure.In 2002, approximately 3% of active duty military women and 1% active duty military men experienced sexual assault.A more recent report found that 6.8% of active duty women and 1.8% of men reported unwanted sexual contact.New screening programs can detect MST and facilitate access to mental health services for both male and female victims of MST, thereby mitigating the burden of psychiatric illness for these service personnel.Workshop participants praised the VA for being proactive in addressing MST by mandating universal screening of all veterans for a history of MST. According to workshop participants, each VA facility has identified a Military Sexual Trauma Coordinator to oversee the screening and treatment referral process.

New Systems of Care for Combat-Related PTSD

A study published in 2004 found that for those Iraq war returnees who screened positive for a moderate to severe mental health disorder and wished to receive help for those services, only 23- 40% reported receiving professional help in the preceding 12 months. A more recent survey found that only 53% of military personnel with a probable diagnosis of PTSD had sought care in the previous year. Of those who sought care, just over half received minimally adequate care. In 2007 the military launched RESPECT-Mil (Re-engineering Systems of the Primary Care Treatment (of depression and PTSD) in the Military) to improve access to mental health services for those military personnel suffering from PTSD and depression. The program involves routine screening for PTSD and depression during all primary care visits, assessing all those who screen positive for depression and PTSD, referrals to appropriate treatment, and care coordination and follow-up by primary care providers.This program may be particularly effective for identifying and treating PTSD in female service members and veterans since women are more likely than men to report problems to and seek help from their primary care providers.The VA and military are also exploring other avenues of treating PTSD. An internet-based, therapist-assisted self-management program for PTSD has shown promise as a means to deliver effective treatment to service personnel.

The VA system will be an invaluable source of mental health services for women returning from deployment. Currently, 12%, or more than 45,000, of the total number of OEF/OIF veterans using VA services are women. Workshop participants noted that female veterans may be more likely to use VA care than are their male counterparts, but that women may be less likely then men to report PTSD symptoms in a VA setting. Participants noted that women are more likely to report depression and general anxiety symptoms and are twice as likely to be diagnosed with personality disorders. Workshop participants praised the VA for being a leader in its efforts to care for the female veteran, citing the VA’s appointment of a full-time Women Veterans Program Manager at every VA facility and a Women’s Health Science Division in the National Center for PTSD as examples of its leadership. They also discussed the need for the VA to develop more gender-sensitive programs for diagnosing and treating PTSD in female veterans.

Diagnosing and Treating Combat-Related PTSD in the Private Sector

Once a female service member becomes a veteran or a contractor/consultant returns home, new problems accessing services for PTSD can arise. Since PTSD symptoms do not generally manifest until three to six months after a traumatic event,7 many women may leave the military without a diagnosis of PTSD in their medical charts. Workshop participants stated that upon leaving active duty, many women, especially those who were/are reservists, may receive their healthcare through the private sector. Participants noted that veteran status is not generally ascertained in most health plan and employer eligibility files. Without an adequate history of veteran status, providers may not screen for combat-related disorders. Further complicating the delivery of services for women is that even if the provider knows a patient’s veteran status, there is a misperception about women’s roles in the military – that women are not directly exposed to combat situations. As such, PTSD symptoms may go unrecognized or be misdiagnosed. Private sector providers not familiar with the treatment of PTSD may mistakenly prescribe drugs such as benzodiazepines for symptom management, despite the fact that benzodiazepines have not been shown to be effective in treating PTSD.42 Workshop participants cited a concern that when private sector physicians do recognize PTSD symptoms in their patients, they may not be familiar with the VA and available services for PTSD. Further, there is a financial disincentive to the physician for referring patients to the VA for care.

Participants discussed the opportunities for the private sector to improve the diagnosis and treatment of combat-related PTSD. For example, during this workshop, Magellan Health Systems presented information about its CME programs promoting evidence-based practices guidelines for diagnosing and treating PTSD. These training programs include modules on military cultural competence and meeting the mental health needs of returning veterans.43 Further research is needed into developing appropriate screening and treatment of PTSD for service members returning from combat and reentering into the private sector.

Summary: Developing a Research Agenda and Improving Patient Care: What Health Care Professionals Need to Know

As the above report states, there are multiple areas in which our knowledge of PTSD in female service personnel is lacking. Most research models for PTSD were built around men. These models will need to be reexamined and redesigned to better target women. In the field of psychobiology, there is a need to look for new models for high stress populations in which there are a greater proportion of women (e.g., competitive athletes, law enforcement personnel) as an approach to supplement our limited knowledge of sex differences in the development of PTSD. Additionally, while research has been examining the role of sex hormones (estrogen in women and testosterone in men) in the development of PTSD, researchers should also look at the effects of androgens in women and estrogen in men.

Genetics may also play a significant role in the development of PTSD. More research is needed into the effects of polymorphisms in ethnic groups, as well as the effects of polymorphism on the effectiveness of medications and cognitive approaches to treating PTSD. In order to facilitate genetic studies, the Department of Defense and the VA will need to coordinate efforts and facilitate the implementation of research networks across facilities.

The military furthers our knowledge about combat-related PTSD in women by developing command awareness of the importance of medical studies to promote participation by their troops. Recruitment into research studies will be especially important for women as this will be the first time we will be observing the effects of combat on a large number of female service members. As the military begins to draw down from its current theaters of combat and women are released from active duty, it is important that we track how they are discharged and with what medical appointments or treatment referrals.

As women are returning from combat to their families, we will need to examine the effects of women’s PTSD on families. Additionally, women are at high risk for divorce and domestic violence when men return from combat. Will we be seeing the same for men who have stayed home while their spouses were deployed? Questions to ask include the following:

  • How do women react when they return post-deployment?

  • How do they treat their spouses, and/or children?

  • How do we instill health promotion behaviors early in the separation process and not wait

    until post-deployment?

  • What are the effects of PTSD on parenting and children’s mental health?

    Researchers need a better understanding of the natural course of PTSD over the lifecourse. Further, we know little about the effect of multiple deployments on women over time. For example, we know that former military men with PTSD are at higher risk for substance abuse. We do not yet know if women develop co-morbid substance abuse problems at the same rate as their male counterparts. A focus on sex differences in treatment and outcomes measurements is needed to better understand the needs of female service personnel.

    Ideally we would like to prevent PTSD in our combat troops. Until effective prevention strategies are developed, the best the military can do is to train healthcare professionals in identifying early symptoms of PTSD so that those displaying such symptoms can receive early intervention. As cumulative trauma can significantly increase one’s risk for developing PTSD, military healthcare providers will need to be especially cognizant of service members’ prior exposure to combat and other stressors, whether though multiple deployments or service members’ experiences prior to enlistment.

    Within the military system, military leaders should talk to their troops about the importance of seeking help for mental health disorders. The language and attitudes of commanders can significantly impact a service member’s willingness to seek and comply with mental health treatment. Service members need to be able to believe that getting mental health care won’t impact their career.

    In the private sector, clinicians first and foremost need to know a woman’s military status. As stated earlier, clinicians in the private sector do not routinely screen for military service. Training must be provided to primary care physicians including OB/GYNs, to help them identify potential cases of PTSD in their female patients and to assist them in making informed referrals for these patients. Possible avenues for such training programs include health plans and medical professional societies. Additionally, models for collaboration between private sector and VA providers need to be developed to overcome private sector physicians’ fear of ‘losing’ patients to the VA system.

    Private sector clinicians need more and better tools for opening a dialog about PTSD with their female patients. Posters about the signs and symptoms of PTSD could be posted in waiting rooms or restrooms of clinics. These posters could trigger a discussion of symptoms between patient and provider. Clinicians need better and more appropriate screening tools, as well as access to suitable resources if a patient does screen positive for PTSD.

All clinicians need to have a better understanding of the role of co-morbidities as they relate to PTSD. In the absence of better screening tools for PTSD, co-morbidities such as alcohol and substance abuse, irritable bowel syndrome, and migraines may signal an underlying case of PTSD. We need to develop effective working relationships across systems at the state, federal, and local, as well as across the military and private sector. A better electronic infrastructure is essential for sharing medical records across these systems. The Departments of Defense and Veterans Affairs, as well as the private sector, have been working on such systems for some time. Attention should now be focused on making those systems work across agencies and public/private sectors. 

Taken from - A Report by the Society for Womens Health Research. Link to paper with full refrences - https://swhr.org/wp-content/uploads/2014/07/PTSD_in_Women_Returning_From_Combat-reduced_file_size.pdf

Published in General

Older man in yoga pose shutterstock 737381545 web


For thousands of years, yoga has been used to calm both mind and body. 

Now, clinical yoga therapy has been found to alleviate the symptoms of chronic combat-related post-traumatic stress disorder (PTSD), potentially providing a treatment to deliver much-needed relief for the hundreds of military veterans in Australia suffering from the debilitating condition.

In a dynamic industry partnership, the research from the  
Repatriation General Hospital
, the University of South Australia and Mindful Movement Physiotherapy, reveals across-the-board improvements for PTSD sufferers, including reduced stress, depression and anxiety.

 Lead researcher, Senior Psychiatrist and Director of the PTSD Unit at the Repatriation General Hospital, Dr Linda McCarthy says the Australian-first study confirms the clinical utility of yoga as an adjuvant strategy for combat-related PTSD.

 “Combat-related PTSD is the one of the most common mental health conditions impacting veterans and their families, representing 15 per cent of claims through the Department of Veteran’s Affairs,” Dr McCarthy says.

 “Following the yoga intervention, 64 per cent of veterans in the study scored less than the diagnostic cut-off point for PTSD, with their average scores being nearly 10 per cent below the lower limit.

 “And 85 per cent of participants showed decreased scores on the PTSD assessment tools; both clearly indicating the positive effects of yoga as a treatment for PTSD.”

 The research used a range of clinical assessment tools and biomarkers to track the responses of 30 Vietnam veterans as they participated in a series of eight weekly trauma sensitive yoga sessions, each lasting 90 minutes.

 “By providing yoga as a treatment therapy, we’ve been able to clinically reduce the markers of depression, anxiety and stress among military veterans. This has also extended to improvement in their sleep quality and quality of life scores,” Dr McCarthy says.

 Lead research consultant, UniSA’s Associate Professor Chris Alderman says that the relative scarcity of effective treatment options for managing chronic PTSD presents a strong case for the exploration of alternative therapies.

 “While psychological interventions and pharmacological treatments exist to treat PTSD, these are often labor intensive and are associated with adverse side effects,” Prof Alderman says.

 “The research gives us reason to be optimistic about this as a new treatment strategy for sufferers of PTSD, with proven positive health benefits.

 “Now we need to undertake further research into yoga as a potential treatment method for combat-related PTSD.

 “As we prepare to mark Remembrance Day this weekend, the positive results of new approaches to this important issue are something to celebrate and embrace.”



Notes for editors

Diagnostic measures used to diagnose PTSD, include: the PTSD checklist (PCL), the Depression, Anxiety and Stress Scale (DASS), the Pittsburgh Sleep Quality Index (PSQI), the Adult/Adolescent Sensory Profile, and the SF36 Quality of Life Instrument.

Media contact: Annabel Mansfield mobile: 0417 717 504 email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Published in General

whats next

More than a decade of war in the Middle East has pushed post-traumatic stress disorder (PTSD) to the forefront of public health concerns. The last several years have seen a dramatic increase in the number of Iraq and Afghanistan war veterans seeking help for PTSD, shining a spotlight on this debilitating condition and raising critical questions about appropriate treatment options and barriers to care.

While PTSD extends far beyond the military—affecting about eight million American adults in a given year—the problem is especially acute among war veterans. Not only are recent veterans at higher risk of suffering from PTSD than those in the general population, they also face unique barriers to accessing adequate treatment. These include the requirement that they have either an honorable or general discharge to access Department of Veterans Affairs (VA) medical benefits, long waiting lists at VA medical centers, and the social stigma associated with mental illness within military communities. According to a study conducted by the RAND Center for Military Health Policy Research, less than half of returning veterans needing mental health services receive any treatment at all, and of those receiving treatment for PTSD and major depression, less than one-third are receiving evidence-based care.

PTSD in Combat Veterans

The existence of war-induced psychological trauma likely goes back as far as warfare itself, with one of its first mentions by the Greek historian Herodotus. In writing about the Battle of Marathon in 490 b.c., Herodotus described an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier himself had not been wounded. Such accounts of psychological symptoms following military trauma are featured in the literature of many early cultures, and it is theorized that ancient soldiers experienced the stresses of war in much the same way as their modern-day counterparts.

The symptoms and syndrome of PTSD became increasingly evident during the American Civil War (1861–1865). Often referred to as the country’s bloodiest conflict, the Civil War saw the first widespread use of rapid-fire rifles, telescopic sights, and other innovations in weaponry that greatly increased destructiveness in battle and left those who survived with a myriad of physical and psychological injuries.

The Civil War also marked the start of formal medical attempts to address the psychological effects of combat on military veterans. Jacob Mendez Da Costa (1833–1900), a cardiologist and assistant surgeon in the U.S. Army, undertook research on “irritable heart” (neurocirculatory asthenia) in soldiers, and during the Civil War, this PTSD-like disorder was referred to as “Da Costa’s syndrome.”  Da Costa reported in the American Journal of Medical Science that the disorder, marked by shortness of breath, rapid pulse, and fatigue, is most commonly observed in soldiers during times of stress, especially when fear is involved.

Over the next century of American warfare, PTSD would be described by many different names and diagnoses, including “shell shock” (World War I), “battle fatigue” (World War II), and “post-Vietnam syndrome.” An estimated 700,000 Vietnam veterans—almost 25% of those who served in the war—have required some form of psychological care for the delayed effects of combat exposure. The diagnosis of PTSD was not adopted until the late 1970s, and it became official in 1980 with inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders

Prevalence of PTSD in Veterans

Estimates of PTSD prevalence rates among returning service members vary widely across wars and eras. In one major study of 60,000 Iraq and Afghanistan veterans, 13.5% of deployed and nondeployed veterans screened positive for PTSD, while other studies show the rate to be as high as 20% to 30%. As many as 500,000 U.S. troops who served in these wars over the past 13 years have been diagnosed with PTSD.

It is not clear if PTSD is more common in Iraq and Afghanistan veterans than in those of previous conflicts, but the current wars present a unique set of circumstances that contribute heavily to mental health problems. According to Paula P. Schnurr, PhD, Executive Director of the VA National Center for PTSD, the urban-style warfare tactics in Afghanistan and Iraq, marked by guerrilla attacks, roadside improvised explosive devices, and the uncertain distinction between safe zones and battle zones, may trigger more post-traumatic stress in surviving military members than conventional fighting.

In addition, Dr. Schnurr notes, improvements in protective gear and battlefield medicine have greatly increased survivability—but at a high price. “Between the way we’re protecting the troops and responding to injuries on the ground, a lot of soldiers are surviving with very significant injuries who would not necessarily have survived before,” she says. “And they’re returning stateside with both the physical and psychological trauma.”

Comorbidity of PTSD in Veterans

Complicating the diagnosis and assessment of PTSD in military veterans are the high rates of psychiatric comorbidity. Depression is the most common comorbidity of PTSD in veterans. Results from a large national survey show that major depressive disorder (MDD) is nearly three to five times more likely to emerge in those with PTSD than those without PTSD. A large meta-analysis composed of 57 studies, across both military and civilian samples, found an MDD and PTSD comorbidity rate of 52%.

Other common psychiatric comorbidities of PTSD in military veterans include anxiety and substance abuse or dependence. The National Vietnam Veterans Readjustment Study, conducted in the 1980s, found that 74% of Vietnam veterans with PTSD had a comorbid substance use disorder (SUD). In one study of recent veterans, 63% of those who met the diagnostic criteria for alcohol use disorders (AUDs) or drug use disorders had co-occurring PTSD, while the PTSD prevalence among those who met criteria for both AUDs and drug use disorders (e.g., alcohol dependence and cocaine abuse) was 76%.

Studies also suggest that veterans with comorbid PTSD and SUD are more difficult and costly to treat than those with either disorder alone because of poorer social functioning, higher rates of suicide attempts, worse treatment adherence, and less improvement during treatment than those without comorbid PTSD.

PTSD is associated with physical pain symptoms, as well. For veterans returning from Iraq and Afghanistan, chronic pain continues to be one of the most frequently reported symptoms. Approximately 15% to 35% of patients with chronic pain also have PTSD.

Risk Factors for PTSD in Veterans

A number of factors have been shown to increase the risk of PTSD in the veteran population, including (in some studies) younger age at the time of the trauma, racial minority status, lower socioeconomic status, lower military rank, lower education, higher number of deployments, longer deployments, prior psychological problems, and lack of social support from family, friends, and community (Table 1). PTSD is also strongly associated with generalized physical and cognitive health symptoms attributed to mild traumatic brain injury (concussion).

Table 1

Significant Risk Factors for Combat-Related PTSD in Military Personnel and Veterans

FactorsOdds Ratio (95% CI)
Pretraumatic Factors
Female gender 1.63 (1.32–2.01)
Nonwhite race 1.18 (1.06–1.31)
Lower education level 1.33 (1.14– 1.54)
Lower rank (nonofficer) 2.18 (1.84–2.57)
Army as branch of service 2.30 (1.76–3.02)
Combat specialization 1.69 (1.39–2.06)
Number of deployments (≥ 2) 1.24 (1.10–1.39)
Longer length of deployments 1.28 (1.13–1.45)
Adverse life events 1.99 (1.55–2.57)
Prior trauma 1.13 (1.01–1.26)
Psychological problem(s) 1.49 (1.22–1.82)
Peritrauma Factors
Combat exposure 2.10 (1.73–2.54)
Discharged a weapon 4.32 (2.60–7.18)
Saw someone wounded/killed 3.12 (2.40–4.06)
Severe trauma 2.91 (1.85–4.56)
Deployment-related stressor 2.69 (1.46–4.96)
Post-Trauma Factors
Postdeployment support (yes) 0.37 (0.18–0.77)

CI = confidence interval; PTSD = post-traumatic stress disorder.

Female gender has also been implicated as a potential risk factor for PTSD in veterans. A number of factors may account for these findings, including a history of military or civilian sexual assault, which may increase a woman’s risk for PTSD. According to one study, during 2002–2003, approximately 22% of screened female veterans reported military sexual trauma (MST), a term adopted by the VA to refer to sexual assault or repeated threatening sexual harassment that occurred while the veteran was in the military.

Despite numerous studies, according to Dr. Schnurr, whether PTSD is a greater risk to female veterans than male veterans is still largely unknown. However, she says that as women continue to play more active roles in the wars in Iraq and Afghanistan and are increasingly exposed to combat situations, their likelihood of experiencing PTSD rises.

More research is needed to better understand these and other risk factors for PTSD and to help clinicians and other care providers offer the necessary treatment before symptoms become chronic. Several large VA studies are under way that include both psychological and neurobiological measurement, Dr. Schnurr says. She notes the benefit of studying the effects of war-related acute stress in real time, using both pre- and post-deployment assessments, as well as data from military members currently in theater. “These wars have given us the best opportunity to longitudinally track what happens to people and to examine the risk and resilience factors associated with the outcomes,” she adds.

Defining and Redefining PTSD

The VA defines PTSD as “the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury.”  In addition to military combat, PTSD can result from the experience or witnessing of a terrorist attack, violent crime and abuse, natural disasters, serious accidents, or violent personal assaults.

In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5), moving PTSD from the class of “anxiety disorders” into a new class of “trauma and stressor-related disorders.” As such, all of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. DSM-5 categorizes the symptoms that accompany PTSD into four “clusters”:

  • Intrusion—spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress
  • Avoidance—distressing memories, thoughts, feelings, or external reminders of the event
  • Negative cognitions and mood—myriad feelings including a distorted sense of blame of self or others, persistent negative emotions (e.g., fear, guilt, shame), feelings of detachment or alienation, and constricted affect (e.g., inability to experience positive emotions)
  • Arousal—aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance or related problems.

PTSD can be either acute or chronic. The symptoms of acute PTSD last for at least one month but less than three months after the traumatic event. In chronic PTSD, symptoms last for more than three months after exposure to trauma.

PTSD Diagnosis and Assessment

Two main types of measures are used to help diagnose PTSD in veteran populations and assess its severity: structured interviews and self-report questionnaires. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is considered the gold standard for PTSD assessment in both veterans and civilians. The detailed 30-item interview has proven useful across a wide variety of settings and takes approximately 30 to 60 minutes to administer.

The well-validated PTSD Checklist for DSM-5 (PCL-5) is one of the most commonly used self-report measures of PTSD. Administration of the 20-item questionnaire is required by the VA for veterans being treated for PTSD as part of a national effort to establish PTSD outcome measures. The PCL-5 can be completed in five to seven minutes.

Another widely used self-report measure for veterans is the Mississippi Scale for Combat-Related PTSD, a 35-item questionnaire in which respondents are asked to rate how they feel about each item using a five-point Likert scale (e.g., “Before I entered the military, I had more close friends than I have now.” [1 = not at all true to 5 = extremely true]).

Nonpharmacological Treatment Of PTSD in Veterans

The use of psychological interventions is regarded as a first-line approach for PTSD by a range of authoritative sources. Of the wide variety of psychotherapies available, cognitive behavioral therapy (CBT) is considered to have the strongest evidence for reducing the symptoms of PTSD in veterans and has been shown to be more effective than any other nondrug treatment.

Two of the most studied types of CBT—cognitive processing therapy (CPT) and prolonged exposure (PE) therapy—are recommended as first-line treatments in PTSD practice guidelines around the world, including the guideline jointly issued by the VA and the Department of Defense (DoD).

First developed to treat the symptoms of PTSD in sexual assault victims, CPT focuses on the impact of the trauma. In CPT, the therapist helps the patient identify negative thoughts related to the event, understand how they can cause stress, replace those thoughts, and cope with the upsetting feelings.

PE therapy has been shown to be effective in 60% of veterans with PTSD. During the treatment, repeated revisiting of the trauma in a safe, clinical setting helps the patient change how he or she reacts to memories of traumatic experiences, as well as learn how to master fear- and stress-inducing situations moving forward. PE and CPT treatments each take approximately 12 weekly sessions to complete.


Once highly controversial, eye-movement desensitization and reprocessing (EMDR) has been gaining acceptance and is now recommended as an effective treatment for PTSD in both civilian and combat-related cases in a wide range of practice guidelines. In EMDR, the therapist guides patients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. The general theory behind EMDR is that focusing on other stimuli while revisiting the experience helps the patient reprocess traumatic information until it is no longer psychologically disruptive.

Pharmacotherapy of PTSD in Veterans

Some patients do not respond adequately to nondrug treatment alone, may prefer medications, or may benefit from a combination of medication and psychotherapy. In these cases, pharmacotherapy is also recommended as a first-line approach for PTSD.

Selective Serotonin Reuptake Inhibitors

Antidepressants are currently the preferred initial class of medications for PTSD, with the strongest empirical evidence available to support the use of the selective serotonin reuptake inhibitors (SSRIs). Currently, sertraline and paroxetine are the only drugs approved by the Food and Drug Administration (FDA) for the treatment of PTSD.

All other medications for PTSD are used off-label and have only empirical support and practice guideline support. These include the SSRI fluoxetine and the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine, which are recommended as first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD. Venlafaxine acts primarily as an SSRI at lower dosages and as a combined SNRI at higher dosages.

Although SSRIs are associated with an overall response rate of approximately 60% in patients with PTSD, only 20% to 30% of patients achieve complete remission. In a study of extended-release (ER) venlafaxine, the response rate was 78%, and the remission rate was 40% (both assessed with an abbreviated version of CAPS) in patients with PTSD. Hyperarousal, however, did not show significant improvement. The ER formulation of venlafaxine is approved for patients with major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder.

Second-Line Therapies

Second-line therapies for PTSD are less strongly supported by evidence and may have more side effects. They include nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors. Prazosin has been found to be effective in randomized clinical trials in decreasing nightmares in PTSD. It blocks the noradrenergic stimulation of the alpha1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time.

Alternative Pathways

Antidepressants have been the central focus of pharmacotherapy research in PTSD, but better treatments are greatly needed. “Right now, the interest is in novel medication development rather than simply relying only on the SSRIs that we have because we only get so far with them,” Dr. Schnurr says.

Researchers are looking closely at the role of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory neurotransmitter glutamate in PTSD. Both GABA and glutamate play a role in encoding fear memories, and therapeutic research targeting these systems may open new avenues of treatment for PTSD. For example, the novel multimodal anti depressant vortioxetine (Trintellix, Takeda) modulates GABA and glutamate neurotransmission.

According to ClinicalTrials.gov, several ongoing studies are investigating the efficacy of vortioxetine and another new multimodal antidepressant, vilazodone (Viibryd, Allergan), in PTSD. Both drugs have been approved by the FDA for the treatment of depression but not for PTSD.

Anticonvulsants or antiepileptic drugs, which affect the balance between glutamate and GABA by acting indirectly to affect these neurons when their neuronal receptor sites are activated, could also provide a useful option in treatment of PTSD symptoms in patients who fail first-line pharmacotherapy. Topiramate, an anticonvulsant used to treat certain types of seizures, has demonstrated promising results in randomized controlled trials with civilians and veterans with PTSD. Topiramate is currently listed in the VA/DoD Clinical Practice Guideline for PTSD as having no demonstrated benefit, and further studies are needed regarding the place of this drug in PTSD treatment.

Clinical research also suggests that smoking cannabis (marijuana) is associated with reduced PTSD symptoms in some patients. One study indicated that PTSD patients reported an average 75% reduction in CAPS symptom scores while using cannabis.

Although the use of medical marijuana to treat PTSD remains controversial, recent actions by the federal government have brought veterans closer to being able to obtain medical marijuana. In April 2016, the Drug Enforcement Administration approved the first-ever controlled clinical trial to study the effectiveness of cannabis as a treatment for PTSD in military veterans, and in May, Congress voted to lift a federal ban that has prevented veterans’ access to medical marijuana through the VA in states that allow it. Medical marijuana is legal in 23 states and the District of Columbia for the treatment of glaucoma, cancer, human immunodeficiency virus, and other conditions.

Suggested nonpharmacological and pharmacological treatments for PTSD are listed in Table 2.

Table 2

Selected Treatments for PTSD in Veterans

First-LineSecond-LineAlternative Pathways
  • Cognitive behavioral therapy
    • ○ Cognitive processing therapy
    • ○ Prolonged exposure therapy
  • Eye-movement desensitization and reprocessing
  • Antidepressants
    • ○ Sertraline*
    • ○ Paroxetine*
    • ○ Fluoxetine
    • ○ Venlafaxine
  • Nefazodone
  • Mirtazapine
  • Tricyclic antidepressants (e.g., imipramine)
  • Monoamine oxidase inhibitors (e.g., phenelzine)
  • Prazosin
  • Gamma-aminobutyric acid
  • Glutamate
  • Vortioxetine
  • Vilazodone
  • Anticonvulsants (e.g., topiramate)
  • Antiepileptics
  • Cannabis

PTSD = post-traumatic stress disorder.

*These are the only drugs approved to treat PTSD by the Food and Drug Administration.

Combined Pharmacotherapy and Psychotherapy

Medications and psychotherapies are used both separately and in combination to treat the symptoms of PTSD, as well as related comorbid diagnoses. Guidelines suggest a combination may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either approach alone. For example, studies have shown combined SSRIs and psychotherapy appear to be more effective than treatment with either intervention used alone.

Reducing Benzodiazepine Use Among Veterans

The VA/DoD Clinical Practice Guideline for PTSD cautions against any use of benzodiazepines to manage core PTSD symptoms because evidence suggests that they are not effective and may even be harmful. However, despite this guidance, almost one-third of VA patients being treated for PTSD nationally were prescribed benzodiazepines in 2012, says Nancy Bernardy, PhD, Associate Director for Clinical Networking at the VA National Center for PTSD.

According to Dr. Bernardy, the rates of benzodiazepine use among veterans with PTSD are declining, but focused interventions are needed to achieve further reductions. She says the VA is studying the use of an academic detailing approach to share decision support tools around the appropriate use of these drugs. The initiative targets subgroups of veterans with PTSD in which there are increased rates of benzodiazepine prescription, including those with comorbid substance use disorders and those with comorbid traumatic brain injury. Designed to be used by providers with their patients, the decision support tools incorporate safety concerns related to the targeted subgroups and offer tapering guidance and information on alternative, evidence-based treatments for PTSD.

“It’s taken a while, but we’re beginning to see success,” Dr. Bernardy says of the initiative, adding that the involvement of family members is an integral part of the tapering process. The VA is also looking at other models for increasing engagement in evidence-based PTSD treatment through shared decision-making.

“Shared decision-making has not been used widely,” Dr. Bernardy says. “So we are trying to create a culture where providers meet with patients and discuss PTSD treatment options—the pros and cons of each—and then let patients and family members make the best decisions for their care.”

Treatment-Resistant PTSD

For patients with PTSD who do not respond to initial drug treatment, it may be necessary to explore additional pharmacotherapy options to control their symptoms. A number of pharmacological agents, including antipsychotics, antiadrenergic drugs, and anxiolytics, have also demonstrated some efficacy in treating PTSD.

However, for most pharmacological therapies, there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more clinical studies in this area. According to Dr. Schnurr, psychotherapy remains the most effective treatment for PTSD. “Antidepressants may be effective,” she says, “but we see more results—and we also see more durable results—with the psychotherapies because they essentially go to the heart of helping the patient address the problem.”

Economic and Societal Burden of PTSD

The need for better solutions is shown by the immense economic and societal burden of PTSD. First-year treatment alone for Iraq and Afghanistan veterans treated through the VA costs more than $2 billion, or about $8,300 per person. Health care costs for veterans with PTSD are 3.5 times higher than costs for those without the disorder. According to the VA, PTSD was the third most prevalent disability for veterans receiving compensation in 2012 (572,612 veterans), after hearing loss and tinnitus.

PTSD and Suicide

Veterans now account for 20% of all suicides in the U.S., with the youngest (18–24 years of age) four times more likely to commit suicide than their nonveteran counterparts of the same age. An estimated 18 to 22 veterans die from suicide each day. According to a recent study published in JAMA Psychiatry, the likelihood of suicide increases once a person leaves active military service, and that risk is further increased in veterans whose service time was less than four years.

The association between PTSD and suicide has been a subject of debate, with some studies showing that PTSD alone is associated with suicidal ideation and behavior, and others indicating that the higher risk is due to comorbid psychiatric conditions.

Barriers to Effective PTSD Treatment

Despite efforts to increase access to appropriate mental health care, many military veterans continue to face barriers to getting PTSD treatment. The largest single barrier to timely access to care, according to a VA audit, is the lack of provider appointment availability. An acute shortage of doctors in the VA, particularly in primary care, combined with the rising population of veterans seeking treatment, has led to months-long waiting times.

Poor availability of mental health services in many parts of the U.S. also presents a significant barrier for Iraq and Afghanistan veterans and their families. Mental health specialists tend to concentrate in larger urban areas, and even in those areas, there are disparities in the per capita number of psychiatrists. Some rural areas have none. According to the VA Office of Rural Health, veterans from these areas are less likely than urban veterans to access mental health services, in part because of the greater distances they must travel.

One of the most frequently cited barriers to veterans getting timely and adequate care for PTSD is the social stigma associated with mental illness. Research indicates that service members may feel ashamed and embarrassed to seek treatment, perceive mental illness as a sign of a weakness, or feel that it is possible to “tough it out.”

According to Dr. Schnurr, considerable effort has been made to destigmatize seeking mental health treatment among military veterans. For example, the VA is developing initiatives to enhance collaborative care services that integrate mental and physical health, which is thought to help minimize the stigma associated with PTSD. Additionally, the VA has implemented various outreach initiatives, such as the “About Face” awareness campaign, a series of online videos that introduces viewers to veterans who have experienced PTSD and provides guidance on seeking care.

“It’s a culture change,” Dr. Schnurr says. “By working at both the community level and within the system, we are trying to comprehensively make the changes that will make it easier for veterans to recognize that they need help and then to seek help.”

In an effort to address access to care issues, the VA is focusing on telehealth or the use of tele communications technology to provide behavioral health services to veterans diagnosed with PTSD. Telehealth, which can be both convenient and destigmatizing, has particular potential in rural areas, where a large portion (38%) of VA enrollees diagnosed with PTSD live. A recent study of rural veterans with PTSD showed that receiving psychotherapy and related services via telephone or video conferencing can have positive effects, including the initiation of and adherence to appropriate treatment.

In another study of rural veterans in VA care, patients who received treatment remotely had greater reductions in PTSD scores at six months and at one year than those who were offered on-site care. According to the researchers, participants in the telemedicine group were much more likely to engage in their own care, a critical component of recovery.

Community-Based PTSD Care

Research indicates that community-based mental health providers are not well prepared to take care of the special needs of military veterans and their families, including evidence- based treatment of PTSD and depression. According to Dr. Schnurr, there has not been sufficient dissemination and implementation of the most effective psychotherapies in community-based settings, such as primary care practices, behavioral health centers, substance-abuse treatment facilities, and hospital trauma centers. To help meet these needs, the VA developed the PTSD Consultation Program for Community Providers (vog.av@tlusnocDSTP" class="oemail">vog.av@tlusnocDSTP), which offers free education, training, information, consultation, and other resources to non-VA health professionals who treat veterans with PTSD.

A number of initiatives across the country provide training and/or treatment support to providers who offer services to veterans with PTSD. The Center for Deployment Psychology, a nationwide network of medical centers, trains military and civilian behavioral health professionals to address the emotional and psychological needs of military personnel and their families through live presentations, online learning resources, ongoing consultation, and education. Star Behavioral Health Providers is a resource for veterans, service members, and their families to locate behavioral health professionals with specialized training in understanding and treating military service members and their families. The service is currently offered in California, Michigan, New York, Indiana, Ohio, Georgia, and South Carolina.

Challenges and Opportunities Ahead

challenges ahead


While many important advancements have been made over the past few decades in understanding and treating symptoms of PTSD, the rising number of American veterans who suffer from the disorder continues to be a serious national public health problem. Cognitive behavioral therapy is a widely accepted method of treatment for PTSD, but there is clearly an urgent need to identify more effective pharmacological approaches for the management of symptoms, as not all patients will respond adequately to psychotherapy or evidence-based/first-line pharmacotherapy. Further understanding of the underlying physiological and neurological processes will be helpful in developing new and effective therapies to treat PTSD.

Research also suggests further opportunities for the VA and other health care systems to develop new and innovative ways to overcome barriers to treating veterans with PTSD. With veterans and their families increasingly seeking care outside of the VA system, community providers play a key role in helping to address these challenges. It is critical they receive the education, training, and tools to improve their understanding of and skills for addressing the needs of this unique population.


Articles from Pharmacy and Therapeutics are provided here courtesy of MediMedia, USA | Miriam Reisman
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