Those who helped reshape VA health care more than a decade ago were fond of saying: "It's not your grandfather's VA."
Anyone looking for proof of the ongoing transformation could find it at a May 17 meeting convened by VA's Office of Research and Development. The topic was therapies such as meditation, massage, and yoga to help Veterans with posttraumatic stress disorder.
The goal of the 30 or so attendees—including experts from VA, the Department of Defense, the National Institutes of Health, and academia—was to explore the existing evidence on complementary and alternative medicine (CAM) for PTSD and forge a future research agenda.
According to survey results presented at the meeting, 9 in 10 VA facilities now offer some form of CAM, either in-house or through referrals to outside contractors. The most common forms are meditation or other relaxation techniques. (See Complementary and Alternative Medicine in VA.)
Kicking off the meeting, VA Deputy Secretary W. Scott Gould said: "We've done a lot of work in many areas of PTSD research that has produced effective treatments, but we are not done preventing, relieving, or curing PTSD in all Veteran patients. And that is why we need to keep our curious minds open and receptive to new ideas. In addition to the outstanding medical care we already provide, we are learning to extend that care to include many CAM treatments."
At the same time, Gould stressed the importance of focusing the research effort. He said meditation, because it is already offered widely in VA and seems to be a logical approach to helping Veterans cope with PTSD, was a good target for rigorous study.
The discussion at the meeting was lively from the outset. Gould, in response to a question about meditation as opposed to movement-based therapies such as tai chi or yoga, referenced his experience as a tae kwan do practitioner and instructor in the Navy. He acknowledged the meditative aspects of such disciplines, underscoring the sometimes blurry definitions of the modalities the researchers would be discussing.
VA investigators and others have done numerous CAM studies to date. But robust evidence specifically on CAM for PTSD is hard to come by. A VA team tasked with doing a literature review for the meeting culled through hundreds of references and reviewed dozens of studies in-depth, but they turned up only little more than a handful of randomized clinical trials—the most rigorous and respected type of study. Overall, the therapy with the strongest evidence base was acupuncture, followed by relaxation techniques and meditation.
But some attendees at the meeting—including several medical acupuncturists—suggested it might make sense to look beyond randomized clinical trials for evidence to steer future research. One idea was to take a harder look at the biological mechanisms of CAM treatments.
Along those lines, Jack Killen Jr., MD, deputy director of the National Center for Complementary and Alternative Medicine, stressed the need to further explore the efficacy of various treatments before launching into large randomized trials. One approach, he said, would be "looking into what we know about the basic science of therapies such as meditation and acupuncture. Are there unique contributions of these treatments to the pathology of PTSD?"
To better understand the effects of various CAM treatments on brain and nervous-system biology, some attendees suggested measuring heart rate variability, or proteins in the blood or cerebrospinal fluid that serve as biomarkers. Another approach would involve brain-scan technologies such as functional magnetic resonance imaging, magnetoencephalography, or positron emission tomography. All of these methods are increasingly used in VA and academia to study a range of mental health issues, especially PTSD and traumatic brain injury.
"How about pre- and post-brain scans?" asked Capt. Anita Hickey, MD, of the Naval Medical Center in San Diego, who in 2000 became the first Navy physician to become certified in medical acupuncture.
David Atkins, MD, MPH, director of VA's Quality Enhancement Research Initiative (QUERI) program, suggested expanding the evidence review to look at CAM successes in areas related to PTSD. "Maybe there's something well-established in an area close to PTSD—such as depression—that we can apply. What are we already doing in these areas that's working, and could we evaluate it for aspects of PTSD?"
A theme running through the day was that in VA and most mainstream medical settings, CAM is used mostly as an adjunctive treatment. Citing meditation as an example, psychologist Paula Schnurr, PhD, deputy executive director of VA's National Center for PTSD, said: "There's a very big increase in the use of meditation and other CAM techniques. But people are generally using it as adjunctive therapy. They don't see it as standalone therapy."
Several of those at the meeting suggested capitalizing on existing trends by focusing research on CAM's adjunctive role. As Schnurr put it, "Can we use CAM to make existing treatments more effective or more efficient, or to boost retention in treatment?"
Schnurr led a seminal VA clinical trial including 284 women, published in the Journal of the American Medical Association in 2007, that helped establish prolonged exposure therapy as a key treatment for PTSD. Among other innovative PTSD work, her group is now developing a "mindfulness meditation" app for smartphones.
Antonette Zeiss, PhD, VA's acting deputy chief of mental health services, underscored the importance of adjunctive therapies for PTSD. "Let's not forget that 'adjunct' is a huge and important category. It can be an entry point for other treatments, or it can be used to help sustain gains that have been made through other treatments." She added that her office, concurrent with ORD's efforts, is looking to fund demonstration projects of meditation for PTSD, leveraging sites that already have existing programs and expertise.
Jill Bormann, PhD, RN, who has pioneered the use in VA of a meditative technique known as mantram (sacred word) repetition, suggested that this type of approach could help prepare patients for participation in psychotherapy. For example, it could help with the distress they might experience in exposure therapy, in which patients gradually re-experience the emotions surrounding their traumas in safe, controlled settings. Bormann admitted that the spiritual nature of her work and certain other CAM approaches "raises flags" among some in the medical community. At the same time, she asserted that such approaches could be powerful for Veterans, and that many welcome a spiritual underpinning for their healing journey.
Other practitioners and researchers in the room said CAM techniques might be studied for their role in treating "sub-clinical" PTSD. Less intense symptoms might benefit from the gentler treatments associated with CAM.
Another idea was to explore CAM for problems outside of core PTSD symptoms—such as pain or sleeplessness—that might be getting in the way of patients' ability to engage in standard psychotherapy. "This is a clinically messy population," asserted Frances Stewart, MD, a psychiatrist at the National Naval Medical Center in Bethesda. "They don't walk through the door with just PTSD. Sometimes you can't address the core PTSD symptoms till you've dealt with some of the other issues." She said, also, that CAM could be a gateway for some patients into more conventional forms of treatment.
Much of the day's discussion focused on meditation, which is being taught by an increasing number of VA psychologists and other clinicians to their patients. Earlier this year, VA issued a call for research proposals specifically on meditation to treat PTSD, and proposals are now under review. The agency hopes to support up to three clinical trials, lasting up to two years.
Considering the broader range of CAM therapies, and even within the arena of meditation itself, Killen of NCCAM stressed the need to distinguish one modality from another, and to carefully weigh the unique pros and cons of each. He said doing otherwise would be akin to studying "surgery" in general, and not any particular type of operation.
Schnurr concurred. By way of example, she said that while 80 VA sites may be providing "mindfulness" meditation, even that sub-category of meditation could include dozens of variations on the theme. "We need standardization," she emphasized. "That should be a priority."