Future directions in
PTSD research and care
In a recent survey by the RAND Corporation of nearly 2,000
veterans of operations Enduring Freedom and Iraqi Freedom,
half the respondents reported they had a friend who was killed or
seriously wounded. Nearly half—45 percent—said they saw
dead or seriously injured non-combatants. Not surprisingly, the
rate of respondents who met the diagnostic criteria for posttraumatic
stress disorder (PTSD) or depression was relatively
high, at 18.5 percent. Based on these data, RAND estimates that
some 300,000 veterans who have returned from Iraq and
Afghanistan are suffering from PTSD or major depression.
For an overview of key issues and emerging trends in PTSD
research and care, Research Currents spoke with Terence M.Keane, PhD, associate chief of staff for
research at the VA Boston Healthcare System
and director of the behavioral science
division of VA's National Center for PTSD,
headquartered in White River Junction, Vt.
He is also a professor of psychology and
professor and vice chairman of the division
of psychiatry at Boston University School of
Medicine. He is recognized internationally as
a leading expert on trauma and PTSD and
has authored numerous books, journal
articles and clinical guidelines on PTSD.
Keane served as guest editor for the current
issue of VA's Journal of Rehabilitation Research and Development (JRRD), which
focuses on PTSD.
Research Currents: VA Secretary Peake
has spoken of the need to properly diagnose
and treat PTSD but not "over-label"
returning veterans with diagnoses that may
no longer be appropriate as these men and
women move forward and readjust. Is that a
difficult balance to achieve?
Terence Keane: Yes. We need to
mitigate the stigma that's associated with a
diagnostic label at the same time that we
encourage people to come forward to get
appropriate treatment. That's a balancing act
on the best of days. Most importantly, we
need to do the right thing by the returning
veterans—whether that means providing
diagnosis and intervention early on, or
adopting a wait-and-see attitude. I think
both approaches have a place.
RC: The Department of Defense has
stepped up efforts to remove the stigma of
PTSD treatment—for example, by changing
its security-clearance procedure so that
applicants need not disclose past mental
health care that was "strictly related to
adjustments from service in a military
combat environment." Do you think this
will have a positive impact on PTSD care?
TK: It may take some time to gauge the
real impact, but I think this is a major step
forward for DoD and a very optimistic change
in policy. I'm convinced that DoD leadership
is invested in the mental health fitness of their
workforce and has every reason to promote
the use of treatment resources. From my point
of view, what's important is making sure these
policies are implemented all the way up and
down the line.
RC: Where are we today with PTSD
care in relation to the Vietnam era?
TK: We're so much better equipped today
than even after the first Persian Gulf War, letalone Vietnam, Korea or World War II. We now have screening
instruments, real-time information about the psychological status of
returning troops, diagnostic interviews, and new treatment models
and methods. We now need to apply these models consistently
across the entire country and disseminate the evaluation and
treatment tools that have been developed in and outside VA.
RC: To what extent has closer collaboration between VA and
DoD helped to enable these advances?
TK: I was on a Web broadcast this morning with Col. [Elspeth
Cameron] Ritchie, a psychiatrist for the Army in DC, and there
were over 500 people across the country taking part and interested
in learning about returning war vets. This would not have
happened 15 or 20 years ago. The fact that so many professionals
tuned in to hear this program represents the great progress that’s
been made, in part through increased collaboration between VA
RC: What steps have been taken to ensure uniform assessment
TK: Brian Marx, Paula Schnurr, Matthew Friedman [of the
National Center for PTSD] and I are involved in a project that will
disseminate evidence-based approaches to the assessment of
PTSD nationwide. We've developed a Best Practice Guideline for
the assessment of PTSD. Following a recommendation from the
Institute of Medicine, VA will disseminate these best practices
nationwide to bring uniformity to the process of evaluating
veterans seeking compensation for psychological war injuries.
RC: In your JRRD editorial, you write that "silo-based studies
of PTSD may have contributed to the current state of knowledge,
but what is needed now is greater integration across disciplines
and specialties." Could you elaborate?
TK: I was calling for the integration of molecular biology,
genomics, proteomics, clinical psychology, and psychiatry. That's
the next direction that has to be explored. These are the kinds of
things that will yield important and fruitful directions for PTSD.
RC: One of the major themes emerging for clinicians and
researchers is the overlap and interplay between PTSD and
traumatic brain injury (TBI)—sorting out the effects of each and
identifying the best treatments. How is that problem being
TK: This particular cohort of war veterans is going to stimulate
much greater research on the role of traumatic brain injury and the
role of psychological stress in health outcomes, much as the
Vietnam veterans served to improve recognition, diagnosis and
treatment of people with PTSD of all sorts. We’re looking very
carefully at trying to understand blast injury, TBI and stress
concurrently. But the answers aren’t there yet. There will need to be
a lot of cross-disciplinary collaboration and some public sector and
private sector integration—VA, DoD, the National Institutes of
Health and the private sector all have a role to play in trying to help
provide the best possible assessment and treatment for people with
RC: VA recently gave an additional $2
million in funding to the National Center
for PTSD. What are the current research
priorities for the center?
TK: Our priorities are the development
of a PTSD registry, the development of
telehealth and Internet-based
interventions, and the dissemination of
existing evidence-based assessment
instruments and treatment tools. Keeping
in mind that VA has hired hundreds of new
mental health providers in the last couple
of years, it seems important that we
provide outstanding mentorship and
education for these new people so they
benefit from the prior generation’s
experiences in developing these
instruments and treatments.