TCPR: Dr. Keane, you are a psychologist in the VA health system. Is it true that PTSD is one of the greatest mental health concerns in veterans?
Dr. Keane: Yes. We also are concerned with depression, suicide, mild traumatic brain injury, and substance abuse—alcohol in particular.
TCPR: Is there reluctance among veterans or active duty military personnel to seek help for mental health problems?
Dr. Keane: Stigma is a big concern in active duty military. But there is also a sort of generic stigma that applies, predominantly to males, but not exclusively so, about issues related to seeking mental health services. I think there is a reluctance to endorse certain symptoms when screening is done, or to ask for care when one is having trouble in one’s life.
TCPR: How are these hurdles being addressed?
Dr. Keane: A few years ago the Secretary of Defense actually issued a policy statement that seeking help for problems related to deployment like PTSD would not necessarily result in a loss of clearance or an inability to be promoted in the military setting. This was a very big step forward in reducing stigma and alleviating the concerns that people in the military had about coming forward. Another tool we’re using is to provide a service via the Internet in an anonymous, confidential way. Hundreds of people signed up to participate in an online alcohol and PTSD treatment program that we provided for returning veterans. I also think having care available in primary care settings is really important. Many people come to primary care, they say they are having problems, they get a referral to specialty mental health care, and then they never follow up on it. So making mental health care available in the primary care setting may be another step forward for us.
TCPR: Are there any correlations between particular events that a person may have experienced or witnessed while on duty and the later development of, say, PTSD?
Dr. Keane: The amount of combat exposure is correlated with the development of post-deployment mental health problems (Smith TC et al, BMJ 2008;336(7640):366–371).
TCPR: What is the best way to inquire about military stressors? Are there guidelines for those of us who don’t work in the Department of Defense or VA to bring these things up in a helpful and compassionate way?
Dr. Keane: There is an instrument called the Deployment Risk and Resiliency Inventory (DRRI) that was developed by Drs. Dan and Lynda King. It includes a number of scales administered in an interview-type format, and it addresses many of the possible kinds of stressors that people experience in a war zone. It runs the gamut from the climate (either too cold or too hot), to the living condition, to the number of firefights. [The DRRI can be found at http://1.usa.gov/qAKWHX]
TCPR: Are there any psychological or mental health screenings performed before deployment that might determine a person’s likelihood of developing PTSD, or conversely, predict resiliency?
Dr. Keane: The general notion is that the best thing you can do for people going into military combat is make sure they are prepared to do their jobs. That being said, there has been a sincere interest on the part of researchers at the University of Pennsylvania and elsewhere across the country to provide some understanding of the skills new soldiers might learn in anticipation of the life and death experiences of combat to help them process their experiences, solicit social support, and manage their anxieties. There have been efforts to try to equip people psychologically to manage the stress of being in the war zone, but randomized controlled trials have not been done yet.
TCPR: How long after a person returns from active duty do we typically see problems such as PTSD or depression or substance use arise? Is there a “normal” course, or is it variable?
Dr. Keane: At the VA, we might have someone come in for the first time today who was traumatized in Vietnam or the Korean War. So it can be 50 years before someone seeks treatment. However, my view is that people are usually having problems very early upon their return home, even while still in the war zone. Some people can put one foot in front of the other, and get employment and take care of themselves, but it is when the stressors of life start to add up that they begin to have trouble.
TCPR: Are there some external factors—relationships, jobs, financial security—that seem to enable a person to cope more effectively, despite having been exposed to tremendous stress or trauma while on duty?
Dr. Keane: Oh yes. We think that unit cohesion and the support systems that exist in the unit are very important. When people move from one place to another, if they remain in an intact unit, there is a degree of trust and social support that actually is a protective feature. Similarly, when people return back to the states, having continued contact with people who have been through similar things is quite protective. In addition, there are the usual social support symptoms—support from a spouse and from the family of origin. Being able to work and having a supportive workplace is very important. Towns, communities, memorials, celebrations—all of these things help people feel like the sacrifices they have made were worth it and that their communities are appreciative.
TCPR: Are there any other tools that a clinician can use now to screen for PTSD?
Dr. Keane: Sure, the most commonly used screen is the PTSD Checklist. It takes five minutes for patients to complete it. For a more formal assessment, the CAPS (the Clinician-Administered PTSD Scale) is the most widely used structured diagnostic interview. A third screen that is used very frequently in military and veteran settings is the Mississippi Scale for Combat-related PTSD, which is widely used in the literature. These are all available on the National Center for PTSD’s website (www.ptsd.va.gov).
TCPR: What does PTSD treatment look like in the VA, and what can private practice psychiatrists do to emulate that?
Dr. Keane: The VA is working very hard to standardize care across the country. There has been a tremendous effort to disseminate evidence-based treatment, whether it be psychotherapies or pharmacotherapies, so that whether people walk into a VA in Boston or in Iowa, they will get comparable evaluation and get comparable services for PTSD. There is a set of guidelines, the VA-DOD Best Practice Guideline, that were developed many years ago and were updated just this year. We focus on providing a continuum of care: residential care; inpatient care for acute crises; support for people in workplaces so that they can stay employed; pharmacotherapies; and psychotherapies. So we try to meet people where they are and we try to provide them with what they perceive they need and what we perceive would result in optimal outcome. We have a wide range of programs that address alcohol, drugs, PTSD, depression, schizophrenia, and bipolar disorder, and we are working very hard to be state-of-the-art in the provision of care for all of these conditions.
TCPR: What are some evidence-based psychotherapies for PTSD?
Dr. Keane: There are several that are widely used in the VA system. Prolonged exposure or exposure therapy, cognitive therapy, cognitive processing therapy, and acceptance and commitment therapy all have reasonable to substantial evidence bases (http://1.usa.gov/fqJjkU). Exposure therapy and cognitive processing therapy have the strongest evidence of efficacy, and the Institute of Medicine has noted these for treatment of PTSD (Institute of Medicine, Treatment of Posttraumatic stress disorder: an assessment of the evidence. The National Academies Press; 2008).
TCPR: How exactly is exposure therapy done?
Dr. Keane: It is typically done in a one-to-one therapy setting. The idea is to identify the most traumatic and difficult experiences that a person had in the war zone—the things that come back in the form of nightmares and flashbacks and preoccupation. Then we provide exposure to these events in a systematic, repeated fashion, similar to physical therapy where one has to exercise certain parts repeatedly in order to develop strength. We are trying to help the patient master and emotionally process the experiences. What did they experience at that time emotionally? What are they experiencing now? And what do they think is causing the terrible reaction that they have to the experience, which in some cases, was many years ago?
TCPR: Where can we learn more about effective therapies for PTSD?
Dr. Keane: The National Center for PTSD’s website has some training built into it. The Medical University of South Carolina’s National Center for Crime Victims has a website with education and training on it (http://colleges.musc.edu/ncvc). The Uniform Services University of the Health Sciences Center for Traumatic Stress Studies also has a website with education and training materials for professionals (www.usuhs.mil).
TCPR: What do you think about medications for PTSD?
Dr. Keane: The pharmacological treatments of choice are the selective serotonin reuptake inhibitors (SSRIs), two of which (paroxetine [Paxil] and sertraline [Zoloft]) are the only drugs approved by the FDA for PTSD. The treatment effects are actually pretty modest in terms of improvement over time, but the SSRIs show the most consistent effects (Stein DJ et al, Cochrane Database Syst Rev; 2006). After that it becomes a matter of augmentation strategies, and there are many augmentation strategies out there using a variety of medications. There is no single approach that people use; it is really very much still an art. But I will say that most everybody agrees that the benzodiazepines should be used with great care because of their addictive potential, and people with PTSD often have a lot of trouble with the addictions to alcohol and/or drugs. There is an innovative treatment that uses an older antihypertensive agent called prazosin for treating nightmares. While the large-scale clinical trials are just now being completed, there are a lot of encouraging signs that prazosin might be quite useful for people with PTSD.
TCPR: Thank you Dr. Keane.