Veterans' Perceptions of PTSD Treatment in Long-Term Care

Introduction

The wars currently occurring across the globe are taking place at a time when more soldiers are surviving to return home, but often with lasting mental health issues and physical disabilities. Many people can name someone who suffers from post-traumatic stress disorder (PTSD) as a result of having experienced a traumatic event. Diagnosis of PTSD is improving, and along with this has come recognition that the condition can be a persistent and debilitating disorder ("Office of Public Affairs," 2014). Veterans being treated for PTSD may find themselves in long-term care facilities in community settings ("Office of Public Affairs," 2014). The quality of care that these veterans receive, coupled with their own belief in the validity of the treatment approaches, will ultimately determine when and how they reintegrate into society and enjoy a life free from the debilitating symptoms of PTSD ("Office of Public Affairs," 2014). The literature indicates that the perceptions patients hold regarding the quality of care they receive can be a pivotal factor in how well they respond to treatment (Polkinghorne, 2005). The current research explores the perceptions of veterans in long-term care regarding their PTSD treatment.

Background: PTSD Prevalence and the Veteran Population

Post-traumatic stress disorder (PTSD) is a serious, complex disorder that affects veterans from every conflict. In the general adult population, roughly 60.7% of men and 51.2% of women report having experienced at least one traumatic event in their lives ("National Comorbidity Survey [NCS]," 2002). Traumas were most frequently identified as follows: (1) having witnessed someone being badly injured or killed; (2) having been in a fire, flood, or natural disaster; (3) having been involved in a life-threatening accident; and (4) having experienced combat exposure.

In contrast to these trauma exposure numbers, the estimated prevalence of PTSD in the general adult population is 7.8% overall — 10.4% for women and 5% for men. These figures indicate that a relatively small proportion of individuals who have experienced traumatic events actually suffer from, or report suffering from, PTSD. Although people are affected by traumatic events in different ways, the National Comorbidity Survey (2002) concluded that "PTSD is a highly prevalent lifetime disorder that often persists for years. The qualifying events for PTSD are also common, with many respondents reporting the occurrence of quite a few such events during their lifetimes" (p. 12).

The prevalence rates for PTSD among veterans of the Vietnam War are 15.2% for men and 8.1% for women. For Gulf War veterans, the prevalence rate is 12.1%. In 2008, the RAND Corporation's Center for Military Health Policy Research published a report on the prevalence of PTSD among veterans of Operation Enduring Freedom and Operation Iraqi Freedom (Afghanistan and Iraq), derived from a study of 1,938 participants; the prevalence rate for this group was 13.8%. In 2011, 476,515 veterans with a primary or secondary diagnosis of PTSD were treated at medical centers and clinics operated by the Department of Veterans Affairs (VA).

When reviewing PTSD prevalence across populations, consideration of how prevalence is defined is warranted. Prevalence represents the proportion of people in a population with a particular condition or disorder at a particular point in time (Gradus, 2014). It is important to recognize that prevalence estimates shift over time, as they are dynamic and change with respect to people and places (Gradus, 2014).

All veterans who visit VA facilities for the first time are screened for PTSD symptoms and depression. In 2010, Secretary Shinseki reduced the evidential requirements for qualifying veterans for health care and disability compensation related to PTSD. This change simplified and accelerated the process, fostering more accurate decisions and quicker access to medical care. The PTSD treatment offered to veterans is recovery-oriented, taking the needs and preferences of veterans into consideration in order to help them identify and achieve meaningful personal goals and satisfying lives.

Literature Review: Barriers and Treatment Approaches

Significant barriers exist for veterans who have been diagnosed with PTSD and are seeking a full course of treatment (Seal et al., 2010). Demonstrably effective treatments for PTSD take from 10 to 12 weeks to complete (Seal et al., 2010). Nearly 50,000 veterans received a new diagnosis of PTSD between 2002 and 2008 (Seal et al., 2010). Of these veterans from the Iraq and Afghanistan wars, fewer than 30% completed the recommended course of treatment (Seal et al., 2010). Certain groups of veterans are less likely to receive the care they need — specifically, those who are male, under 25 years of age, living in rural areas, and diagnosed with PTSD by primary care clinics before being referred to a mental health program (Seal et al., 2010). The barriers to completing a care regimen include both system-level and personal factors, both of which can cause difficulties with follow-up appointments and sustained engagement (Seal et al., 2010). Seal et al. (2010) determined that new, innovative approaches are needed to overcome these barriers and deliver effective PTSD treatments.

Efforts to prevent PTSD through early intervention following traumatic events have largely been ineffective. Brief counseling, psychoeducation, and prophylactic medication have all been attempted in the immediate period following traumatic exposures ("PTSD Treatment Options," 2014). While some of these approaches appear promising, none have been shown to reliably prevent PTSD ("PTSD Treatment Options," 2014). Early interventions nonetheless serve as a component of PTSD programs developed by public health organizations and Veterans' Associations ("PTSD Treatment Options," 2014).

A substantive body of evidence supports the use of cognitive behavioral therapy (CBT) for PTSD (Grohol, 2013; "PTSD Treatment Options," 2014). Another promising early intervention is Psychological First Aid ("PTSD Treatment Options," 2014). Evidence-based research points to the efficacy of both early CBT and exposure-based treatments as approaches to treating PTSD (Grohol, 2013; "PTSD Treatment Options," 2014). A critical question is whether these interventions can actually decrease the likelihood that PTSD will develop following traumatic exposure (Grohol, 2013; "PTSD Treatment Options," 2014). Considerable new research is needed to demonstrate the effectiveness of early interventions, particularly for populations less likely to receive care due to structural barriers (Grohol, 2013). A case in point is Critical Incident Stress Debriefing (CISD), administered in compulsory groups, which has been found to be ineffective for PTSD prevention following trauma exposure ("PTSD Treatment Options," 2014).

Substantial barriers to treatment of psychological distress in combat personnel returning from Iraq and Afghanistan have been documented in other studies as well (Hogue et al., 2010; Tanielian & Jaycox, 2008). The findings suggest that providing mental health services within the primary care setting helps to overcome perceived barriers of mistrust, poor access, and stigma (Hogue et al., 2010; Sundin et al., 2010). Recent studies have shown that locating mental health providers in primary care clinics substantively encourages veterans to use mental health services for their PTSD (Hogue et al., 2010). Indeed, embedding mental health personnel within primary care clinics enabled them to meet with and assess four times as many patients as did comparable clinics following standard referral procedures (Hogue et al., 2010; Sundin et al., 2010).

In a research study assessing 2-year outcomes for psychological symptoms treated within mental health services nested inside a primary care facility, 48 referred patients were followed (Hogue et al., 2010). Fully 40 individuals — 83% of the sample — confirmed that they found the availability of a mental health professional in a primary care unit to be helpful (Hogue et al., 2010). Among the 15 patients (31% of the sample) who specifically identified reasons for this preference, the most common were the reduced stigma associated with seeking mental health services and the ease of accessing those services (Hogue et al., 2010; Tanielian & Jaycox, 2008). Forty percent (19 individuals) refused treatment or dropped out from the pool of those who agreed to be interviewed (Hogue et al., 2010). The overall conclusion was that veterans are more likely to use mental health services when those services are located within primary care settings, and that embedded mental health services represent viable options for veterans returning from combat (Hogue et al., 2010).