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Treatment of Military-Related Post-Traumatic Stress Disorder: Challenges, Innovations, and the Way Forward

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Treatment of Military-Related Post-Traumatic Stress Disorder: Challenges, Innovations, and the Way Forward International Review of Psychiatry ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: https://www.tandfonline.com/loi/iirp20 Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward David Forbes, David Pedlar, Amy B. Adler, Clare Bennett, Richard Bryant, Walter Busuttil, John Cooper, Mark C. Creamer, Nicola T. Fear, Neil Greenberg, Alexandra Heber, Mark Hinton, Mal Hopwood, Rakesh Jetly, Ellie Lawrence-Wood, Alexander McFarlane, Olivia Metcalf, Meaghan O’Donnell, Andrea Phelps, J. Don Richardson, Nicole Sadler, Paula P. Schnurr, Marie- Louise Sharp, James M. Thompson, Robert J. Ursano, Miranda Van Hooff, Darryl Wade & Simon Wessely To cite this article: David Forbes, David Pedlar, Amy B. Adler, Clare Bennett, Richard Bryant, Walter Busuttil, John Cooper, Mark C. Creamer, Nicola T. Fear, Neil Greenberg, Alexandra Heber, Mark Hinton, Mal Hopwood, Rakesh Jetly, Ellie Lawrence-Wood, Alexander McFarlane, Olivia Metcalf, Meaghan O’Donnell, Andrea Phelps, J. Don Richardson, Nicole Sadler, Paula P. Schnurr, Marie-Louise Sharp, James M. Thompson, Robert J. Ursano, Miranda Van Hooff, Darryl Wade & Simon Wessely (2019): Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward, International Review of Psychiatry, DOI: 10.1080/09540261.2019.1595545 To link to this article: https://doi.org/10.1080/09540261.2019.1595545 Published online: 02 May 2019. Submit your article to this journal View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=iirp20 INTERNATIONAL REVIEW OF PSYCHIATRY https://doi.org/10.1080/09540261.2019.1595545 REVIEW ARTICLE Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward aà bà c d a,e f David Forbes , David Pedlar , Amy B. Adler §, Clare Bennett , Richard Bryant , Walter Busuttil , John Coopera, Mark C. Creamera, Nicola T. Fearg,h, Neil Greenbergg , Alexandra Heberi,j, Mark Hintona, Mal Hopwooda, Rakesh Jetlyk, Ellie Lawrence-Woodl, Alexander McFarlanea,l, Olivia Metcalfa , Meaghan O’Donnella, Andrea Phelpsa , J. Don Richardsonm,n, Nicole Sadlera, Paula P. Schnurro,p, Marie-Louise Sharpg , James M. Thompsoni,q, Robert J. Ursanor, Miranda Van Hooffl, Darryl Wadea and Simon Wesselyg aCentenary of Anzac Centre, Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia; bCanadian Institute for Military and Veteran Health Research, Kingston, ON, Canada; cCenter for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, USA; dNew Zealand Defence Force, Wellington, New Zealand; eSchool of Psychology, University of New South Wales, Sydney, Australia; fCombat Stress, Surrey, UK; gKing’s Centre for Military Health Research, King’s College London, London, UK; hAcademic Centre for Military Mental Health Research, London, UK; iVeterans Affairs Canada, Charlottetown, Canada; jDepartment of Psychiatry, University of Ottawa, Ottawa, Canada; kDirectorate of Mental Health, Canadian Armed Forces, Ottawa, Canada; lCentre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia; mDepartment of Psychiatry, Western University, London, Canada; nMcDonald/Franklin OSI Research Centre, London, Canada; oNational Center for PTSD, White River Junction, VT, USA; pDepartment of Psychiatry, Geisel School of Medicine, Hanover, NH, USA; qDepartment of Public Health Sciences, Queen’s University, Kingston, ON, Canada; rCenter for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA ABSTRACT ARTICLE HISTORY Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and vet- Received 5 February 2019 eran populations. Considerable research and clinical opinion has been focused on understanding Accepted 11 March 2019 the relationship between PTSD and military service and the implications for prevention, treat- KEYWORDS ment, and management. This paper examines factors associated with the development of PTSD PTSD; military; veteran; in this population, considers issues relating to engagement in treatment, and discusses the treatment; trauma empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treat- ments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medi- cine approaches, advancing functional outcomes, family intervention and support, and attention to physical health. Post-traumatic stress disorder in veteran and different contexts. Sometimes, for example, it refers to military populations anyone who has left the military, regardless of their Post-traumatic stress disorder (PTSD) is one of the combat experiences and deployment history, while at common mental disorders in military and veteran other times it refers to anyone who has completed an populations (Magruder & Yeager, 2009; Williamson, operational deployment, regardless of whether he/she Stevelink, Greenberg, & Greenberg, 2018; Wisco et al., is still serving. We recognize that this causes confu- 2014). (The term ‘veteran’ has several meanings in sion in the research literature and have tried, where CONTACT David Forbes [email protected] Centenary of Anzac Centre, Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Level 3, Alan Gilbert Building, 161 Barry St, Carlton 3053, Australia. à These authors contributed equally to the paper. §Disclaimer: Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its publication. The opinions or asser- tions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense. ß 2019 Institute of Psychiatry and Johns Hopkins University 2 D. FORBES ET AL. relevant, to differentiate the two.) While the disorder Once problems develop, cultural factors may affect can present in mild forms, PTSD can often become a the person’s willingness to acknowledge mental health chronic disorder resulting in substantial functional issues, as well as how those problems are expressed impairment and reduced quality-of-life (Australian (Sharp et al., 2015), highlighting the need for special- Centre for Posttraumatic Mental Health, 2013; ized understanding among practitioners about mili- Bruffaerts et al., 2012; Schnurr, Lunney, Bovin, & tary service and the need to build trust with veterans Marx, 2009). The Diagnostic and Statistical Manual of in clinical settings. Those factors, of course, may also Mental Disorder 5th Edition (DSM-5) describes PTSD adversely affect engagement in, and response to, treat- as having four symptom clusters: (1) re-experiencing ment. Without effective engagement, individuals with the traumatic event, including recurring intrusive PTSD (whether military or civilian) are at risk of a memories, flashbacks, or dreams of the trauma; (2) chronic course and long duration of illness with sig- intentional avoidance of traumatic memory triggers; nificant negative consequences for themselves and (3) changes in mood and/or thoughts, such as feelings their families. Regrettably, a detailed discussion of the of anxiety, sadness, shame or anger, negative thoughts impact on families is beyond the scope of this paper. about the self or others, or emotional numbing; and Suffice to say at this point, however, that it is of the (4) hyperarousal in the form of irritability, hypervigi- utmost importance to actively support families—both lance, and trouble with concentration and sleep in their own right and as part of PTSD recovery for (American Psychiatric Association, 2013). The ICD-11 the service member (Fear et al., 2018). PTSD criteria are somewhat simpler and focus on the three symptom clusters of re-experiencing, active Trauma exposure and prevalence of PTSD in avoidance, and hyperarousal (Maercker et al., 2013). military and veteran populations The DSM-5 also introduced a dissociative sub-type characterized by high levels of either depersonaliza- Military-related PTSD can be the result of a diverse tion or derealization. range of operational experiences including combat, PTSD is not unique to military and veteran popu- peacekeeping, and humanitarian deployments, as well lations. Veteran populations, however, are character- as non-deployment trauma. Traumatic exposures may ized by several factors that may influence the include direct threat to the self or others, or witness- development and nature of the disorder. In addition ing significant human suffering and being prevented to the risk of exposure to the trauma of war, for through rules of engagement from intervening to pro- example, adverse childhood experiences prior to join- tect non-combatants. Many of these scenarios are ing the military (a risk factor for the development of characterized by moral
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