What we now know as post-traumatic stress disorder (PTSD) – a mental health problem some people develop after experiencing or witnessing a life-threatening event – is likely as old as the human brain, but for the Department of Veterans Affairs (VA), the effort to establish a national center for supporting and counseling military veterans gained momentum during and after the Vietnam war, as the growing mental health needs of returning American veterans became clearer.
At the time, there was no professional consensus about where PTSD came from. Early concepts of trauma-induced mental health problems – “railway spine” for victims of 19th century railway accidents, or “shell shock” for World War I combatants – focused on physical injury to the nervous system as the cause. Among others who believed a stress reaction to trauma was caused by psychological rather than biological factors, some maintained the reaction was due to inherent mental vulnerability.
In 1980, when the American Psychological Association (APA) named PTSD as a disorder and added it to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM) classification scheme, its diagnosis made two important distinctions: First, it stipulated that PTSD’s “etiological agent,” or cause, was external – a traumatic event outside the range of usual human experience – rather than an inherent “neurosis” or weakness. Second, it made clear that PTSD was a psychological disorder that may or may not be linked to physical injury – though the two are not mutually exclusive.
VA clinicians had been discussing ways to help returning Vietnam veterans cope with trauma for many years, and after the APA’s diagnosis was formalized, research into the neurobiological response to trauma accelerated. In 1984, Congress directed the VA to form a National Center for PTSD “to carry out and promote the training of health-care and related personnel in, and research into, the causes and diagnosis of PTSD and the treatment of veterans for PTSD.”
When the center was established in 1989, one of its earliest contributions was to simply validate, by its very existence, the APA’s diagnosis – which, at the time, wasn’t universally accepted. Paula Schnurr, Ph.D., the Dartmouth College psychiatry professor who became executive director for the National Center for PTSD in 2015, was involved in the center’s formative stages. “At our very first meeting,” she said, “we asked ourselves: What was the single most important thing we needed to do to move the field forward? And we came up with the idea of developing a clinical diagnostic interview that would promote an accurate diagnosis, and also provide an accurate measure of severity, so we could use it for gauging treatment response. We believed that by having a standardized clinical tool that was specialized to assess PTSD, we could immediately move research and clinical care.” In 1989, few effective treatments for PTSD had been identified and many clinicians were focused on coping with the disorder, rather than overcoming it. The tool developed by the center’s experts, the Clinician-administered PTSD Scale (CAPS), helped fill an important gap in standardizing and enhancing the assessment of PTSD.
It’s difficult to overstate how influential the National Center for PTSD, which has grown into one of the world’s leading establishments for research and education on the disorder, has changed the way people – clinicians, researchers, veterans, and the general public – think about PTSD. The center has shaped our basic understanding of the disorder, bolstering the APA’s diagnosis by publishing and disseminating some of the first evidence of PTSD-related biomarkers. “At the time we opened, in 1989, there had been some published reports about biological changes associated with PTSD,” Schnurr said, “and some of the early focus was on stress hormones and neurotransmitters in the brain. But the National Center published the first paper showing anatomical changes in brains that were associated with PTSD. A number of people since, not only the National Center but a number of other people, have been contributing to the literature. We think this publication was critical in expanding the knowledge and opening new doors into research on PTSD.”
Today, a wide range of available treatment options, both pharmacological and psychotherapeutic, can be tailored to the needs of individuals and help achieve meaningful improvements in their daily lives. Research has established that these treatments work – and the center’s multiple education and outreach programs are ensuring that a growing number of people know about them.
“From its very beginning,” said Schnurr, “one of the center’s strengths has been its integrated focus on research and education. We don’t have a separate research budget or a separate education budget. We have some people who are primarily researchers, or primarily educators, but from our very beginning, we tried to integrate people in those communities to enhance research and education and make sure those efforts work hand in hand.”
COMBINING RESOURCES AND EXPERTISE
The National Center for PTSD, while administered by its Executive Division in White River Junction, Vermont, isn’t a “center” in the strictest sense; the reason it was so effective so quickly is that it wasn’t launched from scratch – it was built around existing centers of expertise across the country, which function today as operational divisions. The Behavioral Science and Women’s Health Sciences divisions are in Boston; the Clinical Neuroscience and Evaluation divisions are in West Haven, Connecticut; and the Dissemination and Training Division is in Palo Alto, California. The Pacific Islands Division, in Honolulu, emphasizes cross-cultural factors in the expression, assessment, and treatment of PTSD among ethnic minorities.
The combined expertise of people in these divisions, along with partners in the Department of Defense (DOD) and academia, have brought the National Center to the forefront of PTSD and trauma research. As it sets international standards for promoting better assessment and treatment of PTSD, and for advancing the scientific understanding of it, the National Center continues to look for ways to get help to as many veterans and families as possible. It does this in several ways:
- Leveraging resources for research. When Schnurr and her colleagues began their careers, most research was done in laboratories and funded by grants. A good amount of any investigator’s time was spent in the pursuit of these grants, and a good amount of research was done in relative isolation, or with a small group of co-investigators.
The National Center’s founders wanted a different model: paying a salary to a core group of investigators, and allowing them time to pursue collaborative relationships with other experts in the field. “In order to help our researchers to maximize their productivity,” said Schnurr, “and to enable them to work not only in the areas that might be most fundable, but in the areas they believed were most important, we chose to use money to pay salaries of researchers.” Freeing investigators from the money chase, she said, gave them more room to collaborate – and to participate in educational and outreach initiatives. “Team science is the way we do research,” she said. “We want relevant people to collaborate across the center. And by providing hard money and protected time, we can support that.” Many National Center researchers still pursue grants, and bring these opportunities to colleagues across the enterprise.
- Facilitating access to PTSD treatment and services. The National Center has several strategies for connecting veterans with mental health professionals and services. Its PTSD Consultation Program was launched in 2011 to offer advice, education, training, information, referrals, and other resources to VA providers – and the program was recently extended to non-VA community providers treating veterans. “Any provider helping a veteran anywhere in the U.S. can call us,” said Schnurr. “That’s important because many veterans find it more convenient to seek care outside of VA, and many of these providers don’t have access to the kind of national resources and training, the specialized clinical program, that VA provides in treating PTSD. Our Consultation Program helps veterans access the best evidence-based care.”
The National Center also uses information technology to link patients and service providers, either via the internet or through videoconferencing, and its researchers continue to find that these modes of therapeutic interaction are both effective for PTSD and acceptable to patients.
- Improving the quality of care. About a decade ago, as the VA added a significant number of mental health providers to serve Afghanistan and Iraq veterans, the National Center established a mentoring program to provide advice and support to all directors of specialized PTSD clinical programs. For those who direct outpatient services, Schnurr said, time is always a complicating factor, and implementing best practices and management skills is a challenge. “Some of the evidence-based treatments have additional time requirements that may be hard to balance against the need to ensure timely access,” she said. “It may require some rearranging of the program structure – which clinicians are doing which treatments, and so on. We provide support for these leaders, both one on one and in a national forum, to help them enhance the quality of the care they’re delivering in their specialized program.”
For rural veterans suffering from PTSD, the National Center began a pilot project, the Rural Mental Health Outreach Initiative, in 2014. Administered by the White River Junction VA Medical Center and involving community-based outpatient clinics, the initiative involves periodic visits from a clinical mental health pharmacist who delivers customized education related to consultation, prescribing practices, and overcoming barriers to care. The long-term goal of the initiative is to implement similar programs in other rural VA medical centers around the country.
- Maximizing outreach through information dissemination, training, and education. “When we started,” Schnurr said, “we literally trained people face to face. We put training material in the mail.” The National Center launched its primary outreach tool, its website, in 1995 – early, for a government portal; it’s only a year younger than the White House’s. The National Center’s web presence has evolved into a major conduit of interaction and exchange, its primary distribution vehicle for research and educational materials.
This outreach is extended to VA and community providers, researchers, and veterans and their families, and information technology is an increasingly significant means of connecting people to the help they need. In 2011, the National Center and DOD jointly developed the first publicly available VA mobile app, “PTSD Coach,” which won the 2012 Innovation Award for Telemedicine Advancement by the American Telemedicine Association.
AboutFace, an online video gallery of veterans and their family members talking about living with PTSD and how treatment has helped them, has proven a valuable tool for correcting the misconceptions many people have about PTSD and its treatment. “We’re hoping that someone sees themselves, or a family member, in an AboutFace segment, and gets motivated to get themselves or a family member into care,” said Schnurr.
- Converting research into practice. The National Center was a key contributor to the development of the VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Reaction, and continues to create national training programs in modes of treatment such as Cognitive Processing Therapy or Prolonged Exposure (PE) therapy.
Prolonged exposure therapy, a type of cognitive behavioral therapy that teaches patients to gradually re-approach long-buried trauma-related memories and feelings, is an example of a National Center research initiative whose findings were adopted nationwide in the treatment of PTSD. Until a few years ago, the body of literature on PE therapy was based mostly on female subjects who had been sexually assaulted. “It looked promising,” Schnurr said, “but we had no evidence about its translation to a military veteran.”
Schnurr and Matthew Friedman, M.D., Ph.D., National Center co-founder and its executive director from 1989 to 2014, teamed with Col. Charles Engel, M.D., M.P.H., of the Army Medical Corps to evaluate the effectiveness of PE therapy in treating PTSD of women veterans and active-duty service members at VA facilities and Walter Reed Army Medical Center, an evaluation conducted from 2002 through 2005.
The study – the first to focus on treating PTSD in women veterans – showed that PE therapy was effective. After it was published in the Journal of the American Medical Association, it received much attention, “and we went from doing the research to training providers nationwide in the therapy,” Schnurr said. “It’s one of the most effective treatments for PTSD, and it’s recommended as a first-line treatment in all of the practice guidelines for PTSD, not only in VA but around the world.”
Without the ability to embrace a nationwide pool of research subjects through VA facilities, Schnurr said, it wouldn’t have been possible to achieve a large-scale study of the effectiveness of prolonged exposure therapy for PTSD. “I’m so glad to work in the VA,” she said. “It couldn’t have happened anywhere else. We have the infrastructure where we can fund and conduct the research, deliver the treatment, and push what we’ve learned out to everyone at the national level.”
This article was originally published in the Winter 2017 edition of Veterans Affairs & Military Medicine Outlook.