K2 Capstone GCU Final3

PTSD: Establishing 1

Running head: PTSD: ESTABLISHING EVIDENCE-BASED

PTSD: Establishing Evidence-Based Treatment

NRS-441V

Katherine R. Eckroth

Grand Canyon University

Nora Hamilton

March 17, 2013


Abstract

The impact of post traumatic stress disorder (PTSD) on United

States service members (SM) is of particular interest, as they

reintegrate with civilian populations having polarized societal

and economic issues. The potential for societal fallout is great,

as this disorder affects not only the individual, but the family

and society surrounding them. Fifteen peer-reviewed articles were

identified through key word searches in the Cumulative Index to

Nursing and Allied Health (CINAHL) database. A literature review

was conducted with 14 of those articles, recognized as

appropriate through critical appraisal. According to the Satir

Change Model, our society is in the resistance stage as it braces

for the return of SMs with increasing diagnoses of PTSD.

Treatment modalities appear to be in the chaos stage. Current

practice guidelines (CPG) include the use of selective serotonin

reuptake inhibitors (SSRI), prolonged exposure therapy (PE), and

cognitive processing therapy (CPT). They have been established


with the support of empirical studies. However, much of the

research is flawed because of the difficult nature of the study

of this diagnosis and its therapies. Research discloses that

treatment outcomes vary, and there is a lack of consensus

regarding the available evidence-based treatment options for

PTSD. This warrants research of other interventions. The

Resilient Life Mentor Program shows promise for prevention,

screening, identification, and implementation of early

intervention for PTSD. Its multifaceted approach addresses many

of the variables associated with the disorder. The Institute of

Medicine’s (IOM) recent recommendations encourage registered

nurses (RN) to further their educations and assume advanced

practice roles. Therefore, they must develop an evidence-based

treatment plan to ensure the holistic care of this population.

The health care burden is likely to increase, unless definitive

care can be established for this unique and deserving population.

If we do not know how to help these individuals, we cannot.

Key words: post traumatic stress disorder, selective serotonin

reuptake inhibitors, prolonged exposure therapy, cognitive

processing therapy, military, combat, veteran.


Problem Statement

Post traumatic stress disorder (PTSD) has many aliases,

which include: shell shock, irritable heart, and combat fatigue,

among others. Although it occurs throughout humanity, its impact

on United States (US) service members (SM) is of particular

interest, as they reintegrate with civilian populations having

polarized societal and economic issues. PTSD is the most commonly

diagnosed service-related mental disorder among military

personnel returning from Iraq and Afghanistan (National Academies

Press, 2007).

Recent studies disclose that there is a lack of consensus

regarding the available evidence-based treatments for PTSD.

Selective serotonin reuptake inhibitors (SSRI) show promise, but

their potential side effects require careful consideration. Of

the two drugs that are approved by the US Food and Drug

Administration (FDA), effectiveness in treating combat-related

PTSD is found only 50% of the time (Phillips, 2012). Furthermore,

“the side effects from these drugs can be harmful to service


members and veterans” (Phillips, 2012, para. 7). Studies did find

sufficient evidence to conclude efficacy and support for

prolonged exposure therapy (PE), a form of cognitive behavioral

therapy (CBT) (National Academies Press, 2008). However, PE is

limited in acceptability by both patients and practitioners

(Codd, 2011). Cognitive processing therapy (CPT) is another form

of CBT supported and utilized by the Veteran’s Administration

(VA) to treat PTSD (Meyers, 2013). A consensus regarding

treatment modalities supported by empirical evidence is lacking.

As registered nurses (RN) further their education and assume

advanced practice roles, according to the Institute of Medicine’s

(IOM) recommendations, they must develop an evidence-based

treatment plan to ensure the holistic care of this population.

Health care systems, civilian and federal alike, risk

increasing burdens, as they face budget constraints, an increased

elderly population with comorbidities, and the return of SMs,

whose injuries may have meant certain death in previous conflicts

and have increased associated consequences. Furthermore, only 17%

of veterans carrying this diagnosis have no accompanying

comorbidity (Sharpless, 2011). Disability payments for veterans


with PTSD rose 148.8% between 1999-2004 (Bastien, 2010), as

diagnoses increased by 79.5% (Sharpless, 2011). Up to 25% of

newly returning veterans are diagnosed with PTSD, and these

younger veterans have a 124% higher rate of health care visits

than those without the diagnosis (Meyers, 2013). This burden is

likely to be exacerbated unless definitive care can be

established for this unique and deserving population. If we do

not know how to help these individuals, we cannot. The potential

for societal fallout is great, as this disorder affects not only

the individual, but the family and society surrounding them.

Further extensive research is warranted with this subject

material. Will United States veterans diagnosed with PTSD show

greater symptom improvement with PE, CPT, the use of SSRIs only,

or the use of SSRIs in conjunction with PE or CPT?

A Presentation of Current Issues

As the United States ends the longest war fought in its

history, it struggles to address expanded accountability for the

fallout of increased casualties, both seen and unseen, at levels

higher than previously recorded in the past. Its response will be


dictated by internal and external influences driven by politics,

economics, ethics, morals, and numerous other socio-economic

issues.

SSRIs show promise, but their potential side effects require

careful consideration and monitoring. A literature review

discovered that paroxetine, sertraline, and venlafaxine are the

most promising pharmaceuticals, but PE and CPT have the most

supporting empirical evidence and should be the treatments of

choice (Sharpless, 2011). Davis and colleagues found that the

long-term use of SSRIs prevented relapses of PTSD and converted

some non-responders of short-term therapy (2006). Bastien found

no ideal pharmacological treatment for PTSD (2010).

PE is a cost-effective gold standard treatment for PTSD, and

trials demonstrate its efficacy, even among complex patients with

comorbidities (Rauch, 2012). CPT is comparable to PE in treating

PTSD (Meyers, 2013, Sharpless, 2011). Rauch (2012) and Macdonald

(2011) found that these trauma focused therapies (TFT) did not

exacerbate PTSD symptoms. Though they have the strongest evidence


for efficacy, these interventions are not universally accepted by

providers or patients (Chard, 2012, Rauch, 2012).

CPGs support that initiation of pharmacotherapy that

preceded psychotherapy interventions assists in bridging the gap

between primary, specialty, and definitive mental health

services, while increasing patient engagement by addressing

symptoms that may act as barriers to participation (Jeffreys,

2012). However, three separate studies reveal three different

results, and each is flawed (Rodrigues, 2010), (Hetrick, 2010),

and (Stewart, 2009). Alexander’s literature review concedes that

many studies have contradictory results (2012). The nature of the

disorder and its examining variables make for confounding

research.

A Proposal

Approval will be sought for this proposal per Army Clinical

Investigation Program Directives (AR 40-38, Policy Memorandum 20,

2012). This policy states that research activities must be

Command approved through the Tripler Army Medical Center (TAMC)

Institutional Review Board (IRB). The proposal will be presented


to the Scientific Review Committee (SRC) per TAMC Human Use

Protocol Instructions. If approved, it will be sent to the IRB,

followed by the Human Use Committee (HUC) for further

endorsements. Once approved, a presentation will be offered with

Schofield Barracks Health Clinic Command in attendance.

Soldiers will be solicited to provide scenes depicting

current issues and stressors affecting active duty SM. This

introductory method was chosen to generate involvement,

ownership, empathy, participation, and leadership among all

levels from within. The attached dialogue (Appendix A) will be

spoken by participants in different locations throughout the

room. This will be followed by a brief discussion of the issues

with those present.

The following will be accompanied by a PowerPoint

presentation (PowerPoint 1).

Perhaps, the best way to change the culture is from within.

Marjorie Morrison is a civilian psychologist, who took time away

from her private practice to work with active duty Marines in San

Diego (Thompson, 2012). Through her work, she became convinced


that “making counseling an ongoing requirement is the only way to

effectively help this population” (Thompson, 2012, para. 7).

Given that CPGs are not universally accepted, practiced, or

effective, I propose a trial of Morrison’s Resilient Life Mentor

Program for and Army Company of choice at Schofield Barracks. The

program was developed with drill instructors at Marine Corps

Recruit Depot San Diego. Morrison founded the PsychArmor

organization upon the work she conducted with these drill

instructors. It is to be implemented with the 1st Marine Regiment

at Camp Pendleton in 2013. Her teams, immersed and educated in

military culture, can be hired to facilitate the necessary

interventions for our soldiers. The program enacts proactive

models, mitigating effective change before it becomes

detrimental. Although this is a preventive program, it, also,

provides a safety net for those who have not yet come forward

with symptoms as well as those who would not without the change

needed within our cultures, civilian and military alike. It

addresses the numerous variables and challenges unique to these

individuals and the current federal health care system, tying

them together and addressing the SM holistically.


The program consists of individual and group components.

Counseling sessions are designed to collaborate with existing

resources, and team members understand when and how to use them

to maximize their benefit. Resilience building, emotional

intelligence, and leadership mentoring are tied together to

support SMs in their individual and group roles. Individual

groups focus on communication techniques, counseling skills,

resiliency, values, and goals through personal discovery,

discussion, and role play. Group discussions focus on engaging

the team to the current mission, strengths and vulnerabilities

among members, and lending a hand. The topics include moral

injury, decision making, and PTSD (PsychArmor, 2012).

Morrison acknowledges that the military is made up of

leaders at many different levels, and junior active-duty leaders

do not have the knowledge or experience necessary to help their

subordinates (2012). “The paradigm needs to shift and the leaders

themselves are going to need to take the first step in that

change” (Morrison, 2012, p. 4012). The culture within America and

the Army is one of self-reliance and self-improvement (McIlvaine,

2012). If the culture is saying “take care of yourself”, while


the Army is saying “you can’t take care of yourself, you need to

seek and get help”, a mixed signal is being sent (McIlvaine,

2012). “A population of people, who are molded from the very

beginning of their careers into being strong and reliant on their

commanders for orders, will rarely seek help on their own, and if

they do, it’s often too late” (Thompson, 2012, para. 17).

Though no official research was completed, Morrison did

conduct a survey among four battalions. She received results from

25 Command surveys and 85 drill instructor surveys with good

results (Morrison, 2012, p. 3411-3559).

Anticipated costs are not disclosed at this time, as

contract negotiations are currently frozen because of

sequestration. This, also, affects program initiation.

Evaluation

It is recommended that the program be researched both

quantitatively and qualitatively, as standards, according to

both, should be addressed. It is suggested that the Military

Operational Medicine Research Program be contacted regarding this

research, as they are funded for and actively involved in related


research at this time. This may assist with local budget issues

and constraints for program implementation. The program is to be

followed over a one-year period and reassessed for continuation.

The program will be initiated upon approval of TAMC’s IRB

and direction of the Schofield Barracks Health Clinic (SBHC)

Command once identified intervention Company’s Command offers

consent. PsychArmor staff will present an informational and

educational overview of their program to SBHC providers, staff,

and chosen intervention Company Command and staff with each

Command’s full support. The PsychArmor staff’s education will

continue, as part of program criteria.

The following methods will be employed to study the effects

of the proposed intervention. Controlled trials will be executed

by following two randomly chosen Companies at Schofield Barracks,

Hawaii. One Company will participate in the Resilient Life Mentor

Program, and the other will not. Each will continue to receive

the services currently offered at Schofield Barracks, Hawaii.

The Armed Forces Health Longitudinal Technology Application

(AHLTA) database will be accessed to extract the following data


and records, respective to the Companies: Primary Care visits,

Warrior Behavioral Health (WBH) visits, Emergency Room (ER)

visits, Acute Care Center (ACC) visits, Alcohol and Substance

Abuse Program (ASAP) referrals, Medical Command form 774 (MEDCOM

774) results and trends, Patient Health Questionnaire 9 (PHQ-9)

results and trends (if applicable), and Post Traumatic Stress

Disorder Checklist (PCL) results and trends (if applicable).

The MEDCOM 774 is a screening tool used in the primary care

setting to alert providers to symptoms of depression and PTSD.

The PHQ-9 is a tool that offers a further in-depth screening of

the severity of depressive symptoms. The PCL categorically

screens severity according to the intrusive, numbing or

avoidance, and functional impairment symptoms associated with

PTSD. If a SM scores positive on the MEDCOM 774, they are

provided the PHQ-9, the PCL, or both as indicated by the MEDCOM

774 (RESPECT-Mil, n. d.).

Garrison reports will be accessed through the Office of

Personnel to obtain and trend (if applicable) crime, absent

without leave (AWOL), non-judicial punishment (NJP), court


martial, and domestic dispute incidents and rates, respective to

the Companies studied. Military personnel discharges and

separations date will, also, be obtained and analyzed.

The Marital Satisfaction (Appendix B) and Hurt, Insulted,

Threatened, or Screamed at them (HITS) (Appendix C) surveys are

quantitative evaluations that will be administered monthly.

A qualitative study questionnaire regarding troop morale,

cohesion, stigma, trust, and leadership (Appendix D) will be

conducted prior to program initiation and every three months

thereafter throughout the study.

A cost analysis will be conducted at the one-year mark.

Individual variable costs will be compared to program costs and

outcomes. These will be weighed according to risk versus benefit

and cost versus savings analyses.

Each of these variables, though isolated, correlate strongly

with the others. Results will be studied by a group comparison.

Any changes may indicate positive program outcomes. For example:

Increases in health care visits and positive screening forms may

be suggestive of decreased stigma and greater acceptance of


seeking and receiving care. Less visits, positive screenings, and

negative garrison reports may indicate that the preventative

aspects were successful. Interpretation and identification of

positive and negative results will be assisted by the supporting

qualitative study addressing stigma, leadership, trust, morale,

cohesion, and program evaluation by participants.

Project outcomes are paramount. Program evaluations are,

too. Insight may be provided about why an unknown or unexpected

outcome occurred if the program is examined. Qualitative study

questions will be asked of officer (Appendix E) and enlisted

(Appendix F) ranks, respectively.

Dissemination

It is hope that through improved surveillance, behavioral

health issues may be detected earlier and better responses will

be employed. Studies have suggested that early intervention is

more effective in the treatment of behavioral health disorders.

Ideologically, this early interventions would assist SM s in

maintaining readiness and retention in the United States Army.


However, this is not likely to occur unless the culture is

changed. This is impossible without leader engagement across

every level and requires unit cohesion and social support of

those affected individuals. The many complexities and issues

raised surrounding ability and safety further convolutes this

philosophy.

The SM is at the center of this labyrinth. Their

satisfaction is dependent on issues out of any one entity’s

ability to control. Collaboration, understanding, and care are

crucial to their outcomes. Unfortunately, the individual SM’s

voice is rarely heard. Outcomes are, often, dependent upon what

their leadership does or does not do. Their care is reliant upon

the decisions and efforts of leaders, whether they are those of

business, health, policy, law, ethics, or morals. The results of

this study will assist in determining appropriate understanding

and interventions.

The multifaceted issues of this study will require a broad

dissemination of findings presented according to the various

audiences it will affect. Therefore, numerous agencies, types,


and levels of publications will need to be addressed to ensure

its appropriate application. The study and its outcomes will be

disseminated according to Department of Defense Directive 5230.9.

If release is approved, dissemination to Congress, the IOM, the

Military Press, the American Psychiatric Association (APA), the

American Psychiatric Nurses Association (APNA), and the American

Nurses Association (ANA) are expected. The results should be

summarized, published, and presented to all service branch

leaders at every level throughout the organizations.

A Change Theory

The Satir Change Model is congruent with the current state

of affairs regarding PTSD. The linear graph and explanation of

the model coincide with the impact PTSD is having on society, as

well as the theories supporting current psychotherapy modalities.

Society continues to debate and struggles to accept the

possible consequences associated with increased numbers of SM

returning with diagnosed PTSD. The CPGs continue to be evaluated

and have not been universally accepted or implemented.


This is a five stage change model that carries one from the

status quo to a more updated, relevant, and appropriate situation

through recognition that improvement is always possible (Smith,

2013). This is accomplished by assisting individuals to improve

their lives by transforming the way they see and express

themselves. Its foundation is akin to those of the CBTs used to

treat PTSD.

Stage one is identified as the status quo. Stage two is

termed resistance when a foreign element is added. I believe this

is where society is, as we brace for the return of SMs expected

to have increased diagnoses of PTSD. Stage three is called chaos.

I believe this stage is congruent with current treatment

modalities. While CPGs are present and supported by empirical

studies, much of the research is flawed because of the difficult

nature of the study of this diagnosis and its therapies.

Universal support and agreement is limited. Stage four is dubbed

integration. I hope society and medicine reach this period soon.

Returning SMs are striving for reintegration into our civilian

society and facing much resistance. Established CPGs and ongoing

research are moving medicine in the right direction. Society has


far to go with the many concurring issues affecting individuals

with this diagnosis and the family and community surrounding

them. Stage five will occur when a new status quo is established.

This will, likely, occur over years, as cultural change is

necessary on many levels. The proposed intervention is

instrumental in enacting this.

If one identifies these stages accordingly on a linear

graph, the validity of the incorporated change theory can be

illustrated and used as a visual guide depicting where the

variables of society and medicine are and where they need to go

to establish the proposed change (Appendix G).

A Literature Review

Alexander, W. (2012). Pharmacotherapy for post-traumatic stress

disorder in combat veterans:

Focus of antidepressants and atypical antipsychotic agents.

P&T, 37 (1), 32-38.

Clinical trial results of the most commonly used

antidepressants and atypical


antipsychotics in the treatment of PTSD in combat veterans

(CV) are reviewed in this

publication.

Many studies have contradictory results, and only two

antidepressants are approved for

use in PTSD by the FDA. Others being studied are being

used off label, and many do

not address all of the symptoms of PTSD.

PTSD may be acute or chronic, accompanied by various other

comorbidities, and

specific to the trauma encountered by the population being

examined. A collaborator

approach to the understanding, establishment, and

implementation of appropriate

therapies will only be accomplished through further

research.


Bastien, D. (2010). Pharmacological treatment of combat-induced

PTSD: A literature review.

British Journal of Nursing, 19 (5), 318-321.

This literature review evaluated nine articles that

addressed the use of pharmacotherapy

for the treatment of PTSD.

Results were limited in practicality of application to CVs

with PTD, because samples

were heterogeneous and small, and diagnoses were not

limited to PTSD.

There is no ideal pharmacological treatment for PTSD in

CVs. It suggests that a

combination of pharmacotherapy and psychotherapy would be

most beneficial.

Chard, K. M., Schumm, J. A., Owens, G. P., & Cottingham, S. M.

(2010). A comparison of OEF


and OIF veterans and Vietnam veterans receiving cognitive

processing therapy. Journal

of Traumatic Stress, 23 (1), 25-32.

An outpatient sample of Operation Enduring Freedom (OEF)

and Operation Iraqi

Freedom (OIF) veterans is compared to Vietnam veterans

before and after treatment

for PTSD with CPT.

This systematic review’s sample consisted of 101 make CVs

admitted for outpatient

treatment of PTSD who attended at least one session of CPT

at a VA medical center

between June 2005 and June 2008. Patients were assess

prior to program admission

during a two-three hour interview in which the Clinician-

Administered PTSD Scale


(CAPS), PCL, and Beck’s Depression Inventory II (BDI-II)

were administered.

Exclusion criteria were identified. Data analysis was

strong, rigorous, and reinforced.

Strengths included the evaluation of a real world

population and thorough pre and post

treatment assessments. Limitations are that the data do

not reflect a randomized control

trial (RCT), sample size is small, and variables are

confounded, specifically age and

time since onset of trauma. Post treatment self reports

were missing on 16 patients, and

medication management for some patients does not limit the

study to the effects of CPT.

Bivariate results illustrated little significant

differences in outcomes between the studied


Groups, while multivariate models suggested that OEF and

OIF veterans may have less

severe PTSD symptoms following CPT than their Vietnam

counterparts. These findings

confirm that it may be more difficult to treat those with

chronic PTSD, and CPT may be

better used as a short-term treatment without extended

sessions that do not appear to

contribute to a reduction in symptoms.

Chard, K. M., Risksecker, E. G., Healy, E. T., Karling, B. E., &

Resick, P. A. (2012).

Disseminations and experience with cognitive processing

therapy. Journal of

Rehabilitation Research & Development, 49 (5), 667-678.

This study reviewed the dissemination, implementation, and

outcomes of CPT among

VA therapists and treatment recipients.


Evidence-based literature reviews and system processes

were examined by the authors.

A thorough history and overview of CPT, including how it

is administered and its

evidence base were provided. CPT’s teaching and

administration within the VA system

was evaluated. Patient outcomes and provider knowledge,

confidence, and satisfaction

were considered and presented.

Limitations include that CPT is young in its

implementation within the VA and is not

universally accepted. However, it is well established, and

most that use it show good

results in relation to reduction of PTSD and depression

symptoms in CVs.

Continued research and its dissemination, accompanied by

training and implementation


systems and standards will improve the quality of and

access to care for veterans.

Davis, L. L., Frazier, E. C., Williford, R. B., & Newell, J. M.

(2006). Long-term

Pharmacotherapy for post-traumatic stress disorder. CNS

Drugs, 20 (6), 465-476.

This literature review evaluates the long-term

pharmacological treatment of PTSD.

Limitations include that the samples studied were

heterogeneous, and none of the drugs’

effectiveness was compared to that of another. The studies

raise ethical concerns

because those in placebo groups essentially remain

untreated.

Results support the long-term use of SSRIs in the

treatment of PTSD and prevention of


its relapse. This applies to severe PTSD, as treatment

response is more likely to be

delayed and incidence of relapse is greater. Results

acknowledge that some who do not

respond to short-term therapy convert to responder status

during extended SSRI

treatment.

Hetrick, S. E., Pucell, R., Garner, B., & Parslow, R. (2010).

Combined pharmacotherapy and

psychological therapies for post traumatic stress disorder

(PTSD). Cochrane Database of

Systematic Reviews, 7 (2010).

If the combination of psychological therapy and

pharmacotherapy would provide a more

Efficacious treatment for PTSD than either of them being

implemented alone is

assessed.


A literature review of four RCTs was completed.

Limitations follow. The few trials available had small

sample sizes. Samples lacked

homogeneity and measurement of total PTSD symptoms.

Functional outcomes, adverse

events, and comorbidities were not identified.

No trials revealed a difference among outcomes between

individual or combined

interventions.

Jeffreys, M., Capehart, B., & Friedman, M. (2012).

Pharmacotherapy for posttraumatic stress

Disorder: Review with clinical applications. JJRD, 49 (5),

703-716.

OIF, OEF, and Operation New Dawn (OND) veterans have

higher utilization rates of

mental health services than other CVs. This population

will typically be seen first in


primary care settings indicating that providers across all

specialties should be aware of

and initiate the best evidence-based pharmacotherapy in

collaboration with appropriate

psychotherapy per CBGs.

Electronic databases were searched for RCTs of PTSD

pharmacotherapy for the period

between January 2002 and August 2009. Identified articles

were reviewed and rated

according to their strength of evidence in supporting

CPGs. Pertinent studies published

after August 2009 were combined with personal clinical

experiences in providing

clinical applications.

This literature review was in reference to CPGs and

personal experiences. It is unknown


what sample populations or criteria were studied in their

establishment.

CPGs support that initiation of pharmacotherapy that

precedes psychotherapy

interventions assists in bridging the gap between primary,

specialty, and definitive

mental health services, while increasing patient

engagement by addressing symptoms

that may act as barriers to participation.

Macdonald, A., Monson, C., Doron-Lamarca, S., Resick, P., &

Palfai, T. (2011). Identifying

patterns of symptom change during a randomized control trial

of cognitive processing

therapy for military-related posttraumatic stress disorder.

Journal of Traumatic Stress,

24 (3), 268-276.


The response of symptoms and their associated timeline in

response to CPT for the

diagnosis of PTSD resulting from military trauma is

examined. Patterns of self-reported

symptom change across various points of assessment while

CPT progresses and at one

month after its cessation are compared.

In this RCT, veterans were referred from a VA medical

center. Of those, 60 were

Randomly assigned to receive either CPT beginning

immediately, or to a 10-week wait

list. A diagnosis of PTSD resulting from military trauma

was necessary for inclusion.

Exclusion criteria were identified. There were no baseline

differences in PCL or

subscale severity scores between the groups.


Seven blinded master’s and doctoral-level clinicians

conducted clinical interviews and

Monitored the completion of the PCL at baseline, mid-

treatment, post-treatment, and

one month post-treatment. The CAPS was administered by

providers after sessions 2, 4,

8, and 10. An expert clinician reviewed 10% of clinician

administered therapies and

assessments, and good strength in outcomes was noted.

Investigators found the

logarithmic model superior in assessing symptom change

across a timeline, and results

were obtained through its application.

Limitations include the timing difference of assessments

between the studied groups.

Only self-reported scores were considered in this

research. The authors of this study


found a correlation between PCL and CAPS scores over time.

The sample size was

small, and only one facility was included.

PCL scores and avoidance symptoms decreased faster among

those receiving CPT.

Rapid declines upon initiation of CPT were followed by a

slower rate of symptom

change across a timeline. The study suggests that this TFT

did not exacerbate PTSD

symptoms.

As more SM return with alarming rates of PTSD, it is

imperative that effective

treatments be established and implemented. The continued

dissemination of

empirical support for the tolerability of TFT may assist

in engaging providers and

SMs in their use.


Meyers, L., Strom, T., Leskela, J., Thuras, P., Kehle-Forbes, S.,

& Curry, K. (2013). Service

utilization following participation in cognitive processing

therapy or prolonged exposure

therapy for post-traumatic stress disorder. Military Medicine,

178 (1), 95-99.

This article acknowledges that recent wars have resulted

in a heightened awareness of

PTSD and increased the need for behavioral health

services. PTSD carries a higher

association of health care utilization.

PE and CPT are the current recommended treatments for

PTSD. The impact of these

treatments on health service utilization and cost is

examined.

This controlled trial included veterans at a Midwestern VA

medical center, who had


successfully completed either PE or CPT and were

identified via existing administrative

databases. The majority of participants (91.4%) were

diagnosed with PTSD. There were

no formal inclusion or exclusion criteria. The subjects

were placed in their respective

group upon interest in participating in the group therapy

segment of CPT and the

availability of mental health providers. Symptoms were

determined by providers’

administration of the PCL and the BDI-II at baseline and

final sessions.

The study’s strengths are that “real” subjects were

examined through the use of

computerized medical records and year-long pre and post

comparisons. Limitations


include a small, impure, not truly randomized sample. Only

one clinical site was

involved, and controls were lacking. High risk individuals

were excluded from the

study. Providers’ experience varied.

PE and CPT demonstrated significant decreases in PTSD and

depression symptoms

without significant differences, thus their results were

combined. Direct costs associated

with mental health reduced significantly in the one-year

period following completed

therapies. There were no associated decreased costs for

primary or emergency care.

Successful completion of PE and CPT for PTSD reduces

mental health service

utilization and is cost-effective. These findings are not

universal, but may suggest that


providers can maintain large caseloads with implementation

of these therapies.

Rodriguea, H., Figueira, I., Goncalves, R., Medlowicz, M., Maceo,

T., & Ventura, P. (2010).

CBT for pharmacotherapy non-remitters – a systematic review

of a next-step strategy.

Journal of Affective Disorders, 129 (2011), 219-228.

This study reviews current literature considering CBT as a

next-step intervention in

treating PTSD that fails to remit with pharmacotherapy.

Four RCTs obtained through

two database searches were used for this portion of the

study.

Limitations follow. Samples were limited to Cambodian and

Vietnamese refugees with


varying levels and exposures to traumas. Samples varied

among demographics, types of

trauma exposures, comorbidities, and outcome measures.

Standardization lacked in

terminologies and treatment protocols. Some studies failed

to define remission, and only

one provided follow-up information.

Each study revealed significantly lower symptomology after

CBT was introduced with

concomitant pharmacotherapy.

Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of

exposure therapy: A gold

standard for PTSD treatment. JJRD, 49 (5), 679-688.

Evidence used to support the updated CPGs for the

management of PTSD for the VA

and Department of Defense (DOD) is examined. The efficacy

of PE, its perception


among patients and providers, and the dissemination of

knowledge and its application

throughout the VA were examined.

This meta-analysis was conducted through literature review

and personal

communication with principle investigators on primary

ongoing PE for PTSD clinical

trials.

PE is a cost-effective gold standard treatment for those

diagnosed with PTSD. Trials

demonstrate its efficacy even among complex patients with

comorbidities.

Misconceptions regarding symptom exacerbation and

tolerability were disproved, and

drop-out rates for those receiving PE were lower than

those receiving any other various

type of therapy.


Sharpless, B. A., & Barber, J. P. (2011). A clinician’s guide to

PTSD treatments for returning

Veterans. Professional Psychology: Research and Practice, 42 (1), 8-15.

This literature review summarizes and evaluates the

evidence in favor of PTSD

Treatments and their CPGs.

The review found that, aside from CBTs initiated for

symptomatic trauma survivors and

psychological first aid, there are not other preventative

recommendations found in

CPGs. There is evidence that psychological debriefing may

be detrimental in

asymptomatic individuals. Although use is recommended in

many CPGs, the IOM

concluded that there is insufficient evidence for the

efficacy of medications in treatment


of PTSD. CPGs encourage concurrent psychotherapy. PE

retains the most evidence in

favor of its efficacy, closely followed by CPT. PE and CPT

are the psychotherapies of

choice, while paroxetine, sertraline, and venlafaxine are

the most promising

pharmaceuticals.

PE and CPT have the most supporting empirical evidence,

and should be the treatments

of choice.

Stewart, C. L., & Wrobel, T. A. (2009). Evaluation of the

efficacy of pharmacotherapy and

psychotherapy in treatment of combat-related post-traumatic

stress disorder: A

meta-analytic review of outcome studies. Military Medicine, 174

(5), 460-469.


This meta-analysis of previous pharmacotherapy and

psychotherapy outcome

research evaluates the efficacy of these treatment

modalities in decreasing PTSD

symptoms in CVs.

The PsychINFO database was accessed to identify 12

pharmacotherapy and 12

psychotherapy studies from years 1988-2006. Inclusion and

exclusion criteria were

identified.

There were a total of 11 strong, validated outcome

measures, but they varied

according to study and may have skewed results. The

pharmacotherapy group’s mean

severity of PTSD was significantly greater than that of

the psychotherapy group’s at


baseline. Psychotherapy subjects may have been stabilized

with pharmaceuticals prior to

commencement of the study. The timeline of the study

interventions was limited to four

months, and samples were small.

Pharmacotherapy and psychotherapy showed linear trends in

reduction of PTSD

symptoms, but pharmacotherapy subjects had more rapid

declines in symptoms. This

study suggests that pharmacotherapy be considered as the

initial intervention for CVs

diagnosed with PTSD if the intensity of symptoms interfere

with their ability to

participate in psychotherapy.


Appendix A:

Introductory Dialogue

“Values are only important when the organizations’ members have accepted them” (LTC

Bell, 1999, para. 4).

He returned from a deployment, promoted to sergeant, and received three medals for

valor. He told no one of his night terrors. He knew the signs and symptoms, but decided

to just grit it out. He received two phone calls from the behavioral health team and was

provided contact numbers that he didn’t call (Sheehy, 2012).

“Nearly 8% of the active duty Army is now on sedatives and more than 6% is on

antidepressants – an eightfold increase since 2005. We have never medicated out

troops to the extent we are doing now…And I don’t believe the current increase in

suicides and homicides in the military is a coincidence” (Murphy, 2012, para. 9-12).

Twenty percent of 1.1 million active duty troops surveyed were taking some form of

psychotropic drug (Breggin, 2009). “The drugs often change the personality of the


soldier, making them irritable, edgy, and angry. They fear these drugs may unleash

impulsive violence. Meanwhile, because many soldiers don’t want to take psychiatric

medications, they avoid seeking help of any kind” (Breggin, 2009, para., 9-10).

“I mean, I know guys who have had 10 (veterans who served) in their battalion who

have committed suicide” (Zoroya, 2013, para. 7).

“For more than a year, I struggled to find someone who would simply listen to me,

listen to my specific situation, and use their knowledge and experience to try to help me

feel more normal again. I felt like I was fighting with the Army to get people to do their

jobs in a meaningful way and not blow me off, telling me I was fine, and to go back to

work. I was far from fine. In the end, after jumping through countless hoops, I ended

up getting some pills to help me put up with things, but I couldn’t even take them when

I needed them, at work, because they put me to sleep. During this time, I realized that

the people around me, guys I had known before, during, and after deployment had

changed, too, and were going through the same thing, running into the same problems

that I was with the mental health system, as well as the difficulty with our leadership. I

found the Army’s mental health system to be very confusing, very repetitive, very

frustrating, and a complete joke. I had to explain my whole life story over and over to

different therapists and psychologists, who inevitably ended up giving me a pamphlet

that said to take deep breaths, or some other such nonsense, and had the number for


the National Suicide Hotline, telling me to call if I felt like killing myself” (Miller, 2012,

para. 12-14).

“It is important that soldiers look after other soldiers” (Myers, 2013, para. 15). “The

whole system being strained, more temper, stigma is rampant, leaders who should be

getting more education for mental health issues but are not” (Myers, 2013, para. 18).

“The stigma discourages soldiers from reporting issues related to stress in the combat

zone. To the extent that a military service branch is having basically an epidemic of

post traumatic stress disorder (PTSD) is not embracing it as an epidemic, but instead

sees it as ‘they’re faking’ which has been part of the stigma problem” (Myers, 2012,

para. 19-20).

“The number of soldiers forced to leave the Army solely because of a mental disorder

has increased by 64% from 2005-2009” (Morrison, 2012, p. 4326).

“One of every three SMs returning from Iraq and Afghanistan has been treated by the

Veteran’s Administration for mental health issues” (Morrison, 2012, p. 4163).

Progress made in understanding PTSD therapies has already shown a ceiling effect.

Many continue to suffer despite receiving treatment. “PTSD remains prevalent, chronic,

disabling, and costly” (Shaley, 2009, para. 62).


Appendix B:

This questionnaire is designed to measure the degree of satisfaction you have with your present marriage. It is not a test, so there are no right or wrong answers. Answer each item ascarefully and as accurately as you can by placing a number besideeach one as follows.


1 = None of the time

2 = Very rarely

3 = A little of the time

4 = Some of the time

5 = A good part of the time

6 = Most of the time

7 = All of the time

1. _____ My partner is affectionate enough.

2. _____ My partner treats me badly.

3. _____ My partner really cares for me.

4. _____ I feel that I would not choose the same partner if I hadit to do over again.

5. _____ I feel that I can trust my partner.

6. _____ I feel that our relationship is breaking up.

7. _____ My partner really doesn’t understand me.

8. _____ I feel that our relationship is a good one.

9. _____ Ours is a very happy relationship.

10. ____ Our life together is dull.

11. _____ We have a lot of fun together.

12. _____ My partner does not confide in me.

13. _____ Ours is a very close relationship.

14. _____ I feel that I cannot rely on my partner.


15. _____ I feel that we do not have enough interests in common.

16. _____ We manage arguments and disagreements very well.

17. _____ I feel that I should never have married my partner.

18. _____ My partner and I get along very well together.

19. _____ Our relationship is very stable.

20. _____ My partner is a real comfort to me.

21. _____ I feel that I no longer care for my partner.

22. _____ I feel that the future looks bright for our relationship.

23. _____ I feel that our relationship is empty.

24. _____ I feel there is no excitement in our relationship.

25. _____ We do a good job of managing our finances.

26. _____ We agree on how to parent our children.

27. _____ We have similar spiritual beliefs.

28. _____ I am happy with our level of intimacy and sexuality.

29. _____ We have very similar values and beliefs.

30. _____ We both agree and are working toward mutual goals for our future.

Looking at your answers to the questions above, how satisfied areyou with your relationship?


Mandarin Counseling (2010)

Appendix C:

"HITS" A domestic violence screening tool for use in the communityHITS Tool for Intimate Partner Violence Screening: Please read each of the following activitiesand fill in circle that best indicates the frequency with which you partner acts in the way depicted.How often does your partner? Never Rarely Sometimes Fairlyoften Frequently1. Physically hurt you O O O O O2. Insult or talk down to you O O O O O3. Threaten you with harm O O O O O4. Scream or curse at you O O O O O 1 2 3 4 5Each item is scored from 1-5. Thus, scores for this inventory range from 4-20. A score of greaterthan 10 is considered positive.


(Sherin, 2003)

Appendix D:

Company Questionnaire regarding stigma, leadership, trust,

morale, and cohesion:

1. Do you trust your Command to take care of your issues and

problems?

2. Do you feel your leadership understands your issues and

problems?


3. Do you feel your leadership has your best interests in mind?

4. Is your Command supportive of you seeking treatment or

assistance for your issues and problems?

5. Have there been repercussions for you seeking treatment or

assistance with your issues and problems?

6. Describe the morale in your unit:


7. How well does your Unit function? Is there good cohesion?

8. How well does your Company function? Is there good cohesion?

Appendix E:

Company Officer’s Program Evaluation Survey:

1. Did you find that PsychArmor’s proactive counseling services

were helpful and beneficial for your Company?

2. Did you receive feedback of Command climate from PsychArmor

staff as they worked with your SMs?


3. Did you ever feel that a SM’s confidentiality was

jeopardized during PsychArmor staff’s conversations with

you?

4. Did you notice an improvement in Company camaraderie after

they completed a group with PsychArmor staff?

5. Do you think it is beneficial for SMs to have ongoing

periodic counseling on a regular basis?

6. Do you have any comments or feedback that could provide

insight on how you think behavioral health services are

perceived, utilized, and delivered?

Morrison (2012)

Appendix F:


Company Enlisted Program Evaluation Survey:

1. Although one-on-one meetings with PsychArmor staff were

mandatory, did you feel comfortable talking with them?

2. Did you find PsychArmor staff easy to talk to about personal

things?

3. Did you trust that what you shared with PsychArmor staff

would remain confidential?

4. Did you feel meeting with PsychArmor staff, proactively for

15 minutes, was a good use of your time?

5. If there was an issue you needed assistance with, did you

find that meeting with PsychArmor staff helped give you the

tools you needed to solve your problems?

6. If you needed help in the future, would it be easier to ask

for help after having your one-on-one meetings with

PsychArmor staff?

7. Was it helpful to see the same counselor during every pick-

up and throughout the cycle?

8. Was it a positive experience for you to meet with PsychArmor

staff privately every three months?


Regarding Group Meetings:

1. Did you get to know personal things (i.e. names of spouses

and children) about your fellow SMs better after the group?

2. Were the group meetings to be a good use of your time?

Would you like to see this type of program continue?

Morrison (2012)

Appendix G:


Foreign Element: Increased numbers veterans diagnosed with PTSD upon return of troops.

Transforming Idea: Effective Evidence-Based Treatments must be identified and implemented.

Stage I: Prior generations.

Stage II: Current society status.

Stage III: Current treatment status.

Stage IV: Medicine is working toward this goal.

Stage V: Once reached, it will need to be maintained until another foreign element is added.

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