Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment
Disclaimer on Source and Methodology
The information summarized herein is derived from the publication Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment (National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, 2014), available through the National Academies Press. The source document was provided in full by the requester and reviewed in detail.
This breakdown was created by:
Reading the original text, including the Executive Summary, detailed findings, and supporting tables.
Extracting relevant passages and data points from the original report.
Paraphrasing and reorganizing the material to group related findings under thematic headings (e.g., “Leadership and Communication,” “Workforce and Access to Care”).
Incorporating direct data points (such as prevalence percentages and program counts) as stated in the original report.
Citing line references to the source document where possible for traceability.
No new empirical data were generated. All statistical information, program descriptions, and recommendations originate from the cited National Academies publication. Interpretive comments and organizational structure of this breakdown are the work product of the summarizer and are intended solely to improve clarity and usability for advocacy, research, or educational purposes.
This summary does not represent an official position of the National Academies, the Department of Defense, or the Department of Veterans Affairs. Readers seeking the complete context, detailed methodology, and full set of findings are encouraged to consult the original report, available at: http://www.nap.edu/catalog/18724.
Purpose of the Report
Mandated by the 2010 National Defense Authorization Act.
Conducted in two phases:
Phase 1 (2012): Gathered data on PTSD programs, prevention, diagnosis, treatment, and rehabilitation.
Phase 2 (2014): Analyzed the data to determine program effectiveness, gaps, and made recommendations.
Scope of the Problem
PTSD is one of the “signature injuries” of Iraq (OIF) and Afghanistan (OEF) conflicts.
Estimated prevalence:
7–20% of OEF/OIF service members.
Rates increased from <1% (2004) to >5% (2012) in active service.
Higher in women and nonwhite service members.
In 2012, ~502,000 veterans received VA outpatient PTSD care.
Findings
DoD Programs
Programs vary by service branch; often local, not centrally coordinated.
Screenings occur at 30 days and 3–6 months post-deployment.
Treatments include psychotherapy, medications, and some complementary therapies (acupuncture, art therapy).
Lack of comprehensive outcome data to measure effectiveness.
VA Programs
Uniform minimum standards set by VA policy.
Offers evidence-based treatments (Prolonged Exposure [PE], Cognitive Processing Therapy [CPT]) but delivery consistency is unclear.
Some specialized PTSD programs exist (SOPPs, SIPPs), but most patients are seen in general clinics.
Limited outcome data, especially outside specialized programs.
Major Issues Identified
Fragmentation in DoD PTSD management.
Inconsistent use of evidence-based treatments.
Poor performance measurement—no system-wide outcome tracking.
Staffing shortages and uneven training for direct and contracted providers.
Limited integration between DoD and VA systems, especially during service member transition to veteran status.
Family engagement is inconsistent.
Research gaps—especially on implementation and new treatment development.
Key Recommendations
A. Strategy & Leadership
Develop a unified, integrated PTSD management plan across DoD and VA.
Hold leaders accountable for PTSD care quality.
B. Performance Measurement
Implement standardized, validated symptom/outcome tracking.
Use measurement-based care with feedback loops.
C. Workforce
Ensure enough trained mental health providers.
Apply consistent training and monitoring for all providers, including contracted care.
D. Evidence-Based Treatment
Prioritize PE and CPT.
Evaluate new and complementary therapies rigorously.
E. Centralized Information
Create a DoD–VA shared database of PTSD programs and services.
F. Family Involvement
Increase family participation in treatment and support programs.
G. Research
Focus on overcoming treatment barriers, developing better prevention, and tailoring care to diverse populations.
Bottom Line
While both DoD and VA have invested heavily in PTSD care, the report concludes that:
Neither department knows if their programs actually reduce PTSD prevalence or improve long-term outcomes.
Greater integration, performance tracking, and use of proven treatments are urgently needed.
“Can you go much further in depth on the findings from this article”
ChatGPT said:
Yes — I can unpack the findings from this report in much greater detail so you can see exactly what the committee concluded, where the gaps are, and what it means in practice.
The report’s “Findings” are embedded throughout the Summary and expanded in later chapters, but here’s a detailed, section-by-section breakdown based on what the document covers.
1. PTSD Management Strategies
Finding:
DoD’s PTSD care system is fragmented, reactive, and locally driven, not strategic or population-based.
Prevention, screening, treatment, and rehabilitation programs differ by service branch (Army, Navy, Air Force, Marine Corps).
Many initiatives are created ad hoc, often in response to crises rather than as part of a unified long-term plan.
No overarching DoD authority ensures consistent policy or quality across branches.
VA, by contrast, has a more centralized structure, enabling greater consistency in PTSD care delivery — but even in VA, policies are inconsistently implemented at facility level.
Current DoD–VA coordination efforts (e.g., Integrated Mental Health Strategy, National Research Action Plan) exist but are insufficient to ensure consistent best practices or continuity of care during transition from active duty to veteran status.
Implication:
There’s no integrated “lifecycle” PTSD care plan that follows a service member from enlistment through transition to veteran care — meaning many fall through the cracks.
2. Leadership and Communication
Finding:
Installations and facilities with engaged, informed leaders show better coordination and more comprehensive PTSD services.
In DoD, leaders aren’t consistently held accountable for PTSD management — including stigma reduction and care access.
In VA, engagement varies by facility; central policies on PTSD care exist but aren’t always enforced or tracked.
Poor communication between leaders and front-line clinicians results in:
Duplication of ineffective programs.
Loss of potentially effective but unsupported programs.
Implication:
Leadership culture directly affects PTSD program quality — and right now, outcomes often depend more on local leadership commitment than system-wide standards.
3. Performance Measurement
Finding:
Neither DoD nor VA consistently measures PTSD treatment outcomes for psychotherapy or medications across the system.
No standardized, validated, system-wide outcome tools are in place (with the exception of VA’s SIPPs — specialized intensive PTSD programs).
DoD’s Behavioral Health Data Portal could help, but is not fully deployed.
VA’s electronic health record is being updated to track psychotherapy type, but still won’t include standardized outcome measures.
Many veterans with PTSD never enter specialized programs — so no data is collected on their treatment or outcomes.
Implication:
Without systematic outcome tracking, there’s no way to know whether the majority of PTSD care is effective, wasting resources and missing opportunities to improve.
4. Workforce and Access to Care
Finding:
Staffing for mental health has increased in both systems, but demand still outpaces supply.
Recruiting/retaining providers in rural/underserved areas remains difficult.
Many clinicians don’t have enough time to deliver full, protocol-adherent evidence-based therapies (e.g., CPT/PE).
In 2013, only 53% of OEF/OIF veterans with PTSD at VA received the recommended 8 therapy sessions in 14 weeks.
Purchased care providers (civilian contractors) often:
Lack training in evidence-based PTSD care.
Don’t share treatment updates with DoD/VA providers.
VA is developing standards for purchased care; DoD has no similar system.
Implication:
Without provider standards, tracking, and adequate staffing, quality of PTSD care is inconsistent and often diluted.
5. Evidence-Based Treatment
Finding:
Both DoD and VA officially require first-line, evidence-based treatments (CPT, PE) for PTSD.
In practice, many providers do not deliver them consistently or with fidelity to protocols.
Use of complementary and alternative treatments (e.g., acupuncture, equine therapy) is growing but evidence is limited — and may divert patients from proven therapies if not integrated properly.
Telehealth and tech-based tools are being piloted, but effectiveness data is still sparse.
Implication:
There’s a gap between policy and actual practice. Without fidelity monitoring, “evidence-based” care often isn’t truly evidence-based.
6. Central Database of Programs
Finding:
DoD has no master list of all PTSD programs, making:
Comparison.
Replication of best practices.
Elimination of ineffective programs
virtually impossible.VA tracks specialized programs, but:
Doesn’t include general mental health or women’s health PTSD care.
Lacks detailed program descriptions and isn’t widely used as a referral tool.
Implication:
Both providers and patients lack a clear map of available PTSD resources.
7. Family Involvement
Finding:
DoD offers multiple family education/support resources; staff are trained to spot PTSD signs and refer for care.
VA has family-related resources, but no formal system-wide program for involving families in treatment or offering structured family support groups.
Some VA facilities offer couple/family therapy, but this is not consistent.
Peer counselors help engage veterans, but data on impact is lacking.
Implication:
Family engagement — which can improve outcomes — is inconsistent and dependent on local initiative.
8. Research Priorities and Gaps
Finding:
Collaboration between DoD, VA, NIH, and others exists, but:
No systematic effort to identify and remove research barriers.
No single unified research agenda tied to clinical priorities.
Gaps include:
Overcoming barriers to using evidence-based care.
Understanding biological/psychological processes of PTSD.
Identifying prevention markers and predictive indicators.
Tailoring treatment for different populations and timeframes.
Developing and evaluating new delivery methods (tech, pharmacological, somatic).
Establishing evidence-based competencies and effective training methods.
Implication:
Without strategic, coordinated research that’s tied directly to clinical gaps, innovation will remain scattered and slow.
9. Core Systemic Problem Identified
Across all findings, the committee repeatedly points to three interrelated system weaknesses:
Lack of integration between DoD and VA — service members lose continuity of care upon transition to veteran status.
Failure to measure outcomes — prevents accountability, quality improvement, and best practice dissemination.
Policy–practice gap — official guidelines aren’t consistently implemented or enforced.
Awesome—here’s a deeper, “what did they actually find?” walk-through of that National Academies report. I’ll keep it tight but rich, and I’ll cite exact lines so you can trace anything you care about.
What problem are they sizing?
How common is PTSD here? Since 2001, over 2.6M U.S. troops deployed; the share diagnosed with PTSD jumped from <1% (2004) to >5% (2012). In 2012 specifically: Army 13.5%, Marines 10%, Navy 4.5%, Air Force 4%. Higher rates in women (13% vs 9%) and non-white service members (11% vs 8.5%).
VA burden: In 2012, ~502k veterans had ≥2 PTSD outpatient visits (9% of all VA users). Among veterans in specialty PTSD outpatient programs (SOPPs): 47% OEF/OIF, 20% Gulf War, 34% Vietnam. Female veterans more often had PTSD diagnoses than males (29.4% vs 24.5%, 2013).
What care exists—and how is it organized?
DoD
Screening cadence: Everyone is screened ~30 days after redeployment (PDHA) and again at 3–6 months(PDHRA). Referrals are made off those results.
Where care happens: Mostly outpatient (general MH clinics, primary care, or specialized PTSD programs); mental health providers are embedded in primary care to lower barriers.
Data gaps: For DoD’s intensive/outpatient/inpatient PTSD programs, short- and long-term outcomes aren’t tracked, with a notable exception: NICoE has limited, short-term outcomes for severe PTSD/TBI.
VA
Policy baselines: VA requires annual PTSD screening for the first 5 years in care and requires two first-line psychotherapies—Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT)—to be available to every veteran who needs them.
Where veterans are treated: 2012 snapshot—29% of PTSD-diagnosed veterans seen in SOPPs, ~1% in SIPPs(specialized intensive programs); many get care in general MH/primary care; tens of thousands use Vet Centers.
Outcome tracking: No outcome data are collected in general MH clinics, Vet Centers, or SOPPs; SIPP data exist but show only modest symptom improvements post-treatment.
Handbook + templates: VA’s “Uniform Mental Health Services” handbook sets minimums; VA has been adding EHR templates for CPT/PE—but as of early 2014 they weren’t fully operational, and process measures aren’t tied to outcomes.
The big theme: great effort, weak measurement
The committee’s blunt finding: across DoD and VA, PTSD outcomes aren’t consistently measured, so leadership can’t know what’s working, can’t spread best practices, and can’t manage at a population level. They call this out explicitly and recommend a measurement-based care system using standardized instruments (e.g., the PCL), with data visible at patient, clinic, facility, service, and national levels, and feedback loops for continuous improvement.
DoD’s progress: The Behavioral Health Data Portal (BHDP) is rolling out so patients complete PTSD assessments before each visit; clinicians see results in real time. Rollout is incomplete as of the report.
VA’s gap: VA can code where care occurs but not consistently what psychotherapy occurred nor how patients changed over time (beyond meds). Templates for PE/CPT exist, but linkage to outcome tracking is the missing piece.
Leadership & system design issues
In DoD, PTSD management is described as local, ad hoc, incremental, and crisis-driven; each branch runs its own prevention and treatment programs. VA is more unified but still shows variable leadership engagement and inconsistent adherence to performance goals.
Accountability gaps: Commanders aren’t consistently accountable for PTSD policies; prevention and treatment lines of authority are split; this fragmentation breeds duplicative or ineffective programs while promising ones “languish.”
Access & workforce
Both systems expanded mental health staffing and purchased care, but demand still outpaces supply; hiring/retention is difficult in underserved areas; and without enough time, delivering evidence-based psychotherapies with fidelity is hard. (VA’s own performance targets show room to grow; e.g., raising the share of OEF/OIF veterans getting ≥8 psychotherapy sessions in 14 weeks was a strategic goal.)
VA performance reviews also found wide variation across VISNs and that only ~20% of PTSD patients who should have received an evidence-based psychotherapy actually did, at that time.
Screening specifics (nuts & bolts)
DoD deployment cycle: PDHA at ~30 days post-deployment; PDHRA at 3–6 months; both include a four-item PTSD symptom screen; referrals follow positive screens (activation rates were historically incomplete).
VA primary care: Policy is to screen for PTSD, MST, depression, and problem drinking at first visit; then PTSD annually for 5 years and every 5 years thereafter; positive primary screens trigger 24-hour contact and follow-up within 14 days.
What they recommend (the “A–H” set)
A. Build one integrated PTSD strategy across DoD/VA to plan for the rising burden (including women and minority veterans).
B. Leadership mandate & accountability: Top leaders must signal PTSD management (using best practices) is a priority down the chain.
C. Measurement-based care: Implement standard metrics, HIT documentation of all care, and feedback loops; today, no consistent outcome tracking exists (except in VA SIPPs).
D. Right-size & standardize the workforce: Ensure adequate staffing (direct & purchased care), training standardsfor EBPs, clear referral/monitoring/reporting—especially for purchased-care providers. (VA was moving toward better purchased-care standards; DoD needed analogous mechanisms.)
E. Treat with evidence first: Make PE/CPT (and other EBPs) the default and deliver with protocol fidelity; evaluate innovative/complementary tools so they don’t crowd out first-line care without evidence.
F. Create a central, living directory of DoD/VA PTSD programs so clinicians (and families) can see what exists, where, admission criteria, modalities, outcomes—and so leaders can compare and cull.
G. Bring families in: Scale up partner/family engagement in treatment; veterans want it; VA has resources (e.g., National Center for PTSD, Vet Centers) but lacks a formal, system-wide family engagement program.
H. Focus the research agenda: Prioritize implementation science (getting EBPs used, accepted, and accessible), biomarkers, heterogeneity/prediction, prevention, and new delivery models (incl. tech like VR, telehealth). Also coordinate NIH/DoD/VA efforts and fill gaps (e.g., BHDP to support screening/measurement).
A couple “watch this space” operational details
BHDP (Army → AF/Navy adopting): patients complete the PCL (and others) before each visit; results are in-hand for the clinician—exactly how measurement-based care should feel. Rollout still in progress at the time.
Vet Centers as prevention/engagement front door: ~200k veterans and families used them in 2013; 70 mobile centers expand rural access.
RICO & KOWALSKI TAG TEAM
🎙️ PTSD CARE FOR OUR WARRIORS: THE TRUTH, THE GAPS, AND THE CALL TO ACTION
🔥 I. The Stakes: A Signature Wound of Modern War
PTSD isn’t rare — it’s one of the signature injuries of Iraq and Afghanistan.
Prevalence is 7–20% of OEF/OIF service members; rates climbed from less than 1% in 2004 to over 5% by 2012.
Higher rates in women and nonwhite service members — because trauma doesn’t hit everyone equally, and neither does support.
In 2012 alone: ~502,000 veterans received VA outpatient PTSD care.
💡 Translation: This isn’t a fringe issue. This is a wave, and both DoD and VA are standing in the surf without knowing if their lifeboats float.
🎤 II. The Systems: Big Effort, Bigger Fragmentation
DoD:
Local programs by service branch — no unified chain of command for PTSD care.
Screening at 30 days & 3–6 months post-deployment, then? Inconsistent follow-through.
Mix of therapy, meds, and some alternative options — but no system-wide outcome tracking.
VA:
Central policies exist: PE (Prolonged Exposure) and CPT (Cognitive Processing Therapy) are supposed to be standard.
But… actual delivery is spotty, and many veterans never see those treatments.
Outcome data? Limited, especially outside specialized programs.
💡 The Problem: Two huge systems, billions spent — and neither can say if their programs actually work.
✊🏽 III. The Core Failures: Three Blind Spots
Fragmentation — DoD & VA don’t operate as one PTSD care system; service members lose continuity the moment they take off the uniform.
No Outcome Measurement — Without tracking, there’s no proof of success, no accountability, no way to spread what works.
Policy–Practice Gap — Official guidelines aren’t consistently enforced; care depends on where you land, not just what you need.
💡 If you don’t measure, you can’t manage. If you don’t integrate, you can’t protect.
🧠 IV. The Human Impact Behind the Stats
Workforce strain: Even with hiring boosts, demand outpaces supply. Rural vets? Often out of luck.
Training gaps: Contracted providers sometimes lack PTSD expertise and don’t report back to DoD/VA.
Incomplete therapy: Only ~53% of OEF/OIF vets at VA get the recommended eight sessions in 14 weeks.
Family left out: Family involvement is proven to help, but across both systems, it’s inconsistent and not formally embedded.
💡 We’ve got the tools, but not the follow-through.
🎯 V. The Fix: The Report’s Seven-Point Battle Plan
A. Unified Strategy: One integrated PTSD care plan across DoD and VA.
B. Accountable Leadership: Hold commanders and directors responsible for PTSD care quality.
C. Measure Everything: Standardized tools, feedback loops, real-time data in every clinic.
D. Staff & Train Right: Enough providers, trained in evidence-based therapies, monitored for fidelity.
E. Evidence First: Make PE and CPT the default; rigorously test alternatives before adoption.
F. Central Directory: A live database of all PTSD programs for providers and patients.
G. Bring Families In: System-wide family engagement programs, not just optional extras.
H. Research That Matters: Focus on barriers to care, prevention, and tailored treatments — and coordinate nationally.
🎬 VI. The Closing Argument
We send them to war as one unit. We bring them home as one nation. But we treat their wounds in pieces.
This report’s truth is simple:
The will is there. The money is there.
The measurement isn’t. The integration isn’t.
Until DoD and VA act as one system, measure every outcome, and enforce evidence-based care at every point of contact, we’re gambling with the lives of those who already paid the highest price.
Personal Truth + Public Injustice + Measurable Action = Real Change
That’s the formula. That’s the fight. And that’s the charge from this report — whether you wear the uniform or not.
🎤 Carlin Mode – Military Drug Program Timeline
“You ever notice how the government always says it’s protecting you… right before it starts inspecting you? Yeah. They went from ‘Let’s help the troops kick heroin’ to ‘Let’s ruin their careers for smoking a joint’ in about ten years.
In Vietnam, they’re handing out rifles and napalm — but if you rolled a little grass, they acted like you were the real threat to national security. Nixon’s big idea? Urinalysis! Not to punish — no, no — to rehabilitate. Which is political code for: ‘We’ll keep you in the system just long enough to make you someone else’s problem.’
By the 80s, we get the USS Nimitz crash. Fourteen dead, partly from drug use. Tragic. But instead of looking at command failures or safety culture, the brass decides: ‘Time to piss in the cup, boys — and this time, we’re watching.’ Punitive action, discharges, courts-martial. Because nothing says “unit cohesion” like publicly shaming your shipmates over THC metabolites.
And they keep lowering the cutoffs — from 100 nanograms to 50, from 20 to 15 — until you could fail a test for walking past a reggae concert. Every few years they add a new drug to the menu — ecstasy, oxy, LSD — like they’re running a Starbucks of suspicion. Meanwhile, labs get centralized, standards get “forensic,” and oversight keeps bouncing from office to office like a bureaucratic shell game.
The big arc? Rehab to retribution. They didn’t just move the goalposts — they tore up the field and built a testing lab on it. All wrapped in the same old euphemisms: ‘Readiness,’ ‘safety,’ ‘discipline.’ Which, in plain English, means: We’re in control — and we’ll know what’s in your bloodstream before you do.”
📈 Shapiro Mode – Military Drug Program Timeline
“Okay, let’s walk through this logically, because the history here is actually fascinating — and the narrative is very clear if you look at the data.
In the 1960s and early ’70s, you had massive drug use in Vietnam — marijuana and heroin were widespread. Nixon’s 1971 urinalysis policy was rehabilitation-focused — key word: rehabilitation. Then in 1972, the DoD amnesty program brought over 16,000 admissions of drug problems. By 1973, research shows 42% of troops had used opioids in Vietnam, with roughly half developing dependency. That’s the baseline.
Now — fast-forward to 1980: A Defense survey finds 27.6% of troops used illegal drugs in the past month. That’s not fringe, that’s one in four service members. Then comes the USS Nimitz tragedy in 1981 — 14 dead, with drugs as a contributing factor. That’s the inflection point. At that moment, policy shifts from clinical to punitive. We get court-martial authority for positive tests, and the drug testing menu expands significantly — marijuana, cocaine, heroin, amphetamines, barbiturates, methaqualone, PCP.
Throughout the ’80s and ’90s, standards tighten. THC cutoff goes from 100 ng/mL to 50; cocaine thresholds drop; confirmation methods like GC/MS become mandatory. LSD is added. Ecstasy is added. This isn’t arbitrary — it’s driven by prevalence data and forensic improvements. And the numbers drop — by 1995, usage is down to about 3%. That’s a nearly 90% decline from Vietnam-era levels.
Labs consolidate for efficiency — fewer facilities, more oversight. By the early 2000s, the panels expand to include synthetic opioids like oxycodone and oxymorphone, while removing low-prevalence drugs like LSD. Policies extend to deployed troops, reserves, and even DoD civilians. This is now a fully integrated system — with standardized procedures across all branches.
The macro takeaway? This program moves in three phases: rehabilitation in the ’70s, punitive enforcement in the ’80s, and integrated, forensic-level deterrence in the 2000s. If you want to understand military drug policy today, you have to understand that shift — from managing a crisis to embedding zero-tolerance into the DNA of force readiness.”