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Military Matters: Complementary Integrative Health in the Movement towards Transforming Patient Centered Care in the VA – Belle Zaccari, PsyD

by | Jun 3, 2016 | Military and Combat, StressPoints | 0 comments

Best practices for posttraumatic stress disorder (PTSD) treatment in the U.S. Department of Veterans Affairs (DVA or VA) and the U.S. Department of Defense (DoD) identify psychopharmacology, stress inoculation, and trauma focused therapy (i.e. often exposure and/or cognitive based therapies) as the front-line, gold standard approaches to PTSD treatment1. While the literature indicates that historically used and empirically based treatment models are efficacious, there are studies which show that clinician fidelity to those models is often compromised1, and drop-out rates average approximately 20 percent2. Recently, examination of the use of these treatment models has identified shortcomings in the methodology and application of the findings3, 4.

Converging with such findings, emergence of a patient centered care model in the VA is broadening the available options of treatment modalities for Veterans with PTSD. The Office of Patient Centered Care and Cultural Transformation (OPCC & CT) is transforming the disease model approach of Veteran health care to one that is proactive, holistic, and preventative where possible. Complementary Integrative Health (CIH) (also, Complementary Alternative Medicine [CAM]) offers patient-centered approaches to wellness and supports the change in focus within the VA. Such modalities are also receiving more attention in VA funded research5.  

CIH/CAM approaches may include various mind-body practices (e.g., acupuncture, meditation, qi gong, yoga)6 or natural products (e.g. dietary supplements, herbs and botanicals)7. Integrative health (IH) modalities are often used in conjunction with conventional or traditional approaches to medicine and therapies. However, in some cases, consumers choose to use IH modalities as alternatives to mainstream approaches. While some IH modalities require the presence of a practitioner (i.e., massage and acupuncture), others can be taught to consumers and then practiced alone once learned (i.e., yoga, meditation/mindfulness, prayer).

In the past five years, coordinated efforts of VA research brought CIH/CAM to the fore of Veteran care. In 2011, VA Health Services Research & Development (HSR&D) completed an efficacy examination of integrative health modalities for treating PTSD8. The project asked three key questions about efficacy studies of CIH, manipulative and body based therapies, movement and energy based therapies for PTSD symptoms and health related quality of life versus control groups. The final key question of that project looked at what evidence suggested when there was a lack of RCTs. Conclusions drawn from that project clarified limitations in the existing research and identified future directions for CIH focused research such as the effects of a given intervention compared to a waitlist control condition or examining the possible placebo effects in the clinical outcomes of those intervention studies8.

Another step towards incorporating CIH via the patient centered model and improving patient care was taken in 2014. The Evidence Based Synthesis Program of HSR&D/Quality Enhancement Research Initiative took a more specific look at the effectiveness and adverse effects associated with yoga as a treatment for several conditions of interest including low back pain, fall risk, depressive disorders, generalized anxiety disorder, panic disorder PTSD and insomnia9. Systematic reviews and recent RCTs were examined to answer the project’s key questions and created an evidence map of yoga. Evidence map investigators found high quality reviews showing effectiveness for low back pain and depressive disorders9. The remaining conditions of interest (fall risk/prevention, generalized anxiety disorder, panic disorder, PTSD and insomnia) were only reviewed in moderate to low quality systematic reviews.

A more recent and comprehensive look at CIH services in the VA was released in 2015 with promising movement made towards their goal of a patient centered model integrating CIH approaches. The Fiscal year 2015 Veterans Health Administration Complementary and Integrative Health Services Survey found that 93 percent of VA medical facilities offered at least one type of CAM for various mental and physical health conditions10. Findings from the Survey showed that the top five CIH modalities offered in VHA were stress management relaxation therapy, mindfulness, guided imagery, yoga and progressive muscle relaxation9. The survey showed that since 2011, of the 25 different CIH modalities offered for PTSD treatment, nearly all approaches saw an increase in the number of sites providing such therapies10.

While CIH is still coming of age in terms of access in the VA, IH modalities are available at most VAs (9 out of 10 VAs offer some type of CAM)10 and are used by Veteran populations to manage stress and promote wellness. IH approaches complement mainstream treatments for various mental and physical health issues. Given the needs and issues that affect Veteran populations, IH for stress management and PTSD are particularly emphasized by clinicians. Mounting evidence suggest beneficial effects of IH approaches for PTSD11. A survey of CAM use showed that military populations report using CAM at a higher rates than civilians (44.5 percent in 2005 and 36-38.3 percent, in 2002 and 2007, respectively) with prayer, massage, and relaxation cited as the most commonly used therapies12. Among individuals with PTSD, some preliminary research shows that 39 percent of people reported using a CAM treatment to for emotional and mental health problems, though only 13 percent reported seeing a CAM practitioner for that treatment13.

The VA research from 2011, 2014 and 2015 identified the need for more robust randomized trials examining efficacy of IH modalities and the biological mechanisms of those treatments as next steps towards incorporating IH more widely in VA. Valuable information about the barriers that limit availability of CIH was gleaned from the FY 2015 survey and points to future directions for VA initiatives in programming. What is not yet present in the literature is how CAM use is impacting treatment outcomes when used in addition to or in place of traditional medicines and approaches and what the associated cost offset is to consumers and providers.  

While the VA continues to move in the direction of adding CIH approaches to the options available for Veterans, more research is needed. The slow and steady road shows much promise.

About the Author

Belle Zaccari, PsyD, is a second year psychology research fellow in the Northwest Mental Illness Research, Education, and Clinical Center (MIRECC) at the Veterans Administration Portland Health Care System (VAPORHCS). Dr. Zaccari earned her doctorate in clinical psychology at the Adler School of Professional Psychology in Chicago and completed her pre-doctoral internship at the Southern Arizona Psychology Internship Center in Tucson. She is interested in the field of Complementary and Integrative Health (CIH) in the VA and is piloting a study examining yoga as a complementary/alternative medicine (CAM) for the treatment of post-traumatic stress disorder (PTSD). She also collaborates on research investigating co-occurring PTSD and traumatic brain injury (TBI). Her clinical work specializes in and substance use, co-occurring mental health and addictive disorders and CIH approaches to the treatment of trauma in Veteran populations.

References

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  2. Schottenbauer, M.A., Glass, C.R., Arnkoff, D.B., Tendick, V., and Gray, S.H. (2008). Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry, 71(2), 134-168.
  3. Steenkamp, M. (2016). True evidence-based care for posttraumatic stress disorder in military personnel and veterans. JAMA Psychiatry, 73(5), 431-432.
  4. Yehuda, R. & Hoge, C.W. (2016) The meaning of evidence-based treatments for veterans with posttraumatic stress disorder. JAMA Psychiatry, 73(5), 433-434.
  5. Office of Research & Development. (2015, March). Retrieved May 16, 2016, from http://www.research.va.gov/topics/cam.cfm
  6. Taylor, S.L & Elwy, A.R. (2014). Complementary and alternative medicine for US veterans and active duty military personnel: Promising steps to improve their health. Medical Care, 52(1), S1-S4.
  7. NCCIH. (2011). Retrieved May 11, 2016, from https://nccih.nih.gov/health/integrative-health
  8. Strauss, J.L., Coeytaux, R., McDuffie, J., Williams, Jr., J.W., Nagi, A. and Wing, L. (2011). Efficacy of complementary and alternative medicine therapies for posttraumatic stress disorder. Department of Veterans Affairs Veterans Health Services Research & Development Service, Evidence-based Synthesis Program.
  9. Coeytaux, R., Nagi, A. (2014). Evidence map of yoga for high-impact conditions affecting veterans. Department of Veterans Affairs Veterans Health Services Research & Development Service, Evidence-based Synthesis Program.
  10. Gaudet, T. & Vandenberg, P. (2015). FY 2015 VHA Complementary and Integrative Health Services (Formerly CAM). Healthcare Analysis& Information Group (HAIG).
  11. Strauss, J.L, & Lang, A.J. (2012). Complementary and alternative treatments for PTSD. PTSD Research Quarterly, 23(2), 1-7.
  12. Goertz, C., Jonas, W.B. (2013). Military report more complementary and alternative medicine use than civilians. The Journal of Alternative and Complementary Medicine, 19(6), 509-517.
  13. Libby, D.J., Pilver, C.E., & Desai, R. (2013). Complementary and alternative medicine use among individuals with posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 5(3), 277-285.