United States Department of Veterans Affairs
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Volume 49 Number 5, 2012
   Pages xxix — xxxii

JRRD at a Glance

Review of VA/DOD Clinical Practice Guideline on management of acute stress and interventions to prevent posttraumatic stress disorder

William P. Nash, MD; Patricia J. Watson, PhD

Figure 1. National Research Council-Institute of Medicine mental health intervention framework.

This article summarizes the revised Department of Veterans Affairs/Department of Defense Clinical Practice Guideline (CPG) for the management of posttraumatic stress and the prevention of posttraumatic stress disorder. The revised CPG includes screening and early interventions for early stress states, like acute stress reaction, combat operational stress reaction, and acute stress disorder. The article aims to help providers work with veterans in a way that is consistent with the CPG’s evidence-based or evidence-informed recommendations. For instance, the CPG advises that treatments in the first 4 days after a potentially traumatic event should focus on safety; basic needs; and physical, emotional, and social resources. Further medical and psychiatric assessment and brief, trauma-focused cognitive- behavioral therapy are necessary if the veteran’s distress or inability to function continues or gets worse after 2 days or becomes an acute stress disorder. Medicine and self-calming techniques are recommended for symptoms like insomnia and hyperarousal. Follow-up monitoring and rescreening are recommended for at least 6 months. Four successful Federal programs illustrating these principles are also described.

Assessment of posttraumatic stress disorder-related functional impairment: A review

Paola Rodriguez, PhD, et al.

Posttraumatic stress disorder (PTSD) has been associated with difficulties in functioning across a number of areas, including work, education, intimate relationships, parenting, family, friendships and socializing, and self-care. This article is meant to provide clinicians with recommendations for the assessment of these types of difficulties in functioning associated with PTSD and other stress-related disorders. We provide specific recommendations on how clinicians should obtain and organize information from interviews, selfreport questionnaires, and, when possible, reports from other individuals who are close to the client (for example, the client’s spouse) to aid designing a comprehensive treatment plan for each client to better serve the needs of veterans and Active Duty personnel.

Dissemination and experience with cognitive processing therapy

Kathleen M. Chard, PhD, et al.

Cognitive-behavioral therapies are recommended for the treatment of posttraumatic stress disorder (PTSD) according to clinical practice guidelines. One of these treatments, cognitive processing therapy (CPT) is a treatment that has been shown to be effective at treating PTSD from a variety of traumatic events. The Department of Veterans Affairs (VA) has implemented an initiative to disseminate CPT as part of a broad effort to make evidenced-based psychotherapies widely available throughout the VA healthcare system. This article provides an overview of CPT and reports on evaluation results from the VA CPT dissemination initiative.

Review of exposure therapy: A gold standard for PTSD treatment

Sheila A. M. Rauch, PhD, et al.

This article reviews the clinical practice guideline for posttraumatic stress disorder (PTSD) with focus on the extensive data supporting the use of exposure therapy (ET) for the treatment of PTSD. We review the use of ET to reduce PTSD as well as depression, anxiety, and related issues. In addition, we review the effective use of ET with complicated patient presentations. Finally, we describe the Veterans Health Administration training program for prolonged ET, one type of ET. ET is a first-line treatment for veterans and others with PTSD.

Review of group treatment for PTSD

Denise M. Sloan, PhD, et al.

Posttraumatic stress disorder (PTSD) represents a substantial problem for the veteran population. Although individual treatments have been identified for this disorder, group therapy currently is not recognized as a first-line treatment by the Department of Veterans Affairs or Department of Defense clinical practice guidelines (2010) or by other PTSD treatment guidelines from around the world. Despite this lack of formal endorsement, the group treatment format is frequently used in healthcare settings. The purpose of this article is to provide a brief review of the available data on the efficacy of group treatment for PTSD and to provide recommendations for future work in this area.

Pharmacotherapy for posttraumatic stress disorder: Review with clinical applications

Matthew Jeffreys, MD, et al.

Figure 1. Stepped care for pharmacotherapy in posttraumatic stress disor-der (PTSD). Adapted from Department of Veterans Affairs/Depart-ment of Defense Clinical Practice Guideline for Management of Post-Traumatic Stress. SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = selective serotonin reuptake inhibitor, TCA = tricyclic antidepressant, TX = treatment.

Posttraumatic stress disorder (PTSD) is a common mental health problem in veterans and often occurs with other medical and mental health problems. Evidencebased psychotherapy focusing on traumatic events is the most effective treatment for PTSD. Medications can provide additional or alternative treatment for some patients. This article provides practical guidance to clinicians based on the 2010 revised Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for PTSD. Both first-line and second-line medications are discussed. Certain medications, such as benzodiazepines and antipsychotics, are not recommended in PTSD. The CPG provides evidenced-based interventions for PTSD treatment.

Couple/family therapy for posttraumatic stress disorder: Review to facilitate interpretation of VA/DOD Clinical Practice Guideline

Candice M. Monson, PhD, et al.

Figure 1. Heuristic for understanding target of different couple/family inter-ventions for posttraumatic stress disorder (PTSD).

There are well-documented associations among veterans’ posttraumatic stress disorder (PTSD) symptoms, family relationship problems, and mental health problems in partners and children of veterans. This article reviews the recommendations for couple/family therapy made in the newest version of the Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for PTSD. Research on couple/family therapy for PTSD with veterans is described, and a heuristic is offered for clinicians and researchers to consider when incorporating couple/family treatments into veterans’ mental health services for PTSD.

Treatment of sleep disturbances in posttraumatic stress disorder: A review

Frank B. Schoenfeld, MD, et al.

Poor sleep is a common problem for people who have posttraumatic stress disorder (PTSD). Treatments have been developed to treat nightmares and problems in getting a full night’s sleep. Clinicians across the United States are being trained to give these treatments. These treatments help people with PTSD learn special skills to help improve their sleep and make their nightmares less frequent and frightening. Medication can also help if the skills training does not give all the relief that is needed. This article reviews the progress that has been made to help people with sleep problems from PTSD.

Review of posttraumatic stress disorder and chronic pain: The path to integrated care

Carrie-Ann Gibson, MD, DAAPM

With veterans returning from combat deployments and then seeking treatment for both PTSD and chronic pain, treatment teams that can work with veterans and their families to address not only mental health issues, but also physical health problems such as chronic pain, that will be best suited to address these complex care needs. Through this integrated care approach and addressing PTSD and chronic pain at the same time, it is hopeful that veterans will be able to meet their goals faster and be able to move forward in their lives with their loved ones.

Assessment and treatment of posttraumatic anger and aggression: A review

Casey T. Taft, PhD, et al.

This article discusses the recent Department of Veterans Affairs/Department of Defense guidelines for the treatment of posttraumatic stress disorder (PTSD)- related anger and aggression. Empirical evidence related to the association between anger, aggression, and PTSD is reviewed. Suggested assessment measures, approaches to assessment, and effective treatments are reviewed. Clinical concerns and process-related issues related to work with veterans with anger and aggression are discussed.

Review: Managing posttraumatic stress disorder in combat veterans with comorbid traumatic brain injury

Bruce Capehart, MD, MBA; Dale Bass, PhD

When a patient has been diagnosed with both posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), the best care occurs when the treatment team understands both conditions. This understanding should include the shared clinical symptoms of PTSD and TBI and an understanding of how treatment for one condition can affect the other. This review considers treatment recommendations from the Department of Veterans Affairs/Department of Defense clinical practice guidelines for PTSD from the perspective of simultaneously managing comorbid TBI.

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