Posttraumatic Stress Disorder

PTSD is a psychiatric disorder that can develop after the direct personal experience of or the witnessing of an event that poses a perceived threat of death or serious injury (Criterion A, see Table 4-1). DSM-5 categorizes four different domains of PTSD symptoms: intrusion symptoms (re-experiencing symptoms such as flashbacks, nightmares, and reactivity to trauma reminders) (Criterion B); avoidance of trauma-related thoughts, feelings, or external trauma reminders (Criterion C); negative alterations in cognitions and mood (for example, negative beliefs and emotions, self-blame, and constricted affect) (Criterion D); and arousal and reactivity (for example, hypervigilance, irritability, excessive startle response, sleep disturbance, and concentration difficulties) (Criterion E). The manual states that if the symptoms persist for 3 days to 4 weeks, the diagnosis is acute stress disorder, while if the symptoms endure for more than 1 month, the diagnosis is PTSD.

TABLE 4-1

Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for Posttraumatic Stress Disorder (PTSD).

According to DSM-5, the onset of PTSD usually begins within 3 months of exposure to the traumatic event, but it may occur months later. “Delayed expression” refers to cases in which some symptoms appear soon after the trauma but take months (or even years) to meet the full diagnostic criteria (APA, 2013). Military-related traumatic events that may trigger PTSD include exposure to war, threatened or actual physical assault, threatened or actual sexual assault, being taken hostage, torture, incarceration as a prisoner of war, and motor vehicle accidents (APA, 2013). DSM-5 also includes certain indirect exposures through professional duties, such as clearing body parts, engaging in first-responder activities, and experiencing accidental or violent death of a friend or relative, as possible triggers of PTSD.

Individuals with PTSD often display a heightened startle response in reaction to unexpected stimuli (such as a loud noise or unexpected movement). Additionally, many with PTSD have difficulty remembering daily events and have difficulty concentrating or staying focused on tasks (APA, 2013). PTSD can be chronic and have no remission, or it can be recurrent with periods of remission and recurrence (Friedman, 2013).

Table 4-1 shows a comparison of the previously used DSM-IV-TR criteria with DSM-5 criteria. Of note in the DSM-5 is the elimination of criterion A2 and the splitting of criteria category C into two categories (C and D). Other criteria in categories D and E have been added and are noted in Table 4-1. PTSD has become part of a new DSM chapter titled Trauma- and Stressor-Related Disorders and is no longer considered an anxiety disorder, as it was in DSM-IV-TR.

Generalized Anxiety Disorder

GAD is characterized by persistent and uncontrollable anxiety and worry. As described below, studies have found high rates of GAD in the veteran population. GAD is one of seven anxiety disorders in DSM-5. The six others are separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, and agoraphobia. (PTSD, formerly classified as an anxiety disorder in DSM-IV-TR, was reclassified as a trauma- and stressor-related disorder in DSM-5.)

The DSM-5 diagnostic criteria for GAD are as follows: (1) excessive anxiety and worry, occurring more days than not for at least 6 months; (2) the individual finds it difficult to control the worry; (3) in adults, the anxiety and worry are associated with at least three of the following symptoms: restlessness, feeling keyed up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance; (4) the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in important areas of functioning; (5) the disturbance is not due to the physiological effects of a substance or medical condition; and (6) the disturbance is not better explained by another medical disorder (APA, 2013).

Major Depressive Disorder

MDD is characterized by a depressed mood most of the day (nearly every day) or a loss of interest or pleasure, or both, accompanied by at least four the following symptoms: marked unintentional weight loss or weight gain; insomnia or hypersomnia; psychomotor agitation or retardation observable by others; fatigue nearly every day; diminished concentration or increased indecisiveness; and recurrent thoughts of death, or suicidal ideation (APA, 2013). According to DSM-5, to receive a major depression diagnosis, five of the above symptoms must be present nearly every day for at least 2 weeks and one of the symptoms must be depressed mood or loss of interest or pleasure.

Substance Use Disorders

SUDs include the misuse of intoxicating substances, including alcohol, illicit drugs, prescription drugs, and other toxic agents. A major feature of SUDs is “an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders” (APA, 2013). According to DSM-5, “[t]he behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment” (APA, 2013, p. 483).

A diagnosis of a substance use disorder is based on an individual's pattern of behavior and usage of the substance and is marked by a cluster of cognitive, behavioral, and physiological symptoms. An individual with a substance use disorder will continue using the substance despite the presence of substance-related symptoms and the problems they cause. In DSM-5, symptoms associated with a substance use disorder fall into four major groupings: impaired control, social impairment, risky use, and pharmacological criteria (that is, tolerance and withdrawal).

Although the previous definitions of SUDs (for which most prevalence data are currently available) made a distinction between “abuse” and “dependence,” DSM-5 abandoned this dichotomy and classifies the disorder by severity based on the number of symptoms present: mild substance use disorder (two to three symptoms), moderate substance use disorder (four to five symptoms), or severe substance use disorder (six or more symptoms). Additionally, DSM-5 removed the criterion for legal problems and added one for cravings. DSM-5 establishes eight types of substances that these criteria may apply to: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, or anxiolytics; stimulants; and tobacco (Horvath et al., 2015).

Table 4-2 shows a comparison of the previously used DSM-IV-TR criteria with DSM-5 criteria for SUDs.

TABLE 4-2

Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for Substance Use Disorders (SUDs).

Suicidal Ideation and Behavior

The Centers for Disease Control and Prevention (CDC) has developed a uniform classification system for self-directed violence in order to improve public health information in this area (Crosby et al., 2011). The standardized definitions enhanced data quality for public health surveillance, research, and clinical management purposes. The VA has adopted CDC's nomenclature for self-directed violence (Brenner et al., 2011a).

According to CDC, suicidal thoughts and suicidal behavior should be addressed separately because these two aspects of self-directed violence “are vastly different in occurrence, associated factors, consequences, and interventions” (Crosby et al., 2011, p. 23). Along these lines, CDC considers terms which refer simultaneously to thoughts and behavior, such as “suicidality,” unacceptable in the self-directed violence nomenclature.

In CDC's nomenclature, the term suicidal ideation is used to describe a person's thoughts of engaging in suicide-related behavior that may or may not involve suicidal intent. Suicidal behavior is “acts or preparation towards making a suicide attempt” or behavior that “deliberately results in injury or the potential for injury to oneself” with evidence of suicidal intent. The precise definition of suicide is “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” (Crosby et al., 2011).

The DSM has never included a separate diagnostic category for suicidal ideation or behavior. DSM-5 (APA, 2013) states that suicidal behavior disorder as a condition warrants more research before it might be considered a formal disorder. Discussions of suicide risk are spread throughout the DSM-5 within various disorders to highlight suicide risk as a cross-cutting issue of mental disorders.

Posttraumatic Stress Disorder

Generalized Anxiety Disorder

Major Depressive Disorder

Substance Use Disorder

Suicidal Ideation and Behavior

Posttraumatic Stress Disorder

For making a diagnosis of PTSD, VA/DoD guideline recommendations include using the Clinician-Administered PTSD Scale (CAPS), considered the gold standard for diagnosing PTSD, and a self-report instrument known as the PTSD checklist (PCL). The 2010 VA/DoD PTSD guideline pre-dates the release of revised PTSD clinical criteria in DSM-5; consequently, the guideline refers to CAPS and PCL versions corresponding DSM-IV-TR criteria. The updated instruments, CAPS-5 (Weathers et al., 2013a) and PCL-5 (Weathers et al., 2013b), support a PTSD diagnosis on the basis of DSM-5 diagnostic criteria.

The National Center for PTSD reports that the change in the rating scale for the PCL combined with the increase from 17 to 20 items means that PCL-5 scores are not compatible with PCL for DSM-IV scores and cannot be used interchangeably. Psychometric work on the PCL-5 to determine the scoring thresholds is in process. Although the National Center for PTSD gives initial scoring guidelines, it cautions that the information may be subject to change until further psychometric work is available (National Center for PTSD, 2014).

Major Depressive Disorder

The VA/DoD guideline for depression management recommends that clinicians assess patients who are diagnosed with depression using the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001). PHQ-9 is a validated self-report or interviewer-administered instrument that serves as an indicator of depression severity or of a patient's response to treatment. The PHQ-9 is integrated into the VA clinical reminder system, which prompts clinicians to perform the PHQ-9 test if a PHQ-2 test is positive (VA, 2007).

Substance Use Disorder

For patients who screen positive for unhealthy alcohol use, the VA/DoD guideline recommends assessing current alcohol consumption relative to the limits established by the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2008).⁵ If the limits are exceeded, brief alcohol counseling by a clinician or counselor (often termed brief intervention) is recommended. Brief interventions can be a single session or multiple sessions involving motivational interviewing techniques focused on drinking-related consequences and the benefits of reducing alcohol use.

The VA/DoD guideline recommends referral to specialty SUD care for addiction treatment for a patient who has an Alcohol Use Disorders Identification Test Consumption score of 8 or higher (on a scale of 0–12) or who meets one of the following criteria: needs additional evaluation, does not respond to a brief intervention, has a DSM diagnosis of alcohol or other substance dependence, or has received previous treatment for SUDs.

Suicidal Ideation and Behavior

According to the 2013 VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (VA and DoD, 2013), “any person who is identified as being at possible suicide risk should be formally assessed for suicidal ideation, plans, intent and behavior, the availability of lethal means, and the presence of risk factors and warning signs” (p. 8). In addition, the level of suicide risk (high acute risk, intermediate acute risk, and low acute risk) should be determined, and a formulation of the care setting should be decided upon.

As reported in the VA/DoD guideline, there is insufficient evidence to recommend any specific measurement scale to determine suicide risk. Several instruments have demonstrated the capability of detecting important risk factors for suicide; however, the evidence for the effectiveness of available suicide assessment instruments to predict suicide attempts and suicide is very limited and inconclusive (Fowler, 2012; Haney et al., 2012). Instruments like the PHQ-9, which assesses depression severity and includes a question regarding the presence of suicidal ideation, are widely accepted and administered to patients in VA primary care settings.

Suicide Prevention

In addition to issuing VA/DoD clinical guidance about suicide risk screening and assessment, VA has implemented a number of other strategies to support veterans at risk of suicide (Bagalman, 2016). VA policy requires every VAMC to have at least one suicide prevention coordinator with a full-time commitment to suicide prevention activities, including tracking and reporting on veterans at high risk for suicide and coordinating clinical care for high-risk veterans.

According to VA policy, it is the responsibility of suicide prevention coordinators to submit suicide behavior reports for all known suicide events (deaths, attempts, and serious suicidal ideation). They submit these reports to a centralized database, the VA Suicide Prevention Applications Network (SPAN). An entry of a suicide event into SPAN results in the placement of the veteran on the VA high-risk list, the use of treatment flags in the electronic medical record system, and enhancements to care and case management. Hoffmire et al. (2016) assessed VA data on suicide attempts and found that the use of SPAN substantially increased the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VA's medical records identify all suicide attempters. The author concluded that additional research is needed to better understand how to optimize VA information systems for comprehensive surveillance of suicide attempts among VA service users (Hoffmire et al., 2016).

Another VA suicide prevention activity is the implementation of a safety planning protocol for use with high-risk patients. A safety plan is a written document developed jointly by a patient and a clinician that identifies strategies for coping in a crisis (Stanley and Brown, 2008). As used in the VA, the safety plan involves the following elements in episodes of suicidal ideation: recognizing signs of increasing risk; using specific coping strategies; getting support from social contacts; seeking assistance from family members, friends, or professionals; and reducing access to lethal means such as firearms (Claassen and Knox, 2011). VA protocol requires that the plan be included in the patient's medical record and that a copy be given to the patient.

To reach veterans in the community, in 2007 the VA established the Veterans Crisis Line (VCL) which veterans can access by calling a national toll-free number, connecting to online chat, or sending a text message. A 2016 Government Accountability Office (GAO) report reviewed VA's administration of the VCL found that the “VA cannot ensure that the VCL is providing consistent, high-quality services to callers and cannot effectively track and publicly report progress or results” (GAO, 2016, p. 2). In April 2017, VA Secretary David Shulkin announced that less than 1 percent of calls were now being rerouted to back-up centers (VA, 2017c). While lawmakers commended this improvement, they also cautioned that other improvements were still needed, such as filling the director position of the VCL (Ogrysko, 2017). Similarly, the Government Accountability Office and the VA Office of Inspector General have both recently identified continued problems related to wait times, leadership, and performance monitoring (GAO, 2017; VA Office of Inspector General, 2017). VA has raised awareness about the Veterans Crisis Line and suicide prevention through awareness campaigns such as Power of One and Be There.

In the VA's ongoing effort to prevent veteran suicides, VA Secretary Shulkin announced in 2017 that the VA would offer emergency mental health care to veterans with an other-than-honorable (OTH) discharge status (VA, 2017d). As described in Chapter 6, veterans with an OTH discharge are routinely denied health care services unless they request an eligibility adjudication from the VBA, asking that their discharge be ruled not dishonorable. Very few requests for eligibility adjudication are granted (Swords to Plowshares, 2016). Under the new initiative, veterans with OTH discharges will be eligible to seek treatment at a VA emergency department or Vet Center or to contact the Veterans Crisis Line. For individuals requiring emergency mental health care, a full array of mental health services, including inpatient mental health care and follow-up outpatient, residential, and substance use disorder services, may be provided for up to 90 days. If longer-term services are needed, the VA will coordinate a transition to community-based care, but it does not have the legal authority to provide ongoing care to veterans with OTH discharges at the VA's expense (VA, 2017b).

Within the VHA, research on suicide prevention is supported by three research components: the Office of Research and Development, a center of excellence in suicide prevention, and a mental illness research, education, and clinical center on suicide prevention. The research components conduct veteran-specific research to identify characteristics associated with higher rates of suicide (that is, risk factors) and lower rates of suicide (that is, protective factors) as well as research evaluating the effectiveness of suicide prevention interventions (Bagalman, 2016).

International experts who reviewed the literature on suicide-prevention interventions have concluded that restriction of access to lethal means is one of the few suicide-prevention policies that has proven effectiveness. A systematic review on suicide prevention by Mann et al. (2005) concluded that among the methods used to reduce suicide (physician education, restricting lethal means, public education, screening programs, and mass-media education), restricting access to lethal methods and the education of physicians in depression recognition and treatment were found to prevent suicide.

The VA promotes safe use of firearms as part of its comprehensive suicide prevention strategy. The VA has distributed over 3 million gunlocks nationwide since 2010 and disseminates a safety video and brochure (VA, 2017b).⁶ See Chapter 6 for a discussion of veteran treatment-seeking behavior as it relates to firearms.

Posttraumatic Stress Disorder

Determining the appropriate treatment for PTSD can be complicated because PTSD presents with varied psychosocial morbidity and functional impairment and is often comorbid with other psychiatric disorders, particularly SUD, major depression, and mild TBI. In general, the treatment for PTSD symptoms includes three broad intervention categories: psychotherapy (based on psychology techniques), pharmacotherapy (using prescription medication), and education (including the teaching of coping mechanisms for the patient and family members).

The first-line psychotherapy treatment recommended by the VA/DoD guideline for PTSD (VA and DoD, 2013) is trauma-focused psychotherapy that includes components of exposure or cognitive restructuring or stress inoculation training (SIT). Specifically, the approach may include an exposure-based therapy, such as prolonged exposure (PE); a cognitive-based therapy, such as cognitive processing therapy (CPT); stress management therapy (such as SIT); or eye-movement desensitization and reprocessing. In addition, the guideline identifies other approaches as having possible benefits in treating for PTSD, including relaxation techniques, imagery-reversal therapy, brief psychodynamic therapy, hypnosis, and group therapy. However, the VA/DoD guideline for PTSD indicates there is insufficient evidence to recommend for or against dialectical behavioral therapy (a type of cognitive-behavioral psychotherapy) or family and couples therapy as first-line treatments for PTSD. Of the various psychotherapies, VA policy requires that CPT and PE must be available to all veterans with PTSD who need and want it (VA, 2015c).

As discussed in more detail in Chapter 14, the use of technology for the delivery of psychotherapy treatment for PTSD is increasing. The VA/DoD PTSD guideline supports the use of telephone delivery and videoconferencing—clinical videoconferencing technology (CVT)—particularly to overcome geographic distance or other barriers to care. Randomized clinical trials published since the 2010 VA/DoD PTSD guideline have demonstrated that PTSD outcomes with CVT delivery of trauma-focused therapies are generally comparable to outcomes associated with traditional service delivery methods (Morland and Ruzek, 2015). On the other hand, the VA/DoD guideline does not recommend Internet-based interventions for treatment for PTSD. More research is needed to establish the efficacy of both online tools and mobile applications (apps) that provide either educational information, screening and self-assessment, treatment, or social support. However, researchers indicate it is reasonable to use such tools—for example, VA's app called PTSD Coach—to augment psychotherapy or case management and to provide initial psychoeducation as these tools pose no risk and have advantages over paper and pencil tools (Morland and Ruzek, 2015).

Among the pharmacotherapy interventions, the first-line agents recommended by the VA/DoD guideline are mainly two closely related classes of antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). When necessary, the guideline suggests that the use of second-line agents, such as mirtazapine, nefazodone, tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs), be considered. In addition, the guideline recommends the atypical antipsychotics risperidone or olanzapine as adjunctive treatment with antidepressants.

The VA/DoD guideline cautions against treating the primary symptoms of PTSD using benzodiazepines, a type of anti-anxiety medication, due to the lack of efficacy data and the potential risk of tolerance and dependence. Yet VA data show that these medications are prescribed often, presumably to manage secondary symptoms of PTSD such as insomnia and anxiety, suggesting a gap between guideline recommendations and actual clinical care (Bernardy, 2013). Evidence of efficacy is growing for prazosin, an alpha-1 adrenergic antagonist, in the treatment of nightmares and sleep disturbance among veterans with PTSD (De Berardis et al., 2015; George et al., 2016).

Major Depressive Disorder

For initial treatment for mild or moderate MDD, the VA/DoD guideline advocates the use of monotherapy—either psychotherapy or pharmacotherapy with a single antidepressant (Management of Major Depressive Disorder Working Group, 2016). A combination treatment with pharmacotherapy and psychotherapy should be used for moderate to severe MDD or for patients who have a poor response to monotherapy. The guideline advises that patients who receive a diagnosis of mild or moderate MDD may be treated with the use of the collaborative care model in primary care (see Chapter 12 for more information about VA collaborative care). Patients who have severe MDD or any complicated MDD and comorbidities should be referred to specialty care for treatment.

The VA/DoD guideline indicates that the evidence does not support recommending a specific evidence-based psychotherapy or pharmacotherapy over another. The recommended first-line medications include SSRIs (excluding fluvoxamine), SNRIs, bupropion, and mirtazapine. Most people need to be on medication for at least 6 to 12 months after adequate response to prevent relapses.

The recommended first-line psychotherapies include cognitive behavioral therapy (CBT), behavioral therapy/behavioral activation, interpersonal therapy (IPT), mindfulness-based cognitive therapy, and problem-solving therapy and acceptance and commitment therapy (ACT). Of these treatments, a VA policy directive states that all veterans who have depression (or anxiety disorders) must have access to ACT, as well as CBT and IPT (VA, 2015c). In addition, the VA's initiative to disseminate evidence-based psychotherapies includes ACT on a priority list, and the VA has already provided training in ACT to hundreds of its clinicians. It is worth noting that while VA policy and the joint VA and DoD MDD guideline promote ACT as a first-line treatment for depression, there is a debate in the scientific community about the strength of the evidence (Zettle, 2015). While the Society of Clinical Psychology (2016) considers the current empirical support of ACT in the treatment of depression to be modest, some recent reviews have concluded that additional research with more rigorous methodological designs is needed before definitive claims can be made about the efficacy of ACT for depression (Montgomery et al., 2011; Ost, 2014). The results of a recent randomized clinical trial of ACT for the treatment of distress in OEF/OIF/OND veterans suggest that ACT may not be a first-line therapy for veterans with anxiety and depression (Lang et al., 2016). The study involved 160 veterans from five VAMCs with a diagnosis of anxiety or depressive disorder who were randomized to ACT or to present-centered therapy (PCT) (another manualized psychotherapy). Participants were assessed before, during, and after treatment and during a 3- to 12-month follow-up. The trial found that, overall, veterans did not respond differently to ACT than they did to PCT. Although ACT led to greater improvement in insomnia than did PCT (standard deviation = 0.63 and 0.08, respectively), the response to the two interventions did not differ on the primary outcome or on most secondary outcomes.

The VA/DoD MDD guideline recommends that the first-line psychotherapies be offered in an individual or group format based on patient preference. The guideline also cites computer-based CBT as an alternative to traditional individual or group psychotherapy. The guideline authors noted that next revision of the guideline should formally review the literature on the broader array of telehealth approaches and incorporate this information into the guideline, as supported by the evidence.

For patients who have severe MDD, additional treatments that should be considered include electroconvulsive therapy, and the two classes of medications, MAOIs and TCAs.

Among the possible complementary and integrative health modalities for depression, the VA/DoD guideline recommends the use of exercise as an adjunct to other empirically supported treatments. For patients who have mild MDD, light therapy can be considered to treat seasonal affective disorder, and St. John's wort may be used by those who prefer herbal treatments. The guideline indicates there is insufficient evidence to recommend for or against acupuncture, yoga, tai chi, or qi gong as treatments for MDD. The VA offers a variety of complementary and integrative health interventions that have almost no evidence base in the treatment of depression, but which have been used for relaxation in other settings.

Substance Use Disorder

The goals of SUD treatment include abstinence or reduction in substance use, relapse prevention, and improvement in psychologic and social functioning. The specific type of intervention or treatment chosen will depend on the type of substances used, the intensity of use, and the patient's individual needs. SUDs commonly occur with other mental health conditions (such as PTSD and depression) and with chronic medical illnesses (such as diabetes) that also require treatment. For many, a SUD is a chronic disorder that requires multiple interventions and continuing monitoring.

Detoxification and withdrawal management is often a necessary first step toward treatment of those who have SUDs. Pharmacologically supervised withdrawal is warranted only for alcohol, sedative hypnotics, and opioids; it is not warranted for stimulant and cannabis disorders.

For inpatient treatment for alcohol withdrawal, the VA/DoD guideline (VA and DoD, 2009) recommends the use of benzodiazepines as first-line treatment, with other agents (such as beta-blockers and clonidine) as adjuncts in some patients. For opioid withdrawal, the guideline recommends initial stabilization and then short or extended tapering with buprenorphine and naloxone or methadone in 4 to 7 days in an inpatient setting. Withdrawal management should be followed by appropriate pharmacologic maintenance or behavioral therapies.

For patients with alcohol use disorders, the first-line pharmacotherapies recommended by the VA/DoD guideline are oral naltrexone and acamprosate; both are Food and Drug Administration (FDA) approved for this indication. The guideline discusses psychosocial interventions that research has shown to be effective: behavioral couples counseling, cognitive behavioral coping skills training, community reinforcement, motivational enhancement, and 12-step facilitation.

For patients who are dependent on opioids, the VA/DoD guideline recommends as first-line treatment methadone or the sublingual combination product of buprenorphine and naloxone. Those medications are used in opioid-agonist treatment (OAT), which consists of administering one of the opioid-agonist medications in combination with a variety of medical, counseling, and rehabilitative services. OAT can be delivered through a VA-licensed OAT clinic or through office-based treatment; however, buprenorphine is the only medication approved for office-based OAT. As adjunct interventions with pharmacotherapy, the guideline identifies CBT and contingency management as effective psychosocial therapies for opioid dependence.

The VA/DoD guidance regarding the management of cocaine and marijuana use is limited to recommendations for psychosocial interventions. CBT, behavioral couples therapy, and contingency management are identified as the interventions that are supported by the most evidence of effectiveness in treating cocaine dependence. For cannabis, the guideline indicates that there is some evidence that CBT is effective.

Suicidal Ideation and Behavior

This section describes the recommendations for treating patients at risk for suicide as identified by the 2013 VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (VA and DoD, 2013). The guideline first recommends developing a treatment plan with the patient in mind and notes that patients with suicidal thoughts most often benefit from a combination of different treatments. The main treatments discussed in the VA/DoD guideline are psychotherapy, pharmacotherapy, and electroconvulsive therapy. Research shows that 90 percent of people who committed suicide had psychiatric and mood disorders and that more than 80 percent had not received treatment at the time of death (Mann et al., 2005). Thus, a primary component of suicide prevention is prompt evidence-based treatment for the relevant psychiatric illness.

Psychotherapy is first discussed in the VA/DoD guideline in the context of suicide-focused psychotherapy, then in the context of psychotherapy for co-occurring mental disorders associated with suicide risk. Evidence-based cognitive therapies are found to be used in both settings. In patients who have a history of suicide attempts, CBT is recommended for reducing the risk of further suicide attempts. The guideline notes that one randomized controlled trial found that 10 sessions of CBT led to 50 percent fewer suicide attempts than enhanced usual care (tracking and referral) without reducing rates of suicidal ideation (Brown et al., 2005). Similarly, Rudd et al. (2015) found that “brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt” (p. 441). A specific type of cognitive therapy called problem-solving therapy (PST) has proven to be a suitable suicide-focused psychotherapy for at-risk patients. Hawton et al. (2016) conducted two systematic reviews based on multiple studies and found that PST contributed to decreases in deliberate self-harm in suicidal patients.

Psychotherapies for co-occurring mental disorders associated with suicide risk are discussed in relation to borderline personality disorder, schizophrenia, and SUD. The VA/DoD guideline notes that in cases of treating co-occurring mental disorders the treatment plan should be modified to specifically address the risk of suicide. Dialectical behavior therapy (DBT) is said to be “the most thoroughly studied treatment of existing psychotherapies for suicidal behavior” (VA and DoD, 2013, p. 97). A number of studies support the use of DBT for decreasing the reoccurrence of suicide-like behaviors (e.g., Mann et al., 2005; Tarrier et al., 2008).

While the evidence for the use of pharmacotherapy to explicitly address suicide risk is limited and drug treatment as a specific intervention for preventing suicide is not recommended, there are pharmacological treatments that can be included in a treatment plan to address suicide risk for patients with established mental illnesses. The guideline cites evidence for the benefits of lithium in reducing suicide risk and suicide attempt relapses in patients with major depressive disorder and bipolar disorder. In a review of 372 randomized, double-blind, placebo-controlled trials, the FDA found that although there is no indication that prescribing antidepressants to patients with mood disorders helps to lessen the risk of suicide, antidepressants were not shown to increase the risk of suicidal ideation or behavior in patients over age 25 either (Stone et al., 2009).

The final treatment discussed in the VA/DoD guideline is electroconvulsive therapy (ECT). ECT should be considered in cases where other treatments have not proven effective or when an immediate resolution of suicidal symptoms is needed. This therapy can be used on patients with certain types of MDD, manic episodes, bipolar disorder, depression, PTSD, and acute schizophrenia. The VA/DoD guideline for PTSD (2010) suggests considering ECT for severe, medication- and psychotherapy-resistant PTSD.

Comorbid Conditions

As discussed at the beginning of the chapter, military service members and veterans are often diagnosed with more than one mental health condition. Conditions that frequently occur simultaneously are commonly referred to as “comorbid” and “co-occurring” conditions. Comorbid mental health conditions are important to recognize because they can modify the clinical determinations of prognosis, patient or provider treatment priorities, the selection of interventions, and the setting where care will be provided (Lew et al., 2008). Current evidence-based practices to identify and treat people for conditions may be less accurate or effective when conditions co-occur (Carlson et al., 2009).

As described in previous chapter sections, substantial evidence-based clinical guidance exists for the management of individual mental health conditions that are prevalent among veterans. However, much less is known about the best clinical practices for patients with multiple mental health diagnoses that occur simultaneously.

The literature is insufficient to determine whether the diagnostic or even screening instruments commonly used for assessing the symptoms of a particular condition perform accurately when a person has more than one condition. Nor does the literature support the use of any one instrument over others (Carlson et al., 2011; Guillamondegui et al., 2011). In addition, there is a gap in knowledge about whether evidence-based treatments for a single condition are effective when conditions co-occur or whether unique therapies are necessary for people who have multiple conditions. There are no empirically validated therapies for comorbid PTSD, MDD, SUD, and postconcussive disorders (Lew et al., 2008).

Co-Occurring Substance Use Disorder

There is a growing body of empirical data on interventions for patients diagnosed with PTSD or MDD and co-occurring SUD. For example, studies have shown positive results for Seeking Safety, a treatment model for co-occurring SUD and PTSD (Boden et al., 2012; Desai et al., 2008). To test how Seeking Safety fares when incorporated into the VA SUD programs, Boden et al. (2012) conducted a randomized controlled effectiveness trial with 117 veterans who had diagnoses of SUD and co-occurring PTSD symptoms. They concluded that their findings provided support for the feasibility and benefit of addressing PTSD and SUD simultaneously and early in SUD treatment as opposed to requiring separate or sequential treatments or a period of abstinence before PTSD-focused care. A review of the evidence by the National Center for PTSD was more tempered: the authors noted that the results of randomized controlled trials, although promising, were equivocal, and they thus concluded that Seeking Safety should probably be combined with other treatments to ensure that all problematic behaviors decrease (Gulliver and Steffen, 2010).

Studies have also examined pharmacological treatment approaches for patients diagnosed with MDD and co-occurring SUD. For example, the findings of one controlled trial (Pettinati et al., 2010) show positive results from treating alcohol-dependent patients diagnosed with MDD with sertraline (an antidepressant) combined with naltrexone (to treat alcohol dependence). On the other hand, evidence of the efficacy and safety of antidepressants for treating MDD in people who are dependent on opioids (such as morphine and heroin, codeine, oxycodone, and hydrocodone) is inconclusive, according to one systematic review of the literature on this topic (Pani Pier et al., 2010).

There are a few clinical trials that have examined the efficacy of psychotherapy for co-occurring MDD and SUD. Hides et al. (2010) reviewed the research and concluded that there is minimal evidence for CBT being effective either alone or in combination with antidepressant medication for treating co-occurring MDD and SUD.

Individually the VA/DoD clinical guidelines for MDD, PTSD, and SUD acknowledge that few published trials can provide clinicians with guidance in treating conditions that are complicated by comorbid illness. Given the lack of evidence on efficacious treatments for comorbid conditions, the best practices involve treating for symptoms regardless of etiology. Experts agree that clinical judgment informed by available clinical guidance, systematic symptom monitoring, and the clinician–patient relationship is needed in deciding which specific treatments to implement, for which patients, and under which treatment conditions (Brenner et al., 2009; National Center for PTSD, 2010a,b; Otis et al., 2011).

In 2009 the VA Office of Mental Health and Suicide Prevention and the VA Office of Rehabilitation Services sponsored two consensus panels to make practice recommendations related to the diagnosis and management of common comorbid conditions in veterans. One panel addressed comorbid PTSD, pain, and mild TBI (National Center for PTSD, 2010b), and another panel addressed comorbid SUD and PTSD (National Center for PTSD, 2010a). Both panels concluded that the existing guidance in the individual VA/DoD CPGs was appropriate for treating patients who simultaneously meet the diagnostic criteria for these disorders. In addition, the consensus panel addressing comorbid SUD and PTSD (National Center for PTSD, 2010a) urged VA SUD and PTSD specialists to use effective first-stage treatment strategies, such as the use of motivational interviewing principles and Seeking Safety, a treatment for co-occurring SUD and PTSD (discussed above), which is recommended in the VHA Handbook for Uniform Mental Health Services in VA Medical Centers and Clinics (VA, 2015c).