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The Department of Veterans Affairs (VA) is
committed to providing care for Veterans with
post-traumatic stress disorder (PTSD) and to
preventing suicide among Veterans. VA has
undertaken extensive efforts in the last five
years to implement enhancements to mental
health care, many focused on PTSD care and
on suicide prevention. VA is committed to
improving and enhancing access to care and
the quality of care delivered, and to expanding
knowledge through research.
VA develops Clinical Practice Guidelines
(CPGs) in conjunction with the Department
of Defense (DoD) on a wide array of health
care issues, including several mental health
diagnoses and problems. The CPGs are developed
in a thoughtful, data-driven process,
resulting in documents that guide assessment
and disease management, and, when possible,
prevention of disorders. The most recently
revised CPG for PTSD was published in 2010,
as an update from the original 2004 CPG for
PTSD.
The role of CPGs is to guide clinical decisionmaking,
not to dictate clinical care. VA
emphasizes that patient preferences must be
addressed, with the patient being a full collaborator
in treatment planning and decisions.
As potentially effective treatment options
increase, Veterans can take an active role in
deciding how each option fits with their goals,
strengths, and challenges.
VA must develop providers who can deliver
with clinical skill and fidelity the treatments
shown most likely to be effective. To support
this, the VA Office of Mental Health Services
(OMHS) has taken a lead role in identifying
the training needs of VA's mental health
work force and developing programs to target
those needs. VA has trained thousands of
mental health clinicians to provide the psychotherapies
rated most effective for PTSD
in both the CPG and in an independent 2007
report by the Institute of Medicine: Cognitive
Processing Therapy and Prolonged Exposure
Therapy. VA's National Center for PTSD
(NCPTSD) also delivers training for PTSD
treatment providers through a national mentoring
program that shares best practices in
PTSD care across Veterans Integrated Service
Networks (VISNs) and VA medical facilities.
The PTSD CPG must continue to evolve as
knowledge progresses through research. For
example, many Veterans want their family
members more involved in PTSD treatment.
While VA has expanded authority to allow
family involvement in PTSD treatment, little
empirical evidence exists to guide how clinicians
may effectively adapt to these preferences.
Additionally, the value of the PTSD
CPG would be greatly increased by an evidence
base to guide adjustments to treatment
when clients present with common comorbidities,
such as pain, insomnia, anger, substance
use disorders, or traumatic brain injury.
Suicide prevention is integral to VA's mental
health efforts. Currently, a suicide prevention
CPG is under development with the DoD, and
should provide invaluable clinical guidance. The
2008 recommendations of a Blue Ribbon panel
of suicidology experts have contributed to development
of these guidelines. The foundation
for effective suicide prevention is good mental
health care for PTSD and for all diagnosable
mental illness and other emotional challenges.
At the core of VA's program is VA's Crisis
Line, a 24/7 phone line run in collaboration
with SAMHSA's Lifeline, established in 2007.
Veterans, or those concerned about a Veteran,
can call 1-800-273-8255 and then press 1 to be
connected to a VA mental health professional
trained to work with those in crisis or who may
be potentially suicidal. Since its founding, the
Crisis Line has received over 500,000 calls and
initiated over 19,000 rescues. Such rescues involve
dispatching emergency personnel to the
site of an imminent suicide, securing the person
and any others in the area, and ensuring the person
receives urgent care.
One invaluable feature of VA's Crisis Line
is that staff can link to the Veteran's Electronic
Health Record, if the Veteran is willing
to share his or her name and social security
number. This feature allows the Crisis Line
responder to link the caller to mental health
providers who have seen the Veteran previously
and to get immediate help. In addition,
VA employs Suicide Prevention Coordinators
(SPCs) at every facility and large clinic to arrange
immediate local response. The SPCs
follow up with Veterans to ensure they continue
care and receive the support they need,
and to develop safety plans.
Building on the success of the call line, VA
has opened a written Chat Service at www.
veterancrisisline.net and a texting service, at
838255, both of which connect those seeking
care directly to mental health professionals
who staff Crisis Line calls. These services especially
appeal to younger Veterans, for whom
these communication options are familiar and
preferred.
Numerous opportunities for research remain.
Many relationships between suicidality and
diagnosed mental illness are known, but there
is much to learn, particularly about the same
issues of chronicity and comorbidity that are
central for PTSD care. In addition, one of the
most challenging issues is that a large proportion
of suicides occur in those without any
known mental illness. Often such suicides
occur after a primary care visit, and without
any obvious warning signs that the individual
is at risk for suicide. Research focused on the
underlying issues for such patients, how to
identify them, and what care could best prevent
suicide in this group would be invaluable
for VA and for the nation.
-
Batten, S. V. et al. "Veteran Interest in Family
Involvement in PTSD Treatment,"
Psychological Services 2009; 6:184-9.
- Institute of Medicine (2007). Treatment of Post-traumatic
Stress Disorder: An Assessment of the Evidence. Washington,
DC: The National Academies Press.
-
VA/DoD Clinical Practice Guideline (2010). Management
of Post-Traumatic Stress, Version 2.0. Washington,
DC: Department of Veterans Affairs and Department
of Defense.
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