Annual Report for Fiscal Year 1997EXECUTIVE SUMMARYDuring FY 1997, the National Center for PTSD conducted a range of research and educational activities in order to meet the needs of stakeholders: veterans, VA staff, other federal agencies, and the national and international communities of trauma scholars. This summary describes our accomplishments during FY 1997 in the following areas: Research, Education, Networking and Communication, Resource_Center, Evaluation, and Program_Planning. BACKGROUNDAs it continues to carry out its Congressional mandate, the National Center for PTSD has become a world leader in research and educational programs focusing on PTSD and other psychological and medical consequences of traumatic stress. The Center also has made a major and continuous effort to respond to the changing needs of all stakeholders, including veterans and their families, VA clinicians, researchers and educators, facility and VISN executives, and VA policy makers. As the VA itself has undergone restructuring and developed cost-effective innovations, the NCPTSD has shifted its priorities to support these vital changes in VA's delivery of services for veterans. Perhaps the best way to evaluate the unique contributions and added value to VA provided by the NCPTSD is in the context of VA's strategic plan, "Prescription for Change." NCPTSD program priorities are most relevant to Mission Goal I, to provide excellence in healthcare value; Mission Goal III, to provide excellence in education and research; and Mission Goal V, to be an employer of choice. With regard to Mission Goal I, NCPTSD activities promote excellence in VA healthcare. Broadly speaking, these can be summarized in five major areas: evaluation of PTSD clinical programs; educating VA clinicians on treatment for PTSD; participating in the development of clinical practice guidelines; increased utilization of electronic commerce; and leadership in the VA/DoD emergency preparedness role with respect to mental health concerns. Through program evaluation of all inpatient and outpatient clinical activity, the Evaluation Division has established a performance monitoring system that routinely tracks performance and provides timely feedback to providers of PTSD treatment. Data developed in this process have led to the development of performance measures by which to promote cost-effective treatment. The NCPTSD (sometimes in collaboration with the Employee Education System) has developed a wide assortment of educational programs to facilitate accomplishment of the vision of the "new VA," to assist the transition from an inpatient to an ambulatory care system, to disseminate the latest treatment advances in order to promote clinical excellence, and to develop innovative cost-effective practice models that integrate PTSD and primary care. The NCPTSD has worked closely with the Mental Health Strategic Health Care Group and RCS to develop practice guidelines on PTSD and associated (affective, anxiety, and chemical abuse/dependency) disorders. The Executive Division's Resource Center has utilized the Internet as an efficient and cost-effective way to disseminate information on PTSD to veterans, clinicians, scientists, and educators. The NCPTSD's heavily utilized Web page provides a rich assortment of scientific and clinical material. Computer users can access both the NCP Clinical Quarterly and the PTSD Research Quarterly, which are published electronically as well as in hard copy. Also, the largest computerized bibliographic database in the world on trauma and PTSD, PILOTS (Published International Literature on Traumatic Stress) is available through our web page. The NCPTSD has worked closely with VA (EMSHG, MHSHCG, and RCS) as well as DoD, HHS (PHS), FEMA, and American Red Cross to develop a mental health intervention strategy as a component of VA's emergency preparedness role during national security contingencies, for VA internal emergencies, and as a federal support organization for major catastrophic disasters. With regard to Mission Goal III, the NCPTSD's educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans. Its research program is responsive to the needs of the VA and consistently seeks to expand collaborative investigative efforts with government and non-government entities. Moreover, the Center's research program capitalizes on the special research opportunities available in the VA. PTSD has been identified as a high-priority area in which VA has become a world leader. The National Center for PTSD has responded to the needs of veterans by developing programs targeted specifically for veterans and their families as well as for mental health and primary care providers who provide their treatment. NCPTSD research programs focus on a range of topics related to advancing knowledge on the pathophysiology, assessment, and treatment of PTSD. Specific major research initiatives have been undertaken as VA has identified new needs for scientific data. A major focus has been treatment research. Other high-priority areas include trauma and stress-related problems of women veterans, Persian Gulf veterans, the veterans of tomorrow currently participating in military operations, ethnocultural minority veterans, and older veterans. Some projects have necessitated large-scale collaborative efforts directed by the NCPTSD. These include two VA Cooperative studies on assessment and treatment of PTSD, a VA/NIMH epidemiological survey, two joint NCPTSD/NIMH conferences, and collaboration with the VA Boston Environmental Hazards Center to understand the possible impact of stress on unexplained medical complaints of Persian Gulf veterans. Several important ongoing collaborative projects with DoD on active-duty military personnel have generated opportunities to understand the longitudinal course of PTSD from acute reactions to chronic PTSD. The DoD collaboration enables us to promote early detection, identify risk factors, and test acute interventions that may forestall the later development of PTSD. The NCPTSD has capitalized on special research opportunities within VA and elsewhere, such as cooperative studies, Merit Review, HSR&D projects, and one-time Requests For Proposals in high-priority research areas. NCPTSD investigators have successfully competed for VA, HHS, DoD, and other research funding and consistently generate approximately $8 million per year in additional funding to advance the overall NCPTSD research agenda. The NCPTSD also has promoted Mission Goal V by performing as an employer of choice that increases employee training and career development opportunities. On-site employee training is provided at the Education Division's week-long Clinical Training Program. Also, the NCPTSD has developed national training conferences in conjunction with EES. Young investigators, clinicians, and trainees enrolled in residencies, psychology internships, and fellowships at affiliated institutions (Boston University, Dartmouth, University of Hawaii, Stanford, and Yale) have participated in educational opportunities at each NCPTSD site and have moved on to productive careers as clinicians, researchers, and educators at other VA and non-VA institutions. In this way, the seeds of excellence and rigor sown during their NCPTSD period blossom elsewhere, thereby disseminating better treatment and scientific understanding of PTSD and related disorders. In summary, the NCPTSD consortium exemplifies an organization in which the whole is greater than the sum of its parts. Effective resource management within and between each division has enabled the Center to carry out its mission effectively, creatively, and proactively. Research in the NCPTSD is broadly focused on issues related to assessment and diagnosis, etiology, epidemiology, and treatment of trauma-related problems in military veterans and active-duty personnel. Specific projects included the following: Matsunaga Vietnam Veterans Project. The MVVP, directed by Dr. Matthew Friedman, is a Congressionally-mandated epidemiological survey of the prevalence of PTSD among Native American and Asian Pacific Islander American Vietnam veterans. The MVVP was completed and a final report was distributed in FY 1997. Findings from the final report were presented to Secretary Brown and VA's top leadership in November 1996. Persian Gulf War Veterans. Since 1991, Dr. Jessica Wolfe has been conducting a longitudinal study of 3,000 male and female PGW veterans. She continued her work with Drs. Susan Proctor and Roberta White, as well as other senior public and environmental health specialists, into investigating the etiologies of Gulf War illnesses. Over the past five years, Drs. Steven Southwick, Andrew Morgan, and Douglas Bremner have followed a cohort of PGW veterans, focusing on the natural evolution of trauma-related symptoms and on the longitudinal consistency of memory for traumatic events. With funding received from the Department of Defense in FY 1997, PGW veterans with PTSD are being studied using memory testing and MRI measurement of hippocampal volume. PTSD Treatment Research. Drs. Matthew Friedman and Paula Schnurr continued their multi-site randomized clinical trial of trauma focus group therapy for PTSD, "Group Treatment of PTSD" (Cooperative Study #420). This project is a major initiative involving a total of ten sites chosen from both Center and non-Center VAMC PTSD programs and spanning 3.5 years. Participant enrollment began in Summer 1997. The study design and methods were presented at several scientific meetings and have generated interest among national and international audiences. Also, the Clinical Neurosciences Division completed participation in a multicenter clinical trial of nefazodone (Serzone), conducted by Bristol-Myers Squibb. Women Veterans. The Women's Health Sciences Division recently completed an HSR&D-funded national survey of 1,000 women veterans' perceptions and experiences in their efforts to access VA healthcare services. A collateral study in FY 1997 involved an internal and external needs assessment among women veterans in Massachusetts. Dr. Jessica Wolfe and staff also completed baseline data collection in a DoD-funded study of adjustment to first-term enlistment among 1,500 female and male Marine Corps recruits at Parris Island. Etiology. An exciting program of research on the etiology of PTSD is being conducted by a collaboration of Drs. Dan King and Lynda King. Along with Dr. Terence Keane and other colleagues, they completed an NIMH-funded series of studies that modeled the etiology of PTSD by using data from the 432 female and 1,200 male Vietnam veterans who participated in the NVVRS. Neurobiological Research. In a study conducted at the Clinical Neurosciences Division, investigators used positron emission tomography and magnetic resource imaging in the measurement of hippocampal structure and function in women with a history of childhood sexual abuse-related PTSD and in men with Vietnam combat-related PTSD. In another study, Drs. Andrew Morgan and John Mason studied the neurohormonal dynamic responses to special forces military training. Dr. Steven Southwick and colleagues completed the initial phase of a study of the effects of yohimbine hydrochloride on the acquisition of memory for arousing events. Studies of Peacekeeping Forces. Dr. Brett Litz continued his research program on the psychological consequences of peacekeeping and peace enforcement for combat-trained US military personnel. Dr. Litz and colleagues were able to evaluate large cohorts of soldiers before they deployed to Bosnia so that, for the first time, mental health outcomes can be compared with pre-exposure baselines. During FY 1997, NCPTSD staff wrote 160 articles and 132 in-press publications and made 126 scientific presentations. Funding for all NCPTSD research comes from both Center funds and peer-reviewed grants from VA, PHS, and private foundations. These funds are crucial to maintaining the Center's research program. As of September 30, 1997, NCPTSD staff held 66 grants, 16 of which were newly funded during the fiscal year. The 66 grants, which had a multiyear total of $33,419,629, brought in a total of $5,886,501 during FY 1997. NCPTSD education initiatives continued to draw upon diverse research, clinical, administrative, policy, and lay sources to enrich the PTSD patient care provided to veterans, and to facilitate timely dissemination of scientific findings concerning trauma and PTSD. The Center continued to develop educational programs and products in FY 1997 based upon four themes derived from parallel areas of focus in the VA's healthcare mission: veteran and public education, effective prevention and treatment, and ethnocultural and gender issues; PTSD education for mental health providers to support and enhance patient care for PTSD; PTSD primary care education for medical/nursing and mental health care providers; and disaster mental health education conducted in collaboration with VA's key emergency response organizations. Newsletters. The NCPTSD publishes two of the primary sources of scientific and clinical information in the field of PTSD, the NCP Clinical Quarterly and the PTSD Research Quarterly. Each publication has a circulation of more than 5,000 recipients and is distributed to all VA Medical Centers and Vet Centers, all US academic departments of clinical psychology and psychiatry, and all members of ISTSS, as well as to government and private-sector sources who shape research, clinical practice, and policy concerning traumatic stress. Ethnic Minorities. At the direction of the Secretary of the VA and in collaboration with the VA's Center for Minority Veterans, RCS, Strategic Healthcare Group for Mental Health, Office of Primary Care, Veterans Benefits Administration, and Chief Information Officer, the NCPTSD designed, presented, and co-produced (with the Salt Lake City National Media Development Center) a national Satellite Video, "Ethnocultural Issues in PTSD: The Matsunaga Vietnam Veterans Project." Educational brochures were prepared for VA clinicians, veterans service officers, VA Benefits officers, veterans, and family members, and were distributed to every VA Healthcare, Benefits Administration, VISN, Employee Education, and Vet Center facility. Clinical Training Program. Under the leadership of Mr. Fred Gusman, the Education Division?s Clinical Training Program has become a major center for advanced professional education in the PTSD field, providing advanced experiential training via week-long intensive mentoring to small groups of PTSD and healthcare clinicians from around the world. The 99 trainees in FY 1997 included VA-based health and mental health clinicians, RCS staff, and PTSD professionals from across the US and 7 countries internationally. Educational Conference Calls. The NCPTSD's Education Division presented educational colloquia on monthly nationwide telephone conference calls sponsored by the Evaluation Division for all VA outpatient and inpatient Specialized PTSD programs. FY 1997 presentations included: Trauma Management Therapy; Lessons Learned from Teaching Veterans about Pharmacotherapy; and the Jackson, Mississippi Critical Incident Team. PTSD Practice Guidelines. The Executive Division initiated a project with VAMH, RCS, and the forthcoming VISN 1 and 20 MIRECCs to develop practitioner fact sheets and a best-practices guide to support the VA's Depression Practice Guidelines PTSD Module. PTSD and Primary Care Working Group. The Executive and Education Divisions continued to convene a multidisciplinary working group to develop curricula for educating mental health and primary healthcare providers concerning the detection, evaluation, and treatment of healthcare patients with untreated PTSD. Participants were drawn from VA's Office of Primary Care, VA's Mental Health Strategic Healthcare Group, VISN Clinical Managers, the civilian academic healthcare research sector, and NCPTSD personnel. Disaster Mental Health Training. The Education and Executive Divisions' Guide to Disaster Mental Health Services was completed and field-tested in two VISN-wide Disaster Mental Health trainings conducted in Dallas (February 1997) and Boston/Providence (June 1997). The NCPTSD disaster mental health training series will be launched officially in FY 1998. Communication with trauma researchers, educators, clinicians, and program administrators outside the NCPTSD -- within and outside the Department of Veterans Affairs -- is essential to the fulfillment of the Center's mission. Communication and coordination across the seven NCPTSD sites also is essential because of the multisite nature of the Center itself. During FY 1997 the Center began using videoconferencing to augment existing communication technologies. Although the telephone is still the primary means of conducting multisite meetings, videoconferencing is used to hold monthly research and education meetings. The NCPTSD maintained linkages to VA clinicians providing PTSD treatment through an electronic mailgroup established on Forum for instantaneous networking and mutual support. Collaborative activities with RCS continued through ongoing contacts concerning research, evaluation, and education issues. NCPTSD members worked with RCS Director Dr. Alfonso Batres and his associates on large-scale projects. The NCPTSD's Executive Director and Division Directors continued to work closely with the Director, Dr. Thomas Horvath, Associate Director, Dr. Laurent Lehmann, and administrative liaison, Ms. Gay Koerber, of the Mental Health Strategic Health-Care Group. NCPTSD staff members served on several VA committees: Under Secretary's Special Committee on Seriously Mentally Ill Veterans (Dr. Rosenheck); New Knowledge Committee for Mental Health (Drs. Keane, Friedman); VA Headquarters' Field Advisory Board (Dr. Keane); Executive Committee in Mental Health (Dr. Keane); the interdisciplinary VA Task Force to develop, implement, and oversee a systemwide clinical and educational program addressing the needs of women veterans (Dr. Wolfe); and Persian Gulf Expert Scientific Committee (Dr. Friedman). NCPTSD staff members served on VISN-level committees as well: VISN 1 Mental Health Feasibility Task Force (Dr. Rosenheck); VISN 1 Mental Health Advisory Board (Dr. Keane). Also within VISN 1, the Women's Health Sciences Division, in conjunction with the affiliated Boston Women's Health Center, forged clinical partnerships with the other eight VISN 1 sites. Dr. Wolfe served as Special Project Coordinator for Strategic Planning, VISN 1, during most of FY 1997. Dr. Matthew Friedman and Mr. Fred Gusman continued to serve on the VA Under Secretary for Health's Congressionally mandated Special Committee on PTSD. The Center maintained active consultative and research relationships with DoD, particularly through Dr. Brett Litz's studies of the long-term consequences of peacekeeping for US military personnel. Also, Dr. Friedman was appointed to the interagency Presidential Review Directive (PRD-5) Research Working Group, which involves representatives from VA, DoD, HHS, the Environmental Protection Agency, and the CDC. Drs. Matthew Friedman and Terence Keane were designated as official spokespersons on PTSD for the Anxiety Disorder Initiative conducted by Drs. Elaine Baldwin and Jack Masur of the Office of Scientific Information at NIH. Extensive networking with trauma professionals was accomplished through the ISTSS as a result of Dr. Keane's tenure as President, and membership on the Board of Directors by Drs. Friedman, Southwick, and Wolfe, and Mr. Gusman. The NCPTSD's World Wide Web site continued to provide information about the Center's organization and activities, access to the PILOTS database, and the ability to download back issues of the PTSD Research Quarterly. During FY 1997 the number of citations in the PILOTS database increased from 10,307 to 12,262. This past year, the Evaluation Division developed a National Mental Health Program Performance Monitoring System that evaluates PTSD as well as other mental health care provided at each VA medical center and in each of VA's 22 VISNs. In addition, the Division monitored the treatment outcomes of specialized intensive PTSD programs in terms of veterans' PTSD symptoms, alcohol abuse, drug abuse, violence, and work. These data, along with several recent evaluation reports described more fully below, were widely used in making programmatic changes as part of VA's reorganization during FY 1997. The Evaluation Division also completed its intensive study of the cost-effectiveness of VA specialized PTSD inpatient programs. The final report of this study was disseminated throughout VA and has been the basis for changing program configurations in many VISNs. Our first priority is to provide the proactive leadership needed to maintain the creative momentum exemplified by our current research, education, and program evaluation activities. A dynamic and responsive organization, however, must be in a continual state of evolution. In that spirit, we identify important new areas which we plan to emphasize in the coming year: Special emphasis will be placed on research regarding treatment, collaboration with DoD, and physical health. The largest ongoing treatment initiative is the 10-site randomized clinical trial, CSP #420, "Group Treatment of PTSD." The ongoing collaboration with DoD will be enhanced in FY 1998 by the Center's participation in developing a Presidential Research Directive that contains a strategic plan to conduct research on the health and well-being of all military personnel. Research on the physical health consequences of trauma and PTSD also will continue, especially focused on understanding medical symptoms among PGW veterans. Educational initiatives will continue to emphasize programs for veterans and their families, mental health clinicians, primary care providers, and emergency medical personnel. We plan to increase collaborative activities with EES both system-wide and within each VISN. We have begun to offer specific training programs on a VISN-by-VISN basis. In collaboration with EES, we are currently planning two national conferences in FY 1998. We also plan to continue expansion of our internet website which has received growing utilization because of the wealth of information that is easily accessible by veterans, clinicians, scientists and other stakeholders. Within VA, NCPTSD will continue to support clinicians at the facility level, to promote clinical, research, and educational programs at the VISN level, and to consult on special priority concerns identified by VA officials. Outside government, NCPTSD experts will maintain their leadership in the stress, trauma, and PTSD field through participation on research review and journal editorial boards, academic curriculum development, participation in professional and scientific organizations, and supporting a national and international network of clinicians and scholars dedicated to the understanding and treatment of PTSD.
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