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Brief Reports   |    
Complementary and Alternative Medicine in VA Specialized PTSD Treatment Programs
Daniel J. Libby, Ph.D.; Corey Elizabeth Pilver, Ph.D.; Rani Desai, Ph.D.
Psychiatric Services 2012; doi: 10.1176/appi.ps.201100456
View Author and Article Information

Dr. Libby and Dr. Desai are affiliated with the Department of Psychiatry, Yale University School of Medicine, 300 George St., Suite 901, New Haven, CT 06511(e-mail: danieljlibby@gmail.com).
Dr. Desai is also with the National Center for PTSD and Dr. Pilver is with the Northeast Program Evaluation Center, U.S. Department of Veterans Affairs Connecticut Healthcare System, West Haven.

Objective  This survey documented the provision of complementary and alternative medicine (CAM) treatments in U.S. Department of Veterans Affairs (VA) specialized posttraumatic stress disorder (PTSD) treatment programs.

Methods  Program coordinators or designated staff from 125 of 170 VA specialized PTSD treatment programs completed and returned surveys between September 2010 and March 2011, indicating which of 32 CAM treatments were offered in that program.

Results  Ninety-six percent of programs reported use of at least one CAM treatment. Eighty-eight percent offered CAMs other than those that are commonly part of conventional PTSD treatments (guided imagery, progressive muscle relaxation, and stress management–relaxation therapies).

Conclusions  The widespread use of CAM treatments in VA PTSD programs presents an opportunity for researchers to assess the effect of CAM on mental health service use and PTSD symptoms among veterans. Future research should assess the effectiveness of CAM treatments and develop methods to tailor these treatments to veterans with PTSD.

Abstract Teaser
Figures in this Article

Complementary and alternative medicine (CAM) refers to a group of health care systems, practices, and treatments that are not considered to be a part of conventional medicine (1). CAM therapies include those that are used as an adjunct to (complement) or a replacement for (alternative) conventional care. The distinction between CAM treatments and conventional treatments, however, is not always clear. Several treatments that are considered CAM are included in standard psychotherapies for mental disorders. For example, relaxation therapies, including progressive muscle relaxation and breathing techniques, are standard components of cognitive-behavioral therapies for posttraumatic stress disorder (PTSD) (2), yet they are also defined as CAM by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. Further, CAM practices, such as mindfulness meditation, have been integrated into some conventional psychotherapies. A comprehensive discussion of CAM definitions and descriptions can be found elsewhere (1,3).

Survey data have shown that use of CAM for the treatment of mental and emotional problems is highly prevalent and increasing (4). For example, results from a nationally representative survey showed that over 50% of individuals with PTSD reported past-year CAM use to address emotional problems or substance abuse issues (5). Another survey found that a diagnosis of PTSD was significantly associated with CAM use in general and with biofeedback and relaxation in particular (6). Rates of CAM use among veterans are comparable to rates observed among civilians, ranging from 23% to 50% depending on the specific population surveyed and the types of CAM examined (68). Surveys have also indicated that 76% of veterans who are nonusers of CAM would use CAM treatments if they were offered at the VA and 40% of CAM users would use additional CAM therapies if they were provided (8,9).

Use of CAM in the treatment of PTSD is an area of increased interest within the VA (10), and a stated goal of the NCCAM 2011 Strategic Plan is to “increase understanding of ‘real-world’ patterns and outcomes of CAM use and its integration into health care” (11). Understanding patterns of CAM provision in VA specialized PTSD treatment programs is an important first step in understanding how CAM might be most effectively integrated with conventional PTSD treatment. Although research suggests widespread use of and interest in CAM among veterans, the extent to which CAM is offered in VA PTSD treatment has not been explored. This study addressed that gap in the literature.

Program coordinators from eight VA PTSD treatment programs that were known to offer CAM treatments were interviewed to help generate a list of CAM treatments for the survey. The list of treatments was intended to be comprehensive and was derived from those described by the program coordinators and by NCCAM (1). The final survey created for this exploratory, cross-sectional study consisted of 81 mixed-format questions covering 32 CAM treatments (and an “other” response option). Study procedures, including a waiver of informed consent, were approved by the Human Studies Subcommittee of the VA Connecticut Healthcare System.

The VA’s Northeast Program Evaluation Center (NEPEC) directory of specialized PTSD programs (12) was used to identify program coordinators from each of the 170 specialized PTSD programs listed in the directory. NEPEC is responsible for conducting evaluations of VA specialized PTSD treatment programs nationwide. Although PTSD treatment is offered in VA mental health services outside of these programs, the designation of “specialized PTSD program” is used for programs staffed by experts who have concentrated their clinical work in PTSD treatment and who meet specific staffing and reporting requirements (12).

The program coordinators identified were asked to complete the survey and return it in a postage-paid envelope provided. Two follow-up e-mails were sent in the event of nonresponse, followed by an attempt to make telephone contact.

Of the 170 surveys sent, 125 were completed between September 2010 and March 2011 (16% by telephone), representing a 74% response rate. Table 1 presents data on 24 types of CAM offered in VA specialized PTSD programs by program type. (Eight CAM treatments were not offered by any program: applied kinesiology, ayurvedic medicine, aromatherapy, chelation therapy, homeopathy, naturopathic medicine, somatic experiencing, and traditional Chinese medicine.) Ninety-six percent of the programs reported offering at least one CAM treatment. However, when guided imagery, progressive muscle relaxation, and stress management–relaxation therapy, which are commonly part of conventional PTSD treatments, were excluded, the percentage was 88%. The most popular forms of CAM offered were mindfulness, stress management–relaxation therapy, progressive muscle relaxation techniques, and guided imagery; each was offered by more than 50% of treatment programs. Several programs reported offering “other” CAM treatments: two programs offered equine-assisted therapy, two programs offered therapeutic riding, and one program offered aikido.

 
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Table 1

Department of Veterans Affairs specialized posttraumatic stress disorder (PTSD) treatment programs offering complementary and alternative medicine (CAM) treatments, by program type

Table Footer Note

a Any CAM treatment except guided imagery, progressive muscle relaxation, and stress management–relaxation therapy, which are commonly part of conventional PTSD treatments

This study found that CAM is widely offered in VA specialized PTSD treatment programs. Only 4% of programs responding to the survey indicated that CAM was not offered. For the CAM treatments most commonly offered, there is an evidence base indicating effectiveness for the development of autonomic regulation (13), an important skill for individuals with PTSD. In fact, many of these treatments, although categorized as CAM, are often offered as part of conventional psychotherapeutic treatment of PTSD (for example, stress management–relaxation therapy).

The study had several limitations. Only 74% of programs returned the survey. The availability of CAM treatments may be overestimated if programs that did not offer CAM were less likely to return the survey. In addition, the survey did not gather information on the number of veterans using these treatments, the frequency with which the treatments are offered, or their effectiveness. In addition, some CAM practices can be accurately categorized under several headings, leading to ambiguity in responses. For example, yoga often includes meditation and guided imagery, and a program offering yoga may have reported that it offered yoga, meditation, and guided imagery or only yoga.

Although the VA has invested resources in disseminating evidence-based treatments for PTSD, research has shown that many veterans do not complete these treatments and that many who complete them continue to have symptoms (14). Furthermore, the efficacy of these treatments among veterans with comorbid disorders and prolonged, complex trauma histories has not been established. Future studies should examine whether participation in CAM therapies that have been shown to help with autonomic regulation (such as yoga and meditation) increases retention rates in evidence-based practices and improves outcomes by giving participants additional skills in self-regulation and affect management.

Many CAM treatments are not standardized or manualized. Those that are manualized, such as mindfulness-based stress reduction, may be improved by making them “trauma sensitive” (15). For example, yoga therapy for veterans with PTSD may be more effective if tailored specifically to emphasize autonomic regulation, mindfulness, and acceptance. In addition, yoga therapy for veterans with PTSD can be customized to reinforce therapeutic concepts used in other evidence-based practices for PTSD. Similarly, meditation may be more effective for the treatment of PTSD when it incorporates psychoeducation about effectively managing symptoms of reexperiencing that may arise during meditation. These are empirical questions that deserve research attention.

Use of CAM in VA PTSD treatment is widespread. Researchers, therefore, have an excellent opportunity to determine whether offering CAM treatments has an impact on treatment engagement and outcomes. Future research should assess the efficacy of CAM treatments, both as an alternative and as an adjunct to conventional PTSD treatment, and develop methods to tailor these treatments to veterans with PTSD.

This project was supported by the Advanced Fellowship Program in Mental Illness Research and Treatment of the VA’s Office of Academic Affiliations and by the National Center for PTSD.

The authors report no competing interests.

What Is Complementary and Alternative Medicine? Bethesda, Md, National Center for Complementary and Alternative Medicine, 2012. Available at www.nccam.nih.gov/health/whatiscam
 
Foa EB, Rothbaum BO: Treating the trauma of rape: cognitive-behavioral  therapy for PTSD .  New York,  Guilford, 1998
 
Lake J, Spiegal D: Complementary and alternative treatments in mental  health care: overview and significant trends; in  Complementary and Alternative Treatments in Mental Health Care . Edited by Lake  J;  Spiegal  D.  Washington, DC,  American Psychiatric Publishing, 2007
 
Barnes  PM;  Bloom  B:  Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007 .  Hyattsville, Md,  National Center for Health Statistics, 2008
 
Libby DJ, Pilver CE, Desai R: Complementary and alternative medicine use among individuals with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, in press
 
Micek  MA;  Bradley  KA;  Braddock  CH  III  et al:  Complementary and alternative medicine use among Veterans Affairs outpatients.  Journal of Alternative and Complementary Medicine 13:190–193, 2007
[CrossRef]
 
Baldwin  CM;  Long  K;  Kroesen  K  et al:  A profile of military veterans in the southwestern United States who use complementary and alternative medicine: implications for integrated care.  Archives of Internal Medicine 162:1697–1704, 2002
[CrossRef] | [PubMed]
 
McEachrane-Gross  FP;  Liebschutz  JM;  Berlowitz  D:  Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey.  BMC Complementary and Alternative Medicine 6:34, 2006
[CrossRef] | [PubMed]
 
Campbell  DG;  Turner  AP;  Williams  RM  et al:  Complementary and alternative medicine use in veterans with multiple sclerosis: prevalence and demographic associations.  Journal of Rehabilitation Research and Development 43:99–110, 2006
[CrossRef] | [PubMed]
 
Meeting seeks to expand VA's study of complementary, alternative therapies for PTSD. VA Research Currents, May–June 2011. Available at www.research.va.gov/currents/may-june11/may-june11-01.cfm
 
 Exploring the Science of Complementary and Alternative Medicine: Third Strategic Plan 2011–2015 .  Bethesda, Md,  National Center for Complementary and Alternative Medicine, 2011
 
Desai  R;  Spencer  H;  Gray  S  et al:  The Long Journey Home: XVIII. Treatment of Posttraumatic Stress Disorder in the Department of Veterans Affairs: Fiscal Year 2009 Service Delivery and Performance .  West Haven, Conn,  US Department of Veterans Affairs, Northeast Program Evaluation Center, 2010
 
Moore  M;  Brown  D;  Money  N  et al:  Mind-Body Skills for Regulating the Autonomic Nervous System .  Arlington, Va,  Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, 2011
 
Schottenbauer  MA;  Glass  CR;  Arnkoff  DB  et al:  Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations.  Psychiatry 71:134–168, 2008
[CrossRef] | [PubMed]
 
Emerson  D;  Sharma  R;  Chaudhry  S  et al:  Trauma-sensitive yoga: principles, practice, and research.  International Journal of Yoga Therapy 19:123–128, 2009
 
References Container
Anchor for Jump
Table 1

Department of Veterans Affairs specialized posttraumatic stress disorder (PTSD) treatment programs offering complementary and alternative medicine (CAM) treatments, by program type

Table Footer Note

a Any CAM treatment except guided imagery, progressive muscle relaxation, and stress management–relaxation therapy, which are commonly part of conventional PTSD treatments

+

References

What Is Complementary and Alternative Medicine? Bethesda, Md, National Center for Complementary and Alternative Medicine, 2012. Available at www.nccam.nih.gov/health/whatiscam
 
Foa EB, Rothbaum BO: Treating the trauma of rape: cognitive-behavioral  therapy for PTSD .  New York,  Guilford, 1998
 
Lake J, Spiegal D: Complementary and alternative treatments in mental  health care: overview and significant trends; in  Complementary and Alternative Treatments in Mental Health Care . Edited by Lake  J;  Spiegal  D.  Washington, DC,  American Psychiatric Publishing, 2007
 
Barnes  PM;  Bloom  B:  Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007 .  Hyattsville, Md,  National Center for Health Statistics, 2008
 
Libby DJ, Pilver CE, Desai R: Complementary and alternative medicine use among individuals with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, in press
 
Micek  MA;  Bradley  KA;  Braddock  CH  III  et al:  Complementary and alternative medicine use among Veterans Affairs outpatients.  Journal of Alternative and Complementary Medicine 13:190–193, 2007
[CrossRef]
 
Baldwin  CM;  Long  K;  Kroesen  K  et al:  A profile of military veterans in the southwestern United States who use complementary and alternative medicine: implications for integrated care.  Archives of Internal Medicine 162:1697–1704, 2002
[CrossRef] | [PubMed]
 
McEachrane-Gross  FP;  Liebschutz  JM;  Berlowitz  D:  Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey.  BMC Complementary and Alternative Medicine 6:34, 2006
[CrossRef] | [PubMed]
 
Campbell  DG;  Turner  AP;  Williams  RM  et al:  Complementary and alternative medicine use in veterans with multiple sclerosis: prevalence and demographic associations.  Journal of Rehabilitation Research and Development 43:99–110, 2006
[CrossRef] | [PubMed]
 
Meeting seeks to expand VA's study of complementary, alternative therapies for PTSD. VA Research Currents, May–June 2011. Available at www.research.va.gov/currents/may-june11/may-june11-01.cfm
 
 Exploring the Science of Complementary and Alternative Medicine: Third Strategic Plan 2011–2015 .  Bethesda, Md,  National Center for Complementary and Alternative Medicine, 2011
 
Desai  R;  Spencer  H;  Gray  S  et al:  The Long Journey Home: XVIII. Treatment of Posttraumatic Stress Disorder in the Department of Veterans Affairs: Fiscal Year 2009 Service Delivery and Performance .  West Haven, Conn,  US Department of Veterans Affairs, Northeast Program Evaluation Center, 2010
 
Moore  M;  Brown  D;  Money  N  et al:  Mind-Body Skills for Regulating the Autonomic Nervous System .  Arlington, Va,  Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, 2011
 
Schottenbauer  MA;  Glass  CR;  Arnkoff  DB  et al:  Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations.  Psychiatry 71:134–168, 2008
[CrossRef] | [PubMed]
 
Emerson  D;  Sharma  R;  Chaudhry  S  et al:  Trauma-sensitive yoga: principles, practice, and research.  International Journal of Yoga Therapy 19:123–128, 2009
 
References Container
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