Complementary and Alternative Medicine in VA Specialized PTSD Treatment Programs

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 (6–8). 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.

Methods

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.

Results

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.

Discussion

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.

Conclusions

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.