Review of VA/DOD Clinical Practice Guideline on Management of Acute Stress and Interventions to Prevent Posttraumatic Stress Disorder

Article excerpt

INTRODUCTION

The newly revised Department of Veterans Affairs (VA)/Department of Defense (DOD) VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress, published October 2010 [1], draws greater attention than its predecessor to the challenge of promoting prevention of posttraumatic stress disorder (PTSD) and other adverse outcomes of exposure to traumatic stress in service-members, veterans, and their families. The entire Core Module of the CPG is now devoted to reviewing concepts and evidence-informed actions for prevention in three domains: promoting primary prevention through education and training (pre-exposure), identifying high-risk populations based on the nature of traumatic events and other stressors (peri-exposure), and implementing the secondary prevention action of screening for significant trauma-related symptoms so that appropriate early interventions can be undertaken (postexposure). Module A, which immediately follows the Core Module, now provides detailed guidance on specific evidence-informed early interventions to promote recovery from both preclinical acute stress reactions (ASRs) and acute stress disorder (ASD), a possible clinical precursor of PTSD.

As we enter the second decade of war in Afghanistan and Iraq and the rolls of physical and psychological casualties continue to grow, the prevention of PTSD, suicide, violence, substance abuse, and other serious behavioral sequelae of war-zone stress have become a national mandate [2-3]. Over the past few years--since the first VA/ DOD Clinical Practice Guideline (CPG) for management of post-traumatic stress was released in 2004--countless new programs for prevention and resilience-building have been funded and launched in the VA, DOD, and military service branches, including their Active, Reserve, and National Guard components [4]. Besides being great in number, these new prevention programs for military personnel, veterans, and their families are highly diverse in their approaches. Some focus on pre-exposure education, training, and other interventions to promote resilience through multidomain fitness [5-6], while others provide tools for screening and early interventions to promote recovery postexposure [7]. Since the absolute and relative effectiveness of these diverse approaches to prevention have not yet been well studied, the value of expert, evidence-informed consensus recommendations such as those contained in the VA/DOD CPG can hardly be overstated.

Like its predecessor, the revised CPG assigns confidence grades to each of its recommendations in three dimensions: level of evidence, quality of evidence, and strength of recommendation (see Appendix, available online only). In general, stronger recommendations in the CPG are based on higher levels and quality of evidence. Where existing literature is lacking, ambiguous, or conflicting, CPG recommendations are based on consensus of the expert working group tasked with writing the CPG. Particularly in the area of prevention, where the literature has not kept pace with the need for effective programs, the CPG at times makes strong recommendations in the absence of randomized controlled trials incorporating the most relevant outcome measures.

METHODS

We reviewed the sections of the Core Module and Module A of the CPG that specifically address postexposure screening and early interventions for the prevention of PTSD. Included are definitions of the spectrum of preclinical and clinical acute stress states; methods for recognizing them in servicemembers, veterans, and family members; and approaches for early intervention to prevent them from progressing to PTSD and other potentially chronic trauma-related disorders. We compared the approach taken to prevention and early intervention in the CPG to the current framework for classifying prevention interventions developed by the National Research Council (NRC)-Institute of Medicine (IOM) Committee for the Prevention of Mental Disorders. …

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