treating veterans’ chronic pain and mental health disorders: an integrative, patient-centered...

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ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2013.19305 • MARY ANN LIEBERT, INC. • VOL. 19 NO. 3JUNE 2013

While chronic pain and mental health disorders are major health care issues affecting all sectors of society, treating such conditions poses special challenges for the United States mili-tary because of its unique mission, nature of its service popu-lation, and the structure of its health care system. This article reviews efforts to meet these challenges in an integrated man-ner, in the contexts of government initiatives, veterans’ needs, and current health care paradigms.

Demographic and Epidemiologic Contexts

The Veterans Administration (VA) operates the largest inte-grated health care system in the United States. Approximately 8.3 million veterans are eligible to receive treatment by the VA, and 5.4 million of those veterans were treated by the VA in fiscal year 2011.1 There are more than 53,000 independent licensed health care practitioners in the VA system of 152 medical cen-ters and nearly 1400 community-based outpatient clinics, vet-eran readjustment counseling centers, community living centers, and domiciliaries.2 Domiciliaries are places where veterans, in-cluding homeless ones, receive residential-based rehabilitation.

About 1.2 million veterans received mental health ser-vices from VA facilities in fiscal year 2010 (the most recent year for which such data have been reported). Of these pa-tients, 408,167 were treated for post-traumatic stress disorder (PTSD), up from nearly 255,000 in fiscal year 2006.3 How-ever, according to a survey of VA service providers, this number may account for just half of military patients diagnosed with PTSD or major depression.3

It has been estimated that up to 20% of the 2 million troops who have been deployed to Iraq and Afghanistan may require treatment for PTSD.4 Overall, PTSD prevalence at VA pri-mary care clinics has been 11.5%. This percentage far exceeds the estimated lifetime prevalence for the disorder of 7.8% in the civilian population.5 In addition, the spouses of war veter-ans diagnosed with PTSD may develop secondary PTSD and other mental disorders.6

Approximately 27% of soldiers returning from deployment in Iraq met criteria for substance abuse.7 About 14% of veter-ans have been diagnosed with major depression, but this disor-der is probably underdiagnosed in this population, because the symptoms of depression and PTSD overlap, and less stigma may be attached to the latter condition.8 In 2012, the military suicide rate reached an all-time high, exceeding the number of combat deaths in Afghanistan.9 See Chronic Pain and Mental Health Disorders in Veterans: Selected Statistics.

A Paradigm Shift

In August 2009, the Army Surgeon General chartered the Army Pain Management Task Force to make recommenda-tions for a comprehensive pain management strategy using a biopsychosocial model of care “that was holistic, multidisci-plinary, and multimodal in its approach. . . .” With representa-tives from the Army, Navy, Air Force, TRICARE Management (the Department of Defense [DoD]–run medical system), and the VA, the Task Force addressed the challenges of chronic pain management for a patient population whose experience of pain may be complicated by several factors: PTSD, combat in-juries, and/or substance abuse; a culture of peer pressure to not seek help; fragmented services; and overreliance on potentially addicting prescription medications.10 Col. Kevin Galloway, BSN, MHA, chief of staff of the Task Force, commented that opioids have been the standard used in military medicine since the Civil War “to knock that pain down to zero. . . .Medicine is still saying it’s doing its job because the pain is controlled, but this person’s quality of life is probably not what [is wanted], definitely not what the spouse wants it to be, [and] not what [the] family want[s] it to be.”11

Col. Galloway stated further: “There needs to be a shift in the entire objective of pain management. . . .There’s tre-mendous potential to touch a lot of lives with effective, non-pharma[ceutical] therapeutic approaches. . . . The ‘H-word’ [holistic] is no longer forbidden in military medical culture.”

Treating Veterans’ Chronic Pain and Mental Health Disorders

Sala Horowitz, PhD

An Integrative, Patient-Centered Approach

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ALTERNATIVE AND COMPLEMENTARY THERAPIES • JUNE 2013

MARY ANN LIEBERT, INC. • VOL. 19 NO. 3

Although an unprecedented number of wounded soldiers (~ 95%) are surviving, according to Col. Galloway, “once they are out of acute danger, many veterans end up [with] dire physical and mental health. In addition to the addic-tion problems, and the unresolved debilitating pain, the risk of depression and suicide is far higher among [veterans] returning from Iraq and Afghanistan than in the general population.”

Yet, soldiers are also seeking alternatives to drugs for pain. The Task Force worked with The Bravewell Collaborative (see Resources), a leading integrative medicine philanthropic orga-nization, to develop interdisciplinary centers within the armed forces.12 Multidisciplinary treatment approaches are particu-larly warranted because of the high rate of comorbidity among veterans with chronic pain, PTSD, and traumatic brain injury (TBI) that has resulted from the nature of recent combat op-erations in Iraq and Afghanistan.13 The prevalence of TBI is much greater in these operations than in previous modern military conflicts.14

This initiative is aimed at preventing acute pain problems from progressing to harder-to-manage chronic conditions and to improve function and quality of life. The Task Force recognizes that part of the appeal of complementary and alternative medicine (CAM) is that CAM incorporates all aspects of the individual, family, and community, as well as providing the opportunity for greater patient involvement in

individualized health care. The final report’s 100-plus recom-mendations focus on four main areas of objectives:10

(1) Building a full spectrum of best practices—including CAM approaches—for the continuum of acute and chronic pain, based on the best available evidence

(2) Providing tools and infrastructure that collaboratively support and encourage practice and research advancements in pain management

(3) Synchronizing a culture of pain awareness, education, and proactive intervention

(4) Sustaining each service member and family.

With respect to incorporating CAM modalities into an in-tegrative approach for patient-centered plans of care, the Task Force recommended adopting a tiered approach—according to levels of scientific evidence supporting efficacy, safety, and widespread use—to integrating CAM approaches to augment pain management. These modalities are divided into “passive” and “active” therapies. For example, clinic-based acupuncture is considered to be passive, whereas self-administered acupres-sure is considered to be active.10

To support the substantial interest in incorporating CAM approaches in VA and DoD care settings, the National In-stitutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM) in Bethesda, Maryland, recently made supplemental grants available to encourage VA/DoD researchers and clinicians to collaborate on CAM approaches for pain management.15 In a separate but related effort, the Institute of Medicine in Washington, D.C., in its Consensus Report on “Relieving Pain in America: A Blue-print for Transforming Prevention, Care, Education, and Research,” noted that patients with severe persistent pain should obtain care from an interdisciplinary team using an integrated approach.16

Conceptual Contexts

Treating Pain as “a Disease in Its Own Right”As with the civilian American population, pain is the most

frequent reason for which active members of the armed forces and veterans seek health care. The International Association for the Study of Pain (IASP; see Resources) has recommended that chronic and recurrent pain be recognized as a disease in its own right.17 There is accruing evidence indicating that per-sistent pain—caused by continuing nociceptive inputs that can produce a cascade of consequences from mood dysfunction to inappropriate cognition and behavior—cannot be regarded as a passive symptom.18 Data from neuroimaging studies, show-ing changes in brain structure and function, further support the conceptualization of chronic pain as a disease entity.19

The military has promoted recognition of pain as the “fifth vital sign” (in addition to the four standard vital signs of body temperature, pulse or heart rate, blood pressure, and respiratory rate).20 With regard to chronic pain, Steven P. Cohen, MD,

Chronic Pain and Mental Health Disorders in Veterans

Selected Statistics

• Chronic pain—Nearly 50% of veterans report that they expe-rience pain on a regular basis.15

• PTSD—This disorder occurs in 5%–25% of service members who have been deployed to combat zones and in 3%–6% of service members with no deployment experience.33 An estimated 20% of troops deployed to Iraq and Afghanistan may require treatment for PTSD.4 This compares to 8% of the civilian population.5

• TBI—There have been 266,810 cases in the Armed Forces from 2000 to 2012.a

• Suicide—Veterans account for 10% of U.S. adults but 20% of suicides.b

• Abuse—Of soldiers returning from deployment in Iraq, 27% met criteria for substance abuse.7

• Major depression—Depression has been diagnosed in 14% of veterans, but this condition may be underdiagnosed in this population.8

Sources are references except as noted below.

aMilitary Health System. DoD Worldwide Numbers for Traumatic Brain Injury. Online document at: www.health.mil/Research/TBI_Numbers.aspx Accessed April 12, 2013.

bGibbs N, Thompson M. The War on Suicide? Time, July 23, 2012. Online docu-ment at: www.time.com/magazine/article/0,9171,2119337,00.html Accessed December 9, 2012.

PTSD, post-traumatic stress disorder; TBI, traumatic brain injury.

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director of pain research at Walter Reed National Military Medical Center, in Bethesda, MD, commented: “With some people, we run all the tests but just can’t figure out what’s caus-ing the pain. We can’t come up with a diagnosis.”21

A Patient-Centered Care ModelAs a term thought to have been coined in 1969 by British

psychoanalyst Enid Balint, patient-centered medicine con-trasts with biomedicine’s illness-oriented care by focusing on the patient’s needs and concerns rather than on the patient’s pathophysiology and physician’s objectives. The concept of the “patient as consumer” also supports this trend.22 Similar to the model inherent in CAM and the current trend in the main-stream private health care sector, the VA is transforming its health care system to move away from problem-based disease treatment to patient-focused care. Whereas the VA’s approach to treatment of substance abuse was formerly considered out-dated, as noted in one article written last year,23 in another ar-ticle in the same publication in the same year, the more-recent, updated VA health system was cited by health care quality ex-perts as a model for patient-centered care.24

The VA Health System is committed to leading the trans-formation of health care for its veterans and for the country. To help facilitate this change, the VHA established the Of-fice of Patient Centered Care and Cultural Transformation. “Reactive, physician-centered care will be a thing of the past as [the] VA designs and delivers a twenty-first century health care delivery system that is based in lifelong planning and support, and centered on the veteran patient,” explained Tracy Gaudet, MD, director of the VA’s Office of Patient Centered Care and Cultural Transformation,* established shortly after the Pain Management Task Force convened.25 This personalized, pro-active approach to health is based on the VA’s vision for trans-formation, veterans’ goals for their lives and their health, and developing psychologic safety to explore new dimensions of health care.26

To truly transform the system, Dr. Gaudet believes that:

[u]ntil we employ a personalized strategy that considers the veteran’s unique conditions, needs, and circumstances, addressing the full range of physical, emotional, mental, social, spiritual and environmental influences, we will not optimally help our veterans to minimize disease or regain and maintain their health.27

She adds: “In the past we asked, what can we fix? Today we say, how can I help what’s wrong with you? In the future, we need to say, how can I help you live your life fully?”27

A “patient-centered medical home” is another term increas-ingly being applied to an integrated health care model in both civilian and military health care that places the patient, who may have multiple chronic conditions, at the center of atten-

tion. The evidence-based model is predicated upon ongoing patient access to a continuum of care by a multidisciplinary team coordinated by the primary care physician and assistance with navigating a complex health care system.28 Collabora-tion with behavioral- and addiction-medicine specialists in a patient-centered medical home is intended to overcome the significant hurdles encountered when treating chronic pain in primary-care settings, which rely on pharmacologic and inter-ventional therapies.29

One study revealed that a significant number of veterans with depression (n = 550 from a baseline sample of a group-random-ized trial of collaborative care for depression in ten VA primary-care practices) utilized both VA and non-VA services. Therefore,

*Dr. Gaudet was formerly the executive director of Duke Integra-tive Medicine at Duke University Medical Center in Durham, North Carolina.

Resources

Organizations

The Bravewell Collaborative 1818 Oliver Avenue South Minneapolis, MN 55405 E-mail: [email protected] Website: www.bravewell.org

This philanthropic organization works to transform health care in the United States by supporting adoption of the best practices of integrative medicine.

International Association for the Study of Pain (IASP) 1510 H Street NW, Suite 600 Washington, DC 20005-1020 Phone: (202) 524-5300 Fax: (202) 524-5301 E-mail: [email protected]

The IASP is a professional forum for science, clinical practice, and education in the field of pain.

National Center for PTSDUnited States Department of Veterans Affairs

White River Junction, Vermont (headquarters) VA Medical Center (116D) 215 North Main Street White River Junction, VT 05009 Phone: (802) 296-6300 (PTSD information voice mail) Fax: (802) 296-5135 E-mail: [email protected] Website: www.ptsd.va.gov/about/divisions/executive-division.asp

The National Center for PTSD [post-traumatic stress disorder] conducts research into the causes, prevention, assessment, and treatment of traumatic stress disorders. The Center maintains collaborative ties with other government agencies, academia, and clinicians. Research focuses on psychotherapy and disaster mental health. The Division produces PTSD Research Quarterly. The Center consists of seven academic centers of excellence, headquartered in White River Junction, Vermont. Other divi-sions are located in Boston, Massachusetts, West Haven, Con-necticut, Palo Alto, California, and Honolulu, Hawaii.

Recommended reading

Healing War Trauma: A Handbook of Creative Approaches (Routledge Psychosocial Stress series) Edited by Raymond Monsour Scurfield, DSW, LCSW, and Colonel Katherine Theresa Platoni, PsyD New York: Routledge, 2012

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case management strategies for such patients should recognize the need for communication and coordination between VA and non-VA providers.30 A review of a large health insurance data-base of the general population found that patients with better continuity of care had lower emergency services utilization and hospitalization rates, and better care outcomes.31

A U.S. army memo from last year, entitled “Policy Guidance on the Assessment and Treatment of Post-Traumatic Stress Disorder (PTSD)” (Army Medical Command Memo 12-035, dated April 10, 2012), spelled out how a patient-centered care approach is being advocated to standardize the diagnosis and treatment of PTSD and other mental-health problems in active duty and retired military personnel.32 Because of con-tinuing societal stigma, previous models focused on identify-ing malingerers, and other barriers prevented the diagnosis of PTSD. The memo reflects the military’s concern with this problem and how it can be addressed: “It is critical that Army behavioral health professionals do everything they can to ad-vocate for and provide care in a patient-centered manner that reassures patients that they will not be judged and that their primary concerns will be addressed.”32

The VA and other branches of the armed services are also standardizing treatment; while still on active duty, service members are being guided through the transition to VA health care for continuity of care. According to Major General Rich-

ard W. Thomas, MD, DDS, FACS, Commanding General, Western Regional Medical Command, “the Army has devel-oped a collaborative relationship across the medical spectrum in its efforts to find the best treatment possible. For example, surgeons are seeing patients, alongside psychologists, and even practitioners trained in yoga, massage and acupuncture.” Ef-forts are also being made to overcome the stigma still associ-ated with seeking help for mental disorders.33

In accord with this approach, a team of specialists meets at the Walter Reed National Military Medical Center in Bethesda, Maryland, to assess the progress of every wounded armed forces member undergoing treatment at the hospital. Because the team sees all patients, problems are identified early, and the stigma of seeing mental health professionals is eliminated.34

With respect to PTSD, Henri Roca III, MD, assistant pro-fessor of medicine at Louisiana State University (LSU) in New Orleans, and chief of LSU’s Integrative Medicine pro-gram, says that “all the pills in the world won’t solve PTSD. You simply have to take a holistic approach.” For example, a fourth-year student at Bastyr University, in Kenmore, Wash-ington, applied CranioSacral and other naturopathic medical

skills to military personnel in need when her National Guard unit was shipped out to an airbase near Fallujah, Iraq.35 This approach is important, because studies suggest that there is a relationship between combat or war trauma—frequently as-sociated with PTSD—and suicide.36

Veterans’ Utilization of CAM

An estimated 25–50 million civilian Americans experi-ence chronic pain, and many of those seek CAM treatment. While military veterans utilize the VA system seeking relief from chronic pain, they too utilize CAM outside the system. A randomized study of CAM use among 401 veterans who par-ticipated in a collaborative intervention for chronic noncancer pain at five Department of Veterans Affairs primary-care clin-ics, compared CAM users with non-CAM users.37

As part of the Study of the Effectiveness of a Collabora-tive Approach to Pain, the survey showed that a majority of the sampled veterans (82%) reported prior use of at least one CAM modality, and nearly all (99%) were willing to try CAM treatment for pain. Four CAM modalities were con-sidered in this study: massage therapy; herbal medicines; acupuncture; and chiropractic. Massage therapy was the most preferred option (97%) and chiropractic was the least preferred (75%) option.37

CAM users were less likely to have service-connected dis-abilities. These users reported having spent a larger portion of their lives in pain than non-CAM users. The researchers concluded that this disparity might have been the result of a history of lack of access to such modalities at VA facilities, but that these results supported the efforts of the VA to increase access to CAM options for veterans. The researchers also stat-ed: “This is in contrast to our expectations that among veterans with chronic pain, use of CAM would be driven by dissatis-faction with, or a perceived lack of effectiveness of, available treatment options for pain.” They added: “These results sug-gest that veteran patients with chronic pain may use CAM, not as a reaction to perceived inadequacies of conventional care, but rather as an additional tool in pain management.”37

CAM modalities are also attractive to veterans with PTSD and other mental health problems as an alternative to cog-nitive behavioral therapy (CBT), the psychologic therapy primarily used in the VA system to treat such disorders. Raymond Monsour Scurfield, DSW, LCSW, the founding director of the VA’s National Center for PTSD division in Honolulu, Hawaii (see Resources), and Colonel Katherine Theresa Platoni, PsyD, a psychology consultant to the chief of the Medical Service Corps, are both veterans who work with military personnel who have mental health problems. These two clinicians noted that many soldiers do not respond well to standard office-based forms of psychotherapy, such as CBT, because they do not always take into account the unique dynamics, needs, and challenges of this population. “Action-oriented” CAM therapies that have been shown to have an appeal for veterans with psychologic issues include:

Efforts are being made to overcome the stigma still associated with

seeking help for mental disorders.

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culture- or community-specific rituals; expressive-experien-tial approaches (e.g., creative arts therapy, mindfulness prac-tice, and cranial electrotherapy stimulation); animal-assisted and outdoor activity–focused programs; spirituality-based therapies; and virtual-reality simulations.38

In a study of returning combat-exposed active duty mili-tary (N = 123) with PTSD randomly assigned to 6 sessions within 3 weeks of either healing touch with guided imagery or usual care, the CAM intervention produced a clinically sig-nificant reduction in PTSD and related symptoms.39 In case

reports, Chinese scalp therapy—1–2 times per week for 1–4 weeks—relieved pain and restored function in soldiers with complex regional pain syndrome; the soldiers had sustained extremity injuries during combat and had not been helped by conservative treatment. Symptoms of the syndrome include neuropathic pain, sensory changes, and decreased range of motion. The treatment response was sustained at a 20-month follow-up.40

Conclusion

Studies indicate that veterans, just like civilians, frequently seek out CAM modalities for relief from chronic pain and mental-health disorders. In recognition of the complex na-ture of chronic pain and the prevalence of military personnel and veterans with such conditions—often multiple chronic conditions—the U.S. military has launched initiatives to serve its wounded warriors better that entail an integrated, patient-centered approach. n

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6. Klarić M, Frančišković T, Obrdalj EC, et al. Psychiatric and health impact of primary and secondary traumatization in wives of veterans with posttrau-matic stress disorder. Psychiatric Danub 2012;24:280–286.7. National Institute on Drug Abuse. Topics in Brief: Substance Abuse Among the Military, Veterans, and their Families. Online document at: www.druga-buse.gov/publications/topics-in-brief/substance-abuse-among-military-vet erans-their-families Accessed January 24, 2013.8. National Alliance on Mental Illness. Fact Sheet: Depression and Veterans. Online document at: www.nami.org/Template.cfm?Section=Depression&Template=/ContentManagement/ContentDisplay.cfm&ContentID=88939 Ac-cessed December 19, 2012.9. PBS NewsHour. News Wrap: Military Suicides Outnumbered Combat Deaths in Afghanistan in 2012. January 14, 2013. Online document at: www.pbs.org/newshour/bb/military/jan-june13/othernews_01-14.html Accessed January 24, 2013.10. Office of the Army Surgeon General, Pain Management Task Force. Pro-viding a Standardized DoD and VHA Vision and Approach to Pain Man-agement to Optimize the Care for Warriors and their Families: Final Report May 2010. Online document at: www.amedd.army.mil/reports/Pain_Man agement_Task_Force.pdf Accessed April 12, 2013.11. Garamone J. U.S. Department of Defense. Military Medicine Works on Managing Pain. Online document at: www.defense.gov/news/newsarticle.aspx?id=65812 Accessed January 24, 2013.12. Goldman E. Holistic Medicine is Military’s New Marching Order. Online document at: www.holisticprimarycare.net/topics/topics-h-n/news-policy-a- economics/1339-holistic-medicine-is-miltrys-new-marching-order Accessed December 9, 2012.13. Otis JD, McGlinchey R, Vasterling JJ, Kerns RD. Complicating fac-tors associated with mild traumatic brain injury: Impact on pain and post-traumatic stress disorder treatment. J Clin Psychol Med Settings 2011;18: 145–154.14. MacGregor AJ, Dougherty AL, Galameau MR. Injury-related correlates of combat-related traumatic brain injury in Operation Iraqi Freedom. J Head Trauma Rehabil 2011;26:312–318.15. National Center for Complementary and Alternative Medicine. Integrative Ap-proaches to Managing Pain and Co-Morbid Conditions in U.S. Military Person-nel, Veterans, and their Families. June 1, 2012. Online document at: http://nccam. nih.gov/grants/concepts/consider/military Accessed December 12, 2012.16. Institute of Medicine. Relieving Pain in America: A Blueprint for Trans-forming Prevention, Care, Education, and Research. June 29, 2011. Online document at www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx Ac-cessed April 12, 2013.17. The International Association for the Study of Pain, European Federation of IASP Chapters. EFIC’s Declaration on Chronic Pain as a Major Health-care Problem, a Disease in Its Own Right. Online document at: www.iasp- pain.org/AM/Template.cfm?Section=Press_Release&Template=CM/Con tentDisplay.cfm&ContentID=2915 Accessed January 24, 2013.18. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg 2004;99:510–520.19. Tracey I, Bushnell MC. How neuroimaging studies have challenged us to rethink: Is chronic pain a disease? J Pain 2009;10:1113–1120.20. Department of Veterans Affairs. Take 5: Pain as the 5th Vital Sign Tool-kit, rev ed. October 2000. Online document at: www.va.gov/PAINMANAGE MENT/docs/TOOLKIT.pdf Accessed January 14, 2013.21. Griffin RM. Myths about Treating Chronic Pain. Online document at: www.webmd.com/pain-management/chronic-pain-11/myths-facts Accessed Decem-ber 9, 2012.22. Bardes CL. Perspective: Defining “patient-centered medicine.” N Engl J Med 2012;366:782–783.23. Kuehn BM. Treatment of substance abuse in military hampered by “old-fashioned” approach. JAMA 2012;308:1845–1846.

Chinese scalp therapy relieved pain and restored function in soldiers

with complex regional pain syndrome.

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24. Kuehn BM. Veterans’ health system cited by experts as a model for patient-centered care. JAMA 2012;307:442–443.25. United States Department of Veterans Affairs. Health Care: VA’s New Mantra: Treat the Patient, Not the Disease. Online document at: www.va.gov/health/NewsFeatures/20120301a.asp Accessed November 20, 2012.26. U.S. Medicine. What Does the Future Look Like for VA Healthcare? Online document at: www.usmedicine.com/outlook/what-does-the-future-look-like-for-va-healthcare.html Accessed December 8, 2012.27. United States Department of Veterans Affairs. Health Care: Patient Cen-tered Care. A Transformation of Health Care. Reviewed/Updated: August 23, 2012. Online document at: www.va.gov/health/NewsFeatures/20120827a.asp Accessed November 26, 2012.28. American Academy of Family Physicians. The Patient-Centered Medical Home: A Better Approach to Healthcare. Online document at: www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/background/pcmhonep ager.Par.0001.File.tmp/PCMH-one-page.pdf Accessed January 15, 2013.29. Brensilver M, Tariq S, Shoptaw S. Optimizing pain management through collaborations with behavioral and addiction medicine in primary care. Prim Care 2012;39:661–669.30. Chuan-Fen L, Bolkan C, Chan D, et al. Dual use of VA and non-VA ser-vices among primary care patients with depression. J Gen Intern Med 2009; 24:305–311.31. Chan CL, You HJ, Huang HT, Ting HW. Using an integrated COC index and multilevel measurements to verify the care outcome of patients with mul-tiple chronic conditions. BMC Health Serv Res 2012;12:405.32. Department of the Army, Headquarters, United States Army Medical Command, Memorandum for Commanders, Medcom Regional Medical Commands. Policy Guidance on the Assessment and Treatment of Post-Traumatic Stress Disorder (PTSD). April 10, 2012. Online document at:

cdn.govexec.com/media/gbc/docs/pdfs_edit/042312bb1.pdf Accessed April 12, 2013.33. Vergun D. Army Standardizes PTSD Diagnosis, Treatment. Army News Service. August 3, 2012. Online document at: www.army.mil/article/84928 Accessed January 15, 2013.34. Miles D. Collaboration Improves Treatment of Unseen Scars of War. September 23, 2010. Online document at: www.defense.gov/news/newsar-ticle.aspx?id=60974 Accessed January 24, 2013.35. Goldman EL. Holism in Action: Natural Medicine Responds to Di-saster. Online document at: www.holisticprimarycare.net/topics/topics-o-z/reflections/199-holism-in-action-natural-medicine-responds-to-disaster Ac-cessed January 24, 2013.36. United States Department of Veterans Affairs, National Center for PTSD. The Relationship Between PTSD and Suicide. Online document at: www.ptsd.va.gov/professional/pages/ptsd-suicide.asp Accessed December 9, 2012.37. Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. J Rehabil Res Dev 2011;48:1119–1128.38. Scurfield RM, Platoni KT. Healing War Trauma: A Handbook of Creative Approaches. New York: Routledge, 2013.39. Jain S, McMahon GF, Hasen P, et al. Healing touch with guided imagery for PTSD for returning active duty military: A randomized controlled study. Mil Med 2012;177:1015–1021.40. Hommer DH. Chinese scalp acupuncture relieves pain and restores func-tion in complex regional pain syndrome. Mil Med 2012;177:1231–1234.

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