Summary

In addition to providing health care to veterans, the Department of Veterans Affairs (VA) funds research that focuses on health conditions veterans may experience. According to VA, experts estimate that up to 20 percent of Operation Enduring Freedom and Operation Iraqi Freedom veterans have experienced post-traumatic stress disorder (PTSD) and demand for PTSD treatment is increasing. Because of the importance of research in improving the services that veterans receive, GAO was asked to report on VA's funding of PTSD research, and its processes for funding PTSD research proposals, reviewing and incorporating research outcomes into clinical practice guidelines (CPG)--tools that offer clinicians recommendations for clinical services but do not require clinicians to provide one service over another--and determining which PTSD services are required to be made available at VA facilities. To do this work, GAO obtained and summarized VA data on the funding of PTSD research from its medical and prosthetic research appropriation through its intramural research program. GAO also reviewed relevant VA documents, such as those for developing CPGs and those related to VA's 2008 Uniform Mental Health Services in VA Medical Centers and Clinics handbook (Handbook), which defines certain mental health services that must be made available at VA facilities. GAO also interviewed VA officials.

Based on VA data GAO obtained and summarized, GAO found that the amount of funding VA provided for intramural PTSD research increased from $9.9 million in fiscal year 2005 to $24.5 million in fiscal year 2009. From fiscal year 2005 through fiscal year 2009, intramural PTSD research funding ranged from 2.5 percent to 4.8 percent of VA's medical and prosthetic research appropriation. In addition, the number of PTSD research studies VA funded through the Merit Review Program and the Cooperative Studies Program (CSP)--VA's two primary funding mechanisms in its intramural research program--increased from 47 in fiscal year 2005 to 96 in fiscal year 2009. According to VA officials, intramural research proposals, including those on PTSD, are funded primarily according to scientific merit in both the Merit Review Program and CSP. Proposals are evaluated by a panel of reviewers and scored based on their scientific merit. Directors of VA's research and development services--offices that focus on different research areas and administer VA's intramural research program--fund proposals based on their scores, typically up to a specified percentile. The number of proposals funded may vary based on budgetary considerations and, for a small number of proposals, responsiveness to VA research priority areas. VA has a process to review and incorporate relevant research outcomes to develop CPGs for a number of topics, including PTSD. VA relies on the policies of a joint VA and Department of Defense (DOD) work group--comprised of VA and DOD officials--to ensure that systematic reviews of relevant research outcomes are conducted when issuing CPGs. In brief, a systematic review is conducted to identify the most methodologically rigorous research studies that are applicable to each clinical question contained in the CPG. A group of subject matter experts then assesses the individual research studies in order to determine the overall quality of evidence available for each particular clinical question, considers the potential benefits and harms of a clinical intervention to determine its net effect, and, based on an assessment of the overall quality of the evidence and the net effect of an intervention, develops recommendations for the CPG. According to VA officials, the decision to require that two PTSD services--cognitive processing therapy and prolonged exposure therapy--be made available at VA facilities by including them in the Handbook was based on a review of research outcomes and the availability of existing resources. Specifically, VA officials told GAO that these two services were strongly recommended in the 2004 PTSD CPG and had greater evidence supporting their effectiveness than other PTSD services. VA also told GAO that prior to the Handbook's 2008 issuance, VA had already begun investing resources in training programs for cognitive processing therapy in 2006 and prolonged exposure therapy in 2007. While VA provided some documentation regarding the decision-making process for PTSD services, VA officials explained that clinical decision-making processes are not typically expected to be documented in a formal manner. VA officials told GAO that they are currently clarifying language in the Handbook but do not plan to revise any requirements relating to PTSD services at this time. VA provided technical comments that GAO incorporated as appropriate.