This special issue, funded by the Veterans Health Administration’s (VA’s) Office of Patient Centered Care and Cultural Transformation, presents the most recent evidence from health services research on the use of complementary and alternative medicine (CAM) among US veterans and active military personnel. The National Institutes of Health’s National Center for Complementary and Alternative Medicine defines CAM, “simply as a group of diverse medical and health care interventions, practices, products, or disciplines that are not generally considered part of conventional medicine.”1 CAM may include acupuncture, massage, biofeedback, meditation, guided imagery, qi gong, herbs and nutritional supplements, aromatherapy, and energy healing (or Reiki).2 CAM is also more recently referred to as “integrative medicine” or “complementary and integrative medicine.”
Use and provision of CAM is common. In 2011, almost all (89%) VA medical facilities offered at least 1 of 31 types of CAM,3 whereas 29% of military treatment facilities offered 275 CAM programs in 2012.4 Studies report that per-year CAM usage among veterans or active military personnel ranges from 27% to 82%, which is similar to or slightly higher than that of the general population.5–13 CAM use could be common as some view antidepressants and opiates negatively because of their side effects, addictive nature, or modest efficaciousness. In addition, the evidence base for CAM is growing. Over 200 systematic reviews have been conducted on various CAM modalities’ effectiveness on chronic pain, anxiety, posttraumatic stress disorder (PTSD), or depression, common conditions among veterans and military members.14–58 Many concluded that some CAM modalities are moderately effective for these conditions, although studies’ methodological limitations often mitigate significant findings.
Two commentaries were invited for this supplement to describe efforts within the VA and the Department of Defense (DoD) to understand, and thereby foster, the use of CAM among veterans and active duty military personnel.
The first commentary, by Krecji,59 reports on the efforts of the VHA’s Office of Patient Centered Care and Cultural Transformation, which is fostering the use of evidence-based CAM, as CAM’s philosophical approach best aligns with the VHA’s, “number one strategic priority (which is) to provide personalized, proactive, patient driven health care to Veterans.” The second commentary, by Jonas60 from the Samueli Institute, one of the nation’s nonprofit leaders in CAM research, draws on DoD surveys of CAM use and provision to argue that, although almost half of service members use CAM in a year, the vast majority of CAM use occurs outside the military health care system. A recurring theme throughout this supplement is the extent to which veterans and active military seek CAM and pay out-of-pocket for some of it due to VA and military health care policies.
One of the most frequent uses of CAM within the VA and the DoD is as a therapy (adjunct or otherwise) for PTSD, a currently pervasive condition of major consequence among veterans and military personnel that presents challenges in its treatment. This supplement highlights 3 studies on mindfulness meditation (involving nonjudgmental attention to the present moment) and 1 study on loving-kindness meditation to address PTSD. Bormann et al61 examined the effects of a mantram repetition program compared with usual treatment on veterans with PTSD, with mantram being, “a sacred word or phrase that is silently repeated for cultivating mindfulness.” They found that program recipients experienced higher levels of mindfulness, and mindfulness-mediated treatment effects on depression and psychological well-being. Serpa et al62 examined what some consider the gold standard of mindfulness, mindfulness-based stress reduction (MBSR), among veterans. They too found that the MBSR program not only increased mindfulness, but mindfulness mediated the program effects to improve mental health outcomes. Bergen-Cico et al63 studied the effects of an abbreviated brief mindfulness program on cortisol levels of veterans with PTSD. Using random assignment to treatment as usual or the MBSR program, program users showed improved cortisol measurements. Kearney et al64 studied “Loving-Kindness Meditation (LKM), a CAM approach intended to develop an enhanced ability to experience kindness, openheartedness and compassion for self and others.” They found positive effects of a 12-week LKM class on outcomes such as personal growth, self-acceptance, and environmental mastery, among 42 veterans with PTSD.
Also addressing PTSD, Engel et al65 examined the effectiveness of acupuncture on military members’ posttraumatic stress symptoms in a randomized trial of PTSD usual care plus acupuncture compared with usual care alone. Results indicated that adjunctive acupuncture was effective at reducing PTSD symptoms and improved other conditions. Goldstein et al66 assessed the extent to which veterans substitute vitamins and supplements for prescription medications by conducting a cross-sectional survey of primary care VA patients. They found that 75% used vitamins and nutritional supplements, whereas almost half regularly substituted them for prescription medications.
A set of papers provide an understanding of how patients in the VA health care system perceive and use CAM in general. Brooks Holliday et al’s67 study is an important first look at how CAM utilization may differ across veteran groups being offered the same CAM clinic services, findings that may facilitate the development of strategies to increase CAM uptake. Reinhardt et al68 also examined differences in CAM usage between veterans deployed or not deployed to the Gulf War. Their longitudinal analysis determined that massage, chiropractic and relaxation therapies were the most commonly reported CAM modalities across both groups, and that CAM users sought CAM services outside the VA health care system, providing more evidence for the need for VA to offer within-system CAM services. Betthauser et al69 refined the 27-item Complementary, Alternative and Conventional Medicine Attitudes Scale (CACMAS)70 for use among veterans. They found that veterans with higher self-reported posttraumatic stress scores were more likely to report acceptability of CAM use.
Two reviews of the literature are included. Elwy et al71 reviewed 89 studies of CAM mind and body-practice interventions conducted in 8 countries with veterans and military personnel. Meditation practices, relaxation techniques, spinal manipulation, and acupuncture were the most frequently studied practices, whereas yoga, one of the most offered practices at the VA,3 is relatively understudied. Trotter Davis et al72 synthesized information across national and household surveys to examine CAM utilization among military members and veterans. Surveys indicated that dietary supplements were among the most commonly used CAM along with exercise therapy, massage, prayer, and relaxation.
Finally, 2 papers examined providers and CAM implementation. Fletcher examined VA providers’ CAM knowledge, attitudes and perceived value, barriers, and facilitators to CAM program implementation.73 Although providers ranged in their CAM knowledge, many perceived benefits for patients. Implementation barriers included perceived lack of evidence for CAM and absence of supportive leadership. Lisi et al74 examined the implementation of chiropractic care at VA clinics. They not only documented key clinic features and implementation processes, but examined variations in those, and the facilitators and barriers to implementation.
The articles in this supplement provide much needed information regarding the promise of CAM to improve the health of veterans and active military personnel. They mirror the countless stories we hear from veterans and their providers about the positive effect that CAM is having on their lives. The papers also address 4 of the 5 NCCAM Strategic Plan 2011–2015 objectives: (1) Advance Research on Mind and Body Interventions, Practices, and Disciplines, (2) Advance Research on CAM Natural Products, (3) Increase Understanding of “Real-World” Patterns and Outcomes of CAM Use and Its Integration Into Health Care and Health Promotion, and (4) Develop and Disseminate Objective, Evidence-Based Information on CAM Interventions (http://nccam.nih.gov/about/plans/2011).
However, the future is unclear for CAM research. That is, the evidence base for CAM is relatively nascent, although it is growing. One limiting factor to this growth might be the historically relatively low level of funding available for CAM research, which affects the ability of the field to meet NCCAM’s final strategic objective, that of Improving the Capacity of the Field To Carry Out Rigorous Research. Across the National Institutes of Health, FY2013 funding for CAM approached $380 million (http://nccam.nih.gov/about/budget/appropriations.htm). Although this funding was more than that provided to research on Parkinson disease, multiple sclerosis, and others, it was substantially less than that awarded to cancer, mental health, and cardiovascular research. Given the emerging evidence on the benefits of CAM approaches for these conditions, it is time for more funding to be awarded to CAM, both within the NIH and across other federal agencies and private foundations, to improve the capacity of the field to carry out rigorous CAM research, which in turn will benefit veterans and military personnel, as well as the general population.
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