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.
1. National Center for Complementary and Alternative Medicine; NIH. Available at: http://nccam.nih.gov/about/plans/2011/introduction.htm
. Accessed August 1, 2014.
2. Kaptchuk TJ, Eisenberg DM. Varieties of healing, II: a taxonomy of unconventional healing practices. Ann Intern Med. 2001;135:196–204.
3. Ezeji-Okoye SC, Kotar TM, Smeeding SJ, et al.. State of care: complementary and alternative medicine in Veterans Health Administration—2011 survey results. Fed Pract. 2013;30:14–19.
4. Integrative Medicine in the Military Health System Report to Congress. 2014.Washington, DC: Department of Defensehttp://tricare.mil/tma/congressionalinformation/downloads/Military%20Integrative%20Medicine.pdf
. Accessed August 1, 2014.
5. Baldwin CM, Long K, Kroesen K, et al.. A profile of military veterans in the southwestern United States who use complementary and alternative medicine: implications for integrated care. Arch Intern Med. 2002;162:1697–1704.
6. Smith T, Ryan M, Smith B, et al.. Complementary and alternative medicine use among US Navy and Marine Corps personnel. BMC Complement Altern Med. 2007;7:16.
7. Jonas WB, Welton RC, Delgado RE, et al.. CAM in the United States Military: too little of a good thing? Med Care. 2014;52suppl 5S9–S12.
8. Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine use among individuals with posttraumatic stress disorder. Psychol Trauma. 2013;5:277–285.
9. McEachrane-Gross FP, Liebschutz JM, Berlowitz D. Use of selected complementary and alternative medicine (CAM) treatments in veterans with cancer or chronic pain: a cross-sectional survey. BMC Complement Altern Med. 2006;6:34.
10. 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.
11. Barnes P, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. 2008;12:1–23.
12. Eisenberg DM, Davis RB, Ettner SL, et al.. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998;280:1569–1575.
13. Wolsko PM, Eisenberg DM, Davis RB, et al.. Use of Mind–Body Medical Therapies. Results of a National Survey. J Gen Intern Med. 2004;19:43–50.
14. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011;152:755–764.
15. Chou R, Huffman L. Nonpharmacological therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:493–504.
16. Xu M, Yan S, Yin X, et al.. Acupuncture for chronic low back pain in long-term follow-up: a meta-analysis of 13 randomized controlled trials. Am J Chin Med (Gard City N Y). 2013;41:1–19.
17. Ernst E, Lee MS, Choi TY. Acupuncture for depression?: A systematic review of systematic reviews. Eval Health Prof. 2011;34:403–412.
18. Furlan AD, Yazdi F, Tsertsvadze A, et al.. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2012;2012:953139.
19. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005;2:CD005319.
20. Hopton A, MacPherson H. Acupuncture for chronic pain: is acupuncture more than an effective placebo? A systematic review of pooled data from meta-analyses. Pain Pract. 2010;10:94–102.
21. Hutchinson AJ, Ball S, Andrews JC, et al.. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg. 2012;7:36–44.
22. Myers CD, White BA, Heft MW. A review of complementary and alternative medicine use for treating chronic facial pain. J Am Dent Assoc. 2002;133:1189–1196.
23. Rubinstein SM, van Middelkoop M, Kuijpers T, et al.. A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain. Eur Spine J. 2010;19:1213–1228.
24. Terhorst L, Schneider MJ, Kim KH, et al.. Complementary and alternative medicine in the treatment of pain in fibromyalgia: a systematic review of randomized controlled trials. J Manipulative Physiol Ther. 2011;34:483–496.
25. Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: a systematic review of the evidence. J Alternat Complement Med. 2011;17:83–93.
26. Kozasa EH, Tanaka L, Monson C, et al.. The effects of meditation-based intervention on the of fibromylgia. Curr Pain Headache Rep. 2012;16:383–387.
27. Reiner K, Tibi L, Lipsitz J. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013;14:230–242.
28. Dryden T, Baskwill A, Preyde M. Massage therapy for the orthopaedic patient: a review. Orthop Nurs. 2004;23:327–332.
29. Kalichman L. Massage therapy for fibromyalgia symptoms. Rheumatol Int. 2010;30:1151–1157.
30. Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007;8:359–375.
31. Posadzki P, Ernst E. Yoga for low back pain: a systematic review of randomized clinical trials. Clin Rheumatol. 2011;30:1257–1262.
32. Carroll D, Seers K. Relaxation for the relief of chronic pain: a systematic review. J Adv Nurs. 1998;27:476–487.
33. Kwekkeboom K, Gretardottir E. Systematic review of relaxation intervention for pain. J Nurs Scholarsh. 2006;38:57–64.
34. Dissanayake R, Bertouch J. Psychosocial interventions as adjunct therapy for patients with rheumatoid arthritis: a systematic review. Int J Rheum Dis. 2010;13:324–334.
35. Medlicott MS, Harris SR. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Phys Ther. 2006;86:955–973.
36. Bernardy K, Fuber N, Klose P, et al.. Efficacy of hypnosis/guided imagery in fibromyalgia syndrome—a systematic review and meta-analysis of controlled trials. BMC Musculoskelet Disord. 2011;12:133.
37. Posadzki P, Ernst E. Guided imagery for musculoskeletal pain: a systematic review. Clin J Pain. 2011;27:648–653.
38. Engwall M, Duppils G. Music as a nursing intervention for postoperative pain: a systematic review. J Perianesth Nurs. 2009;24:370–383.
39. Reed R, Ferrer L, Villegas N. Natural healers: a review of animal assisted therapy and activities as complementary treatment for chronic conditions. Rev Lat Am Enfermagem. 2012;20:612–618.
40. Smith CA, Hay PP, Macpherson H. Acupuncture for depression. Cochrane Database Syst Rev. 2010;1:CD004046.
41. Zhang ZJ, Chen HY, Yip KC, et al.. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. J Affect Disord. 2010;124:9–21.
42. Fjorback LO, Arendt M, Ornbol E, et al.. Mindfulness-based stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled trials. Acta Psychiatr Scand. 2011;124:102–119.
43. Piet J, Hougaard E. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis. Clin Psychol Rev. 2011;31:1032–1040.
44. Jorm AF, Morgan AJ, Hetrick SE. Relaxation for depression. Cochrane Database Syst Rev. 2008;4:CD007142.
45. Chan MF, Wong ZY, Thayala NV. The effectiveness of music listening in reducing depressive symptoms in adults: a systematic review. Complement Ther Med. 2011;19:332–348.
46. Berget B, Braastad B. Animal-assisted therapy with farm animals for persons with psychiatric disorders. Ann Ist Super Sanita. 2011;47:384–390.
47. Toneatto T, Nguyen L. Does mindfulness mediation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52:260–266.
48. Clucas C, Sibley E, Harding R, et al.. A systematic review of interventions for anxiety in people with HIV. Psychol Health Med. 2011;16:528–547.
49. Kim YD, Heo I, Shin BC, et al.. Acupuncture for posttraumatic stress disorder: a systematic review of randomized controlled trials and prospective clinical trials. Evid Based Complement Alternat Med. 2013;2013:615857.
50. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). The Cochrane Library. 2007
51. Mays KL, Clark DL, Gordon AJ. Treating addiction with tunes: a systematic review of music therapy for the treatment of patients with addictions. Subst Abus. 2008;29:51–59.
52. Cao H, Pan X, Li H, et al.. Acupuncture for treatment of insomia: a systematic review of randomized controlled trials. J Alternat Complement Med. 2009;15:1171–1186.
53. Cheuk DK, Yeung WF, Chung KF, et al.. Acupuncture for insomnia. Cochrane Database Syst Rev. 2007;3:CD005472.
54. Huang W, Kutner N, Bliwise DL. A systematic review of the effects of acupuncture in treating insomnia. Sleep Med Rev. 2009;13:73–104.
55. Lee MS, Shin BC, Suen LK, et al.. Auricular acupuncture for insomnia: a systematic review. Int J Clin Pract. 2008;62:1744–1752.
56. Hempel S, Taylor SL, Marshall NJ, et al.. Evidence map of mindfulness. VA-Evidence Synthesis Program. 2014Available at: http://www.hsrd.research.va.gov/publications/esp/reports.cfm
. Accessed October 1, 2014.
57. Hempel S, Taylor SL, Solloway M, et al.. Evidence map of Tai Chi. VA-Evidence Synthesis Program. 2014Available at: http://www.hsrd.research.va.gov/publications/esp/reports.cfm
. Accessed October 1, 2014.
58. Hempel S, Taylor SL, Solloway M, et al.. Evidence map of acupuncture. VA-Evidence Synthesis Program. 2013Available at: http://www.hsrd.research.va.gov/publications/esp/reports.cfm
. Accessed October 1, 2014.
59. Krejci L, Carter K, Gaudet T. Whole health: the vision and implementation of personalized, proactive, patient-driven healthcare for veterans. Med Care. 2014;52suppl 5S5–S8.
60. Jonas WB, Welton RC, Delgado RE, et al.. CAM in the United States Military: too little of a good thing? Med Care. 2014;52suppl 5S9–S12.
61. Bormann JE, Oman D, Walter KH, et al.. Mantram repetition improves mindfulness awareness in military veterans with posttraumatic stress disorder: a randomized trial. Med Care. 2014;52suppl 5S13–S18.
62. Serpa JG, Taylor SL, Tillisch K. Mindfulness based stress reduction (MBSR) reduces anxiety, depression and suicidal ideation in veterans. Med Care. 2014;52suppl 5S19–S24.
63. Bergen-Cico D, Possemato K, Pigeon W. Reductions in cortisol associated with primary care mindfulness-based intervention for veterans with PTSD. Med Care. 2014;52suppl 5S25–S31.
64. Kearney DJ, McManus C, Malte CA, et al.. Loving-kindness meditation and the broaden-and-build theory of positive emotions among veterans with posttraumatic stress disorder. Med Care. 2014;52suppl 5S32–S38.
65. Engel CC, Cordova EH, Benedek DM, et al.. Randomized effectiveness trial of a brief course of acupuncture for posttraumatic stress disorder. Med Care. 2014;52suppl 5S57–S64.
66. Goldstein JN, Long JA, Arevalo D, et al.. US veterans use vitamins and supplements as substitutes for prescription medication. Med Care. 2014;52suppl 5S65–S69.
67. Holliday SB, Hull A, Lockwood C, et al.. Physical health, mental health, and utilization of complementary and integrative services among Gulf War veterans. Med Care. 2014;52suppl 5S39–S44.
68. Reinhard MJ, Nassif TH, Bloeser K, et al.. CAM utilization among OEF/OIF veterans: findings from the National Health Study for a new generation of U.S. veterans. Med Care. 2014;52suppl 5S45–S49.
69. Betthauser LM, Brenner LA, Forster JE, et al.. Factor analysis and exploration of attitudes and beliefs toward complementary and conventional medicine in veterans. Med Care. 2014;52suppl 5S50–S56.
70. McFadden KL, Hernandez TD, Ito TA. Attitudes toward complementary and alternative medicine influence its use. Explore. 2010;6:380–388.
71. Elwy AR, Johnston JM, Bormann JE, et al.. Systematic scoping review of complementary and alternative medicine mind-body practices to improve the health of veterans and military personnel. Med Care. 2014;52suppl 5S70–S82.
72. Davis MT, Mulvaney-Day N, Larson MJ, et al.. Complementary and alternative therapies among military personnel, an analysis of population surveys. Med Care. 2014;52suppl 5S83–S90.
73. Fletcher CE, Mitchinson AR, Trumble EL, et al.. Perceptions of VA providers and administrators regarding use of complementary and alternative medicine. Med Care. 2014;52suppl 5S91–S96.
74. Lisi AJ, Khorsan R, Smith MM, et al.. Variations in the implementation and characteristics of chiropractic services in VA. Med Care. 2014;52suppl 5S97–S104.