Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), although facing fewer mortality dangers than Vietnam war veterans and other veterans in previous wars because of advances in military technology and practices, face significant post-combat mental health issues. The most common of these mental health problems is Post Traumatic Stress Disorders (PTSD). PTSD refers to the psychological trauma caused by witnessing the traumatic events of the battlefields (Institute of Medicine, 2012). Experience of trauma by the veteran in the past does not quality as PTSD. Three major markers are necessary to establish that the veteran is suffering from PTSD. These include insomnia, which is caused by hyperactive arousal, avoidant behaviors related to the traumatic event such as refusing to talk about the traumatic event and re-experiencing the event after the traumatic event has passed. In addition, the symptoms must be persistent, lasting for more than a month and cause significant impairment because of the distress brought about by the trauma (CRS Summary of APA, 2000). Veterans with PTSD can access the Veteran Health Administration (VA) healthcare system. Treatment in the VA health care system involves the use of cognitive behavioral therapy approach and the use of medication to treat veterans with PTSD. The statistics from the VA Healthcare System on the prevalence of PTSD among OEF and OIF veterans reveal a high prevalence of PTSD among these veterans, which is a major source of concern because of the adverse effects of the disease. PTSD can lead to suicide, injuries to the brain, referred to as Traumatic Brain Injury (TBI) in the literature, which leads to changes in the brain’s biological functioning and therefore affects the veteran’s health. Statistics show that the high number of veterans with PTSD requires attention.

There is a wide variation of the prevalence of PTSD in veterans in different populations and studies on the subject. A study conducted by the Institute of Medicine found that the prevalence rate for PTSD among OEF and OIF veterans range from 13% prevalence rates to 20% prevalence rates (Institute of Medicine, 2012). Another study found even wider variations in prevalence rates for different population samples and studies. According to Ramchand et al. (2010), an analysis of 29 studies on the prevalence of PTSD among OEF and OIF veterans revealed that there was a variation ranging from 1% prevalence rates to 60% prevalence rates. The differences are attributed to differences in samples and differences in study populations for PTSD. This suggests that there are inadequate diagnosis methods for PTSD among war veterans.

In psychotherapy diagnosis, there are no opportunities for using placebo controls in the diagnosis and trials. This presents significant limitations to the diagnostic procedures, probable leading to the perceived differences in PTSD prevalence among different populations and studies. Therefore, healthcare practitioners must utilize current knowledge about a treatment and base their diagnosis on this knowledge. In most researches conducted on the subject, the process involves the assessment of a specific number of participants for a length of time or the application of a treatment option for a selected sample of participants, who are usually selected randomly (Rothbaum, 1997; Chard, 2005). This is a different procedure from clinical trials involving testing of medications because the placebo control group provides a basis for analyzing the viability of a specific treatment option or the response of the trial population to the treatment option. Diagnostic and treatment procedures for OEF and OIF veterans with PTSD could be improved to reflect better treatment and diagnosis outcomes. This is especially important because of the high and rising cases of PTSD reported in various studies such as in the Chard, Schumm, Owens and Cottingham (2010) and Kracen, Mastnak, Loaiza and Matthieu (2013) studies.

The action research project will look at how diagnostic procedures, treatment methods, and procedures can be improved to ensure more accurate PTSD diagnosis among veterans and better treatment outcomes. The research investigates different treatment approaches and procedures such as group and individual therapy in order to develop an appropriate action research problem to deal with the identified problems associated with the diagnosis and treatment of OEF and OIF veterans with PTSD.

Statement of the Problem

The first problem with current procedures and treatments associated with PTSD is the problem of diagnosis. The wide variation in PTSD prevalence among different studies and sample populations suggests a disproportionate and inaccurate diagnosis of PTSD among OEF and OIF veterans. This constitutes a significant health problem for these veterans because of misdiagnosis. The lack of placebo controls in psychotherapy diagnosis in comparison to clinical tests of medicines suggests that practices need to incorporate more effective diagnosis measures based on clearly identifiable markers of PTSD illness that do not produce the wide difference in PTSD prevalence among OEF and OIF veterans. The other problem is the problem of effectiveness of treatment administered to OEF and OIF veterans.

In addition to prevalence differences between different study populations, there is the problem of lack of studies on the difference in treatment outcomes between study populations. Chard et al. (2010) point out that there is only one study, which investigates the differences between response in the treatment across Vietnam veterans and OEF and OIF veterans. This presents a significant gap in research pertaining to the most effective approaches to PTSD treatment among PTSD sufferers in OEF and OIF study populations and veterans from other wars. Chard et al. considered differences between treatment outcomes between Vietnam War veterans and OEF and OIF veterans and found that there were differences in treatment outcomes for the different groups. In the Chard et al. (2010) study that made the comparison that were a new study that no researchers prior to the study conducted, the researchers found that there were differences in the response to treatment between the veterans in the Iraq and Vietnam wars because of hitherto unidentified multiple variables that create differences in treatment outcomes. These multiple variables might also account for the differences in prevalence rates recorded by the Institute of Medicine (2012), and Ramchand et al. (2010).

Finally, treatment approaches such as individual over group therapy can affect the effectiveness of treatment outcomes. A study conducted by Kracen et al. (2013) found that 57% of the 100 OEF and OIF veterans studied preferred individual over group therapy. This might be related to one of the features of PTSD identified by the CRS Summary of APA (2010), which is that PTSD sufferers avoid reflecting on the traumatic events of the war. For this reason, veterans might avoid group therapy because it creates opportunities to speak about the experiences with other members.

The two problems identified, which are:

· Lack of proper diagnostic procedures leading to sharp differences between study populations on PTSD prevalence rates among veterans,

· Multiple variables that might influence diagnosis and treatment outcomes,

These problems need solutions to improve VA health care for OEF and OIF veterans. These gaps in research need to be closed in order to deliver more effective healthcare. Research into these areas will reduce co-morbidities associated with PTSD such as substance abuse, aggressiveness, suicidal ideation and Traumatic Brain Injury.

Contribution to Society

PTSD has a negative not only on the veteran but also on his close family and consequently on society as a whole. The wide variations in reporting on the incidence of PTSD among war veterans means that there are war veterans who do not have access to adequate PTSD treatments. Without treatment, these veterans can prove a burden to their families and society since they are not functioning to their optimum emotional, physical and psychological levels. By understanding other aspects of PTSD, such as the multiple variables that contribute to PTSD prevalence among veterans and the military, important contributions can be made to society. There are economic benefits as well.

The veterans suffering from PTSD have reduced economic output because they are greatly incapacitated by their illness. Providing effective treatment and intervention measures for these veterans can improve treatment outcomes and subsequently lead to better integration of veterans into civilian life. The veterans who are successfully reintegrated into civilian life can live more economically and socially productive lives. In addition, there is reduced the risk of antisocial behavior for those individuals who have experienced the most adverse effects of war. Some of these behaviors might include aggression and suicide. By dealing with the problems identified in the problem statement, the action research project can help improve society by facilitating the proper reintegration of veterans with PTSD into society.

Need for Change

There is a need for change because of the evident underreporting in studies conducted on the prevalence of PTSD among veterans the 1%-60% and the 13%-20% prevalence rates variation provided by research shows that there is no definitive method of ascertaining prevalence rates of veterans with PTSD (Ramchand et al. 2010; Institute of Medicine, 2012). Underreporting is a likely consequence of the reluctance of the PTSD sufferers to seek help from health professionals. Researchers contend that PTSD sufferers rarely seek help for their disease and may wait up to decades before they decide to seek help (Wang, et al. 2005; Sayer, Spoont and Nelson, 2004; Sayer, Clothier, Spoont, and Nelson, 2007). This reluctance to seek help is one of the characteristic identified as characteristic of people who have suffered from trauma related to war in Iraq. Therefore, a more stringent method of identifying veterans suffering from PTSD should be sought to ensure that most of the cases are clearly identified and intervention measures instituted.

Chard et al. (2010) have identified another need to change, which is the presence of multiple variables among populations of veterans with PTSD. These multiple variables can influence how populations deal with PTSD and how the signs of this disease manifest and is treated within different populations. The researchers compared the response to treatment of Vietnam veterans with OEF and OIF veterans and found that the two populations responded differently to treatment using cognitive processing therapy. Finding out the means to identify the variables that contribute to differences between populations in terms of treatment outcomes and prevalence rates can improve access to comprehensive care through better diagnosis and better targeting of individual variables for improved treatment outcomes.

Theoretical Foundation

Diagnosis Procedures

The differences in reporting of prevalence rates among different researches and populations are symptomatic of a problem with current diagnostic procedures. The research literature provides various evidence for the contention that diagnosis might be linked to issues identified to the prevalence of PTSD. The behavioral model is the most frequently used approach to identifying PTSD veterans who need care. This model is dominantly used in identifying veterans that might need PTSD treatment intervention. Andersen and Newman (1973) elaborated on the model. The researchers state that the model looks at the need, enabling and predisposing factors that influence a veteran's access to health care for PTSD. These factors are used in determining whether the veteran with PTSD will seek help for his mental health issue. With reference to the predisposing factor that influences whether an individual will seek health care help, these vary across individuals, and they can be either salient or overt. When they are salient, such as when the individual refuses to speak about the traumatic experience, health professionals might have difficulties identifying those people who need help. This might account for the differences in prevalence rates recorded in studies cited earlier. Various researchers have looked at how these predisposing and other factors influence an individual seeking for professional help (Rosenheck and Fontana, 1995; Koenen, Goodwin, Struening, Hellman, and Guardino, 2003). Despite these studies, there are gaps in research regarding the usefulness of the use of the various factors of the behavioral model in determining when an individual needs help for PTSD. Andersen (1995) has looked at the connection between diagnosis and perceived need for help for PTSD and does not provide adequate means of bridging the gap between perceived need and diagnosis. There needs to be a broader set of factors or variables that is more extensive in its capacity to understand and pinpoint those veterans who need healthcare intervention after or before the onset of PTSD symptoms in the veterans.

Phenotype and genotype differences between individuals might provide additional variables that can help in the identification and treatment of people who have a high susceptibility of suffering from PTSD. The section on multiple variables can provide insights on the possibility of seeking phenotypic and genotypic differences that might help in the diagnosis and intervention process to reduce the differences observed in prevalence rates among different populations of veterans. Treatment is another issue, which is not contentious in the literature but provides effective intervention measures that focus on both cognitive and behavioral aspects of the PTSD problem.

The research on treatment options available for PTSD in VA health care shows that they are broadly characterized as behavioral, cognitive or cognitive-behavioral treatments. The most common of the treatment options available and efficacy is tested is the cognitive behavioral treatment. This treatment is predominantly used in the VA health care treatment. However, the use of group or individual therapy is contentious since most veterans prefer not to engage in group therapy (Kracen et al., 2013). These might be related to predispositions such as genotypic predispositions that make some veterans prefer group while others prefer individual therapy. For the action project, there is the need to identify the differences related to preference in treatment and adopt measures to ensure that veterans with PTSD can work in groups. Group therapy is the better option because of the opportunities for interaction that it presents. Therefore, healthcare providers cannot discount it when delivering cognitive behavioral therapy. Understanding of differences in veteran populations can provide the means of designing groups where the veterans can feel comfortable while accessing healthcare for PTSD.

Multiple Variables Determining PTSD Prevalence and Treatment Outcomes

Research conducted by Mehta and Binder (2012) has found that there are varying levels of susceptibility to PTSD for different individuals. The researchers posit that genetic factors can express themselves phenotypically as PTSD symptoms when individuals with specific predispositions are placed in environments where trauma is experienced. The researchers admit that studies into the role of genetics are inconclusive, there is growing evidence that interaction between the environment and the genetics can lead to certain phenotypic characteristics depending on the individual. These findings provide a basis for reducing the problem of early diagnosis and treatment for those veterans who might be reluctant to seek help from healthcare professionals. Because genetic factors are individual-specific and their phenotypic expressions vary depending on the individual and his environment, they can provide the basis for a broader set of variables that health care professionals can use in early diagnosis and intervention. These set of variables, referred from now ons as biomarkers, have the great potential to broaden the factors or criteria for early diagnosis of individuals with predispositions to developing PTSD after a traumatic event in the battlefield. Research supports the notion that PTSD symptoms are linked to various biomarkers.

Mehta and Binder (2012) point out that the direct impacts of exposure to traumatic events are felt at the hypothalamus pituitary adrenal (HPA) axis. The researchers state that the biomarkers left by traumatic events at the HPA axis are consistent and, therefore, can be reliably used in the diagnosis of PTSD predisposition and effect. Healthcare professionals can, therefore, use the phenotypic characteristics resulting from the biomarkers in the HPA axis to support the behavioral model used in PTSD diagnosis in VA health care organizations. Other researchers have extended research into HPA axis and other potential areas of biomarkers to identify the onset of PTSD early before the symptoms overwhelm the victim. These biomarkers are associated with recovery and diagnosis (Schmidt, Kaltwasser, and Wotjak, 2013; Pitman et al., 2012). Therefore, VA health care organizations can greatly improve analysis of recovery and diagnosis in veterans with the use of biomarkers.

Researchers have proposed the many benefits of using biomarkers in diagnosis and treatment that can help predict PTSD occurrence in veterans and therefore curb the problem in the pre-PTSD phase rather than waiting for behavioral symptoms to manifest under the behavioral model of diagnosis currently implemented by the VA health care organizations. Schmidt et al. (2013) point out that the biomarkers can inform treatment since they predict PTSD severity. Using biomarkers, those veterans with the highest risk of developing PTSD can be helped because they rarely seek help for themselves even with the onset of adverse symptoms of PTSD. However, there are various legal, ethical and social considerations, which research into the use of biomarkers to identify and prevent the occurrence of PTSD has failed to consider. Specifically, psychiatric biomarkers can intrude into an individual’s right for privacy regarding his mental life (Singh and Rose, 2009; Lakhan, Vieira, and Hamlat, 2010). This presents a significant challenge in the utilization of psychiatric biomarkers in intervention measures for PTSD victims. There are other problems associated with the use of biomarkers in the diagnosis procedures for PTSD.

Although the literature supports the contention that biomarkers can prove useful in PTSD diagnosis and treatment, there are no specific and reliable biomarkers identified in the research that can provide conclusive linkages between biological alterations in the individual and observable phenotypic characteristics of PTSD. However, researchers have looked at various potential PTSD biomarkers, and the research looks promising (Zoladz and Diamond, 2013; Bomyea, Risbrough and Lang, 2012). Some of the fields that can support biomarkers research include systems biology.

In conclusion, biomarkers present a significant opportunity for improving the VA health care system intervention for those OEF and OIF veterans with a high predisposition to developing PTSD after a traumatic event. Biomarkers present a significant opportunity also in diagnosis and recovery efforts because they hold the promise of being able to ascertain susceptibility to developing and recovering from PTSD. With the established theoretical foundation, pertaining to the research problems identified in the problem statement section, the next sections deal with various issues regarding the implementation and planning of the action research project.

Investigator Position

The action researcher will perform various roles in the carrying out of the project. The list below provides the various roles the action researcher will carry out during the project implementation:

· Develop information-sharing tools for the different VA healthcare organizations to interact and share information regarding the potential for use of biomarkers in diagnosis and treatment interventions

· Ensure that information systems are used in the collection of data about the veterans for analysis on the susceptibility to PTSD occurrence

· Manage the legal, ethical and social issues that might arise from data collection about veterans, especially pertaining to the potential use of information related to biomarkers

· Investigate research on biomarkers and suggest information systems that might be used in the diagnostic process

· Identify the minimum set of criteria that might be used to identify biomarkers for specific use with OEF and OIF veterans

· Engage in ongoing review of the literature on biomarkers and other developments in PTSD diagnosis and treatment to obtain new insights into the issue and therefore engage in progressive exchange of data between different researchers and organizations

Research Questions, Goals and Objectives of the Project

The research questions for the action research project are listed below:

· Are biomarkers currently feasible as a means of detecting the onset of PTSD and ensuring better treatment outcomes?

· Which variables can be added to broaden the behavioral model of diagnosis for PTSD victims?

· Are biomarkers feasible for grouping individuals with similar predispositions to make them feel safer within their in-group and, therefore, ensure better treatment outcomes?

· What are the legal, social and ethical implications that the action project has to consider when considering biomarkers for PTSD diagnosis and intervention?

The goals of the project are to ensure the broadening of the current behavioral model of PTSD diagnosis. The project expects that such a move will allow for earlier diagnosis of PTSD among the OEF and OIF veterans. It will also assist in assessing response to treatment among the veterans. The main objective is to ensure that the PTSD prevalence in victims of traumatic events is not understated and to reduce the differences in prevalence rates reported among populations.

Action Plan (Look, Think, Act Model)

Look

This is the information-gathering phase of the action research project. The investigator will engage relevant sources of information about biomarkers. He will gather evidence on the feasibility of the use of biomarkers in diagnosis and intervention in the OEF and OIF veterans with PTSD. Using the gathered information, the action researcher will build a picture of the status on the ground and, therefore, inform the action research project on the implementation measures. In addition, the data gathering process will involve gathering data on the social, legal and ethical issues surrounding the action research. This will help deal with any arising issues regarding the use of biomarker information in the action research.

There is also need to identify the tools, such as technology and information tools, needed in carrying out the action research project. These will help with data gathering and information sharing in the action-research implementation phase. The three main areas under consideration are treatment, diagnosis and mechanics of using biomarkers for PTSD intervention.

Think

This is the theorizing phase of the action research project. The action researcher will integrate information and tools obtained from the information-gathering phase in order to determine the possibilities afforded by biomarkers in improving comprehensive care for OEF and OIF veterans with PTSD. In the process, current and future potentials in the field of using biomarkers in PTSD diagnosis and intervention will be unearthed to inform the action research.

Act

The action researcher will develop a plan for implementation based on the findings of the other phases of the action research. The action researcher will report on the findings through an integration of what he or she has learned and theorized about biomarkers for PTSD treatment and diagnosis. The action research will then conduct tests on the feasibility of biomarkers for use with PTSD victims and, therefore, implement the plan through a pilot study based on the feasibility study. Finally, evaluations of the effectiveness of biomarkers in improving diagnosis and treatment outcomes for PTSD will be conducted. The evaluation will determine whether biomarkers can be implemented on a large-scale.

Dissemination Plan

Dissemination of the information acquired will be done through the information systems networks developed through the action research project. The project team will share the information with researchers in health care and biomarker research for ongoing feedback on developments in the field. The results of the action research will also be published in relevant and peer-reviewed journal articles to inform future research.

Action Research Data-Collection Methods

The data collection for the action research includes the use of questionnaires and self-reported surveys of veterans in the VA healthcare system. Study participants will provide biomarker data such as family history and medical background after signing consent and confidentiality agreements.

Assumptions

The major assumption in the action research is that the differences seen in reports of prevalence rates in different researches and sample populations is attributed to improper and narrow diagnostic procedures. The behavioral model is assumed to be at the heart of the problem because of its narrow set of variables for determining PTSD symptoms in war veterans.

Limitations

The list below presents the limitations of the action research project:

· The use of biomarkers in diagnosing and intervention for PTSD is a relatively new field, and therefore research into this area is not definitive

· The action project involves the collection of personal information from participants, which might pose a logistical issue

· The project requires technical expertise in areas such as biological systems and information systems, which might cause problems in the implementation phase because of a potential lack of expertise to carry out the project

Summary

The project meets the hallmark of a good action research project because it deals with an issue that has significant and important social implications. It could provide significant benefits if the results of the action research project prove that biomarkers are feasible as diagnostic and treatment options for PTSD victims in the VA healthcare system. The research questions formulated to deal with the identified problem are solvable and are related to the problem at hand. They are designed to deal with all aspects of the research problem and, therefore, provide definitive and conclusive findings of the problem. The research questions are answerable. Through the implementation process, the project will provide the means of providing answers for the research questions formulated in the action research project. The action research project also admits its limitations and assumptions, but these are not expected to greatly hinder the implementation of the action research project.

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