THE YEAR IN VETERANS AFFAIRS & MILITARY MEDICINE
While all of this investigation into the background and the natural history of PTSD has been going on, there has also been work on therapy. One study that has had profound impact was a study by [Executive Director for the National Center for PTSD] Paula Schnurr, looking at the effect of cognitive processing therapy on PTSD and showing that this approach could be very effective in treating people with PTSD. It doesn’t help everybody. It doesn’t cure people, but it does reduce PTSD symptoms considerably. Interestingly, she focused on women who served in Vietnam, but other studies have grown into widespread adoption of cognitive processing therapy as a treatment for PTSD. And then since the adoption of that, a second therapy has become important and supported by evidence, called prolonged exposure. Now VA is undertaking a study to again compare these two established therapies to find out: Is prolonged exposure better? Is cognitive processing therapy better? Is one better for some people and the other better for other people? So it’s going through this evolution. We’ve also studied the use of drugs for treating PTSD – but those studies have not yielded good pharmacologic interventions, so there’s a need to understand better what is happening in the brain in PTSD. And that’s being pursued in several different ways. One is studies using functional imaging technologies to see what communication looks like in PTSD. Investigators are using all sorts of technologies. Some of them are using something called functional magnetic resonance imaging. Apostolos Georgopoulos in Minneapolis has used something called magnetoencephalography, to look at communication pathways. And on the more basic side of things, a study building upon the Million Veteran Program has begun to look at the genetic heterogeneity, the actual gene changes, that may be associated with PTSD, building upon the Vietnam Twin study that showed there is a genetic influence. The Million Veteran Program (MVP) is in its fourth year now, and has recruited more than 388,000 participants. It’s been suggested that it served, in some ways, as a model for the NIH’s Precision Medicine Initiative (PMI), announced at the beginning of the year by President Barack Obama. How are the MVP and PMI related?
The Million Veteran Program is already the largest epidemiologic cohort ever seen in the United States, and by this time next year, we’ll be at about half a million. We’ve actually shown that in the United States, you can create a large cohort of volunteers that are willing to participate in this kind of research, and we’ve provided at least one model by which it can be done. That model is one in which not only you interact with veterans at the time that they initially agree to become a part of the study; they also agree to allow us to take information developed over time, from their electronic health records, and relate it back to information about their genome.
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The NIH has also proposed a million-person cohort for its database and is really building on the concept that we’ve shown can be achieved – getting information from electronic health records from a broader group of Americans and moving forward. That initiative and ours have a lot of places where there is complementarity. I think we have a clear commitment to be able to exchange data for those veterans that wish to participate in their cohort and for us to be able to learn from veterans that may be participating in the NIH cohort but aren’t receiving care within VA. I think there’s also a developing likelihood that we’ll be helping the Department of Defense to create a framework for looking at precision medicine in the care of soldiers, sailors, airmen, and Marines. As I said, we’re serving the same people at different points in their lives. We also recognize there are things the NIH Precision Medicine cohort can do that we can’t, and vice versa. The NIH Precision Medicine cohort will have a much larger faction of women. We are only enrolling from our health care system, so to enroll 500,000 women in the Million Veteran Program would be an unrealistic expectation. But for a broad population cohort in the United States, enrolling 500,000 women is quite feasible. So there are questions they’ll be able to ask about women’s health that we won’t be as able to ask. At the same time, we and the Department of Defense are interested in understanding what predisposes bad outcomes from traumatic brain injury or what predisposes combat-associated PTSD. We’ll be able to answer that question through the Million Veteran Program; that question will have a sufficiently large population of people exposed to military hazards to answer many of the questions we have. Our efforts, I think, are beautifully complementary. We’re currently involved in the planning activities for the NIH Precision Medicine cohort, deeply involved with the White House staff trying to implement the president’s vision. So what kind of innovations or advances do you think VA Research will be celebrating 90 years from now?
We have three really major thrusts or strategic directions we’re pursuing now. One of them is this movement toward genomics and precision medicine, and the Million Veteran Program is an important part of that. The movement from pure research into the clinical applications of genomics will be an important thrust going forward. At this point, we’re in the discovery phase, and one of our strategic directions is obviously to move from discovery to practical implementation. Both for genomics and for other health care divisions, the use of informatics in high-performance data mining, hypothesis testing, and communications capabilities is a really, really important topic. We have a health care system, but like health care in the United States in general, we implemented electronic health records in the field some time ago in a way that was neither consistent nor homogeneous. The result is 29