For both the Merit Review Program and CSP,  proposals are typically evaluated in two review cycles per year. To be considered for intramural research funding:    The proposal must be veteran-centric. VA Intramural PTSD Research Funding Increased from $9.9 Million in Fiscal Year 2005 to $24.5 Million in Fiscal Year 2009

Based on the VA data we obtained and summarized, we found that overall  intramural PTSD research funding from VA’s medical and prosthetic  research appropriation increased from about $9.9 million in fiscal year  2005 to about $24.5 million in fiscal year 2009, or by about 150 percent (see  fig. 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. The Number of PTSD Studies Funded through VA’s Intramural Research Program Increased from 47 in Fiscal Year 2005 to 96 in Fiscal Year 2009

Similarly, we found that the number of PTSD studies funded from VA’s  medical and prosthetic research appropriations through VA’s intramural  research program increased from fiscal year 2005 through fiscal year 2009. VA Intramural PTSD Research Studies Are Funded Primarily According to Scientific Merit

According to VA officials, intramural research proposals, including those  on PTSD, are reviewed and funded in VA’s Merit Review Program and VA’s  CSP primarily according to scientific merit. According to VA, research and  development service directors may also choose to fund a small number of  additional proposals at the margin that respond to research priority areas. After the reviewers vote, they each provide scores for a proposal  recommended for funding based on scientific merit. According to VA officials, the number of proposals funded  may vary depending on the budget. Third, after receiving summaries of the studies with the highest level of  evidence, the VA and DOD group of clinical leaders and experts rates the  research using an established grading scheme that considers the level of evidence of each research study—the scope and  methodological rigor of an individual study;  the overall quality of evidence—the overall quality of all of the  research that addresses a particular clinical question, considering the  level of evidence of all the studies considered; and  the net effect of an intervention—according to the collective results of  the studies considered, the intervention’s benefits minus the  intervention’s harms. VA Reviewed Research Outcomes and Used Existing Resources in Determining Which PTSD Services to Require Its Facilities to Provide or Make Available to Veterans

According to VA officials, the decision to require that cognitive processing  therapy and prolonged exposure therapy be made available to veterans  diagnosed with PTSD at VA facilities—as indicated in the Handbook,  which established certain requirements for mental health services within  VA—was based on a review of research outcomes and the availability of  existing resources. According to VA, agency officials and  qualified subject matter experts reviewed relevant research outcomes and  the quality of the research to determine the most efficacious PTSD  treatments available when determining which PTSD services to include in  the Handbook and make available to veterans. Furthermore, VA officials said that these two therapies had  greater evidence supporting their effectiveness than other PTSD services  also graded as level “A” in the 2004 PTSD CPG. VA officials told us that prior to  issuing the Handbook in 2008, VA had already begun investing  considerable resources to implement national training programs for  cognitive processing therapy and prolonged exposure therapy in 2006 and  2007, respectively. VA officials explained that they followed a process when  choosing cognitive processing therapy and prolonged exposure therapy,  but added that clinical decision-making processes are not typically  expected to be documented in a formal manner. VA officials  stated that they are currently clarifying the language regarding some of the  requirements, but do not plan to revise any of the requirements relating to  PTSD services at this time. GAO staff members who made key contributions to  this report are listed in appendix V.

Appendix I: VA Research Centers and Programs That Conduct or Support PTSD Research

In addition to post-traumatic stress disorder (PTSD) research studies that  are conducted by individual Department of Veterans Affairs (VA)  investigators, or researchers, VA also funds a number of research centers  or programs that conduct or support PTSD research. Appendix IV: The Process for Developing VA/DOD Evidence-Based Clinical Practice Guidelines

In 1999, the Department of Veterans Affairs (VA) and the Department of  Defense (DOD) formed the VA/DOD Evidence-Based Practice Work Group  to issue joint VA/DOD clinical practice guidelines (CPG)—tools that  provide guidance and evidence-based recommendations to clinicians  regarding the most effective interventions and services for a variety of  health care topics. To develop or update a CPG, the VA/DOD Evidence- Based Practice Work Group has a standardized process to ensure that  systematic reviews of relevant research outcomes are conducted in order  to formulate evidence-based recommendations for prevention,  assessment, and treatment services.
Why GAO Did This Study

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.

What GAO Found

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.