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Library of Research Articles on Veterans and CIH Therapies

January 2021 Edition


Buttner MM, Bormann JE, Weingart K, Andrews T, Ferguson M, Afari N. Multi-site evaluation of a complementary, spiritually-based intervention for Veterans: The Mantram Repetition Program. Complement Ther Clin Pract. 2016 Feb;22:74-9. doi: 10.1016/j.ctcp.2015.12.008. Epub 2015 Dec 19.


Mental and physical symptoms affect Veterans' quality of life. Despite available conventional treatments, an increasing number of Veterans are seeking complementary approaches to symptom management. Research on the Mantram Repetition Program (MRP), a spiritually-based intervention, has shown significant improvements in psychological distress and spiritual well-being in randomized trials. However, these findings have not been replicated in real-world settings.


In this naturalistic study, we analyzed outcomes from 273 Veterans who participated in MRP at six sites and explored outcomes based on facilitator training methods. Measures included satisfaction and symptoms of anxiety, depression, and somatization using the Brief Symptom Inventory-18; Functional Assessment of Chronic Illness Therapy-Spiritual Well-being questionnaire; and the Mindfulness Attention Awareness Scale.


There were significant improvements in all outcomes (p's < .001) regardless of how facilitators were trained. Patient satisfaction was high.


The MRP was disseminated successfully yielding improvements in psychological distress, spiritual well-being, and mindfulness.

Duan-Porter W, Coeytaux RR, McDuffie JR, Goode AP, Sharma P, Mennella H, Nagi A, Williams JW Jr. Evidence Map of Yoga for Depression, Anxiety, and Posttraumatic Stress Disorder. J Phys Act Health. 2016 Mar;13(3):281-8. doi: 10.1123/jpah.2015-0027. PubMed PMID: 26181774.


This study describes evidence of yoga's effectiveness for depressive disorders, general anxiety disorder (GAD), panic disorder (PD), and posttraumatic stress disorder (PTSD) in adults. We also address adverse events associated with yoga.


We searched multiple electronic databases for systematic reviews (SRs) published between 2008 and July 2014, randomized controlled trials (RCTs) not identified in eligible SRs, and ongoing RCTs registered with


We identified 1 SR on depression, 1 for adverse events, and 3 addressing multiple conditions. The high-quality depression SR included 12 RCTs (n = 619) that showed improved short-term depressive symptoms (standardized mean difference, -0.69, 95% confidence interval, -0.99 to -0.39), but there was substantial variability (I2 = 86%) and a high risk of bias for 9 studies. Three SRs addressing multiple conditions identified 4 nonrandomized studies (n = 174) for GAD/PD and 1 RCT (n = 8) and 2 nonrandomized studies (n = 22) for PTSD. We separately found 1 RCT (n = 13) for GAD and 2 RCTs (n = 102) for PTSD. Collectively, these studies were inconclusive for the effectiveness of yoga in treating GAD/PD and PTSD. The high-quality SR for adverse events included 37 primary reports (n = 76) in which inversion postures were most often implicated. We found 5 ongoing trials (3 for PTSD).


Yoga may improve short-term depressive symptoms, but evidence for GAD, PD, and PTSD remain inconclusive.

Elwy AR, Taylor SL, Zhao S, McGowan M, Plumb DN, Westleigh W, Gaj L, Yan GW, Bokhour BG. Participating in Complementary and Integrative Health Approaches Is Associated With Veterans' Patient-reported Outcomes Over Time. Med Care. 2020 Sep;58 Suppl 2 9S:S125-S132.


Veterans Affairs is dedicated to providing a Whole Health approach to care, including offering complementary and integrative health (CIH) approaches to Veterans.


The objective of this study was to examine the association of CIH participation with Veterans' patient-reported outcomes over time.

Research design

A survey of patient-reported outcomes at 5 timepoints: baseline, 2, 4, 6, and 12 months.

Subjects: Veterans participating in any type of CIH approach at 2 Veterans Affairs medical centers.

Measures: Mixed hierarchical models with repeated variables were used to test the hypothesis that participating in any CIH approach would be associated with Veterans' overall physical/mental health [Patient-Reported Outcomes Measurement Information System 28 (PROMIS 28)], pain intensity, perceived stress (Perceived Stress Scale-4), and engagement in their care (Patient Activation Measure-13), controlling for age, male sex, site, participation in other CIH approaches, and surveys completed.


We received 401 surveys from 119 Veterans (72% male, age range: 29-85 y) across all timepoints. Yoga participation was related to decreases in perceived stress (P<0.001), while tai chi participation was associated with improvements in overall PROMIS 28 physical and mental health functioning (P<0.02). Specific types of CIH were associated with significant improvements in PROMIS 28 subscales: meditation participation with physical functioning at 2, 6, and 12 months; tai chi participation with anxiety at 2 and 6 months, and ability to participate in social role activities at 2 months. No CIH approach was associated with Veterans' pain or engagement in their care.


As specific CIH approaches are associated with improvements in patient-reported outcomes, clinicians, Veterans, and family members may use this information in discussions of nonpharmacological options to address health and well-being.

Felleman B, Stewart D, Simpson T, Heppner P, Kearney D. Predictors of Depression and PTSD Treatment Response Among Veterans Participating in Mindfulness-Based Stress Reduction. Mindfulness, 2016, Volume 7, Number 4, Page 886

Posttraumatic stress disorder (PTSD) and depression are prevalent and often co-occur among veterans. There is growing interest in the effects of mindfulness-based interventions among veterans. This study examined PTSD and depression outcomes, and baseline predictors of response, among veterans who participated in mindfulness-based stress reduction (MBSR). Participants included 116 veterans with PTSD before and after MBSR. Multilevel modeling assessed baseline predictors of change in PTSD and depressive symptoms. There were clinically significant reductions in PTSD and depression symptoms posttreatment and at 4 months follow-up. For PTSD, effect sizes were in the medium range posttreatment (d = −.63) and at follow-up (d = −.69), and for depression posttreatment (d = −.58) and at follow-up (d = −.70). Baseline PTSD was a significant predictor of slope (β = .03, p = .04) on PTSD outcomes; higher baseline PTSD predicted greater rate of reduction in symptoms. For depression (β = .04, p < .01,), those with severe or moderately severe depression exhibited the greatest rate of improvement. However, veterans with high symptom severity did remain symptomatic post-MBSR. These findings show preliminary support for MBSR in facilitating symptom reduction for veterans with severe PTSD and co-occurring depression.

Goldberg S, Zeliadt S, Hoggatt K, Simpson T, Fortney J, Taylor SL. Utilization and Perceived Effectiveness of Mindfulness Meditation in Veterans: Results from a National Survey. Mindfulness. Sep 2019: 1-10.


Complementary and integrative health (CIH) approaches are increasingly utilized in health care, and mindfulness meditation is one such evidence-based CIH practice. More information is needed about veterans' utilization of mindfulness to inform integration within the Veterans Health Administration (VHA).


This study involved secondary data analysis of a national survey to evaluate utilization and perceived effectiveness of mindfulness relative to other CIH approaches among military veterans. Military veterans (n = 1230) enrolled in VHA reported CIH utilization rates, reasons for use, perceived effectiveness, treatment barriers, and demographics.


Approximately 18% of veterans reported using mindfulness meditation in the past year, exceeding the proportion using all other CIH approaches (p < .001), with the exception of massage and chiropractic care. Mindfulness was most commonly used for stress reduction and addressing symptoms of depression and anxiety. Among mindfulness users, veterans rated mindfulness with a mean score of 3.18 out of 5 (SD = 0.82) in terms of effectiveness, reflecting a response in the "somewhat helpful" to "moderately helpful" range. This was similar to ratings of other CIH approaches (mean = 3.20, p = .391). Of those who used mindfulness, nearly all (78%) reported only using it outside the VHA. Veterans identified not knowing if the VHA offered mindfulness as the most common reason for using mindfulness outside VHA.


In summary, veterans use mindfulness for a range of reasons and report receiving benefit from its use. Low awareness and potentially low availability of VHA's mindfulness programs need to be addressed to increase access.

Hull A, Holliday SB, Eickhoff C, Rose-Boyce M, Sullivan P, Reinhard M. The Integrative Health and Wellness Program: Development and Use of a Complementary and Alternative Medicine Clinic for Veterans. Altern Ther Health Med. 2015 Nov-Dec;21(6):12-21. PubMed PMID: 26567446.


A movement exists within the Veterans Health Administration (VHA) toward incorporating complementary and alternative medicine (CAM) as an integrative complement to care for veterans. The Integrative Health and Wellness (IHW) Program is a comprehensive CAM clinic offering services such as integrative restoration (iRest) yoga nidra, individual acupuncture, group auricular acupuncture, chair yoga, qigong, and integrative health education.


The current study intended to detail the development of the CAM program, its use, and the characteristics of the program's participants.Design: Using a prospective cohort design, this pilot study tracked service use and aspects of physical and mental health for veterans enrolled in the program.


During the first year, the IHW Program received 740 consults from hospital clinics; 325 veterans enrolled in the program; and 226 veterans consented to participate in the pilot study.

Outcome Measures

Outcome measures included data from self-report questionnaires and electronic medical records.RESULTS Veterans enrolled in the program reported clinically significant depression, stress, insomnia, and pain-related interference in daily activities and deficits in health-related quality of life. Regarding use of the program services, individual acupuncture showed the greatest participation by veterans, followed by group auricular acupuncture and iRest yoga nidra. Of the 226 veterans who enrolled in the program and consented to participate in this study, 165 (73.01%) participated in >1 services in the first year of programming. Broadly speaking, enrollment in services appeared to be associated with gender and service branch but not with age or symptom severity.


Results have assisted with a strategic planning process for the IHW Program and have implications for expansion of CAM services within the VHA..

Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014 Dec;52(12 Suppl 5):S19-24. doi: 10.1097/MLR.0000000000000202. PubMed PMID: 25397818.


Anxiety, depression, and pain are major problems among veterans, despite the availability of standard medical options within the Veterans Health Administration. Complementary and alternative approaches for these symptoms have been shown to be appealing to veterans. One such complementary and alternative approach is mindfulness-based stress reduction (MBSR), a brief course that teaches mindfulness meditation with demonstrated benefits for mood disorders and pain.


We prospectively collected data on MBSR's effectiveness among 79 veterans at an urban Veterans Health Administration medical facility. The MBSR course had 9 weekly sessions that included seated and walking meditations, gentle yoga, body scans, and discussions of pain, stress, and mindfulness. Pre-MBSR and post-MBSR questionnaires investigating pain, anxiety, depression, suicidal ideation, and physical and mental health functioning were obtained and compared for individuals. We also conducted a mediation analysis to determine whether changes in mindfulness were related to changes in the other outcomes.


Significant reductions in anxiety, depression, and suicidal ideation were observed after MBSR training. Mental health functioning scores were improved. Also, mindfulness interacted with other outcomes such that increases in mindfulness were related to improvements in anxiety, depression, and mental health functionality. Pain intensity and physical health functionality did not show improvements.


This naturalistic study in veterans shows that completing an MBSR program can improve symptoms of anxiety and depression, in addition to reducing suicidal ideations, all of which are of critical importance to the overall health of the patients.

Smeeding SJ, Bradshaw DH, Kumpfer K, Trevithick S, Stoddard GJ. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety, and post-traumatic stress disorder. J Altern Complement Med. 2010


The purpose of this longitudinal outcome research study was to determine the effectiveness of the Integrative Health Clinic and Program (IHCP) and to perform a subgroup analysis investigating patient benefit. The IHCP is an innovative clinical service within the Veterans Affairs Health Care System designed for nonpharmacologic biopsychosocial management of chronic nonmalignant pain and stress-related depression, anxiety, and symptoms of post-traumatic stress disorder (PTSD) utilizing complementary and alternative medicine and mind-body skills.


A post-hoc quasi-experimental design was used and combined with subgroup analysis to determine who benefited the most from the program. Data were collected at intake and up to four follow-up visits over a 2-year time period. Hierarchical linear modeling was used for the statistical analysis. The outcome measures included: Health-Related Quality of Life (SF-36), the Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subgroup comparisons included low anxiety (BAI < 19, n = 82), low depression (BDI < 19, n = 93), and absence of PTSD (n = 102) compared to veterans with high anxiety (BAI > or = 19, n = 77), high depression (BDI > 19, n = 67), and presence of PTSD (n = 63).


All of the comparison groups demonstrated an improvement in depression and anxiety scores, as well as in some SF-36 categories. The subgroups with the greatest improvement, seen at 6 months, were found in the high anxiety group (Cohen's d = 0.52), the high-depression group (Cohen's d = 0.46), and the PTSD group (Cohen's d = 0.41).


The results suggest IHCP is an effective program, improving chronic pain and stress-related depression, anxiety, and health-related quality of life. Of particular interest was a significant improvement in anxiety in the PTSD group. The IHCP model offers innovative treatment options that are low risk, low cost, and acceptable to patients and providers.

Wheeler, M.S., Glass, C.R., Arnkoff, D.B. et al. The Effect of Mindfulness and Acup on Psychological Health in Veterans: an Exploratory Study. Mindfulness (2018) 9: 564.

iRest Yoga Nidra® is a guided mindfulness approach that encourages relaxation, focused attention, experience of joy, observation of opposite feelings and emotions, non-judgment, and integration of these principles into daily life. iRest was developed for the military population, but the research on its effectiveness is in its infancy. This exploratory study examined the effectiveness of iRest in combination with acupuncture compared to acupuncture alone in improving psychological health in Veterans. The combined treatment yielded significant psychological benefit in depression, psychological symptom severity, depression or tension due to pain, and emotional interference with life activities, while the acupuncture-only treatment did not. Although both conditions showed significant decreases in perceived stress, the effect size for the treatment group was medium to large compared to a small effect size for those receiving acupuncture only. The combined treatment condition, iRest plus acupuncture, also demonstrated clinically meaningful change, with significant decreases in the number of Veterans meeting criteria for mild, moderate, and severe depression. Finally, the combined treatment was equally beneficial independent of factors such as age, gender, or race. Given the pervasiveness of psychological distress and depression in the Veteran population and the efficiency with which these group treatments can be provided, these findings lend preliminary support for the extension of complementary and integrative health offerings including iRest and acupuncture into more Veterans Administration hospitals across the country to improve military mental health. Indeed, the encouraging results of this exploratory study underscore the importance of expanded research on iRest and acupuncture for the treatment of psychological health.

Williams JW Jr, Gierisch JM, McDuffie J, Strauss JL, Nagi A.  An Overview of Complementary and Alternative Medicine Therapies for Anxiety and Depressive Disorders: Supplement to Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder.  Washington (DC): Department of Veterans Affairs (US); 2011 Aug.


VA is committed to expanding the breadth of posttraumatic stress disorder (PTSD)-related services available to Veterans. Since depressive and anxiety disorders share common features with PTSD, this report was commissioned to examine the efficacy of complementary and alternative medicine (CAM) therapies for the treatment of depressive and anxiety disorders as a means to detect treatments that might be applicable to PTSD.


The key questions (KQs) were adapted from the parent report, Efficacy of Complementary and Alternative Medicine Therapies for Posttraumatic Stress Disorder. We searched MEDLINE® (via PubMed®) and the Cochrane Database of Systematic Reviews for recent English-language systematic reviews (SRs) that examined the literature on mind-body medicine, manipulative and body-based practices, and movement or energy therapies, excluding nutritionals, herbal remedies and other supplements. To be included, SRs had to be published within the past five years and be evaluated as a "fair" or "good" quality. Titles, abstracts, and articles were reviewed in duplicate, and relevant data were abstracted by authors trained in the critical analysis of literature.


We identified five relevant SRs on mind-body CAM therapies, but none on manipulative and body-based, movement-based, or energy therapies. Most primary studies were small trials that did not provide descriptions of CAM strategies adequate to permit replication. Dose, duration, and frequency of interventions sometimes varied widely.