Introduction

Posttraumatic stress disorder (PTSD) occurs in individuals who have been exposed to one or more traumatic events such as death, serious injury, or sexual violence [1]. The clinical presentation of PTSD includes fear-based reexperiencing, emotional and behavioral symptoms, anhedonic or dysphoric mood states, and dissociative symptoms [1]. Active-duty military personnel and veterans often experience or witness terrorist attacks, violent crimes and abuse, natural disasters, serious accidents, or violent personal assaults [2], making them extremely vulnerable to PTSD [3]. Lifetime prevalence of PTSD has been estimated from 1.3%–8.8% [4]. Among Vietnam War veterans, 30.9% were diagnosed with PTSD [5]. In addition, 12.9% of Iraq veterans and 7.1% of Afghanistan veterans reportedly have PTSD [6]. PTSD is usually associated with comorbidities such as depression, anxiety, and substance use disorders [7]. In veterans with PTSD, suicidal ideation was reportedly 23.8% and suicide attempts were 6.8% owing to military combat trauma [8]. Furthermore, PTSD is related to chronic pain [9], cardiovascular disease [10], metabolic syndrome, and elevated C-reactive protein levels [11]. Many military personnel from around the world have been on the battlefield in civil and local wars and counterterrorism [12]. The conflict in Ukraine started in Donbas in 2014 when Russia annexed Crimea and has recently escalated to an all-out war. A study has already been published examining PTSD caused by the war in Donbas [13]. Furthermore, enormous mental health consequences are expected for the people of Ukraine [14].

Most clinical guidelines recommend cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors as first-line psychological and pharmacological therapies, respectively, for patients with PTSD [15]. However, CBT has a limitation in that it is time consuming and costly, requires training to perform treatments [16], and is difficult to use owing to low accessibility [17]. Although internet-based CBT may be an option to increase access to treatment, it may not be suitable for patients who are uncomfortable with technology [18]. Only two medications have been approved by the Food and Drug Administration for the treatment of PTSD in adults (sertraline and paroxetine) [19]. Selective serotonin reuptake inhibitors inhibit cytochrome P450 enzymes in the liver and may cause several adverse effects such as extrapyramidal symptoms, serotonin syndrome, QT prolongation, congenital malformations, and hyponatremia [20]. Stigma exists in military culture, along with treatment barriers such as costs and low accessibility to mental health care [21]. PTSD tends to be more prominent among personnel who meet the criteria for a mental health problem [22].

Recently, complementary and integrative medicine treatments for patients with PTSD have gained increased attention [23]. Acupuncture is a nonpharmacological therapy involving the insertion of needles into specific points on the body or ear, known as acupuncture points. The use of acupuncture in veterans is a promising complementary and integrative medicine approach [24]. Specific forms of auricular acupuncture, such as the National Acupuncture Detoxification Association (NADA) protocol and battlefield acupuncture (BFA), are used in the health management of military personnel. The NADA protocol, which consists of five standard auricular acupuncture points, was originally designed to help acute heroin addiction, although it is also used for a broad range of mental health problems [25]. The NADA protocol was effective in improving PTSD-induced insomnia in combat veterans [26]. BFA, which is a safe, fast, and easily applied acupuncture treatment, has been proven effective for treating a variety of pain conditions [27]. Evidence suggests that BFA can help with chronic pain and sleep disturbances in veterans [28]. Sleep disturbances are a core feature of PTSD and can affect its progression [29]. Furthermore, chronic pain in veterans with PTSD is associated with many negative health-related outcomes, such as disability, depression, sleep disturbance, catastrophizing beliefs, and lower function [30]. Therefore, although BFA has mainly been used for pain, it has the potential to alleviate PTSD symptoms in veterans through pain control and improved sleep.

A scoping review is more appropriate than a systematic review when the research explores a broad range of questions, such as which research design was adopted in the topic of interest, and can help to identify major concepts and characteristics in the existing literature as well as knowledge gaps [31]. As studies on acupuncture for PTSD in veterans have not been actively conducted, our research team determined that a scoping review method with a wider view of the relevant field may be more appropriate for this study than a systematic review of randomized controlled studies.

We aim to explore the clinical research designs used in studies conducted on acupuncture treatment for war veterans with PTSD. We will also focus on detailed methodological characteristics, such as treatment regimens, participant characteristics, and frequently used outcomes. This study will enable us to identify any research gaps between clinical studies and the needs of physicians regarding clinical evidence. The results of our scoping review can be used as fundamental data for identifying the appropriate research questions in research planning of future clinical studies and systematic reviews.

Materials and methods

Stage 3: Study selection

The inclusion and exclusion criteria were developed with the consensus of the research team. Two reviewers (HBS and HYK) will independently conduct the article selection process. After eliminating duplicate publications in the first phase, the titles and abstracts of the screened articles will be reviewed for inclusion. For potential articles in the second screening phase, the full text will be reviewed to determine whether the article meets the inclusion criteria. The reasons for inclusion and exclusion will be recorded for each article according to the predetermined criteria. In cases of discrepancies, an agreement will be achieved through mediation by the independent researcher. Details of the study selection process are shown in Fig 1.

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Fig 1. Flowchart of identification and screening for the eligible studies.

https://doi.org/10.1371/journal.pone.0273131.g001

Discussion

PTSD due to active military combat trauma is very common among military personnel and veterans [2–6]. However, PTSD treatments have many limitations [15–22]. As an alternative, complementary and integrative medicine, including acupuncture, may be considered for the treatment of PTSD [23]. Acupuncture, such as BFA, is widely used for soldiers [27,28]. To date, there have been no comprehensive reviews of acupuncture therapy for PTSD in military personnel and veterans. Therefore, we will perform the first scoping review. Our review will summarize the treatment regimens, participant characteristics, and frequently used outcomes, and will also identify knowledge gaps to assist in the planning of future studies. Because acupuncture is a non-psychological and non-pharmacological intervention, it may help overcome barriers to PTSD treatment, such as stigma in the military culture, high costs, and low accessibility to mental health care [37]. The fundamental data obtained in this scoping review will contribute to the designing of future studies that aim to collect evidence on the effectiveness and safety of acupuncture-based treatments for PTSD in military veterans. Furthermore, the findings from this review will also be helpful to clinicians who want to use acupuncture to manage PTSD in this population. Nevertheless, this study has some limitations. First, consultation, which is both the last step of scoping registration and an optional sixth step, cannot be planned. This is because it is difficult and unethical to verify the results of this review by creating an artificial war environment for patients with PTSD. Second, although we will perform a comprehensive search, related studies published in languages other than English, Korean, Chinese, and Japanese may be excluded.

For further dissemination, the research findings will be submitted to an appropriate scientific journal. This study will also be presented at a neuropsychiatric academic conference. Moreover, we will develop an e-leaflet to provide the key findings of our review to the research community via social network services.

Conclusions

The findings of this scoping review will provide fundamental data that will help researchers identify appropriate research questions and design further studies on the use of acupuncture for PTSD management in military veterans. These results will be helpful for developing disaster site-specific research protocols for future clinical trials on this topic.

Supporting information