Mental Health Needs of Returning Veterans

Mental Health Needs of Returning Veterans

Impact of Serving in War Iraq and Afghanistan Steve Scruggs, Psy.D. OEF/OIF Readjustment Program Team Leader Oklahoma City VA Medical Center Volunteer Clinical Assistant Professor, OUHSC OEF and OIF Veterans Who Have Left Active Duty (Through Jun 2010) 1,207,428 OEF and OIF Veterans have left active duty and become eligible for VA health care since FY 2002 53% (638,774) Former Active Duty troops 47% (568,654) Reserve and National Guard Cumulative from 1st

Quarter FY 2002 through 3rd Quarter FY 2010 2 Demographics of OEF and OIF Veterans Utilizing VA Health Care (June 2010) % OEF/OIF Veterans (n = 593,634) Sex % OEF/OIF Veterans (n = 593,634) Unit Type Male 88.1 Active Duty

53.9 Female 11.9 Reserve/Guard 46.1 Birth Year Cohort* Branch 1980 1994 43.6 Air Force 12.1

1970 1979 1960 1969 1950 1959 1926 1949 27.0 21.5 6.8 1.1 Army Marines Navy 61.8 13.4 12.6 Rank Enlisted Officer

Cumulative from 1st Quarter FY 2002 through 3rd Quarter FY 2010 91.3 8.7 3 Frequency of Possible Mental Disorders among OEF/OIF Veterans since 20021 Disease Category (ICD 290-319 code) PTSD (ICD-9CM 309.81)3 Depressive Disorders (311) Total Number of OEF/OIF Veterans2 156,866 113,653 Neurotic Disorders (300) 94,736

Affective Psychoses (296) 67,517 Nondependent Abuse of Drugs (ICD 305)4 54,712 Alcohol Dependence Syndrome (303) 31,108 Specific Nonpsychotic Mental Disorder due to Organic Brain Damage (310) Special Symptoms, Not Elsewhere Classified (307) Sexual Deviations and Disorders (302) Drug Dependence (304) 20,050 18,504 15,791 15,403

294,536 unique patients. This data does not include information on PTSD from VAs Vet Centers or data from Veterans not enrolled for VA health care. Also, this row does not include Veterans who did not receive a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309). . Through June 2010 4 Combat Stress Typical Reactions to Combat Experiences PTSD Mild/Moderate/Severe Risk Factors in Current War Unpredictability Improvised Explosive Device (IEDs)/Explosively Formed Projectile (EFPs), lack of control, who is

friend/foe? Unclear enemy lines City & street warfare Extended and variable length of deployment Surviving more serious injuries, especially TBIs (traumatic brain injuries) National Guard/Reserve troops Differences with members of National Guard & Reservists

Some are civilians not steeped in military culture Families do not live on military bases (with support) Some did not volunteer for full-time service May not have expected to be deployed for long, dangerous duty in war zone Many have established families and careers Often do not see fellow soldiers for 3 months after return (limited support system) Guard & Reserve personnel from Gulf War had more post-deployment psychiatric problems than did activeduty troops Hoge et al 2008; Milliken et al, 2007 Friedman, 2005; Kang et. al 2003 Current Impact from Iraq War Milliken, Auchterlonie & Hoge (2007)

88, 235 Soldiers assessed both immediately after returning (PDHA) and 4-10 months (median-6 months) after return (PDHRA) Similar rates of traumatic combat exposure, but different rates of Mental Health problems identified: 20.3% Active Duty 42.4% Guard/Reserve Significant alcohol concerns, but few referrals for treatment MH care in active duty and National Guard (NG) soldiers w/MH problems 3 and 12 months after Iraq When asked anonymously, active duty

soldiers reported more mental health problems than NG soldiers at both three months (45% versus 33%) and 12 months (44% versus 35%) postdeployment. NG soldiers reported higher rates of mental health care utilization 12 months after deployment, (27% vs 13%) Psychiatric Services 61:572588, 2010 Stigma and barriers to care Psychiatric Services 61:572588, 2010 Mean stigma scores were higher among active duty than NG soldiers Conclusions: Active duty soldiers with a mental health problem had significantly lower rates of service utilization than National Guard soldiers and significantly higher endorsements of stigma.

Longitudinal Trends for OEF/ OIF Veterans Seal et al. (2009) Journal of Public Health Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD.

Army's Fifth Mental Health Advisory Team (3/2008) 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. This probably underestimates antidepressant use. If the Army numbers reflect those of other services - about 20,000 troops in Afghanistan and Iraq were on such medications fall 2007. 50% antidepressants-largely the class of drugs that includes Prozac and Zoloft 50% prescription sleeping pills, like Ambien.

About One-Third of Returning Servicemembers Report Symptoms of a Mental Health or Cognitive Condition (Rand, 2008) 1,965 returning service members responders 18.5% of all meet criteria for either PTSD or depression 14% of returning servicemembers currently meet criteria for PTSD 14% meet criteria for depression 19.5% reported experiencing a probable TBI during deployment About 7% meet criteria for a mental health problem and also report a possible TBI. Estimate: 300,000 veterans who have returned from Iraq and Afghanistan are currently suffering from PTSD or

major depression, and about 320,000 may have experienced TBI during deployment. Critique Hoge et al., 2009 Being dazed or having a brief concussion is not typically associated with chronic symptoms of head injury Poor criteria for disorders means people have wrong information and expectations Expectations of veterans have big implications for outcome Family Problems Sayers, Farrow, Ross & Olsin, 2009 Journal of Clinical Psychiatry 40.7% feeling like a guest in their house

25.0% children are not warm toward them or are afraid of them 37.2% no sure of their family role Among separated partners 53.7% shouting, pushing or shoving 27.6% partner is afraid of them N=199 Iraq Stress Management Tent Normal vs. Expected War Zones Require a Unique Set of Skills & Behaviors James Monroe, Ed.D. Boston VA WAR ZONE SKILLS Act, then think Unpredictability Chain of command Numb or control emotions

Avoid closeness Physically unsafe HOME SKILLS Think, then act Predictability Cooperation Express feelings Create intimacy Physically safe BATTLEMIND Combat Skills You All Possess

Col Carl Castro, Ph.D. Battlemind skills helped you survive in combat, but may cause you problems if not adapted when you get home. Buddies (cohesion) vs. Withdrawal Accountability vs. Controlling Targeted Aggression vs. Inappropriate Aggression Tactical Awareness vs. Hypervigilance Lethally Armed vs. Locked and Loaded at Home Emotional Control vs. Anger/Detachment Mission Operational Security (OPSEC) vs. Secretiveness Individual Responsibility vs. Guilt Non-Defensive (combat) Driving vs. Aggressive Driving Discipline and Ordering vs. Conflict Battlemind Checks allow Soldiers and their Buddies to identify if and when help is needed. Marine/USN Conceptualization of

Combat Stress Injuries CAPT W. Nash, USN Most warfighters are resilient Sensitivity to military cultures & identity REQUIRED to treat effectively Common normal post-deployment stress problems include (1) aggression, (2) substance abuse, and (3) emotional numbness Traumatic stress injuries are comprised of both biological damage to brain systems and psychosocial damage to beliefs and self-esteem Greek Warrior Ideal: Arete

Brad Pitt as Achilles in Troy Ancient Greek ideal of the aristocrat warrior Features of arete: Strength Valor Courage Fortitude Has continued unchanged in the militaries of the world The foundation of all military core values and identity For a warrior to develop stress symptoms of any kind is to fail to

live up to the warrior ideal! The Warrior Ideal and Identity Must Always Be Respected Warriors and veterans with stress symptoms must be helped to preserve their sense of honor Health and pastoral care personnel must be mindful of military cultures Use language that minimizes shame without trivializing potentially disabling problems Stress Injuries Occur When Stress Is Too Intense or Lasts Too Long CAPT W. Nash, USN Adaptation

A gradual process Can be traced over time Individual remains in control Reversible Injury May be more abrupt A derailment, change in self

Individual loses control Irreversible (though can heal) Three Mechanisms of Stress Injury COMBAT COMBAT // OPERATIONAL OPERATIONAL STRESS STRESS TRAUMA TRAUMA An impact injury Due to events involving terror, horror, or helplessness

FATIGUE FATIGUE A wear-andtear injury Due to the accumulation of stress over time GRIEF GRIEF A loss injury Due to the loss of people who are cared about

Operational Stress Injuries Correlate with DSM-IV Diagnoses Prepared by Capt. William Nash, MC, USN HQ, Marine Corps Combat Combat // Operational Operational Stress Stress TRAUMA TRAUMA PTSD PTSD FATIGUE FATIGUE

Depression Depression Alcohol Alcohol GRIEF GRIEF Anger Anger Drugs Drugs Anxiety Anxiety Once a Warrior, Always a Warrior Charles Hoge, Col., Ret., 2010 + or - Perceptions Matter: How does the warrior views him or herself?

Professional (or society) may label their reactions a disorder (symptoms) verses expected reactions of combat Skills the warrior may need again Warriors need to learn skills to navigate their transition home from combat LANDNAV Charles Hoge, Col., Ret., 2010 Life Survival Skills (warrior reflexes and sleep) Attend to and Modulate Your Reactions Narrate Your Story (write, talk) Deal with Stressful Situations (Graduated exposure) Navigate the Mental Health Care System Acceptance: Living and Coping with Major Losses

Vision, Voice, Village, Joie de Vivre, Victory Since WWI, We Have Blamed Warfighters For Their Own Stress Problems Capt. William Nash, USN MEDIC AL STRESS REACTION DIAGNOSES & THEORIES: 1916 NONMEDICAL nostalgia gods, vice, fate

In March 1916, the Council of Munich voted that stress could produce symptoms only in weak personalities (hysterics). weakness, personality disorder shell shock railway spine insanity, soldiers heart COS R hysteria, fatigue

Trojan War Napoleonic American World War World War Wars Civil War One Two PTSD, stress injuries Vietnam War Today What is Post Traumatic Stress Disorder (PTSD)?

First, there is a Precipitating Event A person is exposed to a traumatic event in which they: Experienced, witnessed, or were confronted by an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others Response was intense fear, helplessness, or horror Is deployment itself a traumatic event? (McNally, 2007) Psychic trauma - implies the subjective meaning of the event for the person Continuum of trauma: Fender bender/Receiving a Dear John/Jane letter while in Iraq /Finding out a family member has died or murdered back home/ Close friend killed in your area, but not exposed directly/ Conceptual bracket creep in the

diagnosis of PTSD (McNally, 2003, 2006b) Problems with conceptual bracket creep 1. 2. 3. 4. 5. Overly broad definitions of trauma make it impossible to understand the psychobiological mechanisms mediating PTSD The causal significance of the stressor is undermined and the focus shifts to underlying vulnerability factors. Traumatic stress can becomes equivalent to

distress Medicalizes increasing numbers of human experiences while trivializing traumatic events. May undermine resilience. PTSD Symptoms Re-Experiencing Intrusive Thoughts, Memories, Images, Perceptions, Dreams, Reliving Experiences, Flashbacks + Physiological Arousal Sleep Difficulties, Irritability, Angry Outbursts, Concentration Difficulties, Hypervigilance, ExaggeratedArousal

Startle Response Avoid Thoughts, Feelings, Conversations, Activities, Places, People, Inability to Recall Trauma Aspects, Detachment or Estrangement from Others, Emotional Numbness, Sense of Avoidance Foreshortened Future Re-experiencing Symptoms (5) Intrusive recollections (memories, thoughts, mental images) Distressing dreams Flashbacks Psychological distress at exposure to

similar events (e.g. dread after nightmare) Physical reactions to exposure to similar events (e.g. heart beating, sweating) Arousal symptoms (5) Sleep problems Irritability Concentration problems Hypervigilance (alert, guarded, watchful) Exaggerated startle response Avoidance symptoms (7) Avoiding: Thoughts/Feelings that bring on memories Places/Persons/Things that bring on memories Inability to recall trauma Decreased interest in activities Emotionally detached Restricted affect like loss of loving feelings

Sense of foreshortened future What Causes PTSD? Risk Factors Intensity of trauma exposure Frequency of trauma exposure Killing Prior traumatic events Combat verses Combat Support

Poor Leadership Lack of support (family, friends, etc.) Context/Meaning Transition (military members) What Causes PTSD? Protective Factors Training Experience (Habituation) Unit cohesion/ leadership Expectations

Support on return Resilience PC PTSD: PTSD Screening Test (PTSD 4Q) 1. Have had any nightmares about it or thought about it when you did not want to? 2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it? 3. Were constantly on guard, watchful, or easily startled? 4. Felt numb or detached from others, activities, or your surroundings? Cutoff=3 Sensitivity (.83) Specificity (.85) Efficiency (.85) Calhoun et al., 2001, Psychiatric Research

The Greater the Exposure to Combat, the Higher the Risk for PTSD 19.3% (3-4 mos. after OEF and OIF-I) Significant PTSD Symptoms 20% 15% 12.7% 9.3% 10% 5% 0% 4.5%

0 1-2 3-5 >5 Number of firefights in Iraq in OEF & OIF-I Ethically Ambiguous or Morally Questionable Situations (Litz et al., 2009) Mistakenly taking the life of a civilian

thought to be an insurgent Unexpectedly seeing dead bodies or remains Seeing ill/wounded women and children and cant help Deployment length associated with an increase in unethical behaviors on the battlefield (MHAT-V, 2008) Witnessing atrocities

Perpetrating atrocities Result: Increased reexperiencing and avoidance symptoms Post-Trauma Reactions that Lead to PTSD Emotions Intrusive Reminders Flashbacks Nightmares Images Angry Scared Horrified Shame Sad Thoughts

Beliefs Assumptions Mild TBI - PTSD: Overlapping Symptoms Scholten/Collins Postconcussion Syndrome (PCS) Insomnia Memory Problems Poor concentration Depression Anxiety Irritability

Fatigue Noise/light intolerance Dizziness Headache PTSD Insomnia

Memory problems Poor concentration Depression Anxiety Irritability Re-experiencing Avoidance Emotional numbing Treatment Options Symptom Management More acceptable to many veterans Easy to try out Gives practical, how to skills and fast relief (e.g. with meds) Best approach for limited symptoms (e.g. nightmares) Trauma Processing

Research strongly indicates best choice for improvement (with Evidenced-Based Psychotherapies) Systematic Time limited Evidence-Based Therapies Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are treatments endorsed by the Veterans Administration as evidence-based treatments for PTSD. A Qualification (Hoge-2010) Effect sizes Meds (59% recovery verses 39% placebo) Psychotherapy (41% Exposure Therapy verses 29% Supportive (no specific)

CPT 3-40% Partial verses Complete Recovery from PTSD may be the case for many veterans Prolonged Exposure (PE) PE is a 10 session program that is done in 90 minute individual sessions. There is also considerable out of session homework involved. 15+ Randomized Controlled Trials/Many Effectiveness studies The Veteran monitors symptoms by completing a symptom checklist (PCL-M). Prolonged Exposure (PE) PE is a treatment that helps survivors of trauma to emotionally process their experiences.

Veterans are helped to confront their trauma memory. This is done to decrease their fear and anxiety. An example of this is the rider that is encouraged to get back on the horse after being thrown off. The rider overcomes the fear of being thrown again. This also prevents the fear from affecting other areas of his life. PE 2 main components Imaginal exposure: Client recounts their worst traumatic event in detail repeatedly in session (and listens to tapes of themselves out of session) In-vivo exposure: Client develops a hierarchy of avoided situations and exposes themselves to these situations for 30-45 minutes daily (starting with situations that are 30 on a 0-100 scale) Resources for Therapist and

Patient Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (Treatments That Work) Edna Foa, Elizabeth Hembree, Barbara Olaslov Rothbaum Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook (Treatments That Work) Barbara Rothbaum, Edna Foa, Elizabeth Hembree Center for Deployment Psychology Course 113 (Online): Cognitive Processing Therapy (CPT) for PTSD in Veterans and Military Personnel National Center for PTSD The Course Cognitive Behavioral Psychotherapies for PTSD outlines the components and empirical support for

two evidence-based treatments: Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). Cognitive Processing Therapy (CPT) 12 Session structured psychotherapy approach 5+ Randomized Controlled Trials/Many Effectiveness studies Based on a social cognitive theory of PTSD that focuses on how the traumatic event(s) is construed and coped with by a person who is trying to regain a sense of mastery and control in his/her life Based on the Cognitive Therapy Model developed by Aaron Beck, M.D.

Also utilizes therapeutic writing strategies developed by James Pennebaker, Ph.D. Cognitive Processing Therapy CPT is a 12 session program that can be done in individual (much research basis) or group sessions (emerging research basis). There is also some out of session homework involved-writing about the trauma and writing about ones thoughts and emotions. This is reviewed with the therapist in session. Cognitive Processing Therapy (CPT) CPT begins with education about trauma. It looks at the normal reactions to the trauma. The therapy then moves to look at and evaluate your thinking and beliefs about the events. You are finally asked to

"talk" about your experiences by writing about them. You read them to the therapist (and/or group members). CPT Reading about your trauma is followed by a discussion of "stuck points." Stuck points are memories or thoughts you have been unable to move past. They continue to impact on your ability to live a full life. The Veteran monitors symptoms by completing a check list (PCL-M). Treatment Model: Cognitive Processing Therapy (CPT) Focus on the content of cognitions and the effect that distorted cognitions have upon emotional responses and behavior

Sees PTSD as a disruption or stalling out of a normal recovery process and works to determined what interfered with normal recovery OEF/OIF Readjustment Program (405) 456-3295 OEF/OIF Readjustment Program Team Members Gina Pierce, M.D., Medical Director Steve Scruggs, Psy.D., Team Leader [email protected] Susan Shead, LCSW, Staff Social Worker Rob Braese, Ph.D., Staff Psychologist Kristi Bratkovich, Ph.D. Postdoctoral Fellow

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