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Ahec veterans mental health project: ( add the title of your program). Speaker names/affiliations. [Speaker’s name] [Speaker’s affiliation] [Speaker’s name] [Speaker’s affiliation] [Sponsoring Agency] [City & state of training] [Date]. welcome. Quote from Lt. Col. Paul Pasquina , MD.

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speaker names affiliations
Speaker names/affiliations
  • [Speaker’s name]
  • [Speaker’s affiliation]
  • [Speaker’s name]
  • [Speaker’s affiliation]
  • [Sponsoring Agency]
  • [City & state of training]
  • [Date]
quote from lt col paul pasquina md
Quote from Lt. Col. Paul Pasquina, MD

There’s nothing normal about war.

There’s nothing normal about seeing people losing their limbs, seeing your best friend die.

There’s nothing normal about that, and that will never become normal…”

Lt. Col. Paul Pasquina, MD, from the movie "Fighting For Life"

introduction 1
Introduction 1

How many of you are:

  • Current/former Service Members
  • Spouse of a current/former Service Member
  • Other family of a current/former Service Member
  • Friend of a current/former Service Member

Introduction

introduction 2
Introduction 2

Introduction

How many of you are:

  • Physicians
  • Psychologists
  • Social workers
  • Licensed Counselors
    • Substance Abuse
    • Marriage and Family
  • Nurses
  • Others
lingo
lingo

Lingo

  • OIF = Operation Iraqi Freedom
    • Iraq war until 31 December 2011
  • OEF = Operation Enduring Freedom
    • current war in Afghanistan
  • OND = Operation New Dawn
    • Iraq war since 1 January 2012
in war there are no unwounded soldiers
In war, there are no unwounded soldiers.

In war, there are no unwounded soldiers.

Jose Narosky

scope of the issue 2
Scope of the issue 2

Scope of the Issue

Length of combat operations

  • As of November 27, 2006, OIF has lasted longer than WW II
  • All volunteer force = multiple deployments
  • Deployment maps
scope of the issue 3
scope of the issue 3

Scope of the Issue

2.2 million Service Members in Iraq and Afghanistan

“Over 75% of Soldiers and Marines [in Iraq] surveyed reported being in situations where they could be seriously injured or killed; 62-66%knewsomeoneseriously injured or killed; more than 1/3 described an event that caused them intense fear, helplessness or horror”

(Office of the Army Surgeon General Mental Health Advisory Team [MHAT] IV,

Final Report, Nov 06)

scope of the issue 4
scope of the issue 4

Scope of the Issue

  • Psychological concerns among family members
  • >1 million children in US under 11 years old experienced deployment of a parent – sometimes both – since 9/11
sesame street series
Sesame Street series

Sesame Street Series

  • Deployments
  • Homecomings
  • Changes
  • Grief

http://www.sesameworkshop.org/initiatives/emotion/tlc

and Military One Source at http://www.militaryonesource.mil/

scope of the issue 5
Scope of the Issue 5

Scope of the Issue

  • July – September 2010
  • Surveyed 911 Army soldiers and Marines
  • All deployed OIF/OEF
  • Report released May 2011
  • Compared to surveys 2005, 2007, 2009

Office of the Army Surgeon General

Mental Health Advisory Team

(MHAT) VII Report, May 2011

scope of the issue 6
Scope of the issue 6

Scope of the Issue

  • Rates of acute stress higher than any previous year except 2007
    • Acute stress
    • Depression
    • Anxiety
  • Ratings of individual morale significantly declined since 2005 and 2009

Office of the Army Surgeon General

Mental Health Advisory Team

(MHAT) VII Report, May 2011

scope of the issue 7
Scope of the issue 7

Scope of the Issue

  • Research on civilian health providers treating military families
  • “Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members, Veterans, and their Families”
scope of the issue 8
Scope of the issue 8

Scope of the Issue

  • Web-based survey of 319 rural and urban community mental health and primary care providers funded by the VA Office of Rural Health

Citation: Kilpatrick, D.G., Best, C.L., Smith, D.W., Kudler, H., & Cornelison-Grant, V. Charleston, SC: Medical University of South Carolina Department of Psychiatry, National Crime Victims Research & Treatment Center, 2011

scope of the issue 9
Scope of the issue 9

Scope of the Issue

Serving Those Who Have Served

full report available at

http://a-tracc.adobeconnect.com/serving/

scope of the issue 10
Scope of the issue 10

Scope of the Issue

Key Findings

  • 56% community providers don’t ask patients about military service
  • Only 16% served in the Armed Forces
  • Although VA is a national leader in provider training, only one third (31%) of community providers are VA trained
scope of the issue 11
Scope of the issue 11

Scope of the Issue

  • Key Recommendations
    • Train civilian providers
      • Understand military culture
      • Understand VA programs
basic training military culture 2
Basic Training – Military Culture 2

Basic Training –

Military Culture

Understanding the nature of the military culture, combat and the stresses of living and working in a war zone are critical to establishing credibility with your patients or clients.

basic training military culture 3
Basic Training – Military Culture 3

Basic Training –

Military Culture

The military has its own laws, its own clothes and its own language. To serve them better and help ease their fears about treatment, we first need to understand what being a veteran is all about and be familiar with all things military.

Scott Swain, 15-year Gulf War veteran,

Senior Director Veterans Services

Valley Cities Counseling and Consultation

Auburn, WA

basic training military culture 4
Basic Training – Military Culture 4

Basic Training –

Military Culture

  • Army/Army National Guard
  • Navy/Naval Reserves
  • Marine Corps/Marine Corps Reserve
  • Air Force/Air National Guard/ Air Force Reserves
  • Coast Guard*
basic training military culture 5
Basic Training – Military Culture 5

Basic Training –

Military Culture

My uniform…

basic training military culture 6
Basic Training – Military Culture 6

Basic Training –

Military Culture

  • Military Occupational Specialty (MOS)
    • Advanced individual training
    • Hundreds of MOS
basic training military culture 7
Basic Training – Military Culture 7

Basic Training –

Military Culture

  • More about lingo…
    • DoD = Department of Defense
    • VA = Department of Veterans Affairs
    • IED = Improvised Explosive Device
    • VBIED = Vehicle Born IED (car or suicide bomb)
basic training military culture 8
Basic Training – Military Culture 8

Basic Training –

Military Culture

  • More about lingo…
    • FOB = Forward Operating Base
    • TDY = Temporary Duty
    • ROE = Rules of Engagement
basic training military culture 9
Basic Training – Military Culture 9

Basic Training –

Military Culture

  • High standard of discipline
  • Distinct ceremony and etiquette
  • Creates shared rituals and common identities
  • Emphasis on group cohesion & esprit de corps
basic training military culture 10
Basic Training – Military Culture 10

Basic Training –

Military Culture

  • Connects service members to each other
  • Continued into retirement
    • Wearing of service uniforms - parades and military unit apparel
basic training military culture 11
Basic Training – Military Culture 11

Basic Training –

Military Culture

  • Guard and Reserve culture
  • Formally a Strategic Reserve
    • Backfill the Active Duty force
    • Train one weekend a month
    • Two weeks a year
basic training military culture 12
Basic Training – Military Culture 12

Basic Training –

Military Culture

  • Guard and Reserve culture
  • Now an Operational Reserve
    • Some units deploy as often as Active Duty
    • Families often see themselves as Military Families
    • May lack community supports
quote from war is a force that gives us meaning
Quote from War is a Force that Gives Us Meaning

“I learned early that war forms its own culture. The rush of battle is a potent and often lethal addiction, for war is a drug, one I ingested for many years....

War exposes the capacity for evil that lurks not far below the surface within all of us.

And this is why, for many, war is so hard to discuss once it is over.”

Chris Hedges, Veteran War Correspondent, War is a Force that Gives Us Meaning

mental health needs oef oif vets 2014 projections
Mental health Needs oef/oif vets (2014 projections)
  • PTSD only 4.7% 113,978
  • MDD only 4.7% 113,978
  • PTSD and MDD 9.1% 220,680
  • Other MH Dx11.6%281,307
  • TOTAL 30.1% 729,943

National Council for Behavioral Health

“Meeting the Behavioral Health Needs of Veterans:

Operation Enduring Freedom and Operation Iraqi Freedom”

November 2012

behavioral health issues1
Behavioral health issues
  • Ideally problems are picked up within DoD or VA continuum of care

BUT…

  • Only 50% of all OEF/OIF Veterans eligible for VA care have come to VA
  • Where are the other 50%?
  • “Silent majority” OEF/OIF veterans not coming to VA
post deployment issues active and reserve components
Post deployment issues – active and reserve components
  • Study - 88,235 US soldiers returning from Iraq
  • Active duty (AD) and Reserve component (RC)
  • Completed Post Deployment Health Assessment (PDHA)
  • Completed Post Deployment Health Reassessment (PDHRA) 6 months later

Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

changes active duty and reserve component at pdhra
Changes Active Duty and Reserve Component at pdhra

Results…

  • Roughly ½ with PTSD symptoms PDHA improved by PDHRA

BUT…

  • Twice as many new cases of PTSD at PDHRA

Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

changes active duty and reserve component at pdhra 2
Changes Active Duty and Reserve Component at pdhra 2

Changes Active Duty and Reserve Component at pdhra

Results…

  • Depression rates at PDHRA
    • Doubled in AD to 10%
    • Tripled in RC to 13%
  • Identified as needing MH treatment post deployment
    • AD 20.3%
    • RC 42.4%

Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

changes active duty and reserve component at pdhra1
Changes Active Duty and Reserve Component at pdhra

Results…

  • 4-fold increase in concerns about interpersonal conflict
  • Alcohol abuse rate high
    • AD 12%
    • RC 15%
    • Only 0.2% referred for treatment

Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

post deployment issues active and reserve components 1
Post deployment issues – active and reserve components 1

Post deployment issues – active and reserve components

  • Why RC is at greater risk than AD…
  • AD - have on-going access to healthcare
  • RC situation -
    • DoD health benefits (TRICARE) expire 6 months after deployment ends
    • Pay for coverage
    • Special VA benefits end at 60 months unless a service-connected condition identified)
post deployment issues active and reserve components 2
Post deployment issues – active and reserve components 2

Post deployment issues – active and reserve components

Why RC is at greater risk than AD…

  • May be geographically separated from military and VA facilities
  • 1/2 service members beyond standard DoD benefit window by PDHRA
  • Lack of day-to-day contact with Battle Buddies
  • Added stress transition back to civilian life
ptsd 1
PTSD 1

PTSD

  • Characterized by a constellation of symptoms
  • Follows exposure to an extreme traumatic event
  • Involves actual or threatened death or serious injury
ptsd 2
PTSD 2

PTSD

  • Response to the event must include
    • Intense fear, helplessness or horror
    • Symptoms persist more one month
    • May involve
      • Re-experiencing the traumatic event through intrusive recollections, dreams or nightmares
      • Avoidance of trauma-associated stimuli, such as people, situations, or noises
ptsd 3
PTSD 3

PTSD

  • Response to the event may involve
      • Persistent symptoms of increased arousal
        • Sleep disturbance
        • Hyper vigilance
        • Irritability
        • Exaggerated startle response
ptsd 4
PTSD 4

PTSD

  • Diagnosis must be accompanied by clinically significant distress or impairment in
      • Social area
      • Occupational situations
      • Other important areas of function
  • Problems must persist at least one month after the event
a national demonstration project
A National Demonstration Project
  • Citizen Soldier Support Program Directory of BH Providers
  • http://www.warwithin.org/
      • Validated licenses
      • Lists special interests and relevant training
      • Specifies insurances accepted including TRICARE
      • Google mapping to site of care
combat stress injury
Combat stress injury
  • Happens to a person (not chosen)
  • Involves loss of normal integrity
  • Causes loss of function at least temporarily
  • Provokes predictable self-protective or healing symptoms
  • Cannot be undone (though it usually heals)

Capt. Bill Nash in Combat Stress Injury

combat stress injury trauma
Combat stress injury - Trauma

Participant in or witness to event(s) involving

  • Horror
  • Feelings that you or someone close to you will die
  • Helpless
  • Powerless

Capt. Bill Nash in Combat Stress Injury

public health model 1
Public health model 1

Public Health Model

  • Most war fighters/veterans do not develop a mental illness
  • All war fighters/veterans and their families face important readjustment issues
public health model 2
Public health model 2

Public Health Model

  • Problems are more functional than clinical
    • There is a difference between having a problem and being disabled
common themes presenting problems 1
Common Themes/Presenting Problems 1

Common themes/presenting problems

  • Marriage, relationship problems
  • Medical issues
  • Financial hardships
  • Endless questions from family and friends
  • Guilt, shame, anger
  • Lack of structure
common themes presenting problems 2
Common themes/presenting problems 2

Common themes/presenting problems

  • Feelings of isolation
  • Nightmares, sleeplessness
  • Lack of motivation
  • Forgetfulness
  • Anger
  • Feeling irritable, anxious, “on edge”
quote from tv show parenthood
Quote from TV show, Parenthood

“He’s been to war…and war is a place where you lose who you were. And then if you get back, you don’t have any idea who you are, and you’re scared to death of what you might become”

November 27, 2012

episode of TV show Parenthood

(In reference to a man who served 2 tours of duty in Iraq.

Spoken to his girlfriend by her grandfather, a veteran of Vietnam)

key question 1
Key question #1

Ask EACH patient this question…

Are you or a close family member a current or former service member?

assessment questions 1
Assessment questions 1

Assessment Question

  • Why did you join the (branch of service)?
  • What did you hope to accomplish?
  • Tell me about any combat tours
    • How many?
    • When?
    • Where?
    • MOS?
    • Intensity in combat?
assessment questions 2
Assessment questions 2

Assessment Questions

  • Were you satisfied with training and preparation you received?
  • Were you satisfied with leadership and equipment while deployed?
  • How do family members feel about the military? About the separations?
assessment measures
Assessment measures
  • Primary Care PTSD Screen (PC-PTSD)
  • Combat Exposure Scale (CES)
  • PTSD Checklist – Civilian Version (PCL-C)
  • Trauma Symptom Checklist - 40 (TSC-40)
  • 3 Question DVBIC TBI Screening Tool
  • Other measures as appropriate
questions 2
Questions? 2

Questions?

take home points
No wrong door to enter to seek help

Know something about military culture

Post deployment MH is not just PTSD

Issues of service members & family are more functional vs. clinical

Ask all patients about military service

take home points…
key question 2
Key question #2

Ask each patient this question…

Are you or is anyone in your family a current or former service member?

key question 3
Key question #3

Ask yourself this question…

  • Is my practice prepared to identify or treat post deployment problems?
web based resources
Web-Based Resources
  • Collaborative development of self-help resources with assessment, tailored feedback, intervention and self-monitoring
  • Information clearinghouses and regional resources
camouflage works
Camouflage works

Finally - just to prove that camouflage works…

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