Homeless Assistance Program Contacts (handout)

1. Homeless Assistance Program Contacts (handout)

2. Criminal Justice: Statistics

3. Criminal Justice Population • Estimates of the rates of severe mental and substance use disorders in jail and prison populations have varied between 3 and 16 percent • Offenders in the U.S. Department of Justice Survey report a high incidence of drug and alcohol abuse. • One third were alcohol dependent, while 6 in 10 were under the influence of alcohol or drugs at the time of offense

4. Criminal Justice Population • Offenders with mental illness were likely to be using substances when they committed their convicting offense and likely to be incarcerated for a violent crime. • The majority of probationers with mental disorders (approximately three quarters) have not been involved in violent crime

5. Criminal Justice Population • Because of the stigma associated with the combination of substance abuse, co-occurring mental illness, and a criminal record, this group of offenders will face barriers to being accepted into an aftercare program. • They also will have difficulty locating effective programs for their complex problems that require specialized treatment

6. How Do We Work With Them?

7. Criminal Justice Population • *The overall goal of substance abuse treatment for criminal offenders, especially for those who are violent, is to reduce criminality • *Staff should be trained and experienced in treating both mental illness and substance abuse. • *Treatment services are integrated whenever possible. • *Comprehensive treatment is flexible and individualized. • *The focus of the treatment is long-term.

8. Criminal Justice Population • Also require: • Smaller caseloads • Shorter and simplified meetings • Special attention to criminal thinking • Education about medication and COD • An effort to minimize confrontation

9. Criminal Justice Population • Therapeutic Community (TC) Work-Release • Post-Prison TC • Cognitive-Behavioral Therapy Programs

10. Criminal Justice Population • Recognize special service needs. • Clarify expectations regarding response to supervision. • Give concrete (i.e., not abstract) directions. • Design highly structured activities. • Provide ongoing monitoring of symptoms.

11. Veterans: Our Pride

12. Veterans: Statistics

13. Veterans • Estimated 23.4 million veterans in the United States • About 2.2 million military service members (reservists) • 3.1 million immediate family members.

14. Structure of the Military (handout)

15. Veterans • Military service members, veterans, and their families are a growing community exposed to traumatic events. • Involvement in combat that causes losses and fears; injuries associated with combat; repeated deployments and/or relocations; and military sexual violence—all may exert an emotional toll on military personnel, their families, and their communities.

16. Veterans • Military men were nearly 3.5 times more likely to report frequent heavy drinking compared with women in the military • Frequent heavy drinking also varied as a function of ethnicity, with Hispanic and nonHispanic Whites exhibiting higher rates of problematic drinking than non-Hispanic Blacks • Rates were six times greater among enlisted personnel with the lowest rankings compared with officers. • Army, Navy, and Marines being more likely to report frequent heavy drinking than those in the Air Force

17. Veterans • Heavy drinking is more likely to occur among younger military members • Rates of heavy drinking were significantly higher among male military personnel aged 18 to 25 years (32.2 percent) compared with male civilians in a similar age range (17.8 percent) • Younger male veterans reported greater alcohol use, which underscores the potentially heightened risk for negative consequences (e.g., legal problems, accident, or injury) among this group in particular. • Significantly elevated rates of heavy drinking among women in the military compared with similarly aged female civilians (5.5 percent). • Alcohol misuse also frequently occurs among a substantial proportion of combat veterans

18. Veterans • Post-traumatic Stress Disorder (PTSD) also called “Combat fatigue” or “shell shock” • Beginning with the Vietnam War, and more recently with the wars in Iraq and Afghanistan Department of Defense (DoD) says PTSD has been the most commonly diagnosed mental health disorder for veterans returning from combat • Epidemiological studies of Operation Enduring Freedom (OEF) & Operation Iraqui Freedom (OIF) veterans treated in the Department of Veterans Affairs (VA) health care system have found that 14 to 22 percent of returning veterans were diagnosed with PTSD

19. Veterans • According to the Veterans Affairs Department (VA), approximately one-third of veterans seeking treatment for substance use disorders also met the criteria for PTSD. • 19.5% report experiencing a traumatic brain injury (TBI) during deployment

20. Veterans & Mental Health

21. Veterans • The demanding environments of military life and experiences of combat contribute to many veterans experience psychological distress. • Many service members face such critical issues including: • Trauma • Suicide • Homelessness • Involvement with the criminal justice system.

22. Veterans • According to an assessment by the Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA), nearly 76,000 veterans experienced homeless on a given night. Some 136,000 veterans spent at least one night in a shelter during a year. • Mental and substance use disorders caused more hospitalizations among U.S. troops in 2009 than any other cause. • A recent Treatment Episode Data Set (TEDS) report, Twenty-one Percent of Veterans in Substance Abuse Treatment Were Homeless (PDF | 488 KB) states that about 70% of homeless veterans also experience a substance use disorder.

23. Veterans • Approximately 50% of returning service members who need treatment for mental health conditions seek it, but only slightly more than half who receive treatment receive adequate care. • The Army suicide rate reached an all-time high in 2012. • In the 5 years from 2005 to 2009, more than 1,100 members of the Armed Forces took their own lives, an average of 1 suicide every 36 hours.

24. Veterans • According to the January 2014 Veterans Health Administration report (PDF | 855 KB), the suicide rate among male and female veterans and military service members exceeds the national rate for the general population. • Veterans comprise 20% of national suicides, with approximately 22 veterans dying by suicide every day. • Three out of five veterans who died by suicide were diagnosed as having a mental health condition.

25. Veterans & PTSD • Not only does military trauma increase the likelihood of developing stress related mental health disorders such as PTSD or depression, but, as alluded to earlier, there is also evidence that traumatic experiences are related to problematic alcohol use among military members. • There is also evidence that military sexual trauma (MST) is associated with alcohol misuse among military personnel. • MST was related to a variety of negative mental and physical health outcomes, including elevated rates of alcohol misuse among those who experienced MST compared with non-traumatized individuals.

26. Veterans & PTSD • Military veterans with PTSD reported using alcohol to specifically cope with re-experiencing and hyperarousal symptoms and given the powerful, short-term negative reinforcement effects of alcohol, the theory postulates that people may begin to use alcohol frequently and excessively, resulting in the development of an alcohol use disorder • Alcohol abuse impedes recovery and even worsens symptoms of posttraumatic mental health disorders • Substance-dependent individuals with co-occurring PTSD relapsed more quickly than those without PTSD

27. Veterans & PTSD • More severe sexual harassment was related to greater depression symptoms among female reservists • Experiencing greater amounts of sexual harassment was related to higher alcohol misuse • Vietnam Era Twin Registry • PTSD and alcohol use problems were both found to be influenced by genetics, although environmental factors explained about one-half of the variance in alcohol misuse and over one-half of the variance in PTSD symptoms • These findings suggest that although genetic factors are notable in explaining these disorders, environmental factors are equal to, if not more substantive, than genetics.

28. Veterans • Pre-existing alcohol misuse contributes to posttraumatic psychiatric maladjustment • Problematic drinking prior to the traumatic combat experience may be a risk factor for some soldiers to exhibit PTSD symptoms following combat exposure. • PTSD symptoms, but not combat exposure, significantly predicted problematic drinking outcomes

29. Veterans • In particular, re-experiencing symptoms were the strongest predictor of both total alcohol use and heavy drinking days during the first-month post-deployment • An attempt to cope with painful memories or images of traumatic events or to reduce frequency of nightmares due to alcohol’s suppression of rapid eye-movement sleep

30. Veterans & TBI • The rates of traumatic brain injury (TBI) resulting from combat have increased dramatically with veterans from OEF and OIF versus veterans from prior conflicts • This increase in rates of TBI may be at least partially explained by improvements in body armor and the medical response to combat injuries. With these modern technologies, OEF and OIF veterans are now able to survive injuries that would have resulted in death in prior combat eras

31. Veterans & TBI • The relationship between alcohol misuse and TBI often is complex because heavy drinking may predate and predispose individuals to experiencing a TBI (i.e., TBI can result from accidents that occur when people are under the influence of alcohol) • Alcohol misuse can exacerbate the complications of TBI by worsening TBI symptom severity (e.g., persistent memory problems) and by further increasing an individual’s risk for experiencing additional alcohol-related TBI events

32. Veterans • Research also shows the negative impacts that deployment and trauma-related stress can have on military families, particularly wives and children: • Cumulative lengths of deployments are associated with more emotional difficulties among military children and more mental health diagnoses among U.S. Army wives. • Children of deployed military personnel have more school-, family-, and peer-related emotional difficulties, compared with national samples.

33. How Do We Help?

34. Veterans • Although active duty troops and their families are eligible for care from the U.S. Department of Defense (DoD), a significant number choose not to access those services due to fear of discrimination or the harm receiving treatment for behavioral health issues may have on their military career or that of their spouse • Many National Guard, Reserve, veterans, and active duty service members as well as their families seek care in communities across this country, particularly from state, territorial, tribal, local, and private behavioral health care systems, often with employer-sponsored coverage.

35. Veterans • Early screening and identification of those who are exhibiting posttraumatic mental health problems is an important first step in intervention • Screen for early signs of alcohol misuse are important to identify at-risk individuals before they are exposed to combat-related trauma • Interventions to screen for a history of alcohol misuse also may help to target individuals who are at risk for developing increasingly severe PTSD symptoms following military trauma exposure

36. Veterans • Re-experiencing symptoms were uniquely predictive of alcohol use suggests that treatment approaches that target these symptoms may impart benefit for both disorders • Evidence-based treatments for PTSD (e.g., cognitive processing therapy, prolonged exposure) that may reduce re-experiencing symptoms may be among the most effective treatment approaches • Integrated PTSD–SUD treatment approaches that directly address both disorders at the same time are likely to produce the most desirable outcomes

37. Veterans • The Veterans Crisis Line(link is external), in partnership with SAMHSA’s National Suicide Prevention Lifeline(link is external), 1-800-273-8255, Ext. 1, connects veterans in crisis and their families and friends with qualified, caring Department of Veterans Affairs (VA) responders through a confidential toll-free hotline, online chat, or text. Veterans and their loved ones can call, chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year.

38. Veterans • Time Limited Care Coordination (TLC) • Features of TLC include: • (1) continuity with the same case managers serving as a bridge across the inpatient and outpatient setting; • (2) cross training of case managers to deliver integrated mental health and substance abuse treatment; and • (3) peer support specialists to assist with engagement and serve as role models to individuals entering recovery

39. Veterans • TLC has been successful in engaging individuals with mental health and substance abuse problems in treatment and assisting them with the transition from inpatient to outpatient services • TLC intervention mitigated some of the problems (e.g., treatment drop out) that arise due to a lack of coordination between inpatient and outpatient care.

40. Veterans • VA/DoD Clinical Practice Guideline for the Management of PTSD • Engage patients in shared decision making (SDM), which includes educating patients about effective treatment options. • Conduct an appropriate diagnostic evaluation that includes determination of DSM criteria, acute risk of harm to self or others, functional status, medical history, past treatment history, and relevant family history. A structured diagnostic interview may be considered. (For patients with suspected PTSD) • Conduct periodic screening for PTSD using validated measures such as the Primary Care PTSD Screen (PC-PTSD) or the PTSD Checklist (PCL). • • Using a quantitative self-report measure of PTSD severity, such as the PTSD Checklist (PCL-5), in the initial treatment planning and to monitor treatment progress.

41. Veterans • Individual, trauma-focused psychotherapy over other pharmacologic and non-pharmacologic interventions for the primary treatment of PTSD. • Pharmacotherapy or individual non-trauma-focused psychotherapy – there is insufficient evidence to recommend one over the other. (When individual trauma-focused psychotherapy is not readily available or not preferred)

42. Veterans • Individual, trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring to include • Prolonged Exposure (PE) • Cognitive Processing Therapy (CPT) • Eye Movement Desensitization and Reprocessing (EMDR) • Specific cognitive behavioral therapies for PTSD • Brief Eclectic Psychotherapy (BEP) • Narrative Exposure Therapy (NET) • Written narrative exposure. • Using trauma-focused psychotherapies that have demonstrated efficacy using secure video teleconferencing (VTC) modality when PTSD treatment is delivered via VTC

43. Veterans • Other Therapies with Potential: • Stress Inoculation Training (SIT) • Present-Centered Therapy (PCT) • Interpersonal Psychotherapy (IPT) • Internet-based cognitive behavioral therapy (iCBT) with feedback provided by a qualified facilitator as an alternative to no treatment

44. Veterans • Insufficient evidence for: • Psychotherapies that are not specified in other recommendations, such as Dialectical Behavior Therapy (DBT), Skills Training in Affect and Interpersonal Regulation (STAIR), Acceptance and Commitment Therapy (ACT), Seeking Safety, and supportive counseling. • Trauma-focused or non-trauma-focused couples therapy for the primary treatment of PTSD. • Augmentation with pharmacotherapy in partial- or non-responders to psychotherapy

45. Veterans • Sleep Disturbances: • Conduct independent assessment of co-occurring sleep disturbances in patients with PTSD, particularly when sleep problems pre-date PTSD onset or remain following successful completion of a course of treatment. • Cognitive Behavioral Therapy for Insomnia (CBT-I) for insomnia in patients with PTSD unless an underlying medical or environmental etiology is identified or severe sleep deprivation warrants the immediate use of medication to prevent harm.

46. Veteran Families • SAMHSA has established a set of core principles that guide its work to improve behavioral health services to veterans and military families: • When appropriate, military families should have access to well-prepared civilian behavioral health care delivery systems. • Civilian, military, and veteran service systems should be coordinated.

47. Veteran Families • Suicide prevention for military families must be implemented across systems. • Emotional health promotion for military families is important in reducing mental and substance use disorders and weathering increased exposure to adverse events. • Military families want and need stable housing.

48. Veterans • In the United States, about 10% of homeless people are veterans. • Among this group, three out of four experience mental and/or substance use disorders. • About one fifth of veterans in substance use treatment were homeless. • At-Risk Populations Among Veterans & Military Families • Children • Minorities • Women

49. Veterans • Controlled studies have not been conducted to evaluate the safety or effectiveness of medical marijuana for PTSD. Thus, there is no evidence at this time that marijuana is an effective treatment for PTSD. In fact, research suggests that marijuana can be harmful to individuals with PTSD.

50. Veterans • Research has consistently demonstrated that the human endocannabinoid system plays a significant role in PTSD. • People with PTSD have greater availability of cannabinoid type 1 (CB1) receptors as compared to trauma-exposed or healthy controls. • As a result, marijuana use by individuals with PTSD may result in short-term reduction of PTSD symptoms. • However, data suggest that continued use of marijuana among individuals with PTSD may lead to a number of negative consequences, including marijuana tolerance (via reductions in CB1 receptor density and/or efficiency) and addiction. • Though recent work has shown that CB1 receptors may return after periods of marijuana abstinence , individuals with PTSD may have particular difficulty quitting