Painting a Moving Train… Harold Kudler, M. D. VISN 6 Deployment health mental illness Research, Education and Clinical C

1. Painting a Moving Train… Harold Kudler, M. D. VISN 6 Deployment health mental illness Research, Education and Clinical Center (MIRECC) Department of Veterans Affairs

2. Introduction “When I come to feeling overwhelmed…I want a one-on-one talk with a trained psychiatrist who’s either been to war or understands war.” --Staff Sgt. Gladys Santos, who attempted suicide after three tours in Iraq. Newsweek February 11, 2008 Painting a Moving Train 2

3. Introduction “The most complex and dangerous conflicts, the most harrowing operations, and the most deadly wars, occur in the head.” (Anthony Swafford, Jarhead from PBS video Operation Homecoming) Painting a Moving Train 3

4. Introduction “For the first time in American history, 90% of wounded (soldiers) survive their injuries” “A greater percentage of men and women are coming home with …TBI and severe Posttraumatic Stress.” (Alive Day Memories: Home from Iraq HBO documentary Painting a Moving Train 4

5. Introduction How many of you are: • A Military Member or a Veteran? • Spouse of a veteran ? • Other family member of veteran? Painting a Moving Train 5

6. Introduction How many of you are: • Psychiatrists, physicians? • Substance abuse counselors? • Psychologists? • Social workers, counselors (including schools)? • Psychiatric nurses or other nurses? Painting a Moving Train 6

7. Introduction Painting a Moving Train General Magnus’ Analogy Scope of issue – why this training? Painting a Moving Train 7

8. Scope of the Issue 8 Painting a Moving Train • Length of current combat operations • As of November 27, 2006, war in Iraq has been going on longer than WWII. • An all volunteer force = multiple deployments

9. Scope of the Issue • 1 ½ million service members have served in Iraq and Afghanistan. • “The war in Iraq remains very personal. Over 75% of Soldiers and Marines surveyed reported being in situations where they could be seriously injured or killed; 62-66% knewsomeoneseriously injured or killed; more than on third described an event that caused them intense fear, helplessness or horror.” --From the Office of Surgeon General Mental Health Advisory Team (MHAT) IV, Final Report, Nov 06 Painting a Moving Train 9

10. Scope of the Issue “The challenges are enormous and the consequences of non-performance are significant. Data…indicate that 38% of Soldiers and 31% of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49%. Further, psychological concerns are significantly higher among those with repeated deployments, a rapidly growing cohort. --Report of the DoD Task Force on Mental Health, June 2007 Painting a Moving Train 10

11. Scope of the Issue • Psychological concerns among family members of deployed and returning OEF/OIF veterans, while yet to be fully quantified, are also an area of concern. Hundreds of thousands of children have experienced the deployment of a parent…” --Report of the DoD Task Force on Mental Health, June 2007

12. 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 clients. Painting a Moving Train 12

13. Basic Training – Military Culture • Army • Army National Guard • Navy • Marine Corps • Air Force • Air National Guard • Coast Guard* Painting a Moving Train 13

14. Basic Training – Military Culture High standard of discipline that helps organize and structure the armed forces Professional ethos of loyalty and self-sacrifice that maintains order during battle Distinct set of ceremony and etiquette that create shared rituals and common identities Emphasis on group cohesion & esprit de corps that connect service members to each other. Painting a Moving Train 14

15. Basic Training – Military Culture A word about lingo… Painting a Moving Train 15

16. Who VA Serves Of 23.4 million veterans currently alive, nearly three-quarters served during a war or an official period of conflict Women account for 8% of all veterans (roughly 1.8 million women veterans) About a quarter of the nation's population is potentially eligible for VA benefits and services because they are veterans or family members VA currently provides health care to 5.5 million veterans (roughly 1 in 5 veterans) Roughly 10% of VA users are women veterans http://www.va.gov/

17. Care Access Points 153 medical centers at least one in each state, Puerto Rico and the District of Columbia 909 ambulatory care and community-based outpatient clinics 47 residential rehabilitation treatment programs 232 Veterans Centers

18. Care Access Points 88 comprehensive home-care programs 4 DoD/VA Polytrauma Centers My HealtheVet http://www.myhealth.va.gov/ 21 Veterans Integrated Service Networks (VISNs)

19. OIF/OEF Veterans and VA As of the 4th Quarter, FY 2008: 945,423 OEF/OIF veterans eligible for VA services 42% (400,304) have already sought VA care Their three most common health issues: Musculoskeletal Mental Health Symptoms, Signs and Ill-Defined Conditions

20. Beyond the DoD/VA Continuum Ideally such problems will be picked up somewhere within the DoD/VA continuum of care but: If only 42% of All OEF/OIF Veterans eligible for VA care have come to VA where are the other 58%? There is a “silent majority” of OEF/OIF veterans not coming to VA

21. Comparison to the National Vietnam Veterans Readjustment Study • Only 20% of the Vietnam Veterans with PTSD at the time of the study had EVER gone to VA for Mental Health Care yet: • 62% of all Vietnam Veterans with PTSD had sought MH care at some point Kulka et al. 1990, Volume II, Table IX-2

22. Boots on the GroundUnderstanding the Experience Painting a Moving Train 22

23. Boots on the Ground:Understanding the Experience 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" Painting a Moving Train 23

24. Boots on the Ground:Understanding the Experience In war, there are no unwounded soldiers. --Jose Narosky Painting a Moving Train 24

25. “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 Painting a Moving Train 25

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29. Post Deployment Concerns among Active and Reserve Component Soldiers • Study followed 88,235 US soldiers returning from Iraq who completed both a Post Deployment Health Assessment (PDHA) and, 6 months later, a Post Deployment Health Reassessment (PDHRA) • Screening includes standard measures for • Posttraumatic Stress Disorder (PTSD) • Major Depression • Alcohol Abuse • Traumatic Brain Injury • Other Mental Health problems Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

30. Changes among Active Duty (AD) and Reserve Component (RC) Soldiers at PDHRA • Roughly half of those with PTSD sx on PDHA improved by PDHRA yet: • There were twice as many new cases of PTSD at PDHRA • Depression rate doubled in AD (10%) and tripled in RC (13%) at PDHRA • Overall, 20.3% AD and 42.4% RC were identified as needing MH tx post deployment

31. Changes among Active Duty (AD) and Reserve Component (RC) Soldiers at PDHRA • 4-fold Increase in concern about interpersonal conflict • Alcohol abuse rate high (12%AD/15%RC) at PDHRA yet few (0.2%) referred for tx • If this is the progression among Service Members over the first 6 months, what about their family members?

32. Why Might Reserve and Guard (RC) Members be at Greater Risk than Active Duty (AD) Soldiers? • AD have ready access to healthcare but RC DoD health benefits (TRICARE) expire in 6 months • More than half of RC soldiers were beyond standard DoD benefit window by PDHRA • Special VA benefits end 24 months after separation so, despite the stigma, the need to secure ongoing VA healthcare may push RC to report sx on PDHRA • Other potential factors unique to RC may be the lack of day-to-day support from war comrades and added stress of transition back to civilian employment

33. Mental Health Among OIF/OEF Veterans • Possible mental health problems reported among 44.6% (178,483) of the 400,304 eligible OEF/OIF veterans who have presented to VA • Provisional MH diagnoses include: • PTSD 92,998 • (23% of all who presented to VA) • Nondependent Abuse of Drugs: 27,246 • Depressive Disorder: 63,009 • Affective Psychoses 35,937 • Neurotic Disorders: 50,569 • Alcohol Dependence: 16,217 • Drug Dependence: 7,412

34. Traumatic Events in OEF/OIFA Sampler Multi-casualty incidents (Suicide Bombers, VB/IEDs, ambushes) Seeing the aftermath of battle Handling human remains Friendly fire Witnessed or committed atrocities Painting a Moving Train 34

35. Traumatic Events in OEF/OIFA Sampler Witnessing death/injury of close friend/favored leader Death/injury of women & children Feeling/being helpless to defend or counter-attack Being unable to protect/save a colleague or leader Painting a Moving Train 35

36. Traumatic Events in OEF/OIFA Sampler Killing at close range Killing civilians/”avoidable” casualties or deaths Painting a Moving Train 36

37. Barriers To Treatment Treatment beliefs not addressed Fears of failure and fears of success Labels and stereotypes Avoidance Realistic concerns Painting a Moving Train 37

38. Identifying/Treating Post Deployment Mental Health Problems Among New Combat Veterans and their Families • OEF/OIF veterans often seek care outside DoD/VA • Family members are also dealing with deployment-related stress and look for help in the community • Is your practice prepared to identify or treat post deployment problems?

39. If You Don’t Take the Temperature, You Can’t Find the Fever • Know something about our nation’s military history and about our present military conflicts • Know something about DoD and VA • Ask each patient if he/she is a Service Member/veteran or a family member/ significant other of a service member or veteran? • Know something about the different Service Branches and respect the difference!

40. Our Focus… Painting a Moving Train 40

41. Posttraumatic Stress Disorder (PTSD) • Characterized by a constellation of symptoms that follow exposure to an extreme traumatic event which involves actual or threatened death or serious injury • The response to the event must include intense fear, helplessness or horror and symptoms that persist more one month, including: • re-experiencing the traumatic event through intrusive recollections, dreams or nightmares • avoidance of trauma-associated stimuli, such as people, situations, or noises; and • persistent symptoms of increased arousal, which may include sleep disturbance, hypervigilance, irritability or an exaggerated startle response

42. Posttraumatic Stress Disorder (PTSD) • PTSD diagnosis must also be accompanied by clinically significant distress or impairment in social, occupational or other important areas of function • Problems must persist at least one month after the event

43. Traumatic Brain Injury (TBI) • Problems with memory, concentration, emotional lability or irritability may also suggest TBI • Screen with the 3-Question Screening Tool developed by the Defense and Veterans Brain Injury Center (DVBIC)

44. Traumatic Brain Injury (TBI) Proximity to explosions, thrown from a vehicle, lost consciousness (knocked out or down) and for how long, having symptoms of concussion (dizziness, headache, irritability, etc.) afterwards the blast Current symptoms: headaches, dizziness, memory problems, balance problems, ringing in the ears, irritability, sleep problems, change in ability to smell or taste, sensitivity to sound or light, irritability, fatigue, trouble with concentration, attention, thinking. Painting a Moving Train 44

45. Combat/OperationalStress Reactions/Injuries Painting a Moving Train 45

46. A 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 Painting a Moving Train 46

47. Combat Stress Injury/Trauma Participant in/witness to event(s) involving horror, feelings that you or someone close to you will die, helpless, powerless Painting a Moving Train 47

48. Combat Stress Injury – Discomfort/Fatigue Accumulation of stress over time, environmental hardships Painting a Moving Train 48

49. Combat Stress Injury –Grief Loss of people who are cared about both in Iraq and at home Painting a Moving Train 49

50. Tricare