The health and wellbeing of Veterans

1. The health and wellbeing of Veterans

2. We will discuss • The context of Veterans • The Armed Forces Covenant • General Practice and Service Personnel • Social issues • Psychological issues • Severe and enduring injuries • Obtaining treatment • Sources of support

3. Veterans in context • A Veteran is defined as anyone who has served In the armed forces for at least one day • In the UK there are circa 5 million Veterans • Most Veterans will have health and social needs in common with the general population • Some will have physical or mental conditions directly related to their military service • The social needs of Veterans may be at their most acute just after discharge

4. The Armed Forces Covenant • Sets out the relationship between the Nation, the State and the Armed Forces • Recognises the disadvantages compared to civilian life • Applies to all 4 home nations • In Wales the WG has supported the all Wales Veterans’ health and wellbeing service to the tune of £485K annually

5. General Practice and the Forces • Regular service personnel have their GP registration removed • Families remain in NHS • Different type of healthcare • The doctor as a ranking officer • Culture of fitness • The medical record

6. Service Related Problems • The majority of Service personnel are discharged fit and healthy • Not all service related problems are immediately obvious • In this presentation it is simpler to deal with the physical, psychological and social separately, although they will inevitably co-exist

7. Social issues • Discharge from service = large life event • Adjustment to civilian life • Many have stable family life • Housing, employment, peer support • Graduated resettlement support service

8. Psychological issues • What barriers may influence access to psychological services for ex service personnel?

9. Psychological issues • In 2009 the Improving Access to Psychological Therapies (IAPT), an English NHS body, published a Veterans positive practice guide http://iapt.nmhdu.org.uk/silo/files/veterans-positive-practice-guide.pdf This highlighted the differing needs of Veterans in accessing mental health services

10. Possible barriers • High levels of social exclusion can mean that some Veterans do not register with GPs and therefore have poorer access to health care • Veterans’ beliefs and behaviours may prevent them from receiving psychological therapies • General Practitioners and other primary care professionals may inadvertently prevent veterans from accessing to psychological therapies services • Specialist mental health services may inadvertently prevent Veterans from accessing services that provide psychological therapies

11. Psychological issues • The All Wales Veterans Health and Wellbeing Service. http://www.veteranswales.co.uk/

13. Mental Health Issues • The vast majority of ex Service personnel do not experience mental health problems either while in Service or after • What are the risk factors for mental health issues that affect Service personnel?

14. Mental Health Issues • Risk factors include:- • Violent or traumatic experiences in combat • Disruption and instability in home life • Repeated or prolonged deployments • Alcohol related

15. Mental Health Issues • The most common Mental Health issues affecting Veterans are:- • Anxiety disorders (including PTSD) • Depression • Psychological trauma-related disorders • Substance misuse (mostly alcohol) • May be multiple issues • May be compounded by Physical or Social problems

16. Mental Health Issues • Anxiety disorders may be further sub classified into:- • panic disorder • obsessive-compulsive disorder (OCD) • post-traumatic stress disorder (PTSD) • social phobia (or social anxiety disorder) • specific phobias • generalised anxiety disorder (GAD)

17. Post Traumatic Stress Disorder (PTSD) • PTSD is seen in active personnel at fairly low rates • Veterans are possibly twice as likely as the remaining civilian population to develop delayed onset PTSD • The first year after discharge commonest • Soldiers, and in particular young, single ex-infantrymen, have the highest rates of PTSD (in common with other mental and physical health problems) related to their relatively higher rates of close combat experience.

18. PTSD

19. PTSD Treatment (NICE) • Initial response to trauma • Not routine practice • Trauma-focused psychological treatment • Individual outpatient basis (first line) • Drug treatments • Not first line, Paroxetine or Mirtazapine in primary care, Amitriptyline or Phenelzine in specialist services

20. PTSD • In the case of Veterans in the community it is likely that the traumatic event(s) triggering the PTSD will have occurred many months or years previously. NICE recommends that the duration of the trauma focussed psychological treatment should last 12 sessions or more in this situation. For most Veterans with PTSD treatment options that should be discussed should include referral (or self referral) to the All Wales Veterans Health and Wellbeing Service. http://www.veteranswales.co.uk/

21. Severe and enduring injuries • Most Service personnel are discharged fit and well • Over 70 partial or full amputations since 2006 • Risk of death for the army in current times is 1 per 1000, this is 150 times the risk for the UK population in other jobs • Severe brain injury, spinal cord damage, partial or full loss of sight, bodily and facial disfigurement, traumatic loss of hearing and burns injuries

22. Specific situations - Visual loss • Partial or full visual loss • Rehabilitation and all treatments necessary should have been undertaken or planned • Transition package should have ensured aids were in place • Useful residual sight and worsening – assess need for same day referral • http://www.blindveterans.org.uk/http://www.rnib.org.uk/Pages/Home.aspx

23. Specific situations - Hearing loss • Noise induced hearing loss common in Service personnel • Perhaps not immediately apparent • Compounded by natural age related hearing loss • Blast induced or structural damage • http://www.actiononhearingloss.org.uk/

24. Specific situations - Disfigurement • A 'disfigurement' is the generic term for the aesthetic effect or visual impact of a scar, burn, mark, asymmetric or unusually shaped feature or texture of the skin on the face, hands or body • Severity of the disfigurement is not always related to the way individuals perceive themselves • http://www.changingfaces.org.uk/Homehttp://admin.changingfaces.org.uk/downloads/Handling%20Reactions.pdf

25. Specific situations – Chronic Pain • Definition • Common in severe injuries • Small numbers • Co-morbid with PTSD and Persistent Post Concussive Symptoms in these cases • Holistic approach – Psychological, Social and Physical

26. Specific situations – Phantom limb sensations/pain, prostheses and stump care • Virtually all amputees experience phantom phenomena • 60-80% will experience painful sensations in the missing limb • Stump pain can cloud the picture • Phantom limb pain tends to be episodic • Severe in between 15-25% of patients • More common in upper limb amputations

27. Specific situations – Phantom limb sensations/pain, prostheses and stump care • More often perceived in the missing hands or feet • Burning, stabbing or prickling quality • Crushing or cramp type pain can also be described • Stump pain may be due to local factors • Veterans should have a well-fitted high quality prosthesis

28. Treatment for phantom limb or stump pain • Very poorly represented in research • Treatment strategy follows that for neuropathic pain • Local attention to the stump (good quality stump sock, use of moisturisers if needed etc.) • Stepwise approach starting with Amitriptyline or pregabalin and titrating the dosage • If ineffective at maximum dose then switch or combine the drugs • Onward referral to a specialist service and to consider oral tramadol in the interim

29. Referring a Veteran • Condition that is possibly related to service • This patient is a military veteran. I consider that his/her current condition may be related to military service. This referral should be considered for priority treatment under Welsh Health Circular WHC (2008) 051

30. Next steps • Can we apply any of this to our practice?

31. Should we • Ask newly registered patients if they are a Veteran? • If a new registrant was recently discharged from the Armed Forces, offer them an early consultation with a GP to address any potential issues? • Code the fact that they are a Veteran? • Check that a copy of the Service medical record is in the GP record? • Ensure priority treatment as per Welsh Health circular?

32. Summary • Most military veterans are discharged from service fit and well and will assimilate well into the civilian community. There are a small but significant group that will have complex problems that may have physical, psychological and social ramifications. Veterans may not access primary care services and may mask psychological symptoms. They are entitled to priority treatment on the NHS and those that have serious injuries should have a care package in place on discharge. • Psychological symptoms can be complex with multiple co-morbidities. The All Wales Veterans Health and Wellbeing service can offer local assessments and co-ordination of care.

33. Sources of support • A list of support services can be found at https://nhswalesappraisal.org.uk/cpd/index.php/summary-a-links