Transcript 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)
Specific Nonpsychotic Mental Disorder due to Organic
Brain Damage (310)
Special Symptoms, Not Elsewhere Classified (307)
Sexual Deviations and Disorders (302)
31,108
Drug Dependence (304)
15,403
20,050
18,504
15,791
294,536 unique patients.
This data does not include information on PTSD from VA’s 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
– Improvised Explosive
Device (IEDs)/Explosively Formed
Projectile (EFPs), lack of control, who
is friend/foe?
 Unpredictability
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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
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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 61:572–588, 2010
Stigma and barriers to care
Psychiatric Services 61:572–588, 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
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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.

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About One-Third of Returning Servicemembers
Report Symptoms of a Mental Health or
Cognitive Condition (Rand, 2008)
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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
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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
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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!
Brad Pitt as Achilles in “Troy”
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
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Injury
–
–
–
–
May be more abrupt
A derailment, change in
self
Individual loses control
Irreversible (though can
heal)
Three Mechanisms of Stress Injury
COMBAT / OPERATIONAL STRESS
TRAUMA
•
•
An impact
injury
Due to events
involving
terror, horror,
or
helplessness
FATIGUE
•
•
A wear-andtear injury
Due to the
accumulation
of stress over
time
GRIEF
•
•
A loss injury
Due to the
loss of people
who are
cared about
Prepared by
Operational Stress Injuries Correlate
with DSM-IV Diagnoses
Capt. William Nash,
MC, USN
HQ, Marine Corps
Combat / Operational Stress
TRAUMA
PTSD
FATIGUE
Depression
Alcohol
GRIEF
Anger
Drugs
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,
soldier’s heart
PTSD,
stress
injuries
COSR
“hysteria”,
fatigue
Trojan War Napoleonic American World War World War
Wars
Civil War
One
Two
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, Exaggerated Startle
Response
Arousal
Avoid Thoughts, Feelings, Conversations,
Activities, Places, People, Inability to
Recall Trauma Aspects, Detachment or
Estrangement from Others, Emotional
Numbness, Sense of Foreshortened
Future
Avoidance
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
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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

19.3%
20%
(3-4 mos. after OEF and OIF-I)
Significant PTSD Symptoms
The Greater the Exposure to Combat,
the Higher the Risk for PTSD
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 can’t 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
Angry
Scared
Horrified
Intrusive
Reminders
Flashbacks
Nightmares
Images
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
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PTSD
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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).
 www.ptsd.va.gov/public/pages/prolongedexposure-therapy.asp
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)
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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 one’s 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