Ahec veterans mental health project: (add the title of your program)

Ahec veterans mental health project: (add the title of your program)
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Speaker names/affiliations
[Speaker’s name] [Speaker’s affiliation] [Sponsoring Agency] [City & state of training] [Date] 2

welcome Read or summarize the welcome scripted in the toolkit. 3

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" 4

Introduction 1 Introduction 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 Almost everyone in the room should have raised their hand in response to the question. Use this slide to explain that the wars in Iraq and Afghanistan have touched all our lives as we all/most of us know someone who is in the military and may have been deployed to war. 5

Introduction Introduction 2 How many of you are: Physicians
Psychologists Social workers Licensed Counselors Substance Abuse Marriage and Family Nurses Others Find out what healthcare disciplines are in the audience and refer to these disciplines throughout the presentation 6

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 These are common abbreviations you will hear today. You will be introduced to more in the section on Military Culture. 7

Scope of the Issue Here is where we will explain why are we spending time and money discussing the behavioral health issues of combat veterans. 8

In war, there are no unwounded soldiers.
Jose Narosky Jose Narosky, an Argentine writer, mainly of aphorisms, who worked as a journalist for the newspaper "The World." 9

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 Certain aspects of this war may create increased stressors and risk of psychological injury. We’ve been in Afghanistan since October 2001 (11 years) and in Iraq since March 2003 (9 years + including OND activities) for a total of 20 years of combat. The Revolutionary War lasted for 8 years and 2 months. The American Civil War lasted 4 years. The Spanish-American War began in February 1898, and ended about 5 months later. World War I lasted 4 years and just under 5 months. The U.S. role in World War II started in December of 1941; it ended with the Japanese surrender in 1945. The U.S. involvement in Vietnam lasted well over a decade. Since our military is all volunteer, it is not unusual for some service members to have as many as 5 deployments to OIF/OEF. There are about 3,300 counties in the US, and 99.2% of those counties (3,273) have deployed at least one person to OIF/OEF since Sept 11, Only 27 counties in the entire nation have not deployed anyone. To see the deployment statistics for your state by county, click on the words “deployment maps”. Review these maps prior to the training. 10

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% knew someone seriously 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) We know how to treat trauma…Why is all this important? The numbers of Americans who have served in Iraq - military and civilian – are significant. The population to be served is huge and growing. It is disbursed throughout the nation in very small “pockets” or concentrations. “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% knew someone seriously 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 The information in red relates to the criteria for PTSD 11

“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) Resource Military Child Education Coalition 12

Psychological concerns among family members >1 million children in US under 11 years old experienced deployment of a parent – sometimes both – since 9/11 Resource Military Child Education Coalition 13

Psychological concerns among family members National concern First Lady Joining Forces initiative Support family members “Families serve, just not in uniform” Dr. Jill Biden The National AHEC Organization is a member of the Joining Forces initiative along with most national healthcare organizations such as American Nursing Association, American Academy of Family Physicians. 14

Sesame Street series Sesame Street Series Deployments Homecomings
Changes Grief Sesame Street has developed a series of programs for children on the issues on this slide. They are available to military families at no charge through Military One Source at and Military One Source at

Scope of the Issue 7 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 Review report prior to giving presentation: 16

Scope of the issue 8 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 Review report prior to presentation: 17

Suicide ideation rates the same Higher exposure to concussive events Service members on 3rd to 4th deployment had lower morale than those on 1st Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011 Review report prior to presentation: 18

Scope of the issue 10 Scope of the Issue Experience 2007 2010
Death of unit member 48.6% 73.4% Shooting at enemy 29.6% 78.5% IED exploded near them 32.8% 62.4% Responsible for death of combatant 8.3% 48.4% Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011 Review report prior to presentation: 19

Dramatic increase in combat exposure over previous surveys Behavioral health stigma unchanged Office of the Army Surgeon General Mental Health Advisory Team (MHAT) VII Report, May 2011 Review report prior to presentation: 20

Scope of the issue: Rural
This section taken with permission from presentation developed in July 2012 by Harold Kudler, MD Clinical Lead VISN 6 Rural Health Initiative Associate Director Mental Illness Research, Education and Clinical Center Associate Professor Duke University Medical Center 21

Scope of the issue 12 Scope of the Issue Defining rural
VA uses US Census Bureau’s definition “Urban”, “Rural” and “Highly Rural” Urban Area: Any block or block group having a population density of at least 1000 people per square mile Rural Area: Any non-urban or non-highly rural area Highly Rural Area: Area having < 7 civilians per square mile (Frontier) At the end of WWII, General Omar Bradley and his new team, charged with growing the VA to meet the needs of returning Veterans, made a strategic and highly successful decision to build new VA Medical Centers near major medical schools. The only problem was that most Veterans didn’t and still don’t live near major medical schools. 22

Scope of the issue 13 Scope of the Issue VA rural health
Legislation approved in 2006 Recognizing needs of Rural Veterans Establishment of the VA Office of Rural Health (ORH) Special appropriations expand VA services for rural veterans 23

Scope of the issue 14 Scope of the Issue Who is rural?
20% of the entire US population 28% of all living veterans (6.1 million of all 22 million living veterans) 41% of all veterans enrolled in VA 3.3 million enrolled rural veterans 54% all rural veterans enrolled (about double the enrollment non-rural) 24

Scope of the issue 15 Scope of the Issue 44% of US military recruits
Who is rural? 44% of US military recruits 39% of OEF/OIF/OND Veterans 44% of soldiers killed in Iraq from communities < 20,000 people 25

Scope of the issue: why train civilians?
Now we’re going to discuss why we need to train civilian providers if those who need help are military members. This topic will be addressed again later in the presentation as well. 26

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” This was a web-based survey done in 2011 of rural and urban mental health and primary care community providers funded by the Office of Rural Health and carried out in partnership with the VISN 6 Mental Illness Research, Education and Clinical Center. 27

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 319 rural and urban community mental health and primary care providers were surveyed. 28

Serving Those Who Have Served full report available at Read report prior to presentation. 29

Scope of the issue 19 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 30

Scope of the issue 20 Scope of the Issue Key Findings
Community providers report less knowledge and confidence in treating PTSD Traumatic Brain Injury (TBI) Substance abuse/dependence Than treating Depression Suicidality Other health issues 31

Scope of the issue 21 Scope of the Issue Key Recommendations
Train civilian providers Understand military culture Understand VA programs 32

Questions? 33

Basic Training – Military culture
If you have been deployed to combat and feel comfortable talking about your experience(s), add personal stories in this section as a way to present the content. Examples: Describe what you and your family went through preparing for deployment as a way to discuss military rules/regulations Talk about your deployment – what it was like for you as a way to explain the military hierarchy and its importance Tell about your transition back to either civilian life (if Guard or Reserve) or life on base (if active duty) and how different it was from your life during deployment. 34

Basic Training – Military Culture 1
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. Being in the military is not like any other job. For most of us, our jobs are what we do, not who we are. We can leave work at work. If we get drunk, bounce a check, get in a fight with our spouse or significant other, or if our kids mess up in school or get in trouble with the law, no one at work will be notified. We can leave the area, fly or drive to where ever we want and no one at work needs to know. We can see a counselor, have a medical procedure, take medication. No one at work needs to know nor can they find out unless we decide to tell them. If our kids go to school hungry or dirty and CPS comes knocking on our door, no one knows except the people we choose to tell…not our employers, a counselor etc. If, on our way home from work, we want to stop for milk or cigarettes or to have dinner with a friend, we don’t have to change clothes first. These are some of the “givens” of being in the military. 35

“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.” This shows the importance of creating a therapeutic relationship with your patients, and one way to do that is to know something about Military Culture. (Expound on this. Explain why you do/do not identify yourself as military when you see a civilian provider be it a dentist, lab technician, nurse, etc.) Staff Sgt. Gladys Santos attempted suicide after three tours in Iraq Newsweek article February 11, 2008 36

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 37

Distinctions among the branches of the US Military (although they are being blurred somewhat): Army: To protect and defend via ground troops, tanks, artillery, attack helicopters, tactical nuclear weapons. Navy: To maintain, train and equip combat-ready Naval forces capable of winning wars, deterring aggression and maintaining freedom of the seas. Marine Corps: To seize and defend by air, sea, ground – a ready force. Air Force: To defend through exploitation of air and space. Operates fighter aircraft, tanker aircraft, light and heavy bombers, transport aircraft and helicopters. Responsible for all military satellites/strategic nuclear missiles. Coast Guard: Safety, security, mobility, defense and protection of natural resources, deploy worldwide in support of maritime missions (including Iraq for port security). Any air assets of the Army, Marine Corps are in support of the ground troops. Navy provides chaplains and medical personnel to the Marine Corps, many of whom are embedded or forward deployed with combat units. Combat support hospitals are as far forward as is practical… All are a part of the Department of Defense, except for the Coast Guard, which is part of Homeland Security. National Guard units are under the control of the governor of the resident state unless activated. 38

Army/Army National Guard Navy/Naval Reserves Marine Corps/Marine Corps Reserve Air Force/Air National Guard/ Air Force Reserves Coast Guard* Distinctions among the branches of the US Military (although they are being blurred somewhat): Army: To protect and defend via ground troops, tanks, artillery, attack helicopters, tactical nuclear weapons. Navy: To maintain, train and equip combat-ready Naval forces capable of winning wars, deterring aggression and maintaining freedom of the seas. Marine Corps: To seize and defend by air, sea, ground – a ready force. Air Force: To defend through exploitation of air and space. Operates fighter aircraft, tanker aircraft, light and heavy bombers, transport aircraft and helicopters. Responsible for all military satellites/strategic nuclear missiles. Coast Guard: Safety, security, mobility, defense and protection of natural resources, deploy worldwide in support of maritime missions (including Iraq for port security). Any air assets of the Army, Marine Corps are in support of the ground troops. Navy provides chaplains and medical personnel to the Marine Corps, many of whom are embedded or forward deployed with combat units. Combat support hospitals are as far forward as is practical… All are a part of the Department of Defense, except for the Coast Guard, which is part of Homeland Security. National Guard units are under the control of the governor of the resident state unless activated. 39

My uniform… Describe your uniform – what colors, what medals, what braids, insignias/patches, etc. 40

Service Member (SM) General term Identify any sworn member of the service Veteran- person who has served in military Combat Veteran- person who has served in combat zone Disabled Veteran- person permanently disabled Result of military service Range from minor injury to severely disabled More lingo to be used throughout the day 41

Military Occupational Specialty (MOS) Advanced individual training Hundreds of MOS 42

Sample MOS positions Food Services Infantry Artillery Chemical and biological experts Construction experts Medical professionals 43

Sample MOS positions Lawyers Investigators Military Intelligence Special Operations Command (SOCOM) members 44

More about lingo… DoD = Department of Defense VA = Department of Veterans Affairs IED = Improvised Explosive Device VBIED = Vehicle Born IED (car or suicide bomb) 45

Basic Training (Boot Camp for USMC) Total control environment Intended to take the SM out of comfort zone Through physical and mental preparedness 46

Service broken up into two major groups… Combat Infantry Artillery Combat Engineers Special Forces All male force 47

Service broken up two major groups… Combat Support Administrative specialties Police Fire Legal Medical Male and female SMs 48

More about lingo… FOB = Forward Operating Base TDY = Temporary Duty ROE = Rules of Engagement 49

Military Rank 1 Military Rank Divided into two groups: Officers
Warrant Officers (WO1-CW5) Regular Line Officers (Second Lieutenant- General)

Military Rank 2 Military Rank Enlisted
Lower Enlisted (Private – Specialist) Non-Commissioned Officers NCOs (Corporal – Sergeant Major)

High standard of discipline Distinct ceremony and etiquette Creates shared rituals and common identities Emphasis on group cohesion & esprit de corps Military is a distinct culture having elements of every other culture: Order/Rules/Norms/Rank/Formal Structure—Code of Conduct, Rule of Law, UCMJ, Chain of Command, Rules of Engagement, Ethical codes, Values Language: Slang marks from soldier from the civilian, distinguishes insiders from outsiders. Slang “binds, like a sauce.” Swear words are interwoven in military-speak, doing duty for most parts of speech. Reference Embrace the Suck Compiled and Introduced by Col. Austin Bay Stories, heroes, histories, myths, legends, jokes, music, an ethos Symbols, Insignias, Ribbons & Medals, Role of Tattoos Rituals, rites, ceremonies, celebrations Even a way of referencing time 52

Connects service members to each other Continued into retirement Wearing of service uniforms - parades and military unit apparel 53

The military - way of life with own expectations Work/family balance Communication Relationship with one’s employer 54

For some military is… Way to pay bills Way to get Health Housing Other benefits for family 55

For many… Military is a profession Same way doctor is a profession 56

Guard and Reserve culture Well luckily as a Reservist you are only dead for one weekend a month Joke told by a Reservist 57

Guard and Reserve culture Formally a Strategic Reserve Backfill the Active Duty force Train one weekend a month Two weeks a year 58

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 59

“When I first met my husband, I didn't know what it meant to be a military wife. I just knew that I loved a soldier. And that my love was strong enough to weather whatever life might hand us. In those early days, Ian was a typical ‘weekend warrior’. I lent him to the Army one weekend a month and two weeks during the summer. And I missed him terribly when he was gone. Especially those two weeks - they were a lifetime without him. But September 11th changed that. Suddenly, he was deploying as often as the Active Duty guys. New Orleans. Guantanamo. Afghanistan.” Randi S. Cairns Founder/Executive Director Home Front Hearts, Inc.

Guard and Reserve culture No typical RC experience Deployment pattern depends on rank and MOS Some RC deploy once a decade Some deploy every 2-3 years 61

Guard and Reserve culture Many deployments fun – opportunity for growth for the service member and family Some deployments scary and isolating Yellow Ribbon - education Operation Purple camp - kids Link to explanation of Yellow Ribbon program Link to explanation of Operation Purple Camp 62

Each uniformed service has its own culture Service members and military families hold a wide variety of views Do not make assumptions about the person in front of you Wait until they tell you 63

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 64

Questions? 2 Questions? 65

Behavioral health issues
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Behavioral Health Issues 1
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 Post Traumatic Stress.” (Alive Day Memories: Home from Iraq HBO documentary) 67

Behavioral health issues 2
> 1.2 million OEF/OIF veterans eligible for VA services (Sept 2010) 50% already sought VA care Three most common health issues Musculoskeletal Mental Health Symptoms, Signs and Ill-Defined Conditions Data from presentation by Harold Kudler, MD VISN 6 MIRECC Durham, NC 68

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 Dx 11.6% 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 MDD = Major Depressive Disorder MH = mental health 69

Behavioral health issues 3
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 The other 50% are seeking care in the civilian community. We’ve already seen that civilian healthcare providers do not routinely ask about military service in their interview with their patients, so the providers are missing very important clinical information! 70

Comparison National Vietnam veterans readjustment study (NVVRS)
Only 20% Vietnam Veterans with PTSD (at the time of the study) had ever gone to VA for mental health care But… 62% of Vietnam Veterans with PTSD sought mental health care at some point Kulka et al. 1990, Volume II, Table IX-2 In comparison, a large majority of the Vietnam veterans with PTSD in the NVVRS had never come to VA for any mental health problem. This certainly does NOT mean that all OEF/OIF veterans who have (so far) chosen not to use VA services have PTSD but it certainly suggests a need to make sure that appropriate care will be available for those of them that do. Full Kulka reference: Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., et al. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study, Volume II. New York: Brunner/Mazel. 71

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 The Army’s Walter Reed Army Institute of Research has provided groundbreaking reports on recently returned war fighters. Key tools in this work include the PDHA and PDHRA. The Post Deployment Health Assessment (PDHA) is a self-administered global health survey (DD2796) performed at the time war fighters return from deployment. The Post Deployment Health Reassessment (PDHRA) is performed 3-6 months post deployment. After completing the self report instrument (DD2900), each Service Member has a private review with a health care provider. VA and community representatives are usually on site to help with seamless transition and parallel programs are often offered to family members at the same time. Copies of PDHA and PDHRA are in the handouts Milliken, Auchterlonie & Hoge (2007). JAMA 298: 72

Post deployment issues – active and reserve components 1
Post Deployment Health Assessment (PDHA) Self-administered global health survey War fighters return from deployment De-mobilization unit Chaotic environment Screening tool not individual assessment Lots of questions Note that samples of the PDHA and PDHRA are in handouts 73

PDHA include standard screening Posttraumatic Stress Disorder (PTSD) Major Depression Alcohol Abuse Traumatic Brain Injury Other Mental Health problems Note that samples of the PDHA and PDHRA are in handouts Milliken, Auchterlonie & Hoge (2007). JAMA 298: 74

Post Deployment Health Assessment (PDHA) Many not report symptoms Do not recognize Don’t want anything to interfere with going home Note that samples of the PDHA and PDHRA are in handouts 75

Post Deployment Health Reassessment (PDHRA) Performed 6 months post deployment Self report instrument followed by private review with health care provider VA and community reps onsite help with transition PDHA vs. PDHRA results on next few slides Note that samples of the PDHA and PDHRA are in handouts 76

Changes Active Duty and Reserve Component at pdhra 1
Results… Roughly ½ with PTSD symptoms PDHA improved by PDHRA BUT… Twice as many new cases of PTSD at PDHRA Link to the article More than twice as many new cases were identified among soldiers who did not have a high PTSD score initially on the PDHA. Ask audience why they think new cases diagnosed 6 months later Possible answers Don’t want to interfere with going home Takes a few weeks/couple of months to realize that coping skills in battle are creating problems at home Family members , especially women , encourage/push men to seek treatment Milliken, Auchterlonie & Hoge (2007). JAMA 298: 77

Results… Depression rates at PDHRA Doubled in AD to 10% Tripled in RC to 13% Identified as needing MH treatment post deployment AD % RC % Milliken, Auchterlonie & Hoge (2007). JAMA 298: 78

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: 79

Changes Active Duty and Reserve Component at pdhra 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) Guard and Reserve members must overcome the same stigma as Active Duty Personnel about reporting post deployment mental health problems but they may be more likely to report because they need to secure VA services and benefits now that they have returned to civilian status. Otherwise their period of entitlement for these services would expire 24 months after they return from deployment. References: TRICARE Management Activity. Transitional assistance management program: a transitional health care benefit for service members and their families [fact sheet]. Updated January 6, Accessed September 8, 2007. Combat veterans are eligible for medical services for 2-years after separation from military service notwithstanding lack of evidence for service connection. Washington, DC: Dept of Veterans Affairs, Veterans Health Administration; September 11, VHA Directive Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22. 80

Changes Active Duty and Reserve Component at pdhra 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 81

Take Home Point Take Home Point 1
Post deployment mental health cannot just be about PTSD anymore. It would be helpful here to have a review of diagnoses other than PTSD that occur in combat veterans – refer back to slide # 78 SLIDE 78: Results… Depression rates at PDHRA Doubled in AD to 10% Tripled in RC to 13% Identified as needing MH treatment post deployment AD % RC % 82

Identifying/treating post deployment mh issues in new combat vets and families
OEF/OIF veterans seek care outside DoD/VA Family members also dealing with deployment-related stress Looking for help in the community Reduced capacity to treat family members in Military Treatment Facilities Is your practice prepared to identify or treat post deployment problems? Emphasize the last point. Tell them there may be time later in the training to have a discussion about what practices could do to make their offices more military friendly. 83

Take Home Point Take Home Point 2
There should be NO WRONG DOOR to which OEF/OIF veterans or their families can come for help. Service members and their families should be able to get help from whatever healthcare provider they see – physician, physician assistant, nurse practitioner, nurse, behavioral health professional – and in whatever setting they are in - primary care practice, urgent care, hospital, counseling center, etc. 84

Posttraumatic stress disorder (PTSD)
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Posttraumatic stress disorder 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) 87

PTSD PTSD 1 Characterized by a constellation of symptoms
Follows exposure to an extreme traumatic event Involves actual or threatened death or serious injury Taken with permission from presentations by Harold Kudler MD May refer to DSM for next slides on diagnosis 88

PTSD PTSD 2 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 89

PTSD PTSD 3 Response to the event may involve
Persistent symptoms of increased arousal Sleep disturbance Hypervigilance Irritability Exaggerated startle response 90

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 Can also be Acute (less than 3 months), Chronic (3 months or more) or delayed (with onset 6 or more months after the stressor) 91

Traumatic Events in oeF/OIF/OND 1
Multi-casualty incidents (Suicide Bombers, VB/IEDs, ambushes) Seeing the aftermath of battle Handling human remains Friendly fire Witnessed or committed atrocities 92

Witnessing death/injury of close friend/favored leader Death/injury of women and children Feeling/being helpless to defend or counter-attack 93

Being unable to protect/save a colleague or leader Killing at close range Killing civilians/“avoidable” casualties or deaths 94

PTSD/Depression, Combat Exposure and Rurality
56% of Rural Veterans screened positive for PTSD and/or Depression Significantly higher rate than Urban Veterans (32%) May reflect finding of higher Combat Exposure Scale scores among rural Veterans 2012 follow-up study in process Another citation on rural Rural Veterans and the West Virginia 2008 Legislative Study. J. Scotti & H. Heady, University of West Virginia

PTSD/Depression Associated with Decline in Function
Rural Veterans and the West Virginia 2008 Legislative Study. J. Scotti & H. Heady, University of West Virginia

Being Rural Predicts Greater Declines
Rural Veterans with PTSD/Depression have lower levels of function on every level than: Rural Veterans without PTSD/Depression OR: Urban Veterans with or without PTSD/Depression

VA/DoD Clinical Practice Guidelines
Treatment VA/DoD Clinical Practice Guidelines 98

Clinical Practice Guidelines 1
Assist clinicians in learning about available treatments Reviewing their evidence base Making practical, patient-specific choices

Clinical Practice Guidelines 2
Provide clinical algorithms to walk clinicians through necessary steps Screening and initial assessment Treatment and re-assessment Most relevant VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress

VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress
Created by a working group of VA and DoD clinicians and researchers Separate algorithms defined for primary care providers and mental health professionals Evidence tables for each recommendation Substantial literature review included Available at isorder_PTSD.asp In the public domain Includes COSR: Combat/Ongoing Operation Stress Reaction for use during deployment. That also translates well into Operational Stress Reaction/Injury which is now spoken of in post deployment (especially Bill Nash of Navy/) Marine Corps

Other Clinical Practice Guidelines 1
The International Society for Traumatic Stress Studies World’s largest international multidisciplinary professional organization working in the field of psychological trauma Comprehensive set of treatment guidelines Link to 2012 Clinical Guidelines on next page

Link to November 2012 guidelines

The American Psychiatric Association Practice Guideline for Patients with Acute Stress Disorder and Posttraumatic Stress Disorder

Treatment Options Treatment Options
Information on next slides taken from National Center for PTSD

Cognitive Therapy (CT)
Identify and clarify patterns of thinking Identify distressing trauma-related thoughts Convert these thought patterns into more accurate thoughts Address core beliefs about self, others, larger world KEEP IN MIND---you’ll often use a combination of these therapies at various stages of treatment From NCPTSD Website: Cognitive therapy represents a systematic approach to challenging the negative trauma-related beliefs that many of our trauma survivors carry with them—feelings of guilt: I should have prevented the trauma from happening, and so on. But, cognitive therapy represents a very systematic way of going after these negative cognitions, starting with educating the patient about the role of beliefs in causing or maintaining his or her distress, going through a systematic identification of distressing beliefs that may be causing problems, going through a very careful review of the evidence for and against the beliefs, a discussion of their implications and a generation of alternative ways of looking at the situation. And finally, moving on to systematic practice of new beliefs. A good example of this cognitive therapy approach is embodied in the cognitive processing therapy developed by Patricia Resick. Aaron Beck, at the University of Pennsylvania, developed Cognitive Therapy as a structured, short term, present-oriented psychotherapy for depression It is an approach that focuses on improving mood by modifying dysfunctional thinking and behavior. Beck and others have successfully adapted CT to the treatment of a diverse set of psychiatric disorders, including PTSD. CT for PTSD typically begins with an introduction of how thoughts affect emotions and behavior. The cognitive model of change and expectations for participation in therapy is reviewed. Early in treatment, new skills to identify and clarify patterns of thinking are taught using techniques such as recording thoughts about significant events, identifying distressing trauma-related thoughts and converting such dysfunctional thought patterns into more accurate thoughts. CT also emphasizes the identification and modification of distorted core beliefs about self, others and the larger world. CT teaches that improved accuracy of thoughts and beliefs about self, others and the world leads to improved mood and functioning. 106

Exposure Therapy (eT) Reduce the fear associated with traumatic experience through repetitive, therapist-guided confrontation of feared places, situations, memories, thoughts, and feelings Exposure can be “imaginal” or “in vivo” Reduced intensity of emotional and physiological response is achieved through habituation. From NCPTSD Website: Exposure therapy is also strongly recommended. This is the practice which involves repetitive exposure to the traumatic memory or to the traumatic stimuli which are continuing to cause distress for the survivor. Confronting the avoidance. Imaginal exposure involves revisiting the event in imagination, usually through repeated retelling of the trauma story. And, while the person is talking about their traumas in detail, they are usually experiencing emotional activation, and that is important to the process. Real world exposure, otherwise known as in vivo exposure, also compliments imaginal exposure. And in this procedure, patients are given the assignments as homework to confront their fear stimuli in a safe environment. So, for example, a woman who might fear visiting a cafeteria because she was sexually assaulted in a cafeteria might be encouraged to now confront that cafeteria in the future and learn to handle the emotion and distress that she experiences there. Exposure therapy is characterized by multiple repetitions of exposure. This is usually accomplished by homework in which a patient is encouraged to listen to a cassette recording of his or her trauma narrative or to write down the experience on a repetitive basis as homework. 107

Stress Inoculation Training (Sit) 1
Anxiety management Among the most useful psychotherapeutic treatments for PTSD clients Determined by Expert Consensus Guideline Series From NCPTSD Website: More familiar and more used by clinicians, are a variety of approaches to stress management or anxiety management. One particular form of this, stress inoculation training, receives a strong recommendation in the guideline. This procedure was developed by Dr. Donald Michenbaum and is a skills approach to giving people skills to manage their anxiety. These skills include muscular relaxation training, breathing retraining and a variety of other skills: assertion skills, role playing skills, thought stopping skills, and so on. 108

Stress Inoculation Training (Sit) 2
SIT can be thought of as a set of skills for managing stress and anxiety Breathing control Deep Muscle Relaxation Assertiveness Training Role Playing Covert Modeling Thought Stopping Positive Thinking Self Talk 109

Eye Movement Desensitization and Reprocessing (EMDR)
Accessing and processing traumatic memories to bring these to resolution. The client focuses on emotionally disturbing material while at the same time focusing on an external stimulus (usually therapist directed bilateral eye movements, hand tapping, sounds) From NCPTSD Website: The final strongly recommended psychotherapy is eye movement desensitization reprocessing, otherwise known as EMDR. This more recent therapy was developed by Dr. Francine Shapiro and has received careful investigation and has a strong evidence base. It involves a number of complex procedures, but at base, patients are encouraged to identify a disturbing imaging which characterizes the worst part of their trauma for them, an associated body sensation and negative cognition, which is also connected with the worst moments of the trauma. They are encouraged to hold that image and sensation in their mind while tracking the clinician’s moving finger with their eyes for twenty seconds at a time. This refers to the eye movement process. Through this process they begin to change their ways of processing the trauma and experience a reduction in posttraumatic stress symptomotology. Through repeated tracking episodes benefits may be obtained. So EMDR has also received strong evidence support for its efficacy with PTSD. 110

Pharmacotherapy Strongest evidence
Specific serotonin reuptake inhibitors (SSRI’s) Venlafaxine Many drugs from a wide range of classes have been studied in PTSD Little evidence for their use except as adjunctive treatment Antipsychotics often prescribed in military settings Harold Kudler Specific serotonin reuptake inhibitors (SSRI’s) and venlafaxine have the strongest evidence base While many drugs from a wide range of classes have been studied in PTSD, there is little evidence for their use except as adjunctive tx Antipsychotics often prescribed in military settings Available research suggests that prazosin reduces the frequency and intensity of posttraumatic nightmares and may be effective in managing other symptoms of PTSD but it cannot yet be recommended as stand-alone tx Benzodiazepines are not effective as first line agents in the treatment of PTSD Because of potential for dependence and abuse, their use as single agents is strongly discouraged 111

A Point of Caution Little evidence to support the use of Critical Incident Debriefing in the prevention of PTSD Debriefing in heterogeneous groups may actually increase the risk of PTSD by re-traumatizing survivors who are not prepared to be re-exposed to horrific memories The effectiveness of Critical Incident Stress Debriefing (CISD) has been questioned since its widespread use after September 11, Most of the research shows it to be ineffective, and in many cases creates more trauma. See link below for further explanation. Citation for this slide

Barriers To Treatment Treatment beliefs not addressed
Fears of failure and fears of success Labels and stereotypes Avoidance Realistic concerns Treatment beliefs not addressed Our clients may consider what they’re doing as a normal way to respond to a frightening world. They question need to change their defensive approach to live…it’s not as dangerous in Jacksonville NC as Fallujah. But it’s dangerous here too. What we consider “trauma symptoms” “feel right” --- almost an arrogance in viewing other’s as stupid or naïve when they don’t see the dangers the veteran sees. Fears of failure and fears of success There’s a usefulness in not admitting “problems”---avoid fears, internal stereotypes of being weak, stupid; seen as damaged, guilt, shame—SECONDARY GAIN The labels or stereotypes —they’ve all heard about/discussed the Vietnam Vet---homeless, crazy…some of them grew up with fathers and grandfathers who suffer from combat PTSD from Vietnam. Realistic concerns—job, confidentiality, relationship and partner and family reaction. Rejection by loved ones. Attitudes: I’m trained to do what I did. I’m too embarrassed and I don’t want people to think I’m crazy. It will hurt my career. My Marines/command won’t trust me when we go back to Iraq. My security clearance will be taken away. 113

A National Demonstration Project
Citizen Soldier Support Program Directory of BH Providers Validated licenses Lists special interests and relevant training Specifies insurances accepted including TRICARE Google mapping to site of care The purpose of the database is to have one place that service members or their families can go to search for a behavioral health provider within 30 minutes of their location.. One of the outcomes of the A-TrACC Veterans Mental Health Project is to increase the number of health providers registered in the database. Go to the website and familiarize yourself with it. Encourage professionals to register their practice in the Database. If you or the audience has questions about it, contact Sheryl Pacelli at

Traumatic brain injury (tbi)
115

TBI tbi 1 Not considered a “behavioral health” disorder
Included in this training Signature disorder of OEF/OIF as is PTSD Often co-occurring with PTSD Sometimes difficult to distinguish the two 116

TBI tbi 2 Ask about Proximity to explosions Thrown from a vehicle
Lost consciousness (knocked out or down) For how long Have symptoms of concussion after the blast (dizziness, headache, irritability, etc.) Assessment questions Handout: DVBIC Defense and Veterans Brain Injury Center (DVBIC) TBI screening tool You’ll want to ask about proximity to explosions, was he/she thrown from a vehicle, lost consciousness (knocked out) and for how long…and having symptoms of concussion afterwards—dizziness, headache, irritability, etc. 117

TBI tbi 3 Current symptoms Headaches
Change in ability to smell or taste Dizziness Sensitivity to sound or light Memory problems Balance problems Trouble with Ringing in ears Concentration Irritability Attention Sleep problems Thinking Fatigue Does he/she currently have 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. So you can see that there are some overlapping symptoms. Proximity to a blast and losing consciousness are triggers to consider referral to rule out TBI. We don’t know how TBI interfaces with PTSD—and we are asking: do we know how to treat that? 118

TBI tbi 4 May co-exist with PTSD One might be mistaken for the other
Screen with The 3-Question Screening Tool Developed by the Defense and Veterans Brain Injury Center (DVBIC) While a full discussion of TBI is beyond the scope of this presentation, it’s a subject often on the minds of clinicians and one about which many clinicians would like more information. What’s key is that Mild TBI (M-TBI) will often result in symptoms that can be mistaken for PTSD or depression and may complicate PTSD and Major Depression. Those with TBI may turn to alcohol or other substances in an attempt to control their symptoms- this generally only makes their problems worse. Perhaps the best brief intro to TBI that I can provide is to review the 3 question screening tool developed by the Defense and Veterans Brain Injury Center (DVBIC): Blast injuries have become common in civilian disasters and military conflicts. It has been suggested that over 50% of injuries sustained in combat are the result of explosive munitions including bombs, grenades, land mines, missiles, and mortar/artillery shells (Coupland & Meddings, 1999). These numbers may be higher for OEF/OIF veterans because Improvised Explosive Devices (IED’s), Rocket Propelled Grenades (RPG’s), and mortars have accounted for so many casualties and new protective gear keeps many alive who, in previous wars, would have been killed outright by such attacks. The data on blast injury induced brain injury is very limited… Between July and November 2003 DVBIC at Walter Reed Army Medical Center screened 155 patients who had returned from Iraq and were deemed as being at risk for brain injury. Ninety-six of the 155 screened or 62% were identified as having sustained a brain injury. Of the 88 blast cases included in the total number screened, 54 or 61% were identified as having sustained a brain injury. 119

Triaging TBI Consider consultation Rehabilitative Medical Specialist
Neurologist Speech Pathologist Audiologist Vision Assessment Refer patients when physical, emotional or cognitive symptoms interfere with normal routines and relationships.

Combat/operational stress reactions and injuries
121

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) William P. Nash, MD, has completed nearly thirty years of active military service, including as Captain in the U.S. Navy Medical Corps. In addition to leading two Navy SPRINT crisis response teams, he has directed two Navy psychiatry residency training programs. CAPT Nash has been stationed with the Marine Corps since 2000, including deploying to Iraq in 2004 with the 1st Marine Division as a psychiatrist. He was awarded a bronze star medal for his service in Iraq in support of combat operations there. Since October, 2005, CAPT Nash has been stationed at Headquarters, Marine Corps, in Quantico, Virginia, where he directs and coordinates combat/operational stress control policies and programs for the United States Marine Corps. He has co-edited a book on combat stress injuries released in 2006. Skin injury analogy Three kinds— Trauma, Fatigue/Discomfort/Wear-Tear, and Grief Capt. Bill Nash in Combat Stress Injury 122

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 DSM IV = ASD/PTSD Occur abruptly; Intense terror, horror, helplessness when confronted with their own or peers mortality PTE (Potentially traumatic events): multi-casualty events – ambushes, IEDs SVBIEDs Friendly fire casualties Death/maiming of children/women, Perceived as avoidable Witnessed or committed infractions of ethics or ROE Witnessed death or serious injury of close friend Killing non-combatants Helpless to defend or counterattack Physical injuries or near misses Killing someone up close We think younger are more susceptible than older Real or threatened death or its aftermath Invisible Feelings of shame, reluctant to admit Most heal spontaneously, briefly disabling Capt. Bill Nash in Combat Stress Injury 123

Combat stress injury - Discomfort/fatigue
Accumulation of stress over time Environmental hardships DSM IV adjustment d/o, major depressive disorder, panic d/o, GAD, Anxiety Occur gradually Small Stressors over time May not completely disappear after sources of stress are no longer present Lack of privacy, sleep deprivation (less than 6-8 hours per day, every day), 6-15 month deployments in combat environment, 24/7 contact with peers, military life, no civilian friends, eating, bathing facilities, high casualty rates in the unit; loss of sustaining friendships in the unit due to death/injury; loss of sustaining relationships back home due to divorce or breakup; unresolved interpersonal conflicts with leaders/peers; physical illness or injury; unsolvable homefront worries such as relationship, health or money problems; prolonged boredom; lack of opportunities for occasional recreation and enjoyment. Older more susceptible than younger service members Capt. Bill Nash in Combat Stress Injury 124

Combat stress injury - Grief
Loss of people cared about In Iraq and at home DSM IV = Grief Reaction, Major Depressive Disorder Death of close friend, such as a “battle buddy” Death of a valued leader or mentor Someone with whom the soldier or Marine closely identified Death of someone for whom the soldier or Marine felt personally responsible Death that is believed to have been preventable Particularly violent or gruesome death Importance of relationship and unit cohesion; casualties w/I unit, death and relationship breakup back home; loss may be spiritual Capt. Bill Nash in Combat Stress Injury 125

Beyond diagnosis 1 Beyond diagnosis
Problems of returning combat veterans and families functional not clinical Work Stress/Unemployment Educational/Training Need Housing Needs Homeless Functionally homeless Most will NOT have PTSD or TBI but it’s still important to ask about common post deployment medical problems (including substance abuse and/or major depression) and identify significant functional problems whether or NOT a specific diagnosis is made Each of these potential problems warrants your involvement as the patient’s primary care provider. 126

Beyond diagnosis 2 Beyond diagnosis
Problems of returning combat veterans and families functional not clinical Financial and/or Legal Problems Family Issues Lack of Social Support Estrangement Family Breakup Kids in trouble Talk about difference between functional problem & clinical diagnosis Clinical diagnosis Involves comparing symptoms of patient to symptom list in a diagnostic manual Assumes a problem/deficit Diagnosis usually leads to specific treatments Functional problem Does not compare symptoms to any symptom list Does not assume a problem/deficit Usually means the patient is lacking a skill, which can be taught 127

Beyond ptsd and tbi diagnosis 1
Psychological trauma may…. Surface indirectly - exacerbation of chronic physical ailments Shortness of breath in an asthmatic Racing heart in a person with congestive heart failure) 128

Beyond ptsd and tbi diagnosis 2
Psychological trauma may…. Be expressed in new somatic symptoms Headaches Abdominal pain Present as new or exacerbated substance abuse Lie veiled behind vague complaints of poor energy, poor sleep or malaise 129

Common themes/presenting problems 1
Marriage, relationship problems Medical issues Financial hardships Endless questions from family and friends Guilt, shame, anger Lack of structure Impatience, problems at work, school, lack of interest in job, family, friends Abusing drugs/alcohol Clients may not make the connection between problems they’re having and their experiences in combat…even/especially those who fought in WWII, Korea, Vietnam 130

Common themes/presenting problems 2
Feelings of isolation Nightmares, sleeplessness Lack of motivation Forgetfulness Anger Feeling irritable, anxious, “on edge” 131

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 132

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) Even current TV shows are addressing the psychological issues of service members returning from war. This is an example of how the American public is being made aware of post deployment behavioral health issues. 133

Public health - population-based approach Less about making diagnoses More about helping individuals and families retain a healthy balance despite the stress of deployment 134

Incorporates Recovery Model and other principles President’s “Freedom Commission on Mental Health” There is a difference between having a problem and being disabled Public health approach requires Progressively engaging Phase-appropriate integration of services Achieving the Promise: Transforming Mental Health Care in America, Executive Summary The President's New Freedom Commission on Mental Health Describes a strategy for mental health care transformation that ensures services and supports that actively facilitate recovery and build resilience. Identifies six goals of transformation and showcases model programs to illustrate goals in practice. 135

Public health model 4 Public Health Model Treatment programs must
Be driven by the needs of the Service Member/veteran and his/her family Not by DoD and VA traditions Meet prospective users where they live These and other aspects of the Public Health Model will, by necessity, require us to seek partners beyond the DoD/VA continuum of care 136

Public health model 5 Public Health Model Treatment programs must
Not wait for them to find their way to the right mix of our services Increase access and reduce stigma These and other aspects of the Public Health Model will, by necessity, require us to seek partners beyond the DoD/VA continuum of care 137

Take Home Point 3 Take home point
Post deployment mental health problems are more FUNCTIONAL than CLINICAL 138

Quote, Dr. Michael Wagner
When a Service Member is wounded, a family is wounded Dr. Michael Wagner Director, Family Assistance Center Walter Reed Army Medical Center 2004

Perceived Family Support: A Key Predictor of Resilience
Social support (including perceived family support) was the most important protective factor against development of PTSD among male and female Vietnam Veterans in the NVVRS King, D. W., King, L. A., Fairbank, J. A., Keane, T. M., & Adams, G. (1998). Resilience-recovery factors in posttraumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, Remind audience NVVRS is National Vietnam Veterans’ Readjustment Study Citation

Combat/operational stress Affects family members
Sympathy Depression Grief Fear and worry Loss of sleep Avoidance Guilt and shame Anger Drug and alcohol abuse Health problems Looks a lot like symptoms associated with the active duty member of the family 141

Deployment cycle Pre-deployment Deployment Post-deployment 142
Use canoe analogy below to explain deployment cycle and its affects on families. Analogy is taken from a training offered by the Military Child Education Coalition . A military family of 4 are in a canoe rowing down a river. The river is calm, everyone knows their job, and all are rowing in sync with the others. All of a sudden the service member stands up in the canoe. What happens when someone stands up in a canoe? (wait for an answer). The canoe rocks throwing everyone off balance temporarily, and there is one less rower in the canoe. This is the PREDEPLOYMENT phase After standing for a time (could be a short time or a long time), the military member dives into the river by pushing off from the canoe and swims away, creating waves in the river. What happens to the canoe when someone jumps out of it? (wait for an answer). The canoe tips over throwing the entire family in the water. This is the DEPLOYMENT phase. The family has to get to the surface of the water, figure out how to right the canoe and get everyone back in the canoe. They also need to re-assign seating in the canoe and rowing responsibilities. It takes them a while to get this new configuration straightened out, but they eventually do, then they have to face the waves created by the swimmer. Now the family is rowing smoothly again with new seating assignments and new rowing responsibilities. They continue like this for a while. Then they hear something in the water, and notice that the service member is swimming towards them creating small waves which make the canoe somewhat unbalanced. The swimmer grabs the side of the canoe and tries to get into the canoe. What happens now? (wait for an answer). The entire family gets thrown into the water, including the swimmer, and they have to figure out again how to get everyone in the boat. They also need to re-assign seating and rowing responsibilities to include the military member back into the rowing routine. This is the POST DEPLOYMENT phase. Everyone gets back into the canoe, but there are still some waves so the canoe is moving forward, but still unstable. Assessment by Deployment Cycle Issues that tend to put people at higher risk for developing PTSD include increased duration of a traumatic event, higher severity of the trauma experienced, having an emotional condition prior to the event, or having little social support in the form of family or friends. In addition to those risk factors, children and adolescents, females, and people with learning disabilities or violence in the home have a greater risk of developing PTSD after a traumatic event. Protective Factors and Posttraumatic Stress Disorder in Veterans With Spinal Cord Injury Journal International Journal of Rehabilitation and Health Publisher Springer Netherlands ISSN (Print) (Online) Issue Volume 5, Number 3 / July, 2000 DOI /A: Pages Subject Collection Behavioral Science SpringerLink Date Sunday, October 31, 2004 142

Assessment – pre-deployment 1
Deployment orders can change/be revised Worry about safety of loved ones and themselves “Activities of Daily Living” Finances Health care Child care Pets Pre-deployment –deployment orders change routinely; revisions to deployment orders; worry about the safety of themselves and families, ensure finances, healthcare, childcare, pets are managed in their absence…single parents – reserve – AD folks who haven’t deployed before prepare not to come home 143

Assessment – pre-deployment 2
Single Parents Reservists Jobs Houses Family members Preparing to not come home Give examples from your practice 144

Assessment - Deployment
Deployment stress in theater and at home Messages you get Messages you don’t get Value of instant communication and disadvantages News Coverage Internet Facebook/Social Networking for good and ill Deployment – Most of us won’t be seeing people in this stage of the deployment cycle high intensity combat operations, changes in operational plans, enemy capabilities are unclear, threat of death/injury, witnessing death, wounding, disfigurement of their companions, enemy forces, civilians, children, killing another human being, heightened physiologic state, high level of emotion, intensity of sensory exposure = high levels of arousal, attempts to avoid emotion and intrusive recollection of events. Highly conducive to ASD and PTSD. E Mail shut down 145

Assessment – Post-Deployment 1
Garrison life Rules, rules, rules Excess adrenaline and distractibility Garrison Life Multiple demands; unknown; taking away friends, safety, weapons, gear Return to “mundane” activities at home and at work 146

Assessment – Post-deployment 2
Readjustment to family life EVERYONE changed/Fifth Wheel Effect Perceived lack of control over family The complexity & pressures of daily life Missing Buddies AD vs RC Turning in weapons /protective gear 147

Erin’s Rules of Thumb for Successful Deployment Reunions 1
Rule #1: Beware the fairytale! Don’t expect life to be perfect. Don’t set yourself or your significant others up for disappointment. Rule #2: Make realistic expectations and be patient. Instead of expecting the fairytale, plan for a good reunion, including things to say, do, and talk about. Give yourselves time to adjust to being back together. Both parties have changed. If internet is available, show the You Tube video of Lieutenant Commander Erin Simmons. She has a unique perspective on deployments. She is a PhD clinical psychologist in the US Navy who counsels service members returning from combat deployments. She is the wife of a Marine who was deployed to Iraq She served 2 tours of duty in Iraq

Rule #3: Avoid “pissing contests!” Both parties had it bad. No one wins when partners fight over who did more work and who suffered the most. It only takes one person to stop this contest. Rule #4: Use good timing! A basic rule of communication is: if you want someone to hear what you are saying, say it when they are listening.

Rule #5: Avoid the “stupid questions:” Did you kill anyone? How was it? Are you glad to be home? Any variation of: Was it hot?, Did you see any camels?, Did you talk to any Iraqis/ Afghanis? Rule #6: Thank each other! Don’t forget who kept the house standing while the other was fighting for the freedom to have it.

Positive aspects of deployment
Foster maturity Encourage independence Strengthen family bonds Positive Aspects of Separation: Many parents worry about the negative impact of deployments on children. However, deployments offer many positive growth opportunities. Several psychological studies show that despite the distress during separation significant developmental gains are made by many children. Some positive aspects of separation include: Fosters maturity: Military children encounter more situations and have broader and more varied experiences than children from non-military families. Induces growth. Military children learn more about the world and how to function within a community at an earlier age. Taking on additional responsibilities in a parent's absence provides a chance to develop new skills and develop hidden interests and abilities. Encourages independence: Military children tend to be more resourceful and self-starters. Prepares for separations. In a life-style filled with greetings and farewells from deployments and relocations, helps for future farewells and building new friendships. Strengthens family bonds: Military families make emotional adjustments during a separation which often lead them to discover new sources of strength and support among themselves. A major function of family readiness is assuring that the family is aware of all support services available to them and how to access these services. It is imperative that the Reserve family realize that they are not alone and, chances are, whatever problem or situation they encounter has been addressed before. 151

Key question #1 Key Question
Ask EACH patient this question… Are you or a close family member a current or former service member? KEY TAKE HOME OF THE TRAINING! Emphasize not to make stereotypes about what OIF/OEF veterans look like. A friend is a 62-year old grandmother who is a retired Colonel in the Army Reserve who is an OIF veteran. She enlisted in the Army Reserve at 40. Changed her unit affiliation so she would get deployed She was the oldest person on the base – 56 years old when she deployed She had to leave the service after 20 years at 60 because she was too old to stay in. If she had not been forced out, she says she would still be there. 152

Assessment questions 1 Assessment Questions
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? Be sensitive to aches/pains/back aches/headaches/hearing loss. Assessment by Personal Report: Unique to assessments of military/former military personnel— With service members, or veterans who report having been in combat, a description of the location and events is helpful. REMEMBER: Witnessing atrocities, seeing the death/injury of children & civilians, seeing friends killed and wounded, feeling responsible for the death of a friend are disturbing elements of some combat and war environments. 153

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? Be sensitive to aches/pains/back aches/headaches/hearing loss. Assessment by Personal Report: Unique to assessments of military/former military personnel— With service members, or veterans who report having been in combat, a description of the location and events is helpful. REMEMBER: Witnessing atrocities, seeing the death/injury of children & civilians, seeing friends killed and wounded, feeling responsible for the death of a friend are especially are disturbing elements of some combat and war environments. ADD: Risk/Resilience Factors 154

Assessment measures 3 Assessment Questions
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 These assessment measures are in handouts. Share and/or review to the extent you feel is appropriate for the audience. 155

Women’s issues 156

Integration of Women in Military 1
1993: Congress opens combat ships to women : First female pilots in all branches 2005: First woman awarded the Silver Star for combat action. 2008: First woman promoted to rank of 4-star General (Army).

Women still restricted from following warfare specialties (with exceptions): Air Force Para-rescue Combat Controllers Army Infantry Armor Artillery Special Forces Combat Engineering

Women still restricted from following warfare specialties (with exceptions): Marine Corps: Infantry Armor Artillery Combat Engineering Reconnaissance Riverine Assault Craft Navy Submarines SEALs

Mental Health Diagnoses Among OEF/OIF Veterans By Gender
Have participants turn to the handout “Mental Health Diagnoses Among OEF/OIF Veterans By Gender” when you get to this slide. Point out: Men are more prone to PTSD than women and twice as likely to become alcohol or drug dependent than women Women are more prone to depression, affective psychoses, neurotic disorders, and personality disorders than men

Possible Sources of Gender Differences in PTSD Presentation AND Diagnosis 1
Women May be exposed to different range and intensity of stressors Have different rules about their involvement in combat More research needs to be done to compare men and women on type, number, length, frequency, and intensity of deployments and/or traumatic experiences The reasons for differences in diagnoses of PTSD in men vs. women is not well documented. This and the next 3 slides give possibilities. only If you know of research or have experience with differential diagnosis between male and female service members, please include it here.

Factors that affect differing rates of PTSD diagnosis in men vs. women Race Ethnicity Age Rank differences

When and how men and women present mental health issues May affect apparent differences between men and women Career impact of reporting a mental health problem may be different for women than for men

Clinicians may have gender-specific biases Less likely diagnosis PTSD in women? More likely diagnosis personality disorder in women? Women OEF/OIF veterans have different tendencies to seek help outside of DoD/VA than men

Quote from a Female Veteran
“I don’t think there’s enough emphasis on women coming home. Like a lot of the videos they show and things they talk about, they all show men’s problems…they don’t show women coming home that don’t look as good as they used to or that their hair is all falling out or anything. It’s all about men. Female Veteran

Conclusions Men and Women are equal but not the same
There is a clear need for gender-specific approaches to the readjustment and health of Women Veterans

15 minute break 168

Department of Veterans Affairs (VA) overview
If providers want to build a partnership with the VA, it would be helpful for community providers to know something about the Department of Veterans Affairs medical system. Two children of American Civil War Veterans are still receiving VA benefits. 169

Care access points 88 comprehensive home-care programs
4 DoD/VA Polytrauma Centers My HealtheVet 21 Veterans Integrated Service Networks (VISNs) Links to explanation of home care programs Polytrauma Centers VISNs 170

VA Overview 1 VA Overview 23.4 million veterans currently alive
Nearly 3/4 served during a war or an official period of conflict Women 8% of all veterans (roughly 1.8 million women veterans) Make the Connection Make the Connection is a website to find local VA resources. You enter your location by zip code or state, in what radius do you want to search, and check what resource you want to find. It would be very helpful to have this website listed as a Favorites on every computer in a healthcare practice. 171

VA Overview 2 VA Overview
About 1/4 US population eligible for VA benefits or services Veterans Family member of veterans Provides health care 5.5 million veterans Roughly 1 in 5 veterans About 10% of VA users are women veterans Link for information about eligibility of care 172

VA Overview 3 VA Overview VA has 153 medical centers
at least one in each state Puerto Rico, District of Columbia 909 ambulatory care and community-based outpatient clinics 47 residential rehabilitation treatment programs 232 Veterans Centers Make the Connections link 173

Tricare presentation You will need an Internet Connect and computer speakers or an audio connection for this. Click on words TRICARE PRESENTATION, and you should be taken to the link of a 23 minute Introduction to TRICARE webinar offered in 2012 by A-TrACC for the Vets Mental Health Project. Link to webinar if hyperlink on slide does not work: 175

Call to action Use this time to discuss
What practitioners can do to make their office, clinic and staff more military friendly What community organizations/non-profits/businesses can do to make the community more military friendly Note the ideas in a Word document, then send the document to each participant. In the evaluation, they are required to note what change they will make, so this will help them remember what they agreed to change. 176

Review of 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

Post deployment MH problems 1
Now that you’ve found them…what to do Be aware of services available through DOD, VA, and other organizations Look for ways to make your office/agency environment ‘military friendly’ Ask about military service on your intake form 178

Now that you’ve found them…what to do When a military family member comes to you for care: Ask them why they came to see you Then ask what else they would like to talk about Observe body language and energy level Listen to what they do say but also to what they don’t say 179

Now that you’ve found them…what to do Key - develop a supportive and collaborative therapeutic alliance with the patient and with his/her significant others 180

Work at State/community levels 1
May enhance access for service members, veterans and family members about seeking help within the DoD/VA continuum May enhance quality of services veterans and family members receive in community 181

Work at State/community levels 2
National Guard programs organized by state Each state has its own veterans outreach program Builds a system of interagency communication/coordination Serves well at times of disaster 182

Key question #1 Ask each patient this question… Are you or is anyone in your family a current or former service member? 184

Key question #2 Ask yourself this question… Is my practice prepared to identify or treat post deployment problems? 185

Web-Based Resources Collaborative development of self-help resources with assessment, tailored feedback, intervention and self-monitoring Information clearinghouses and regional resources These websites are nationally recognized as providing information and evidence-based research in the areas of PTSD, trauma and traumatic brain injury. The National Center for PTSD is a center of excellence for research and education on the prevention, understanding, and treatment of PTSD. Their purpose is to improve the well-being and understanding of American Veterans by conducting cutting edge research. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury oversees three centers, each of which contributes unique insights, standards, clinical tools and research products to the fields of psychological health and traumatic brain injury. The Centers are Defense and Veterans Brain Injury Center, Deployment Health Clinical Center and National Center for Telehealth and Technology. Department of Veterans Affairs has a mission to fulfill President Lincoln's promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans.

After Deployment Website
This website AfterDeployment.org offers wellness resources to military families. It offers self assessments, personal stories and resources on post deployment issues, some of which are shown on this home page.

Programs on AfterDeployment.org

WarWithin.org website This website is mentioned on slide #51.
This is the homepage of the Citizen Soldier Support Program Primary Health Care and Behavioral Health Provider Directory. It is a database of primary and behavioral health care providers who are trained in, or who have expressed an interest in serving the specific needs of military members and their families. Please remind participants again that one of the outcomes of the A-TrACC Veterans Mental Health Project is to increase the number of health providers registered in the database. Please encourage them to register their practice in the Database. If you or audience members have any questions about it, contact Sheryl Pacelli at

Finally - just to prove that camouflage works…

[Speaker’s affiliation]
Boots on the ground [Speaker’s name] [Speaker’s affiliation] Up to now, we’ve talked about statistics, assessments and clinical issues. We’ve given you lots of information about scope of the problem, military culture and transition issues of service members and their families. You may be somewhat confused and/or a little overwhelmed at all the “head” stuff we’ve presented. Emphasize “head stuff”. This next speaker will help to make all that information come alive for you as (s)he tells you their personal story of deployment to a combat area– the “heart” of the issues. Emphasize “heart” of the issues. If the Boots on the Ground speaker is Guard or Reserve: (S)he will tell you about their deployment experience, the transition from combat to civilian life and what their life is like now. If the Boots on the Ground speaker is Active Duty: (S)he will tell you about their deployment experience, the transition from combat to life back on base, and what their life is like now. This will probably be the most memorable presentation of today’s training, especially if you’ve never heard a Boots on the Ground story before now. It is with honor that I present… (give rank, then speaker’s name) 192

evaluations Discuss, administer and collect the A-TrACC/HRSA required evaluations. Mention that a follow-up evaluation will be done with a random sample of 2% of today’s participants. Also mention evaluations required by credit providers if applicable, and how to complete and get credit certificates. 193

Ahec veterans mental health project: (add the title of your program)

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Ahec veterans mental health project: (add the title of your program)

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