1. John P. Allen, PhD, MPA Senior Scientist VISN 6 MIRECC Durham, NC
Treatment of Substance Use Disorders in Veterans with Post Traumatic Stress Disorder (PTSD)
John P. Allen, PhD, MPA
Senior Scientist
VISN 6 MIRECC
Durham, NC

2. Outline of the Presentation
Context of the Issue
Warzone Stressors
Substance Use Disorder and PTSD in Service Members and Veterans
Treatment Considerations
VA Services for OEF/OIF Veterans
Military Culture

3. Scope of the Issue As of April 6, 2012 USA – War Fatalities 6407
USA – War Fatalities
6407
USA - Wounded in Action
47784
Iraq (OIF)
4422
31923
Iraq (OND) 66
301
Afghanistan (OEF)
1919
15560
OVER 1.9 Million service members have been involved in the Global War on Terror (GWOT).
178,876 TBI’s and 1,621 amputations from 2000 through 2010 Q1
Also mention Burns, Vision/Hearing impairment, Spinal Cord injury, Skeletal Injury,

4. Influx of OEF/OIF Veterans
1.9 million have served so far in OEF/OIF
800,000 OEF/OIF Veterans are now VA Eligible
Former Active Duty
Former Reserves/NG
300,000 OEF/OIF Veterans have enrolled
96% of OEF/OIF Veterans have been seen in outpatient care 4

5. Mental Health Issues Among OEF/OIF Veterans
Approximately half of OEF/OIF/OND Veterans receiving VA care have provisional mental health diagnoses. The most common of these are PTSD, affective disorders, neurotic disorders, nondependent abuse of drugs or alcohol, and alcohol dependence.
Note that these are only provisional diagnoses such as are available in VA computer records (for instance, positive screens on the PTSD portion of the OEF/OIF clinical reminder. The range and numbers of mental health diagnoses can be expected to shift as more thorough clinical evaluations are performed and over time.
Also note that the numbers represented are only for OEF/OIF veterans who have presented to VA Medical Centers. Approximately 11,000 more veterans with a possible diagnosis of PTSD have presented to Vet Centers.
81% of those with Nondependent abuse of drugs had a dx of tobacco use disorder- while this may seem reassuring at first blush it is likely a marker for significant stress and a warning of medical as well as mental health sequelae in time to come.
The take home message is that there is a broad range of possible mental health diagnoses to consider with about as many cases of depression and substance abuse as there are of PTSD.
Post Deployment mental health cannot just be about PTSD anymore! 5

6. Mental Health Problems in OEF/OIF Veterans
38% of Soldiers and 31% of Marines report psychological
symptoms.
Among the National Guard, the figure rises to 49%.
Psychological concerns are significantly higher
among those with repeated deployments.
Psychological concerns among family members of deployed and returning OEF/OIF/OND Veterans are also of concern.
Hundreds of thousands of children have experienced deployment of a parent.
To date 52, 375 returnees have been seen in the VA for PTSD symptoms.
“Of 103,788 veterans seen at VA health care facilities, 25% received mental
health diagnosis(es), 56% of whom had 2 or more distinct mental health
diagnoses.
The youngest group of OEF/OIF veterans (age, years) were at greatest risk
for receiving mental health or PTSD diagnoses compared with veterans 40 years
or older.”
“Bringing the War Back Home: Mental Health Disorders among 103,788 US
Veterans returning from Iraq and Afghanistan seen at VA Facilities” Archives
of Internal Medicine, March 2007

7. Warzone Stressors

8. “In war, there are no unwounded soldiers.”
--Jose Narosky
In war, there are no unwounded soldiers.
--Jose Narosky
HOWEVER, resolution of trauma happens as a natural healing process. We expect most wounds to heal and to heal without professional intervention.
In some situations, the natural healing process is interrupted. Our role as mental health professionals is to help unblock the healing process. 8 8

9. Understanding the Experience of OEF/OIF/OND
Caution: Never pretend to know what it’s like to be in a firefight or see a friend become a pink mist…unless, of course, you have that experience. But, trying to understand the experience gives us insight into what our clients bring through our doors.
The war is physically harsh, mentally demanding and dangerous.
There is no privacy, no alcohol, no family or non-military friends. There is chaos, destruction and death. Temperatures can reach 110 degree range. One day last summer, I talked with someone in Iraq…it was 135 F degrees!
Any time a Soldier, Sailor or Marine steps out of a safe zone, he/she is in full combat gear which can weigh 75 pounds or more. The enemy wears no uniform, can be a woman or child, strikes without warning with the intent to kill and terrorize. 9 9

10. There’s nothing normal about war
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" 10 10

11. Traumatic Events in OEF/OIF Service Members (1)
Multi-casualty incidents (suicide bombers, IEDs (improvised explosive devices), ambushes)
Seeing the aftermath of battle
Handling human remains
Friendly fire
Witnessing or being involved in situations of excessive violence 11 11

12. Traumatic Events in OEF/OIF/OND Service Members (2)
Witnessing death/injury of close friend/favored leader
Witnessing death/injury of women and children
Feeling helpless to defend or counter-attack
Being unable to protect/save another service member or leader
Killing at close range
Killing civilians and avoidable casualties or deaths 12 12

13. Exposure to traumatic warzone events (Hoge et al., 2004)

14. 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) 14 14

15. Four Causes of Stress Injury
INTENSE OR PROLONGED STRESS
Life threat
Wear & tear
Loss
Inner conflict
These are the four known causes of stress injury, according to this model. These causes do not have a strong empirical basis, as yet, but the literature on stress, especially on stress of wartime deployments strongly supports these four causes or mechanisms of stress injury.
These descriptors for the four stress injury causes are the ones being written into the Navy-Marine Corps COSC doctrine – they are the terms being taught to Marines and sailors at all levels. They correspond very closely with more clinical terms such as “trauma,” “grief” and “moral injury.”
The second stress injury cause – wear and tear – is unique among the three in that it is not conceived to be due to a specific event or even series of events. Rather, wear-and-tear injuries are conceived to be due to the accumulation of stress from all sources over a period of time – usually many months – in an individual deprived of sufficient sleep, rest, and other opportunities to recover and reset.
In all four stress injury mechanisms, however, the outcome is damage that cannot be undone. Individuals exposed to life threat cannot be untraumatized if they were, in fact damaged by the experience of life threat. They cannot un-lose those they love or identify with who have died or been seriously injured. They cannot forget events that shatter important and deeply held moral values and convictions. And in wear-and-tear injuries, the resulting distress or loss of function not only does not quickly disappear once stressors are removed, but like clinical mood or anxiety disorders, they leave the individual more vulnerable to future episodes of depressed or anxious mood under stress.
Moral injuries or “inner conflict” injuries are the least studied of the four, but clinical experience with warfighters and veterans strongly suggests that such injuries may result either from actions taken (or failures to act) by the individual that violate their own values and beliefs, or by actions taken or failures to act by figures of authority or others in whom values are entrusted. Violations of rules of engagement and breaches of trust of all kinds can result in this type of stress injury.
Events that provoke terror, horror, or helplessness
Accumulation of stress from all sources over time
Death or injury of others who are loved and with whom one identifies
Events that contradict deeply held moral values and beliefs
1515 15

16. PTSD Symptoms Overview
Symptoms of PTSD, present for at least one month, and are divided into three symptom clusters:
Reexperiencing of the traumatic event,
Avoidance of trauma-relevant stimuli and numbing of general responsiveness, and
Heightened physiological arousal. 16

17. Exposure Contributes to Risk Hoge et al., 2006
These results are also from the Hoge et al survey. They show a classic dose-response pattern: The higher the combat reported, the higher the percentage of service members endorsing significant PTSD.
This is also highly similar to the findings in the NVVRS.
If you factor into these findings that many service members will have served, 2 and 3 or more tours of duty in the war-zone, which arguably poses a greater risk than the Vietnam War, than we might see rates go higher over time for those multiply deployed, particularly if the extended sacrifice is perceived by some as being unfair or without sufficient purpose or merit. 17

18. Millennium Cohort Study
Largest prospective military health study personnel ever
21 year duration - began 2001
150,000 participants
Followed every 3 years thru post-discharge
35+ articles published to date

19. Millennium Cohort Findings
Dose Response Relationship
PTSD and Depression – The more trauma exposure – the more likely to develop problems
Substance Use – Highest among younger Veterans and Reserve/National Guard
Smoking initiation and recidivism
Aggressive Driving – Higher among deployed
Aggression and Domestic Violence – higher in PTSD
Hypertension – likely stress related
Eating problems in women with combat exposure 19

20. Common Themes and Presenting Problems in OEF/OIF/OND Veterans
Marriage, relationship problems
Financial hardships
Endless questions from family and friends
Guilt, shame, anger
Feelings of isolation
Nightmares, sleeplessness
Lack of motivation
Forgetfulness
Anger
Feeling irritable, anxious, “on edge”
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 20

21. Military Deployment and Substance Use Disorder (SUD)
Rate of alcohol behavioral problems doubles (25% vs 12%) before and after deployment (Wilk et al, 2010). (Among Reserve Component personnel there were twice as many new onsets of heavy weekly drinking, binge drinking, and alcohol-related behavioral problems among deployed personnel than among their non-deployed peers (Jacobson et al, 2008).)
Post deployment military personnel with SUD problems are rarely referred for care (134 referrals/6669 positive alcohol screens on Post Deployment Health Reassessment (PDHRA) for active duty and 179/4787 for reserve component) (Milliken et al, 2007).

22. Combat Exposure and SUD
Combat exposure is associated with increased rates of weekly heavy drinking, binge drinking, and alcohol-related problems. This is particularly true for personnel aged 24 or younger (Jacobson, et al, 2008).
The threat of death or personal injury is most associated with post-deployment alcohol problems. This relationship is independent of the relationship of these threats to other mental health problems (Wilk et al, 2010).

24. Considerations in Treatment of Substance Use Disorder and PTSD

25. Dynamics of SUD and PTSD in OEF/OIF Veterans (1)
25-50% co-occurrence of SUD and PTSD
The severity of SUD and PTSD tends to be greater and outcomes tend to be worse for both conditions in patients with both PTSD and SUD than in patients with only one of the conditions
PTSD typically precedes SUD
Exposure to trauma stimuli can trigger craving and substance use
Symptoms of the two conditions co-vary. Diminution of PTSD symptoms precedes reduction in alcohol use

26. Dynamics of SUD and PTSD in OEF/OIF Veterans (2)
PTSD is a risk factor for SUD—Use of alcohol or drugs may reduce the anxiety component of PTSD and thus be reinforced
Withdrawal from substances may exacerbate PTSD symptoms
Prolonged exposure as a treatment for PTSD doesn’t increase craving or substance abuse
Patients prefer that the two conditions be treated together

27. Evidence Based Treatments for PTSD
Prolonged Exposure Therapy—Repeated verbalizations of the trauma experience to prompt reprocessing of the trauma. Training in coping skills, stress reduction strategies, cognitive restructuring, real world practice of skills (
Cognitive Processing Therapy—Education about the PTSD symptoms, challenge and modify beliefs about the trauma event, self-monitoring of thoughts and feelings (

28. Effective Alcoholism Treatments (1)
Psychosocial interventions that are well supported by research evidence:
Motivational Enhancement Therapy
Cognitive Behavior Therapy for Relapse Prevention
Community Reinforcement Approach
Behavioral Couples Therapy
Twelve Step Facilitation
Various names for these treatments. Mention National Quality Forum reviews. Describe the treatments briefly. These are treatments with a good evidence base. Note that these “branded” therapies may share several elements in common—active ingredients—these include establishment of rapport, structure, developing sense of self-efficacy, development of more effective social skills, goal setting, problem solving strategy, feedback, practice, therapist allegiance to the treatment modality, etc.
Nice description of interventions in Read, JP, Kahler, CW & Stevenson, JF (2011).
MET—non-confrontive environment created which allows patient to explore drinking and its consequences—Uses FRAMES model
CBT--Teaches more effective life skills and coping skills as well as alcohol-specific skills such as drink refusal.
CRA—Build sup client’s own support system to sustain sobriety
BCT—Works on improving family functioning and defining roles in family
TSF—Incorporates philosophy of AA but individual in nature with homework assignments and structure
CM—Reinforce abstinence or session attendance or other activities that would enhance treatment—Need to monitor, use behavioral contract.

29. Effective Alcoholism Treatments (2)
Medications that can serve as alcohol treatment adjuncts:
Disulfiram (Antabuse®)
Naltrexone/Vivitrol®
Acamprosate
Topiramate (not approved for this indication by FDA. Research is very encouraging on efficacy, especially for Type 2 alcoholics.)
Mention that these medications are too rarely prescribed but would assist many alcoholics.

30. Najavits’ Treatment Seeking Safety
Safety has highest priority in the treatment.
Safety is “abstinence from all substances, reduction in self-destructive behavior, establishment of a network of supportive people, and self-protection from dangers associated with the disorders” (Najavitz, 1998)

31. Seeking Safety (2) Designed for integrated treatment of PTSD and SUD
Theme is to establish safety from substances, dangerous relationships, and extreme symptoms (e.g. suicidality)
Can use in group or individual therapy sessions
Cognitive behavioral approach to develop skills to cope with stress also includes psychoeducation
Present focus
Very popular in the Veterans Health Administration
Uses treatment manual and handouts
25 modules in 4 content areas :
Cognitive
Behavioral
Interpersonal
Case Management

32. Seeking Safety (3) Flexible—Use relevant modules and can vary order
Structured sessions for modules—check-in, quotation to emotionally engage clients, reflect on and comment on relevant handouts/practice skills, check-out asking what clients got out of session and what commitment they are willing to make.
Positive, compassionate tone and positive interactions among clients
Can use with other treatments
Website:

33. Recommendations for Treatment of SUD in Veterans with PTSD (Based on Findings of Subject Matter Expert Panel in November, 2009)
Treatments for the two conditions should be coordinated and generally the treatments should be done simultaneously. There should be a single treatment plan.
The VA-DoD Clinical Practice Guidelines should be followed for each condition.
A community of practice for SUD-PTSD specialists should be created.
Patients should be regularly monitored to ensure that the treatment plan is responsive to their needs.
Family involvement can be very helpful to the treatment of both conditions.
The Clinical Recommendations of the Panel should be revisited/ revised on the basis of new research and the actual experiences of the SUD-PTSD specialists.

34. Issues in Treating SUD in OEF/OIF/OND Veterans (1)
Assessment should include both conditions. Systematic screening for PTSD in SUD programs results in four times as many patients being diagnosed with comorbid PTSD
Establish solid working alliance.
Use term “warzone stress” rather than “combat stress.”
“Normalize” reactions of Veteran and emphasize self efficacy and hope.
Encourage relationships with other Veterans. Encourage involvement with Vet Centers

35. Issues in Treating SUD in OEF/OIF/OND Veterans (2)
Distinguish developmentally-related aspects of substance abuse from risk of chronic dependence and effects.
Computerized aids to enhance SUD services.
Integrate services to address complexity of problems - combinations of SUD with traumatic brain injury, chronic pain, homelessness, PTSD, nicotine dependence, community/family readjustment.
Reduce concerns over confidentiality.

36. Some Good Assessment Questions for OEF/OIF/OND Veterans
Why did you join the Army, Marine Corps, Navy, etc.? What did you hope to accomplish?
Combat tours – Number? When? Where? Military job? Duties in combat zone?
Satisfaction with training and deployment preparation
Satisfaction with leadership and equipment
How do family members feel about the military?
Be sensative 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 36 36

37. Eligibility for VA Care

38. Who is Eligible for VA Health Care Benefits?
Served in the Active military and discharged or released under conditions other than dishonorable
Former Reservists may be eligible if they served full-time and for operational or support (excludes training) purposes
Former National Guard members may be eligible if they were mobilized by a Federal order
The regulation which specifies national guard and reservists are only eligible for healthcare benefits if they were called to active duty per presidential order - Your reference is TITLE 10 -  
Subtitle A - General Military Law
Part I  Organization And General Military Powers Part II Personnel Part III  Training And Education Part IV  Service, Supply, And Procurement
Results in the call or order to, or retention on, active duty of members of the uniformed services under section of this title, chapter  of this title, or any other provision of law during a war or during a national emergency declared by the President or Congress. 38

39. Minimum Duty Requirements
Persons enlisting in the Armed Forces after 9/7/80 or who entered on active duty after 10/16/81 are not eligible for VHA benefits unless they completed:
24 months continuous active service, or
the full period for which they were called or ordered to active duty 39

40. Excluded from the Minimum Duty Requirements
Minimum active duty requirements do not apply to persons discharged or released from active duty for:
Early out
Hardship
Disability that was incurred or aggravated in line of duty or Veterans with compensable service-connected disability 40

41. Combat Veteran (CV) Authority
Title 38, U.S.C., Section 1710(e)(1)(D) gave authority to provide hospital, medical and nursing home care to Combat Veterans despite insufficient medical evidence to conclude that the condition is attributable to such service.
Veterans who served on active duty in a theater of combat operations during a period of war after the Persian Gulf War or in combat against a hostile force during a period of hostilities after November 11, 1998.
The National Defense Authorization Act of 2008 extended the period in which a combat-theater Veteran may enroll for VA health care and services to five years post discharge/release date. (Please note that this includes Reserve and National Guard Personnel mobilized for Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND).)
Enhanced Eligibility for Health Care Benefits181” titled the “National Defense Authorization Act of 2008” was signed into law. Section 1707 amended Title 38, United States Code (U.S.C.), Section 1710(e)(3), extending the period of eligibility for health care for veterans who served in a theater of combat operations after November 11, 1998, (commonly referred to as combat veterans or OEF/OIF veterans).
Under the “Combat Veteran” authority, the Department of Veterans Affairs (VA) provides cost-free health care services and nursing home care for conditions possibly related to military service and enrollment in Priority Group 6, unless eligible for enrollment in a higher priority to:
•Currently enrolled veterans and new enrollees who were discharged from active duty on or after January 28, 2003, are eligible for the enhanced benefits, for 5 years post discharge.
•Veterans discharged from active duty before January 28, 2003,who apply for enrollment on or after January 28, 2008, are eligible for the enhanced benefit until January 27, 2011.
Combat veterans, while not required to disclose their income information, may do so to determine their eligibility for a higher priority status, beneficiary travel benefits and exemption of copays for care unrelated to their military service.
Who’s eligible: Veterans, including activated Reservists and members of the National Guard, are eligible if they served on active duty in a theater of combat operations after November 11, 1998, and have been discharged under other than dishonorable conditions.
Documentation used to determine service in a theater of combat operations:
•Military service documentation that reflects service in a combat theater, or
•receipt of combat service medals and/or,
•receipt of imminent danger or hostile fire pay or tax benefits.
Health benefits under the “Combat Veteran” authority:
•Cost-free care and medications provided for conditions potentially related to combat service.
•Enrollment in Priority Group 6 unless eligible for enrollment in a higher priority group.
•Full access to VA’s Medical Benefits Package. 41

42. Combat Veteran Eligibility Definitions
Combat Zones
Designated by an Executive Order from the President as areas in which the U.S. Armed Forces are engaging or have engaged in combat.
Hostilities
Defined as conflict in which the members of the Armed Forces are subjected to danger comparable to the danger to which members of the Armed Forces have been subjected in combat with enemy armed forces during a period of war.
“Hostile Fire or Imminent Danger Pay”
Hostile fire pay refers to pay to anyone exposed to hostile fire or mine explosion. Imminent danger pay is paid to anyone on duty outside the United States area who is subject to physical harm or imminent danger due to wartime conditions, terrorism, civil insurrection, or civil war.
Documentation used to determine service in a theater of combat operations:
•Military service documentation that reflects service in a combat theater, or
•receipt of combat service medals and/or,
•receipt of imminent danger or hostile fire pay or tax benefits.
For the DoD Definition of Combat Operations for Title 10 Service Members – go to - 42

43. Criteria for Combat Veteran Eligibility
Must first meet the definition of a “Veteran” for VA health care benefits.
Combat-theater Veterans who are ineligible to enroll for VA care are referred to a Vet Center for readjustment counseling services, if appropriate, or to a community provider to obtain services at the Veteran's expense.
If a health care emergency exists for an ineligible Veteran, treatment is provided under VA’s humanitarian treatment authority.
Must meet 24 month rule or completed time for which ordered to active duty. Honorably Discharged. OTH discharge not eligible. 43

44. Beyond Mental Health Diagnosis
Many problems faced by returning combat Veterans and their families are not so much clinical as they are functional:
Work Stress/Unemployment
Educational/Training Needs
Housing Needs
Financial and/or Legal Problems)
Family Issues
Lack of Social Support
Estrangement
Family Breakup
Kids in trouble
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. 44

45. 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. 45 45

46. Identifying/Treating Post Deployment Mental Health Problems Among New Combat Veterans and their Families
OEF/OIF/OND Veterans often seek care outside DoD/VA systems
It is estimated that 50% of those seen in DoD/VA may also receive part of their care in the community
Family members are also dealing with deployment-related stress and look for help in the community
The Governor’s Summit meeting led to an ongoing effort called the Governor’s Focus on Returning Combat Veterans and their Families. Their efforts have helped led to today’s program. The goal is to integrate community services with those of DoD/VA and state programs.

47. Recommendations for Community Mental Health Care Providers
Know something about US military history and about our present military conflicts
Military Culture as a major (yet often invisible) American subculture
Know the different Service Branches and respect the difference!
Know something about DoD and VA
Services, Best practices, Access, Benefits
Ask each patient if he/she has ever served in the Armed Forces or is close to someone who has
In summary thus far…

48. Examples of VA Services Relevant for OEF/OIF Veterans
PTSD Treatment Teams
SUD-PTSD Specialist
Military Sexual Trauma
Homelessness Services
Veterans Justice Outreach Program
Vet Centers
Suicide Prevention Program
Deployment Health Clinics
OEF/OIF Coordinators

49. Frequency of VHA Mental Health Screenings
At-risk drinking (annual)
Post-traumatic stress disorder (every year for first five years and once every five years thereafter)
Depression (annual)
Suicide risk (if depression screen is positive)
Military sexual trauma (once)
Traumatic brain injury (once)

50. VHA Care Access Points (As of November 3, 2010)
153 medical centers--At least one in each state, Puerto Rico and the District of Columbia
951 ambulatory care/community-based outpatient clinics
47 residential rehabilitation treatment programs
271 Veterans Centers
Suicide Prevention Hotline:
TALK
I want to emphasize the special role of Readjustment Counseling Service (the Vet Center program) in providing effective Outreach- you were introduced to them in the Face of the New Veteran clip. Remember that many Vet Centers include staffing by a GWOT Coordinator who is an OEF/OIF veteran. They do a great job of providing outreach and linking new veterans and their families with appropriate services and benefits. Recall that, unlike VA medical centers, Vet Centers offer direct services to family members too. 50 50

51. Key Aspects of VHA Mental Health Care Services
Recovery Orientation
Evidence-Based Practices and Treatments
Continuum of Care
Integration of Mental Health Services with Each Other and with Physical Health Care Services
Role of Principal Mental Health Care Provider
Maximal Access to Care
Continuing Care
Measurement-Based Outcome Indicators
Automated Treatment Adjuncts
(e.g. MyHealtheVet)

52. Prevalence of SUD / PTSD Diagnoses in Veteran Patients in FY 2010
In FY2010, 5,536,526 patients were seen in VA. Around 7% of these are OEF/OIF Veterans.
465,262 Veterans (8.4 %) were diagnosed with SUD. Of these 28% also had PTSD.
553,045 Veterans (10 %) were diagnosed with PTSD. Of these 23% also had SUD.

53. Treatment Services Offered by VA SUD Programs at VA Facilities FY08-FY10 (N=140)
FY 2008 % of Facilities
FY2010
% of Facilities
% Increase
OEF/OIF-specific groups or services
39%
50%
11%
Seeking Safety
58%
71%
13%
Pharmacotherapy and psychosocial intervention for PTSD and SUD
76%
78% 2%

54. Availability of Evidence-Based SUD Psychotherapy Treatment within General Mental Health Clinics at VHA Facilities (N=140)
Therapy Modalities
% of Facilities
Cognitive Behavioral Therapy for Relapse Prevention
57%
12-Step Facilitation
33%
Contingency Management
14%
Seeking Safety
53%
Behavioral Couples/Family Therapy
37%

55. Public Health Model (1)
Most war fighters/Veterans will not develop a mental illness but all war fighters/Veterans and their families face important readjustment issues
This population-based approach is less about making diagnoses than about helping individuals and families retain a healthy balance despite the stress of deployment

56. Public Health Model (2)
Incorporates the Recovery Model and other principles of the President’s New Freedom Commission on Mental Health
There is a difference between having a problem and being disabled
The public health approach requires a progressively engaging, phase-appropriate integration of services

57. Public Health Model (3) This program must:
Be driven by the needs of the Service Member/Veteran and his/her family rather than by DoD and VA traditions
Meet prospective users where they live rather than 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 57

58.
Offers each state its own page
Includes VA facilities and Vet Centers
Over 1500 providers nationally
Over 1200 providers in NC including 96 of 100 NC counties
A model for further populating the National Resource Directory on a state-by-state basis