1. Shannon McCaslin-Rodrigo, Ph.D. Health Science Specialist National Center for PTSD, VA Palo Alto Health Care System Staff Psychologist City College of San Francisco Veterans Outreach Program Assistant Professor (Vol) University of California, San Francisco Combat Stress Injuries in Returning Veterans: The Importance of Community

2. http://www.youtube.com/watch?v=M9Uai2w yJhY

3.  ~ 2,400,000 deployed service members in support of OIF/OEF/OND 1 ◦ > 1,040,000 deployed more than once ◦ >36,000 deployed more than 5 times  ~ 15% female  ~59% married  > 40% of active duty service members have children 2  ~ 39% of returning Veterans from rural areas 1 01/12, Defense Manpower Data Center 2 ICF international; 3 VHA Office of Rural Health

4.  Trauma: General Population and Combat  Overview of PTSD  Co-occurring Conditions and “Polytrauma”  Community and VA Partnership

6.  Examples of psychological trauma ◦ Witnessing someone being badly injured or killed ◦ Being involved in a fire, flood, or natural disaster ◦ Being involved in a life-threatening accident ◦ Being physically or sexually assaulted ◦ Having a life-threatening illness (including traumatic childbirth) ◦ Being in combat Although we might say a negative event was traumatic (e.g., a divorce, loss of job, etc.) these do not technically qualify as traumas.

7.  Over half the general population will experience at least one trauma ◦ 61% men and 51% women  Witnessing injury or death ◦ 36% men and 15% women  Life-threatening accident ◦ 25% men and 14% women  Fire or natural disaster ◦ 19% men and 15% women  Sexual Assault ◦ 10% men and 31% (14-17%) women Kessler et al. (1995)

8.  Traditional Combat Traumas ◦ Firefights ◦ Seeing or handling mutilated bodies ◦ Death and dying ◦ Medical care in the field ◦ Captivity/POW  Torture  Non-traditional Combat Traumas ◦ Atrocities and abusive violence ◦ Guerilla-style warfare  IEDs, suicide bombs, civilian combatants  Other Military Traumas o Sexual assault o Accidents (MVAs, falls, burns, explosions, etc.) o Physical Assaults

9. Extended opportunity for life threat and death, grief and loss  78% reported seeing destroyed homes and villages  67% (95%) reported seeing dead bodies or human remains  65% reported having hostile reactions from civilians  63% (93%) reported receiving small arms fire  61% (89%) reported being attacked or ambushed  59% (86%) reported knowing someone who was seriously injured or killed  37% reported engaging in a firefight  19% (48%) reported being directly responsible for death of enemy combatant  (14%) reported being responsible for death of non-combatant  (22%) reported having buddy shot or hit who was near you  11% (22%) reported engaging in hand-to-hand combat  10% (14%) reported being wounded/injured *Reported during deployment (reported after deployment)

10.  Combat stressors: ◦ 51% reported they had been in serious danger of being injured or killed on at least several occasions during the deployment  Non-combat stressors: “high/very high trouble or concern” ◦ 87% uncertain redeployment ◦ 71% long deployment length ◦ 55% lack of privacy or personal space ◦ 54% boring or repetitive work

11.  23% of female users of VA reported experiencing at least one sexual assault while in military ◦ < 1% of male ???  Rates higher in wartime ◦ Persian Gulf War  Sexual assault (7%)  Physical sexual harassment (33%)  Verbal sexual harassment (66%)

12.  Flight-or-Fight-or-Freeze Response: A Sympathetic nervous system response to threat  Uniqueness of trauma exposure in combat ◦ Training ◦ Extended exposure ◦ Breadth of experience

13. Bonanno (2004)

14.  For most readjustment takes time ◦ Cultural adjustment (e.g., structure, camaraderie) ◦ Family role adjustment ◦ Work and skill adjustment ◦ Grief/loss ◦ Symptoms as skills/adaptive (awareness; sleep)  For some recovery is challenging ◦ Visible injuries  Physical injuries ◦ Invisible injuries  Physical injuries such as tinnitus, sequelae of mTBI  Psychological injuries such as PTSD and Depression

16.  Anxiety Disorder  First included in DSM-III in 1980  Current diagnostic criteria:  Traumatic Stressor ◦ Exposure to a trauma involving actual or threatened injury to self or others ◦ Involving fear, helplessness, or horror  Intrusive recollections of the experience (1)  Avoidant/Numbing (3)  Hyper-arousal (Keyed up) (2)  Present for at least 1 month  Significant distress or impairment APA, 2000

17. Reexperiencing Hyper- arousal Avoidance People, places, conversations, thoughts, situations, etc. Irritability Problems sleeping Always being on high alert Intrusive thoughts or images Nightmares Triggers

18.  Lifetime prevalence: 7.8% ◦ Women (10.4%) twice as likely as men (5%)  Risk of developing PTSD after trauma ◦ Women (20.4%) 2.5 times more likely than men (8.1%)  Rates of PTSD vary depending on trauma type and severity ◦ Natural disaster: 4-5% ◦ Motor Vehicle Accident: 8-12% ◦ Rape: 40% ◦ War  Vietnam War: 18-30%  OIF: 13-20%  OEF: 6-12%  Sub-threshold symptoms can impact functioning and quality of life *Rates vary depending on time since trauma and diagnostic criteria used

19. Brewin et al. (2000); Ozer et al. (2003) Pre-trauma Prior Trauma Psychological Adjustment Family History of Psychopathology Childhood Abuse Peri-trauma Perceived life threat Dissociation (largest) Emotional Responses Trauma Severity Post-trauma Social Support Additional Life Stressors

20. Kessler R, et al. Arch Gen Psychiatry, 1995 33 Drug Abuse Major Depression Social Phobia Agoraphobia Gen Anxiety d/o Panic d/o >3 diagnoses Patients With and Without a Lifetime History of PTSD (%) With PTSD Without PTSD 0 2040 60

22.  6,483 (06/2012) U.S. service members killed serving in OIF/OEF/OND  An estimated 48,505 Wounded in Action  Greater percentage surviving their wounds ◦ Battlefield medicine ◦ Gear WarNo. WIA/KIA Killed in Action Wounds Lethality (%) Revolutionary War, 1775-1783 10,6234,435 42 War of 1812, 1812-1815 6,7652,260 33 Mexican War, 1846- 1848 5,8851,733 29 Civil War (Union Force), 1861-1865 422,295140,414 33 Spanish-American War, 1898 2,047385 19 World War 1, 1917- 1918 257,40453,402 21 World War II, 1941- 1945 963,403291,557 30 Korean War, 1950- 1953 137,02533,741 25 Vietnam War, 1961- 1973 200,72747,424 24 Persian Gulf War, 1990-1991 614147 24 OIF/OEF, 2001- present 10,3691,004 10 Gawande, 2004 http://www.defense.gov/news/casualty.pdf

23.  440,000 (28%) have probable PTSD or Major Depression  Only 53% have sought treatment  Only half have received better than “minimally adequate treatment” (RAND, 2008)

24.  PTSD  Depression  Anxiety  Substance Use Disorders  Adjustment Disorders  27% met 3 or more diagnoses (Seal et al., 2007)

25.  Sleep disturbance  Anxiety while driving  Anxiety in crowds  Anger and irritability  Hypervigilence  Social withdrawal  Grief and guilt  Increased alcohol use

26.  Polytrauma: Injuries to multiple body parts and organs occurring as a result of blast-related wounds seen in OEF/OIF/OND  65% of combat injuries by Improvised Explosive Devices (IEDs), landmines, shrapnel, and other blast phenomena.  > 90% surviving injuries - multiple visible injuries (tissue wounds) - hidden injuries hearing loss; confusion) Lew et al., 2009

27.  Overlap in symptoms ◦ PPCS, PTSD symptoms, Pain  Concentration difficulties  Impaired memory  Avoidance  Anxiety  Depression  Irritability  Impact of co-morbidity  Importance of focusing on function ◦ Target for treatment ◦ Need for interdisciplinary teams and consultation

28.  5 Centers ◦ acute, comprehensive ◦ inpatient rehabilitation  Polytrauma Network Site ◦ 23 specialized programs  87 Polytrauma Support Clinic Teams (PSCT) in VA Medical Centers ◦ Interdisciplinary rehabilitation teams

30.  > 2 million deployed to Iraq or Afghanistan ◦ Consider families, children  49 % returning Veterans seek VA care ◦ General barriers to seeking mental health care  Stigma of mental illness  Logistical barriers (e.g., time for appointments)  Lack of knowledge (e.g., treatments and resources) ◦ Engagement in VA mental health care  Medical record/confidentiality (e.g., military career)  Availability of services in rural areas  Availability of spouse and family care

31.  Call for partnership – meeting Veterans where they are (NAMI)  Opportunities for serving Veterans ◦ Rural communities ◦ Academic settings ◦ Employment settings ◦ Family members  Increased Veteran services in the community ◦ Increasing awareness (e.g., screening; culture) ◦ Training & resources that can support practice ◦ Referring to and collaborating with VA services ◦ Referring to and collaborating with community agencies

32.  Community involvement initiatives ◦ SAMHSA – Policy Academies ◦ Community Blueprint ◦ Got Your 6 ◦ Joining Forces ◦ From the War Zone to the Home Front  Mental health providers in the community ◦ Give an Hour ◦ SOFAR: Strategic Outreach to Families of All Reservists ◦ The Soldiers Project ◦ Local non-profits: Returning Veteran's Project (OR)

33.  VA mission to serve Veterans ◦ Specialized programs ◦ OEF/OIF programs and teams ◦ Women’s programs ◦ Research  Working together ◦ Improved communication ◦ Improved tools in the hands of consumers and providers ◦ Dissemination of products and knowledge

34.  City College of San Francisco/SFVAMC Veterans Outreach Program (CCSF VOP) ◦ VA VITAL initiative – 25 academic/VA programs  Established August 2010  Outreached to 673 Veterans (47% OEF/OIF/OND)  Veterans enrolled in VA healthcare  Campus community ◦ Partnering with:  Faculty (e.g., coursework, consultation)  academic counselors  disability services

35. Thank you for your time & attention Shannon.McCaslin@va.gov Acknowledgements: Eric Kuhn, PhD Jacy Leonardo, PhD Suzanne Best, PhD