1. 1 Ahec veterans mental health project: (add the title of your program)

2. 2 Speaker names/affiliations [Speaker’s name] [Speaker’s affiliation] [Speaker’s name] [Speaker’s affiliation] [Sponsoring Agency] [City & state of training] [Date]

3. 3 welcome

4. 4 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"

5. 5 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 Introduction

6. 6 How many of you are: Physicians Psychologists Social workers Licensed Counselors Substance Abuse Marriage and Family Nurses Others

7. 7 Lingo OIF = Operation Iraqi Freedom o Iraq war until 31 December 2011 OEF = Operation Enduring Freedom o current war in Afghanistan OND = Operation New Dawn o Iraq war since 1 January 2012

8. 8 Scope of the Issue

9. 9 In war, there are no unwounded soldiers. Jose Narosky

10. 10 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

11. 11 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)

12. 12 Scope of the Issue Psychological concerns among family members >1 million children in US under 11 years old experienced deployment of a parent – sometimes both – since 9/11

13. 13 Sesame Street Series Deployments Homecomings Changes Grief http://www.sesameworkshop.org/initiatives/emotion/tlc and Military One Source at http://www.militaryonesource.mil / http://www.militaryonesource.mil /

14. 14 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

15. 15 Scope of the Issue Rates of acute stress higher than any previous year except 2007 o Acute stress o Depression o 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

16. 16 Scope of the issue: why train civilians?

17. 17 Scope of the Issue 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”

18. 18 Scope of the Issue 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

19. 19 Scope of the Issue Serving Those Who Have Served full report available at http://a-tracc.adobeconnect.com/serving/

20. 20 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

21. 21 Scope of the Issue Key Recommendations o Train civilian providers  Understand military culture  Understand VA programs

22. 22 Questions?

23. 23 Basic Training – Military culture

24. 24 Basic Training – Military Culture 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.

25. 25 Basic Training – Military Culture 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

26. 26 Basic Training – Military Culture Army/Army National Guard Navy/Naval Reserves Marine Corps/Marine Corps Reserve Air Force/Air National Guard/ Air Force Reserves Coast Guard*

27. 27 Basic Training – Military Culture My uniform…

28. 28 Basic Training – Military Culture Military Occupational Specialty (MOS) o Advanced individual training o Hundreds of MOS

29. 29 Basic Training – Military Culture More about lingo… o DoD = Department of Defense o VA = Department of Veterans Affairs o IED = Improvised Explosive Device o VBIED = Vehicle Born IED (car or suicide bomb)

30. 30 Basic Training – Military Culture More about lingo… o FOB = Forward Operating Base o TDY = Temporary Duty o ROE = Rules of Engagement

31. 31 Basic Training – Military Culture High standard of discipline Distinct ceremony and etiquette Creates shared rituals and common identities Emphasis on group cohesion & esprit de corps

32. 32 Basic Training – Military Culture Connects service members to each other Continued into retirement o Wearing of service uniforms - parades and military unit apparel

33. 33 Basic Training – Military Culture Guard and Reserve culture Formally a Strategic Reserve o Backfill the Active Duty force o Train one weekend a month o Two weeks a year

34. 34 Basic Training – Military Culture Guard and Reserve culture Now an Operational Reserve o Some units deploy as often as Active Duty o Families often see themselves as Military Families o May lack community supports

35. 35 “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

36. 36 Questions?

37. 37 Behavioral health issues

38. 38 Mental health Needs oef/oif vets (2014 projections) PTSD only4.7%113,978 MDD only4.7%113,978 PTSD and MDD9.1%220,680 Other MH Dx11.6%281,307 TOTAL30.1%729,943 National Council for Behavioral Health “Meeting the Behavioral Health Needs of Veterans: Operation Enduring Freedom and Operation Iraqi Freedom” November 2012

39. 39 Behavioral health issues 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

40. 40 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 Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

41. 41 Changes Active Duty and Reserve Component at pdhra Results… Roughly ½ with PTSD symptoms PDHA improved by PDHRA BUT… Twice as many new cases of PTSD at PDHRA Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

42. 42 Changes Active Duty and Reserve Component at pdhra Results… Depression rates at PDHRA o Doubled in AD to 10% o Tripled in RC to 13% Identified as needing MH treatment post deployment o AD 20.3% o RC 42.4% Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

43. 43 Changes Active Duty and Reserve Component at pdhra Results… 4-fold increase in concerns about interpersonal conflict Alcohol abuse rate high o AD 12% o RC 15% o Only 0.2% referred for treatment Milliken, Auchterlonie & Hoge (2007). JAMA 298:2141-2148

44. 44 Post deployment issues – active and reserve components Why RC is at greater risk than AD… AD - have on-going access to healthcare RC situation - o DoD health benefits (TRICARE) expire 6 months after deployment ends o Pay for coverage o Special VA benefits end at 60 months unless a service-connected condition identified)

45. 45 Post deployment issues – active and reserve components Why RC is at greater risk than AD… o May be geographically separated from military and VA facilities o 1/2 service members beyond standard DoD benefit window by PDHRA o Lack of day-to-day contact with Battle Buddies o Added stress transition back to civilian life

46. 46 Posttraumatic stress disorder (PTSD)

47. 47 PTSD Characterized by a constellation of symptoms Follows exposure to an extreme traumatic event Involves actual or threatened death or serious injury

48. 48 PTSD Response to the event must include o Intense fear, helplessness or horror o Symptoms persist more one month o May involve  Re-experiencing the traumatic event through intrusive recollections, dreams or nightmares  Avoidance of trauma-associated stimuli, such as people, situations, or noises

49. 49 PTSD Response to the event may involve o Persistent symptoms of increased arousal  Sleep disturbance  Hyper vigilance  Irritability  Exaggerated startle response

50. 50 PTSD Diagnosis must be accompanied by clinically significant distress or impairment in o Social area o Occupational situations o Other important areas of function Problems must persist at least one month after the event

51. 51 A National Demonstration Project Citizen Soldier Support Program Directory of BH Providers http://www.warwithin.org/ o Validated licenses o Lists special interests and relevant training o Specifies insurances accepted including TRICARE o Google mapping to site of care

52. 52 Combat/operational stress reactions and injuries

53. 53 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) Capt. Bill Nash in Combat Stress Injury

54. 54 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 Capt. Bill Nash in Combat Stress Injury

55. 55 Public Health Model Most war fighters/veterans do not develop a mental illness All war fighters/veterans and their families face important readjustment issues

56. 56 Public Health Model Problems are more functional than clinical There is a difference between having a problem and being disabled

57. 57 Marriage, relationship problems Medical issues Financial hardships Endless questions from family and friends Guilt, shame, anger Lack of structure Common themes/presenting problems

58. 58 Common themes/presenting problems Feelings of isolation Nightmares, sleeplessness Lack of motivation Forgetfulness Anger Feeling irritable, anxious, “on edge”

59. 59 “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)

60. 60 Key question #1 Ask EACH patient this question… Are you or a close family member a current or former service member?

61. 61 Assessment Question Why did you join the ( branch of service )? What did you hope to accomplish? Tell me about any combat tours o How many? o When? o Where? o MOS? o Intensity in combat?

62. 62 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?

63. 63 Assessment measures 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

64. 64 Questions?

65. 65 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

66. 66 Key question #2 Ask each patient this question… Are you or is anyone in your family a current or former service member?

67. 67 Key question #3 Ask yourself this question… Is my practice prepared to identify or treat post deployment problems?

68. 68 Web-Based Resources Collaborative development of self-help resources with assessment, tailored feedback, intervention and self-monitoring Information clearinghouses and regional resources

69. 69

70. 70 Finally - just to prove that camouflage works…

71. 71 evaluations