1. Combat-related Mental Health Symptoms and Correlates through the Deployment Cycle MAJ Jeffrey L. Thomas, Ph.D. Chief, Military Psychiatry Branch Center for Military Psychiatry and Neuroscience Walter Reed Army Institute of Research The views expressed in this presentation are those of the author and do not represent the official policy or position of the U.S. Army Medical command or the Department of Defense.

2. 5/10/2015 Page 2 WRAIR Psychological Research and Health Program WRAIR’s Psychological Research and Health Program is focused on: Benchmarking the effects of combat Moderating the negative effects of combat Promoting resilience in Soldiers and Families Main Studies: Land Combat Study (epi) Mental Health Advisory Teams (MHATs) (epi) Interventions

3. Epidemiological Studies Mental Health Advisory Team (MHAT) data Behavioral health symptoms during deployment Prescription drug use Risk factors Land Combat Studies data Behavioral health symptoms following deployment Rates of alcohol misuse Risk behaviors The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment & Education Program) 5/10/2015 Page 3 Outline

4. Mental Health Advisory Teams Mission: Assess Soldier behavioral health Examine the delivery of theater behavioral health care Provide recommendations to command 5/10/2015 Page 4 MHAT Mission

5. Estimated rates of mental health problems (MHAT V Report) 5/10/2015 Page 5 MHAT Data: Mental Health Symptom Rates

6. 5/10/2015 Page 6 MHAT Data: Combat Exposure Rates Combat Exposure: Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer. Percent Combat Experiences (OEF)200520072009 During this deployment did you experience being attacked or ambushed49.9%74.3%83.3% During this deployment did you experience receiving small arms fire48.5%68.6%74.1% During this deployment did you experience witnessing violence within the local population or between ethnic groups 44.9%48.4%53.8% During this deployment did you experience seeing dead or seriously injured Americans49.1%63.5%62.2% During this deployment did you experience knowing someone seriously injured or killed70.4%87.1%82.9% During this deployment did you experience being in threatening situations where you were unable to respond because of rules of engagement 33.1%48.2%58.2% During this deployment did you experience shooting or directing fire at the enemy36.0%58.8%74.8% During this deployment did you experience calling in fire on the enemy17.0%30.6%44.1% During this deployment did you experience receiving incoming artillery rocket or mortar fire75.2%91.0%92.9% During this deployment did you experience being directly responsible for the death of an enemy combatant 12.9%30.9%51.6% During this deployment did you experience having a member of your own unit become a casualty 56.4%75.0%77.1% During this deployment did you experience a close call dud landed near you19.6%38.7%39.2% During this deployment did you experience a close call equipment shot off your body3.0%16.1%11.5% During this deployment did you experience a close call was shot or hit but protective gear saved you2.5%11.9%11.0% During this deployment did you experience having a buddy shot or hit who was near you8.8%24.1%36.4%

7. 5/10/2015 Page 7 MHAT: Combat Exposure & Acute Stress (PTSD Symptoms)

8. Medication use for a mental health, combat stress, or sleep problem 14% of MHAT III Soldiers in 2005 (Overall Sample N = 1,124) 13% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320) 12% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279) Medications for sleep and combat stress (Iraq & Afghanistan 2009) Combat Stress: 4.8% of maneuver units Soldiers reported using medications for a mental health problem; 5.1% rate for Support units 2.9% of maneuver units Soldiers reported using medications for a mental health problem; 6.4% rate for Support units Sleep: 8.1% of maneuver unit soldiers reported using sleep medications; 13.5% rate for support units 9.2% of maneuver unit soldiers reported using sleep medications; 13.5% rate for support units 5/10/2015 Page 8 MHAT: Medication Use—Iraq 2009

9. Olfson and Marcus (2009) report rates of antidepressant medications use from nationally representative probability samples collected in 1996 and 2005 Antidepressant use for (a) 21-34 year old (b) males who were (c) employed with (d) health insurance was 2.28% in 1996 and 4.59% in 2005 (Olfson and Marcus: personal communication, 31 AUG 2010) MHAT VI from 2009 Data (repeated for reference) Iraq: 4.8% of maneuver units Soldiers reported using medications for a mental health problem; 5.1% rate for Support units Afghanistan: 2.9% of maneuver units Soldiers reported using medications for a mental health problem; 6.4% rate for Support units 5/10/2015 Page 9 Interpreting MHAT Medication Use

10. In 2009,(Afghanistan) multiple deployments and medication use No significant effect for sleep medications Significant increase for mental health medications by the third deployment 5/10/2015 Page 10 MHAT: Multiple Deployments & Meds

11. Non-random sampling procedure used prior to 2009 provided more anonymity to participants Illicit Drug Use 1.6% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320) 1.4% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279) In-Theater Alcohol Use: 6.8% in MHAT IV 8.0% in MHAT V Because of refinement in sampling (cluster-sampling by platoon), these items are no longer asked in current MHAT assessments 5/10/2015 Page 11 MHAT: Illicit Drug / Alcohol Use

12. Continue to identify correlates of medication use Collect information on use of prescription pain medications Limited ability to collect information about abuse in current MHAT process Human use protection of participants in context where platoons are randomly selected (thus identified) 5/10/2015 Page 12 MHAT: Future Directions

13. 5/10/2015 Page 13 Land Combat Studies Land Combat Studies (LCS) Focused on Brigade Combat Teams—infantry units Large intact unit assessments Majority of data collected in post-deployment time frame LCS I (2003-2008) Initial study to assess the effects of combat in OIF and OEF (n ~ 70,000) LCS II (2008-2013) Examines broader range of outcomes and moderating variables (n ~ 13,000) Publications stemming from LCS Hoge et al., NEJM, 2004, 2008 Thomas et al., Arch Gen Psych, 2010 Wilk et al., Drug & Alcohol Dependence, 2010 Kim et al., Psych Services, 2010

14. 5/10/2015 Page 14 Land Combat Studies: Post-Deployment Mental Health Symptom Rates Thomas et al., Archives of General Psychiatry (2010)

15. Alcohol misuse and aggression Common among veterans of OIF / OEF ~50% of Soldiers with mental health problems and functional impairment reported alcohol misuse or aggression problems From 3 to 12 months post-deployment: Active Duty Soldiers symptoms generally persisted Active Duty Soldiers PTSD symptoms typically increased Despite similar combat exposure levels and unit type, National Guard BCT Soldiers symptoms across all measures increased National Guard BCT Soldiers rates may be higher due to: Lack of peer support during post-mobilization Readjustment problems (military to civilian) Access to care (TRICARE benefits expire after 6 months) 5/10/2015 Page 15 Land Combat Studies: Mental Health Problems & Comorbidities Thomas et al., Archives of General Psychiatry (2010)

16. 10 ~ 25% screen positive for alcohol misuse at post-deployment (source: PDHRA screening data, anonymous surveys) Combat Experience factors associated with alcohol problems post- deployment Threat to oneself Witnessing atrocities 5/10/2015 Page 16 Combat Experiences & Alcohol Misuse Wilk et al., Drug and Alcohol Dependence (2010)

17. Aside from mandatory and random drug testing… DOD health assessment with alcohol screening Periodic Health Assessment (PHA) Post-Deployment Health Assessment (PDHA) Post-Deployment Health Re-Assessment (PDHRA) Modified Two-Item Conjoint Screen (TICS) has used to screen for alcohol misuse (Brown et al., 2001) “ In the past 4 weeks, have you used alcohol more than you meant to?” “In the past 4 weeks, have you felt you wanted or needed to cut down on your drinking?” Validated in primary and military settings. AUDIT-C 5/10/2015 Page 17 Alcohol Screening in US Army

18. Alcohol and Risk Behaviors Alcohol-Related Behavior TICS Positive (%) TICS Negative (%) Adjusted Odds Ratio 3 (95% CI) Drinking and Driving 3610 4.99 4.31 – 5.76 Riding w/ Drunk Driver 317 5.87 4.99 – 6.91 Late or Missed Work 111 9.24 6.73 – 12.68 Illicit Drug Use 92 4.97 3.68 – 6.71 Referral to Rehab Program 71 7.15 4.84 – 10.58 DUI 41 4.84 3.04 – 7.68 Any Alcohol-Related Behavior 5115 5.63 4.94 – 6.41 3 Results of logistic regression, adjusting for gender, race, rank, and status in the reserves or active duty. For all adjusted odds ratios, calculated Wald statistics yielded p <0.001 with 1 degree of freedom. Hosmer and Lemeshow tests showed no significant deviation from fit with 7 degrees of freedom. Santiago et al., Psychiatric Services (2010)

19. Active Component Post-OIF PDHRA from Milliken et al, JAMA 2007 Extremely low referral rates Why? What’s going on? What needs to be improved? 5/10/2015 Page 19 Abuse Prevention: Facilitate Care 2.0% 0.4% Figure from Milliken et al., JAMA (2007)

20. ASAP is a Command program. Command involvement is NOT optional Active participation is mandatory for all Soldiers enrolled in ASAP treatment Until recently, Soldiers enrolled in ASAP treatment were automatically subject to negative personnel actions (barred, flagged, etc.) Soldiers who fail to comply with or respond successfully to ASAP treatment will be processed for administrative separation from military service Subsequent problems also deemed ‘rehab failures’ and AR requires processing for separation 5/10/2015 Page 20 Current ASAP Policy

21. Number of soldiers enrolled in ASAP treatment falls far short of number of soldiers in need of ASAP treatment Senior NCOs & Officers are dramatically under-represented & under- served among ASAP patients Majority of ASAP referrals are not self-referrals Majority of ASAP patients are junior enlisted Soldiers with little to no career investment in military service NCOs & Officers present to ASAP with alcohol problems only rarely & under duress with career on the line 5/10/2015 Page 21 Current ASAP Policy (cont.)

22. Reduce stigma of substance abuse treatment Improve access to ASAP treatment for ALL Soldiers Encourage career-minded Soldiers to obtain care Provide earlier interventions for Soldiers in need BEFORE problem adversely impacts functioning: finances health relationships & social functioning occupational performance military career fitness for duty 5/10/2015 Page 22 How can we do better?...

23. The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment & Education Program)—POC: COL Charles Milliken, MC (WRAIR) Authority: Secretary of Army Scope: Pilot for Soldiers who self-refer to the ASAP with alcohol problems before they have an incident, without consequent compromise to military career Purpose: Test feasibility of trial policy changes to improve Soldiers’ access to alcohol treatment earlier in the course of their illness Pilot Sites: Schofield Barracks, Hawaii 06 July 09 Fort Richardson, Alaska17 Aug 09 Fort Lewis, Washington 24 Aug 09 Expanded to include Ft Riley, Ft Carson, Ft Leonard Wood 5/10/2015 Page 23 Army Alcohol Pilot Study

24. Command involvement in ASAP treatment is OPTIONAL (but encouraged) Active participation in ASAP treatment is VOLUNTARY Soldiers in ASAP treatment are NOT SUBJECT to NEGATIVE PERSONNEL ACTIONS (barred, flagged, etc.) Soldiers who fail ASAP treatment WILL NOT BE automatically ADMINISTRATIVELY SEPARATED from military service Enrollment in CATEP treatment will not count toward the number of trials of rehabilitation allowed per military career 5/10/2015 Page 24 Trial Policy Changes

25. All Soldiers who present to the ASAP clinic as anything but a mandatory command-referral will be screened for eligibility to participate in the ASAP Pilot All Soldiers who present as self-referrals to ASAP for alcohol problems are eligible for Pilot participation if they: have not had an alcohol or drug-related incident that merits mandatory command-referral are not being formally referred by their Commander for an alcohol- or drug-related incident that merits mandatory ASAP referral A Soldier will be removed from Pilot care and back in ASAP if they: have a significant alcohol-related incident, use illegal substances or abuse prescription medication 5/10/2015 Page 25 Pilot Eligibility

26. 5/10/2015 Page 26 Rank Distribution of Standard ASAP vs. ASAP Pilot cases

27. Quantitative data Referral rates from PDHRA and medical referral sources have increased Increased numbers of senior NCOs and Officers are accessing care Qualitative data Soldiers, Commanders, & ASAP clinicians give the Pilot 2 thumbs up Alcohol dependence is safely treated under CATEP 5/10/2015 Page 27 Summary of Initial ASAP Pilot Findings

28. Mental Health Advisory Team data Land Combat Study data The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment & Education Program) 5/10/2015 Page 28 Summary

29. MAJ Jeffrey L. Thomas, Ph.D. Chief, Military Psychiatry Branch Walter Reed Army Institute of Research 503 Robert Grant Avenue Silver Spring, MD 20910 (301) 319-7577 jeffrey.l.thomas@us.army.mil 5/10/2015 Page 29 Points of Contact