1. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Charles C. Engel, MD, MPH Associate Professor & Assistant Chair (Research) Department of Psychiatry Director, Deployment Health Clinical Center F. Edward Hebert School of Medicine Uniformed Services University cengel@usuhs.mil Mental health system response to disasters: potentially applicable military innovations

2. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences ?????

3. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences

4. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Unique Phenomenon? 1992 El-Al Boeing crash in Amsterdam

5. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences

6. USUHS The Post-Traumatic Salami PTSD: The Modal Slice Other trauma-related responses

7. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences 1991 Gulf War Veterans With Health Concerns Diagnosis and Physical Symptoms Engel et al. Psychosomatic Medicine 2000; 62:739-745 symptom count (of nine)

8. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Common ICD-9 Diagnoses CCEP Report on 10,020 Primary DxAny Dx Psychological19%37% Musc-Skeletal 17%45% Ill-Defined17%41% Healthy11%19% Digestive 6%22% Dermatologic 6%20% Respiratory 7%18% Nervous 6%18% Endocrine 2%11% Infectious 3% 9%

9. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Frequency of Provider Diagnoses Among Recent Iraq and Afghan Veterans Diagnosis (n = 168,421) (Broad ICD-9 Categories) Frequency * % Diseases of Musculoskel System/Connective System (710-739) 68,789 40.8 Mental Disorders (290-319) 56,304 33.4 Symptoms, Signs and Ill Defined Conditions (780-799) 52,587 31.2 Disease of Digestive System (520-579) 51,736 30.7 Diseases of Nervous System/ Sense Organs (320-389) 48,151 28.6 Disease of Respiratory System (460-519) 28,781 17.1 Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 27,598 16.4 Injury/Poisonings (800-999) 27,068 16.1 Diseases of Circulatory System (390-459) 22,751 13.5 Diseases of Skin (680-709) 22,469 13.3 Infectious and Parasitic Diseases (001-139) 16,473 9.8 Diseases of Genitourinary System (580-629) 14,561 8.7 Benign Neoplasms (210-239) 5,004 3.0 Diseases of Blood and Blood Forming Organs (280-289) 2,669 1.6 Malignant Neoplasms (140-208) 1,197 0.7 *Hospitalizations and outpatient visits as of 4/24/2006; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 168,421.

10. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Post-OIF / OEF Acknowledge MH problem78-86% Want help38-45% Got help past year Any professional Mental health 23-40% 13-27% Gap between need and service: (Hoge, 2004)

11. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Continuity of care is important ** 80% with PTSD at 3-6 months did not have PTSD at baseline ** Grieger et al. Am J Psychiatry (in press) Rates of probable PTSD 1 mo, 3 mo, and 6 mo after tertiary military hospital admission after Iraq or Afghanistan battle injury (n=243). 1 mo 3 mo6 mo

12. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Challenges « stigma, mistrust, barriers and continuity « inconsistencies in health care safety net « dynamic temporal mental health changes « toxic exposure & physical health concerns « idiopathic physical symptoms & syndromes « traumatic brain injury « the wounded

13. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Pre-Clinical Mitigation Psychological Debriefing At present the routine use of individual debriefing in the aftermath of individual trauma cannot be recommended in either military or civilian life. The practice of compulsory debriefing should cease pending further evidence. Even if further large scale trials do reveal a positive effect of debriefing that has not been detected in the trials to date, the evidence reviewed above suggest the likely treatment effect will be small. Rose et al. Cochrane Review. 2001

14. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Post-Deployment Health Assessments & Reassessments

15. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Spectrum of mental health services after mass trauma Engel et al, 2004, Can We Prevent A Second Gulf War Syndrome? Advances in Psychosomatic Medicine Specialty Mental Health Care

16. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Primary Care Advantages « ~4 primary care visits per year « Stigma is lower « Early intervention is possible « Effective primary care treatments are available, established in 8 randomized controlled trials

17. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Where people seek care (each month) Green et al. Ecology of medical care revisited. NEJM 2001; 344(26):2021-5

18. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences What can we learn from successful primary care depression models? « Use multiple modalities (education is not enough) « Integration / collaboration works! « System integration components prepared primary care practice + education care management resource enhanced specialty care interface

19. RESPECT-MIL Post Deployment Mental Health Care within Ft Bragg Primary Care MacArthur Initiative on Depression & Primary Care DoD Deployment Health Clinical Center Henry M. Jackson Foundation

20. Initial Routine for Screening

21. Routine for Care Management

22. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences One Question Primary Care PTSD Screening Were you recently bothered by a past event in which you thought youd be injured or killed? Not Bothered / Bothered A Little / Bothered A Lot

23. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences One Question Primary Care PTSD Screening PTSD prevalence in primary care – 9.0% (WRAMC, Radar, Dilorenzo) notbotheredbothered bothered a little a lot % endorsed 73.5% 19.0% 6.5% PTSD 2.9% 19.4% 47.7% LR (95% CI) 0.3 (0.1-0.7) 2.4 (1.4-4.7) 9.3 (3.6-27.5) sensitivity ---- 95% 51% specificity ---- 41% 86% mean PCL-17 20.5 31.3 55.8

24. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences DESTRESS-PC Delivery of Self- TRaining & Education for Stressful Situations – Primary Care version

25. Uniformed Services University of the Health Sciences Uniformed Services University of the Health Sciences Spectrum of mental health services after mass trauma Engel et al, 2004, Can We Prevent A Second Gulf War Syndrome? Advances in Psychosomatic Medicine Specialty Mental Health Care

26. USUHS Questions? Q u e s t i o n s ?