Shannon McCaslin-Rodrigo, Ph.D. Health Science Specialist National Center for PTSD, VA Palo Alto Health Care System Assistant Professor (Vol) University of California, San Francisco Tools for Working with PTSD and Associated Conditions Resources and Challenges

 In the Group  Detecting/Assessing for PTSD  Treatments for PTSD  Tools and Resources for Providers

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 Experiences treating Veterans and needs?  VA experiences?  Knowledge of VA and online resources?

 PTSD is the most under-recognized and untreated anxiety disorder in primary care (Schonfeld et al., 1997)  Why? ◦ No one asks ◦ PTSD is a disorder of avoidance ◦ Stigma and lack of problem recognition ◦ Individuals with PTSD present to care for other reasons:  Major Depressive Disorder  Other Anxiety Disorders  Alcohol and Substance Use Disorders  Relationship Problems  Chronic pain  Medical Conditions

Primary Care PTSD Screen (PC-PTSD; Prins et al., 2004) In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you… 1. Have had nightmares about it or thought about it when you did not want to? 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? 3. Were constantly on guard, watchful, or easily startled? 4. Felt numb or detached from others, activities, or your surroundings?  Positive screen if 3 or more answered “yes”

Posttraumatic Checklist (PCL; Weather et al., 1993)  Description ◦ 17-item self-report measure ◦ Rate how much they were “bothered by that problem in the past month” on a 5-point scale ranging from 1 (“not at all”) to 5 (“extremely”).  Scoring ◦ Total score (range 17-85)  Cutoff scores for a probable PTSD diagnosis (44 civilians, 50 military)  Use DSM-IV criteria  Combined scoring  Sample Item “In the past month, how much have you been bothered by: Repeated, disturbing memories, thoughts or images of a stressful experience from the past?” 1 = Not at all 2 = A little bit 3 = Moderately 4 = Quite a bit 5 = Extremely

Unstructured Clinical Interview  Follow DSM-IV-TR criteria Structured Clinical Interview  Clinician Administered PTSD Scale (CAPS for DSM-IV) Additional Information  Self-report measures (e.g., PTSD Checklist)  Collateral report  Chart review

 Expert Consensus Guidelines (Journal of Clinical Psychiatry) ◦ Foa, E.B., Davidson, J.R.T., & Frances, A.J. (1999). Treatment of posttraumatic stress disorder (Expert consensus guideline series). Journal of Clinical Psychiatry, 60, Supplement 10.  ISTSS ◦ Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective Treatments for PTSD. New York: Guilford Press.  American Psychiatric Association Practice Guidelines  VA/DOD Joint PTSD Practice Guidelines 

Significant benefit (good evidence): A strong recommendation that the inter- vention is always indicated and acceptable ◦ Cognitive Therapy ◦ Exposure Therapy ◦ Stress Inoculation Training ◦ Eye Movement Desensitization Reprocessing (EMDR)

 Released October 2007  Sponsored by VA  Identified a total of 2771 studies  Included only randomized controlled trials (RCTs) ◦ 37 pharmaceutical (14 RCTs of SSRIs) ◦ 53 psychotherapy Assessment-of-The-Evidence.aspx

 Exposure-based therapy is the only therapy found evidence sufficient to conclude it is efficacious in PTSD  Overall evidence inadequate to confidently determine efficacy of SSRIs ◦ Minority opinion stated evidence suggestive although not sufficient for efficacy in the general population (not male, chronic, VA)

 88% of U.S. households currently have at least one mobile phone.  44% own a smartphone, as compared with 18 percent two years ago.  By 2013, mobile phones will overtake PCs as the most common Web access device worldwide.  62% of smartphone users downloaded an app within the last 30 days. ◦ Discover apps through searching the public marketplaces (63%) or relying on recommendations of trusted others (61%). ◦ Those who download apps have avg 33 apps on their mobile phones.  This marks the beginning of a wireless era in which smartphones will be the primary mechanism through which consumers will connect with friends, media, and the internet. Acknowledgement to Julia Hoffman and Eric Kuhn

High ratings: IOS 5/5 stars; Android 4.5/5 stars Awards: 2011 FAA Chairman’s Award for Advancement in Accessibility & 2012 ATA President’s Innovation Award Named: Best Federal App (Nextgov.net) and Top 10 Health Apps (Yahoo) 54K downloads in 62 countries

 PE Coach and CPT Coach (in development)

 Linkage to electronic health record and self- entered database  Ability to share directly with clinicians to optimize care. Bidirectional communication including personalization of apps by clinicians  System-wide surveillance to enhance program evaluation and mitigate crisis

 Education  Assessments  Training

Provider Pro Section ◦ Assessments (29 measures)  Symptoms (e.g., alcohol, anger, PTSD) & wellness  PCL –under the military sexual trauma section ◦ Educational Handouts  Symptoms (e.g., depression, PTSD, mTBI)  Work adjustment  Sleep  Resilience ◦ Have a chat feature for Service Members

 Veteran Videos ◦ Can filter by operation, gender ◦ Can filter by signs, symptoms, conditions  Educational Client Handouts ◦ Signs and symptoms ◦ Conditions ◦ Life events and experiences  Resources and Support

 Public and Provider Sections  Video Trainings ◦ PTSD 101 (CEUs)  Military Culture – handouts & training  Educational Handouts  Assessment and Treatment Information

 Trainings in CPT and PE  Handouts on Conditions  Resources  Offer Workshops

 24 hour crisis line  Can download materials  Chat online hour crisis line

 9-hour course  Contact hours maybe available for continuing education credit  Includes video demonstrations of expert CPT clinicians

 VA ◦ ◦ ◦  PTSD 101 (free CEUs)  Clinician’s Trauma Update  VA/DoD Clinical Practice Guidelines ◦  International Society for Traumatic Stress Studies ◦  Cognitive Processing Therapy ◦ (free 9-hour web training)  Seeking Safety ◦  Department of Defense ◦ ◦

Enrollment  Online: Visit the enrollment and benefits webpage  Telephone: VETS (8387), Monday through Friday, between the hours of 8:00 AM and 8:00 PM (Eastern Time). A VA representative will have your completed form sent to you for verification and signature.  Mail: Print the 10-10EZ form or 10-10EZR form or call to have the form mailed to you. Complete and sign the application, then mail it to your local VA Medical Center or clinic.10-10EZ form10-10EZR formVA Medical Center or clinic  In Person: Your client can visit the VA Medical Center or clinic nearest you to apply for enrollment or to update informationVA Medical Center or clinic  Program locator:

Family resources  ◦ Caregiver toolkit ◦ Services ◦ Caregiver support line  National Center for PTSD

DOD militaryhomefront.dod.mil VA National Guard operationmilitarykids.org OR National Guard

Military Wives: Military Husbands: Military Children: NG & R Military Kids: Mothers of Service members: Family Support:

THANK YOU & Questions Acknowledgements: NC-PTSD staff Julia Hoffman PsyD; Eric Kuhn, PhD Suzanne Best, PhD