2. Providing care to OIF/OEF veterans Steve McCutcheon, PhD Matthew Jakupcak, PhD VA Puget Sound Healthcare System, Seattle Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine

3. Acknowledgments Miles McFall, PhD Director, Psychology Service Director, PTSD Patient Care Line VA Puget Sound Health Care System

4. Workshop overview Basic epidemiology and patient characteristics A model of integrated care for OIF/OEF veterans –Federal and State collaboration in Washington State –An integrated model of primary stepped care at VA Puget Sound, Seattle Adapting evidence-based PTSD treatments in secondary prevention efforts for OIF/OEF veterans

5. Faces of the war James –Avoidance and withdrawal Gary –Vigilance and control

6. Facts about the war

7. War in Southwest Asia Population Statistics  Over 1,000,000 military personnel deployed to Southwestern Theater of Operation  505,366 veterans have left active duty (as of 12/31/05)  43% active duty troops  57% Reserve and National Guard VHA Office of Public Health and Environmental Hazards, February 14, 2006

8. War in Southwest Asia Human Costs  2,513 Americans killed (2/7/06)  17,096 officially wounded (2/7/06)  50,000 – 250,000 civilians killed (Nov. 2004)

9. Top 10 Causes of OIF Deaths 3/19/2003 – 11/30/2004

10. Increasing Survival Rate of Injured Soldiers WWII: 23% of injured combatants died Vietnam: 17% of injured combatants died Iraq/Afghanistan: 9% of injured combatants die As many US soldiers have been injured in combat thus far in Iraq/Afghanistan as were in the Revolutionary War, the War of 1812 or the first 5 years of the Vietnam War Gawande A. Casualties of War—Military Care for the Wounded from Iraq and Afghanistan. NEJM 351(24): 2471-2475.

11. Combat Exposure for OIF Soldiers Hoge et al. (2004) Event Army (%) USMC (%) Attacked/Ambushed8995 Being shot at/receiving fire 93/8697/92 Shooting at enemy 7787 Killing enemy combatant(s) 4865 Handling human remains 5057 Seeing injured women/children 6983 Seeing dead/injured Americans 6575 Killing non-combatant(s) 1428 Being wounded 149

12. Service utilization

13. Perceived Barriers to Mental Health Care Positive Screen Cases Hoge et al. (2004) I would be seen as weak 65% My unit leadership might treat me differently 63% My unit would have less confidence in me 59% My leaders would blame me for the problem 51% It would harm my career 50% Difficulty getting time off work for treatment 55% It is difficult to schedule an appointment 45% I don’t trust mental health professionals 38% Mental health care doesn’t work 25% I don’t know where to get help 22%

14. Utilization of Mental Services Active Duty Personnel Only 23% of positive screen active duty Army/USMC personnel sought mental health care in past year 1 35% soldiers in a population-based study sought mental health services in first year after demobilization 2 1 Hoge et. Al. 2004 2 Hoge et. Al. 2004

15. Utilization of VA Services 29% (144,424) have sought VA care nationally (12/31/05)  32% of separated active duty  26% for reserve component  Represents 3% of all vets seen in VA VHA Office of Public Health and Environmental Hazards, February 14, 2006

16. Utilization of VA Services Characteristics of Patients  87% male; 13% female  Age 20-29 = 53%; age 30-39 = 23%  ARMY = 66%, USAF = 13%, USMC = 11%, USN = 10%  Active duty = 49%, Reserve Component = 51% VHA Office of Public Health and Environmental Hazards, February 14, 2006

17. Clinical characteristics

18. Medical Diagnoses (N = 144,424) Musculoskeletal40% Mental disorders32% Digestive System 30% Ill Defined Symptoms30% Nervous system28% Respiratory17% Injury/Poisoning16% VHA Office of Public Health and Environmental Hazards, February 14, 2006

19. Spectrum of Post-Deployment Mental Disorders (N = 46,571) Disorder N % PTSD20,63844% Drug Abuse17,76838% Depression14,317 31% Neurotic Disorders11,48125% Affective Psychosis7,46016% Alcohol Dependence3,116 7% Acute Stress Reaction1,327 3% VHA Office of Public Health and Environmental Hazards, February 14, 2006

20. Prevalence of Mental Disorders by War Zone Strict Diagnostic Criteria War Zone PTSD MDD & GAD ETOH Abuse Viet Nam (Lifetime rates) 30% 5.1 MDD 14.1 GAD 39.2 (11.2) Gulf War 2% - 10% -- Afghanistan6.2 MDD = 6.9% GAD = 7.4% Any disorder = 11.2 18.2 - 24.5 Iraq12.6 MDD = 7.4% GAD = 7.2% Any disorder = 16.4 24.8 – 29.6

21. Outcomes for Symptom Screening (Iraq) Liberal Criteria Disorder Screening at Demobilization Delayed Screening PTSD9.8% 18.9% - 34.6% Depression4.5% 15.2% - 30% Any19.1% 28.5% - 40%

22. Health Risk Screening Outcomes Demobilization Sites  Alcohol = 33%  Hostility = 22.8%  Suicide ideation/risk = 1.1% - 4.1%  Interpersonal Aggression/Domestic Violence = 2.1% - 2.2%  Tobacco Use = 50% (25% - 44% want to quit)

23. Health Risk Behaviors VAPSHCS Clinic Sample (n = 144) Symptom % Endorsing Problematic drinking past 4 months 30% Number of days drunk in past 4 months Mean = 11 days Current smokers 30% Did not engage in physical exercise past month (not at all or only 1-2 times) 54%

24. Post-Deployment Readjustment Reactions Functional Limitations  Unemployment  Financial deficits (lacking money management skills)  Homelessness  Phobias about driving  “Reunion stress” (over-controlling, detached, intimacy problems)  Marital conflict, parenting concerns and family reintegration problems (including divorce, DV, and infidelity)

25. Post-Deployment Readjustment Reactions Prominent Arousal Symptoms  Disturbed sleep and dreaming  Easily startled  Irritability and anger  Hypervigilance (discomfort in crowds)

26. Post-Deployment Readjustment Reactions Common Themes and Concerns  “Addiction” to CNN war coverage  Worry about friends still deployed overseas  Miss excitement of combat, urges to return  Worries about re-deployment

27. Traumatic Brain Injury cognitive problems (e.g., impaired memory, attention, or executive function) headaches headaches sensitivity to light or noise sensitivity to light or noise dizziness or nausea dizziness or nausea irritability, impulsivity, poor frustration tolerance irritability, impulsivity, poor frustration tolerancedepression insomnia insomnia TBI can cause impaired or lost sensory function (e.g., eyesight), mobility, and ability to perform basic activities of daily living