Title: Combat Stress Related Disorders VA Montana Health Care Rosa F. Merino, MD Chief of Behavioral Health
1Combat StressRelated DisordersVA Montana
Health CareRosa F. Merino, MDChief of
Behavioral HealthKurt Werner, MDLead Physician
Ambulatory Care
2What Do We hope to Accomplish
- Upon completion of this activity the participant
should be able to - List three common psychiatric condition found in
a deployed setting - Discuss three different ways post deployed
soldiers may present in a clinical setting - Compare and contrast at least three treatment
options and referral sources for post deployed
personnel
3 Combat StressRelated Disorders
- Rosa F. Merino, MD
- Chief of Behavioral Health
- VA Montana Health Care
4Characteristics of Current Military
- Age mid 30s
- Professional Military with Families
- Majority in Guards and Reserves
- Females 10-12
- Racial/Ethnic Diverse Workforce
5Stress of Combat
- No one comes back unchanged
- COL (Dr.) Tom Burke, Department of Defense,
Director of Mental Health Policy
6What is Normal
7When You Do Not Recover
- PTSD Is Not the Only Outcome
- Studies show the development of new-onset
depression, other anxiety disorders, alcoholism
or behavioral alterations without PTSD
8High Comorbidity Between PTSD and Other
Psychiatric disorders
- Depression, Anxiety disorders and Substance Abuse
Disorders - 59 of men and 44 of women with PTSD met the
criteria for three or more other psychiatric
diagnosis - 48 of the men and 49 of the women with PTSD had
depression - PTSD seems to be an important predictor of
suicidal behavior - Suicidal attempts among individuals with PTSD was
approximately 15 times higher than in individuals
without it - National Comorbidity Survey (NCS) Annals of
General Psychiatry, April 2007
9The Realities of Yesterday and Today
- No Purple Hearts are awarded for the often
hidden wounds of post-traumatic stress disorder,
but ultimately those wounds can be deadly--linked
to suicides, accidents and, over the long term,
increased risk of death from cardiovascular
diseases and cancer. (Boscarino, 2005)
10Realities of Today Recovery I want a life
- Recovery is Hope
- Recovery is Reintegration
- Recovery Takes Time
- Recovery is a Process of Change and
Rehabilitation - Recovery Takes Work
- Recovery Takes a Team Approach
- Recovery Doesn't Erase the Trauma As If It Had
Never Happened, It Just Makes It Easier To Deal
With
11The Recovery Process
12Prevalence of PTSD Veteran Population
- Gulf War Veterans
- (N 11,000) Gulf War veterans
- Current PTSD prevalence 10
- Afghanistan
- Army (N1962)
- Current PTSD prevalence 6-11.5
- Iraq
- Army (N894) PTSD prevalence 13-18
- Marine (N815) PTSD prevalence 12-20
- Vietnam Veterans
- N 3000
- Lifetime prevalence 31 men, 26 women
- Current prevalence 15 men, 8 women
13Symptoms of PTSD
- Longitudinal and Retrospective data suggest PTSD
symptoms fluctuate over the course of an
individuals life - Pattern of immediate onset and gradual decline
followed by increasing PTSD symptom levels as
the individual ages - Cynthia Lindman Port, Ph.D., Brian Engdahl, Ph.D.
and Patricia Frazier, Ph.D. Am J Psychiatry
September 2001
14Impact of Trauma
- There is an assumption that anyone exposed to a
traumatic event will have chronic and severe
PTSD - Different Studies substantiate that only a
fraction of those facing trauma will develop PTSD
- Elliott 1997, Kulka et al 1990, Breslau et al
1991
15Are there Protective Factors?
- Hot topic of discussion
- Evidence Suggests
- Preparation for expected stress
- Successful Fight or Flight responses
- Prior Experience
- Internal Resources
- Support from Family
- Community, and Social Networks
- Debriefing
- Emotional Release
- Treatment
16Information Suggests
- One third of PTSD patients recover within first
year - More than one third of patients with persistent
weekly symptoms after 10 years - Alcohol abuse or childhood trauma lead to
increased duration of illness and decreased
probability of remission persistence of PTSD - Kessler, et al. Arch Gen Psychiatry.
1995521048. Zlotnick, et al. J Trauma Stress.
17The Realities of Yesterday and Today What We Know
about PTSD and Combat
- Intensity and frequency of violence and threat of
death in combat increases risk for PTSD and other
mental health diagnosis - Significantly higher levels of PTSD were found in
U.S. combat units returning from deployment to
Iraq and Afghanistan
18OIF and OEF
- Studies indicate that troops who serve in Iraq
are suffering from PTSD and other problems
brought on by their experiences on a scale not
seen since Vietnam" (Robinson, 2004)
19OIF and OEF Hoge and colleagues. 2006
- Three Most Common Health Conditions of Returning
Veterans - Musculoskeletal
- Mental Health
- Digestive System Problems
20Spectrum of Post-Deployment Mental Disorders (N
46,571)
-
- Disorder N
- PTSD 20,638 44
- Drug Abuse 17,768 38
- Depression 14,317 31
- Neurotic Disorders 11,481 25
- Affective Psychosis 7,460 16
- Alcohol Dependence 3,116 7
- Acute Stress Reaction 1,327 3
- VHA Office of Public Health and Environmental
Hazards, February 14, 2006
21Mental Health OIF/OEF Initiatives
- Dr. Lehmann, Coordinator for Mental Health
Disaster Preparedness Post Deployment
Activities conducted a survey of existing OIF/OEF
mental health programs in August/September 2006 - The results distributed in December 2006 included
responses from 40 funded sites 7792 OIF/OEF
returnees reflected the following diagnostic
categories - 56.7 PTSD
- 45.4 Depression
- 31.6 Employment issues
- 24.7 Substance abuse
22OIF / OEF Early Intervention (Boscarino, 2005)
- Highly refractory disorder 835,000 Vietnam War
veterans reported PTSD symptoms 30 years after
the war - Studies demonstrate the importance of providing
early treatment for both psychiatric and medical
disorders
23We See
- Combat Exposure Associated with
- PTSD
- Depression
- TBI
- Substance abuse
- Anger
- Current unemployment
- Current divorce or separation
- Current spouse or partner abuse
24We See
- Gender Differences Will Present Different
Challenges In Providing Treatment - MST
- Eating Disorders
- Depression
- PTSD
- Substance Abuse
- Psychosocial Problems
25What Is PTSD
- Until the formal inclusion of PTSD in DSM III in
1980, PTSD in the past referred to as - Shell Shock Combat fatigue
- Adjustment reactions Pathological grief response
26What is PTSD
- Post-traumatic stress disorder (PTSD) is a
psychological state taking place after a very
traumatic event or series of events promoting
extreme fear, especially if feelings of
helplessness occurred with the experience - PTSD may be associated with war-related trauma,
physical or sexual assault or abuse, an accident
or a mass disaster - Individuals with PTSD are at greater risk in
experiencing major depression, problems with
addiction, or panic disorder prior to or
subsequently after the development of PTSD
27PTSD and Physical Health
- PTSD increases risk for chronic illnesses
- circulatory
- digestive
- musculoskeletal
- endocrine
- respiratory
- infectious
- Green BL and Kimering R (in press)
28Symptoms of PTSD
- PTSD may occur months or even years after the
original trauma and may include the following - Intrusive thoughts recalling the traumatic event
- Nightmares
- Flashbacks
- Efforts to avoid anything that either reminds the
person of the traumatic event or that triggers
similar feelings - Flattened emotional response
- Lack of motivation
- Depression
- Feelings of guilt (from the false belief that one
was somehow responsible for the traumatic
incident) - Being easily startled
- Irritability
- Poor concentration
- Hypervigilance (excessive awareness of possible
danger) - Insomnia
29PTSD Model Simms et al.
- Two recent studies of PTSD suggested a
four-factor model - Re-experiencing, avoidance, dysphoria, and
arousal factors - large sample (N 3,695) of Gulf War veterans
and non-deployed controls - Dysphoria consisted of emotional numbing,
irritability/anger, difficulty sleeping, and
difficulty with concentration - Hypervigilance and exaggerated startle response
symptoms comprised the arousal factor -
30PTSD
- PTSD can be acute, chronic and delayed
- Acute symptoms lasting
- Chronic symptoms lasting 3 mo
- Delayed onset 6 mo elapses from event to symptom
onset
31Who's Most At Risk?
- Literature demonstrates following factors
increase the risk for PTSD - Environment
- unpredictable, chaotic, unsafe, living in a
high-crime area, or living in a physically or
sexually abusive relationship - working in a high-risk occupation, such as
fire-fighting or law enforcement - Vulnerability
- Pre-existing mental health problems, or prior
exposure to trauma - Biological
- Inadequate social support
- Women at greater risk, twice as likely as men to
develop PTSD
32Risk Factors for PTSD
- Severity of trauma
- Prolonged or repeated exposure
- Sense of vulnerability and Loss of Control
- Proximity and Loss
- Gender (FM)
- Prior Psychiatric history
- Family history of Psychiatric illness
- Genetic factors
33Acute Stress Disorder Is It Different ?
- Acute Stress Disorder subtype of Post-Traumatic
Stress Disorder occurs for a minimum of 2 days - Extends at least a maximum of 4 weeks within 4
weeks of the original stressor
34Acute Stress Disorder
- Person experienced traumatic event or events
involving a threat to the physical integrity of
self - The person must have felt fear, helplessness or
horror - During the event or immediately after, the person
will experience the following - numbing, detachment, derealization,
depersonalization or dissociative amnesia - Continue to re-experience the event with
thoughts, dreams, or flashbacks - Avoids stimuli that remind them of the stressor
- For the duration of this time symptoms of anxiety
pronounced with considerable impairment in at
least one crucial area of functioning
35How Predictive of PTSD is ASD?
- A diagnosis of ASD suggests a strong forecaster
for subsequent PTSD - One study established that more than three
quarters of individuals in MVA who met criteria
for ASD did develop PTSD - Finding consistent with other studies that
established that over 80 individuals with ASD
developed PTSD when assessed six months later
36Prognosis for Improvement of PTSD
- Prognosis difficult to establish
- varies significantly from individual to
individual - Some without care gradually recover over a period
of years - Individuals who obtain appropriate medical and
psychiatric care recover totally or nearly
completely
37Positive Prognosis
- Factors associated with a positive prognosis
- consist of quick access and engagement of
treatment - early and continuing social support
- avoidance of retraumatization
- positive premorbid function
- lack of other psychiatric disorders or substance
abuse
38Comprehensive Primary Care Evaluation
- Medical Record Review
- Medical history
- Review of Systems
- Psychosocial Assessment
- Physical Exam
- Mental Status Exam
- Routine Laboratory Work
- Ancillary testing
39Exam Focus
- Somatic symptoms
- Psychiatric Symptoms suggestive of
- Post-traumatic stress disorder
- Depression
- Anxiety and panic
- Danger to self and or others
- Alcohol and Drug use
- Functional status
- Frequency of health care visits
- Social support
40Medical Record Review
- Medical, family, social, occupational,
deployment, medication, and immunization
histories - Pre- and post-deployment physical exams
- Clinic and emergency room visit notes
- Laboratory, radiological, and other ancillary
test results
41Additional Areas ofMedical History
- Occupational and deployment history, including
risks, hazards and exposures to toxic agents - Combat exposure
- Travel history, including immunizations and
- prophylactic measures
- Prescription history, including over-the-counter
medications and herbal supplements - Tobacco, alcohol, and illicit drug use
42Additional Areas ofMedical History
- Job stability and stress
- Physical and emotional abuse or sexual harassment
and assault - Current support structure, including marital
status, family and friends - Family, development, and psychosocial history
- Sleep habits
- Reproductive history
43MSE
- Appearance
- Mood and Affect
- Speech/ Thought Process rate, volume and
- Thought Content
- Perceptual Disturbances
- Cognitive Processing
- Orientation
- Level of consciousness
- Memory
- General intellect
44Is It PTSD
- Signs and Symptoms
- Alienation from Friends and Family
- Arrests for Intoxication, Incarcerations
- Financial Problems
- Job Loss
- Homelessness
45Post-Traumatic Stress Disorder Screening
- History Tells You that Your Patient
- Has experienced or witnessed a frightening or
violent event - Is having nightmares
- Is easily startled
- Is feeling numb or detached?
46Post-Traumatic Stress Disorder Screening
- 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
47Document Screening
- Positive Screen Does Not Constitute a Diagnosis
- Positive Screen Confirmed by Further Assessment
and Discussed With the Patient
48Signs and Symptoms
- Intrusive thoughts recalling the traumatic event
- Nightmares
- Flashbacks
- Efforts to avoid anything that either reminds the
person of the traumatic event or that triggers
similar feelings - Flattened emotional response
- Lack of motivation
- Depression
- Feelings of guilt (from the false belief that one
was somehow responsible for the traumatic
incident) - Being easily startled
- Irritability
- Poor concentration
- Hypervigilance (excessive awareness of possible
danger) - Insomnia
49MSE
- Easily upset, tearful , anxious, ill at ease
- Depressed and or anxious mood
- Reduced attention
- Poor Concentration
- Expressing
- Feelings of guilt, worthlessness, irritability,
on edge, lack of interest, detached, estranged
from others, lack of connection, little need for
intimacy, - Feeling of unhappiness, miserable, sense of
foreshortened future, hopelessness and wanting
to die suicidal ideation
50Is It Depression?
- Prospective studies demonstrate that individuals
may develop new-onset depression, other anxiety
disorders, alcoholism or behavioral alterations
without PTSD
51 Screening for Depression
- History Tells You that Your Patient
- Is feeling sad, blue, or hopeless?
- Has lost interest in things he/she use to enjoy
- Has unexplained body aches and pains
52Screening for Depression
- Straightforward question "Are you depressed?" has
been shown to be highly sensitive and specific in
diagnosing major depression - "How has depression affected your life over the
past couple of weeks? - How has it influenced your sleep? Your
appetite?" Your concentration? Your
relationships? - For patients disinclined to acknowledge to
depressed mood (or with poor insight) - "Do you have any problems sleeping?" can provide
a non-threatening platform to a discussion about
depression
53SIGECAPS' A Mnemonic for Symptoms of Major
Depression and Dysthymia
- Sleep Disorder
- increased or decreased sleep
- Interest deficit
- anhedonia
- Guilt
- worthlessness, hopelessness, regrets
- Energy deficit
- Concentration deficit
- Appetite disorder
- decreased or increased
- Psychomotor retardation or agitation
- Suicidal
-
54Criteria for Depressive Disorders
-
- Major Depression
- 4 symptoms plus depressed mood or anhedonia for
at least two weeks - Minor Depression
- 2-4 depressive symptoms, one of which is
depressed mood or anhedonia 2 weeks - Dysthymic disorder 2 years
- 3-4 depressive or
- Dysthymic symptoms
- Poor appetite without weight change
- Low self esteem
- Feelings of hopelessness
55DIGFAST Mnemonic for the Cardinal Symptoms of a
Manic Episode
- Distractibility Indiscretion excessive
involvement in pleasurable activities
Grandiosity Flight of ideas Activity increase
Sleep deficit decreased need for sleep)
Talkativeness pressured speech - NOTE A manic episode requires at least one week
of elevated or irritable mood plus three of the
seven symptoms described above
56 Screening For Mania
- Have you ever had a week or more of sustained,
unusually elevated mood, like a "high,"
out-of-control behavior (such as risky sex,
over-spending), racing thoughts, and little need
for sleep?a) Neverb) More than 6 months agoc)
In the past 6 monthsBoth b and c - Have you ever had a week or more of sustained,
excessively irritable mood, with anger,
arguments, or breaking things that led to
difficulties with others?a) Neverb) More than 6
months agoc) In the past 6 monthsBoth b and c - Have you ever had any close blood relative
(parent, child, sister, brother) with depression,
bipolar disorder, alcohol abuse, or who was
psychiatrically hospitalized?YesNoDon't know
57Symptoms of Depression
- Depressed or irritable mood most or all of the
time - Diminished interest or pleasure in nearly all
activities - Significant weight loss or weight gain
- Insomnia (sleeplessness) or hypersomnia
(excessive sleeping) - Physical movement that is excessively slow to
excessively fidgety psychomotor retardation or
agitation)
58Symptoms of Depression
- Fatigue or loss of energy
- Feelings of worthlessness or excessive or
inappropriate guilt - Diminished ability to think, concentrate, or make
decisions - Social withdrawal from long-time friends, family,
etc. - Recurrent thoughts of death or suicide or
attempts
59MSE for Depression
- Easily upset, tearful
- Depressed mood
- Tiredness
- Reduced attention
- Poor Concentration
- Expressing
- Feelings of guilt, worthlessness, low
self-esteem Self-critical and self-blaming
thoughts - hating self - Feeling of unhappiness, miserable and lonely
- Feeling hopelessness and wanting to die suicidal
ideation
60Warning Signs of Suicide
- Verbal Cues
- It wont matter soon
- People would be better off without me
- Im no good anyway
- You wont have to worry about me anymore
- I can't take it any longer
- Behavioral Clues
- Giving away prized possessions
- Withdrawing from people and usual activities
- Angry outbursts, irritability
- Changes in work or school performances or
attendance - Unusual tiredness or sleep problems
61Warning Signs of Suicide
- Situation clues
- Past Suicide attempts
- Recent or unexpected loss, failure, or rejection
- History of being abused
- Serious illness or injury
- Disruption in family or other relationships
62Underlying Risk of Co-Occurring Use of Alcohol
and Substances
- 37 of Patients with Diagnosis of Alcohol Abuse
- 53 of Patients with Diagnosis of Other Substance
Abuse - Have At Least One Serious Mental Illness
- Signs and Symptoms
- Alienation from Friends and Family
- Arrests for Intoxication, Incarcerations
- Financial Problems
- Job Loss
- Homelessness
63Possible Links Between Substance Abuse Disorders
and PTSD
- Substance Use may be a consequence of PTSD
provides temporary relief of painful and
uncomfortable symptoms of PTSD
64Alcohol and Substance Use Disorder Screening
- Drink so much you forget what happened?
- Tried to cut back but couldn't?
- Friends and family concerned about your drinking?
65Alcohol Screening Questions
- Q1 How often did you have a drink containing
alcohol in the past year? - Never (0 points)
- Monthly or less (1 point)
- Two to four times a month (2 points)
- Two to three times per week (3
points) - Four or more times a week (4 points)
- Q2 How many drinks did you have on a typical
day when you were drinking in the past year? - 1 or 2
(0 points) - 3 or 4 (1 point)
- 5 or 6 (2 points)
- 7 to 9 (3 points)
- 10 or more (4 points)
- Q3 How often did you have six or more drinks on
one occasion in the past year? - Never (0 points)
- Less than monthly (1 point)
- Monthly (2 points)
- Weekly (3 points)
66Alcohol Screening Questions
- The AUDIT-C is an alcohol screen that can help
identify patients who are hazardous drinkers or
have active alcohol use disorders - including alcohol abuse or dependence
- The AUDIT-C is scored on a scale of 0-12
- Scores of 0 reflect no alcohol use
- In men, a score of 4 or more is considered
positive - In women, a score of 3 or more is considered
positive - Generally, the higher the AUDIT-C score, the more
likely it is that the patients drinking is
affecting his/her health and safety.
67TBI
- Overlapping symptoms and dysfunction between TBI
and PTSD include problems with sustained
attention and concentration - Depression is common co-morbid condition
following traumatic psychological and brain
injuries
68TBI
- Sixty-four percent of soldiers recently wounded
in action in Operation Iraqi Freedom sustained
blast injuries - Peake JB, N Engl J Med 2005 jan 20
- Important to not just screen for TBI based on
self-report tests and clinician screening but to
test actual cognitive functioning with
standardized neuropsychological tests
69TBI
- Mild TBI refers to the time period of
- unconsciousness, not to the effects on the
persons life - Mild TBI can have MAJOR impact on marriages,
jobs, relationships, children and roles
70TBI
- Patients with head injury
- 50 blast exposed
- 50 motor vehicle accidents
71TBI
- Numbers of patients diagnosed dependent upon
whether or not you are looking - PTSD/TBI at a large VA the rate is 6-10 new
cases per month
72TBI-Associated Disability
- Postconcussive Symptoms
- Sequelae of minor head injury (MHI)
- Minor closed head injury
- Range of symptoms, mood, anger, concentration
difficulties, headaches and fatigue that may
persist for years - Most prevalent TBI
- Often missed at time of initial injury
- 15 of people with mild TBI have symptoms that
last one year or more. - Defined as the result of the forceful motion of
the head or impact causing a brief change in
mental status (confusion, disorientation or loss
of memory) or loss of consciousness for less than
30 minutes.
73TBI-Associated Disability Moderate to Severe
- Moderate brain injury resulting in a loss of
consciousness from 20 minutes to 6 hours and a
Glasgow Coma Scale of 9 to 12 - Severe brain injury resulting in a loss of
consciousness of greater than 6 hours and a
Glasgow Coma Scale of 3 to 8 - Cognitive
- Physical sensory and motor
- Emotional
- Vocational
- Social
- Family
74Neuropsychiatry HistoryTBI
- Psychiatric symptoms do not always fit DSM-IV
criteria - Important to focus on functional impairment
- Document and rate symptoms
- Explore circumstances of trauma
- Period of LOC and Length of post-traumatic
amnesia (PTA) - Hospitalization, medical complications
- Subtle symptoms - may fail to associate with
trauma - Ask how has life changed
- Review of psychiatric symptoms
- Confer with family, friends, caregivers
- Assess level of support and supervision available
- Assess rehabilitation needs and progress
75Symptoms
- Aggression, Irritability, Impulsivity
- Up to 70 within 1 year of TBI
- May last over 10-15 years
76Symptoms
- Reactive - Explosive
- Impulsivity
- Emotional lability
- Pathologic laughing and crying
- Rage and aggression
- Altered sexual behavior
- Bulimia
- Little concern over consequences of actions
- Apathy, Social indifference
- Inappropriate joking and punning
- Superficiality of emotions
77Symptoms
- Headaches or neck pain
- Problems with memory, concentration
- Difficulty making decisions
- Slow thinking, speaking, acting, or reading
- Easily lost and confused, easily distracted
- Fatigue apathy
- Mood changes unexplained sadness or anger
- Changes in sleep too much restless
- Light-headedness, dizziness, or loss of balance
- Urge to vomit (nausea)
- Increased sensitivity to lights, sounds
- Blurred vision
- Loss of sense of smell or taste
- Tinnitus
78Neuropsychiatric Sequelae of TBI
- Delirium
- Depression / Apathy
- Mania
- Anxiety
- Psychosis
79Depression and TBI
- Depression / Apathy
- Prevalence of major depression 44.3
- Increased suicide risk
- Assess pre-injury depression and alcohol use
- Associated with increased functional impairment
- Van Reekum et al. J Neuropsychiatry Clin Neurosci
200012316-327
80Depression and TBI
- Depression is associated with worsening
postconcussive symptoms (Fann et al., 1995) - Depression is associated with more severe
cognitive impairment and slower recovery after
TBI and stroke (Levin et al., 1979 MacNiven et
al., 1993 Robinson et al.,1986) - Depression predicts lower health status and
poorer functional outcome after TBI (Fann, et
al., 1995 Christensen et al., 1994) - There are no large controlled trials of
pharmacotherapy or psychotherapy for depression
in TBI populations
81Complications Associated With An Underlying
Psychiatric Diagnosis
- High Incidence of
- Poor Treatment Compliance
- Housing Instability
- Homelessness
- Medical Problems
- Legal Problems
82Complications Associated With An Underlying
Psychiatric Diagnosis
- Increased Behavioral Problems
- Increased Difficulty in Making Accurate Diagnoses
- Increased Rate of Hospitalizations
- Increased Rates of Suicide Attempts and Suicide
(Gilvarry, 2000)
83Vicious Circle
- Lack of employment
- Lack of financial resources
- Inability to Support families
- Increased depression
- Decreased motivation for health/wellness
- Increased physical pain
- Difficulties seeking employment opportunities
84Patients Are More Likely to Seek Treatment If
- Few Actual or Perceived Barriers to Treatment
- Expectation Is that Treatment Will Work and Make
A Positive Change - Belief They Need Help
- Have Hit Bottom
- No Longer Feel In Control and Can not Change On
Their Own - Want To Change Behavior
- Perceive That Treatment Will Suit Their Needs
85Management of Depression
- PHARMACOTHERAPY
- Effective for
- major depression
- chronic depression (dysthymia)
- Equivocal
- minor depression
86Treatment Caveats
- 50-65 of patients respond to the first
antidepressant - No superior agent in efficacy or time to
response. - Selection directed by matching patients symptoms
to side effect profile, presence of medical and
psychiatric co-morbidity, and prior response - Relative costs can also be considered
- Generics Fluoxetine, Sertraline Hydrochloride.
Paroxetine, Bupropion SR and XL, Venlafaxine - Citalapram
87Treatment Caveats
- Closely monitor for worsening depression or
suicidality, specially when initiating therapy or
with dose increases or decreases - Frequent initial appointments
- assess response to meds as well as support
systems - Continuation therapy
- 9-12 months
- Long term maintenance for selected patients with
history of relapse - Education/support important
- Social stigma contributes to patient resistance
to the diagnosis of depression
88Antidepressants
- Tricyclic
- SSRIs
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- sertraline (Zoloft)
- OTHER
- bupropion (Wellbutrin SR, XL) - DA/NE
- venlafaxine (Effexor XR) - SRI/NRI
- duloxetine (Cymbalta) - SRI/NRI
- mirtazapine (Remeron) - NE/5HT
89Sedative Hypnotics
- Benzodiazepines
- All available as generics
- Short acting Ativan (lorazepam)
- Intermediate Xanax (alprazolam)
- Long acting
- Klonopin (clonazepam)
- Valium (diazepam)
- Librium (chlordiazepoxide)
90MEDICATION ALGORITHM
- Start with SSRI
- Early follow-up (1-2 weeks)
- Increase dose every 2-4 weeks
- evaluate effect of each dose change
- Raise dose or change treatment until
- feel back to normal
91PARTIAL OR NON-RESPONSE
- If no response
- switch class
- If partial response at maximum dose
- consider augmentation or consultation
- Continue medication for at least 12 months after
full remission - Use full-dose maintenance for recurrent
depressions
92Referral
- Consider referral for patients
- 1-2 medication trials failures
- suicidal
- psychotic or bipolar depression
- comorbid substance abuse
- severe psychosocial problems
- require specialized treatments such as MAOI, ECT
- quickly increasing depressive symptoms
- unclear diagnosis or patients with underlying
personality disorders
93Treatment Refractory Depression
- Two more unsuccessful successive trials of
antidepressants with different pharmacologic
mechanisms in adequate doses for adequate periods
of time (4 to 6 weeks) - 10-15 of patients with MDD will not respond to
two trials of antidepressants - Refer out for treatment refractory depression
- Psychiatrists will
- Re-evaluate concomitant
- alcohol or substance abuse
- accompanying psychiatric disorders
- adverse psychosocial circumstances
- Recommend additional treatment
- Intensive or specific psychotherapies
- intensive outpatient treatment of alcohol abuse
- alternative environmental case management
- Alternative med management
94Alternative Approaches
- Minority of primary care physicians/providers
will feel at ease with pharmacologic
augmentation or alternative somatic treatment
with patients who do not respond to standard
antidepressant treatment - Monoamine Oxidase Inhibitors (MAOIs)
- Lithium in addition to an antidepressant
titrated by blood level, with a goal of 0.6-1.0 m
Eq/l - Thyroid hormone supplementation in addition to an
antidepressant in euthyroid patients - Valproic acid, other mood stabilizers
- atypical antipsychotic in addition to an
antidepressant - Higher than usual doses of antidepressants
- Multiple antidepressants, particularly those with
different neurotransmitter actions - Stimulant medication in addition to an
antidepressant - Note many augmentation strategies have limited
evidence of efficacy and studies supporting
95Choice of Agent
- No agent has been proven to be superior to
another in efficacy or time to response - Use what has worked for the patient in the past
- First choice
- SSRIs and Serotonin Noradrenaline Reuptake
Inhibitors (SNRIs) are the agents of first choice
due to ease of use, usually tolerable side
effects and safety in overdose
96Other Agents
- Bupropion lowers the seizure threshold
- Pain
- Mirtazapine (Remeron), venlafaxine (Effexor) and
duloxetine (cymbalta)( mixed receptor agents)
are agents which influence both noradrenergic and
serotonergic transmission may have a speculative
role in the management of chronic pain - They are as effective as SSRIs in the treatment
of major depression - The most frequent side effects are comparable to
those of SSRI
97Managing side effects
- Commonly associated side effects with use of
antidepressants - Insomnia
- Akathisia
- Weight gain
- Sexual dysfunction
- Consider the following strategies for managing
related side effects - Insomnia Add a small dose of trazodone (25-50mg
QHS) to an SSRI - Akathisia Consider adding a small dose of
clonazepam (0.5 mg)
98Managing Side Effects
- Weight Gain
- No proven antidotes
- Recent studies of antiepileptics with
serotonergic and dopaminergic properties - topiramate and zonisamide
- Sexual Dysfunction
- Common with all anti-depressants
- Bupropion least likely associated with this side
effect and can be used inconjunction with SSRIs
or SNRIs - Less well-proven or studied strategies include
the use of sildenafil, cyproheptadine, and gingko
biloba
99Alcohol
- With concurrent alcohol abuse and depression
- address the alcohol use
- endeavor to achieve a period of sobriety
- depressive symptoms may resolve
- If not capable of achieving sobriety patients
with concurrent depression and alcohol abuse may
be treated with an SSRI - Higher suicide rates among depressed patients
with alcohol abuse - Be vigilant in assessing suicidal risk
-
100Management of PTSD
- PHARMACOTHERAPY
- Effective for PTSD
- Studies of pharmacological treatments are
required to make available evidenced based
algorithmic approaches to identify the role of
adjunct medications in patients with limited
responses to first-line agents -
101Management of PTSD
102- VA/DOD CLINICAL PRACTICE GUIDELINE FOR
THEMANAGEMENT OF POST TRAUMATIC STRESS
Interventions Module Summary - VA access to full guideline http//www.oqp.med.va.
gov/cpg/cpg.htm DoD access to full guideline
http//www.qmo.amedd.army.mil/ - Sponsored produced by the VA Employee Education
System in cooperation with the Offices of Quality
Performance and Patient Care Services and the
Department of Defense
103Management of PTSD
104Management of PTSD
105Management of PTSD
106Management of PTSD Anticonvulsants
107Management of PTSD Sedative Hypnotics
108Management of PTSD Atypical Antipsychotics
109Prazosin for Reduction of Nightmares andOther
PTSD Symptoms
- Prazosin
- A centrally active alpha-1 adrenergic antagonist.
- 10 Vietnam combat veterans with chronic PTSD
- 20-week double-blind crossover protocol with
Prazosin and placebo - Prazosin (mean dose9.5 mg/day at bedtime) was
superior to placebo for recurrent distressing
dreams - Difficulty falling/staying asleep
- Change in overall PTSD severity and functional
status - Total CAPS score and symptom cluster scores for
- Reexperiencing Avoidance/Numbing Hyperarousal
- Raskind, et al. 2003.
- This information concerns a use that has not been
approved by the US FDA.
110Effect of Benzodiazepines in ASD
- Contrary to expectation, the early
administration of benzodiazepines to trauma
survivors with high levels of initial distress
did not have a salient beneficial effect on the
course of their illness, while reducing
physiological expression of arousal - Gelpin E, Bonne O, Peri T, et al. J Clin
Psychiatry. 1996(Sept)57(9)390-394.
111Neuropsychiatric TreatmentTBI
- Use Biopsychosocial Model
- Treat signs and symptoms with least possible
medications - TBI patients more sensitive to side effects
START LOW, GO SLOW - May still need maximum doses
- Therapeutic onset may be slow
- Medications may lower seizure threshold
- Medications may slow cognitive recovery
- Monitor and document outcomes
- Few randomized, controlled trials
112Cognitive Impairment
- May accelerate recovery
- Amphetamine
- Norepinephrine (TCAs)
- gangliosides
- methylphenidate, dextroamphetamine
- Amantadine
- L-dopa / carbidopa
- bromocriptine
- Pergolide
- Physostigmine
- Donepezil
- Apomorphine
- Caffeine
- phenylpropanolamine
- May impede recovery
- Haloperidol
- Phenothiazines
- clonidine
- Prazosin
- phenoxybenzamine
- benzodiazepines
- phenobarbital
- GABA
- Idazoxan
- phenytoin
113Treatment of TBI Aggression, Agitation,
Impulsivity (none FDA approved for this
indication)
- Acute
- Antipsychotics
- Benzodiazepines
- Chronic
- Valproate, carbamazepine, gabapentin
- Lithium
- Buspirone
- Serotonergic antidepressants SSRIs
- Trazodone, mirtazapine)
- Beta-blockers (e.g. propranolol, pindolol,
nadolol), - Clonidine
- Antipsychotics (esp. second and third generation)
- Amantadine, bromocriptine, bupropion
- Methylphenidate, naltrexone, estrogen
114TBI Depression / Apathy
- Depression
- Selective Serotonin re-uptake inhibitors (SSRIs)
- sertraline - paroxetine fluoxetine citalopram,
escitalopram - Bupropion
- Mirtazapine
- Venlafaxine
- Tricyclics nortriptyline, desipramine (blood
levels) - Methylphenidate, dextroamphetamine
- Apathy
- Dopaminergic agents
- methylpyhenidate, pemoline, bupropion,
amantadine, bromocriptine, modafinil
115SSRIsCitalopram
- Side Effects/ Feature Used in Selection
- May be initially sedating or initially increase
alertness. Mild initial sedation is
dose-dependent. May be least stimulating SSRI.
Negligible drug-drug interactions - Sexual Dysfunction Common
- Patient Profile Most Likely to Benefit
- Agitated depression, or patient with GI distress
/ sensitivity - Patient Profile Least Likely to Benefit
- Excessive sleep and apathy. Note 20 excreted by
kidney - Dose
- Usual dose 20-40 mg/d
- Max dose 60 mg/d
- Dosing for youthful
- 20 mg P.O. Qam (or QHS if sedating.) Titrate
upward if no response after 6 weeks - Dosing for frail, medically ill
- 5-10 mg P.O. Qam x 3 d, 10-20 mg P.O. Qam x 3 d,
etc. until desired initial dose
116EscitalopramLexapro
- Side Effects/ Features Used in Selection
- May be initially sedating or initially increase
alertness. Mild initial sedation is
dose-dependent. May be least stimulating SSRI.
Negligible drug-drug interactions - Sexual Dysfunction Common
- Patient Profile Most Likely to Benefit
- Agitated depression, or patient with GI distress
/ sensitivity - Patient Profile Least Likely to Benefit
- Excessive sleep and apathy. Note 20 excreted by
kidney - Usual dose/ Max dose 15-20mg/d 40 mg/d
117Prozac
- Side Effects/ Features Used in Selection
- Tends to produce more initial nervousness and
arousal than other SSRIs. Very long half-life
(7-15 days), so less likely to cause withdrawal
on abrupt discontinuation - Sexual dysfunction Common
-
- Patient Profile Most Likely to Benefit
- Noncompliant or forgetful patient (i.e., used
as a depot oral antidepressant) excessive
fatigue. - Patient Profile Least Likely to Benefit
- Patient on several medications and/or frequent
medication changes anticipated - Dose
- Usual dose 20-40 mg/d
- Max dose 80 mg/d
- Fluoxetine weekly (Prozac Weekly)
- Tends to produce more initial nervousness and
arousal than other SSRIs.
118Paxil and Paxil CR)
- Side Effects/ Features Used in Selection
- Tends to cause fewer arousal and insomnia effects
common with SSRIs possesses some
anti-cholinergic effects Initial nausea rate is
14 vs 23 for immediate release -
- Sexual dysfunction Common
- Patient Profile Most Likely to Benefit
- Less likely to produce initial anxiety and/or
insomnia. - Patient profile least likely to benefit
- Patients who may require high doses or elderly/
more susceptible, are more prone to
anticholinergics effects (e.g. delirium) - Dose
- Usual dose 20-40 mg/d
- Max dose 60 mg/d c
- CR 25-50 mg/d 62.5 mg
- Dosing for youthful, reasonable health
- 20 mg P.O. Qam increased doses may be given a.m.
and noon if excessive arousal Give QHS if
sedating.
119SertralineZoloft
- Side Effects/ Features Used in Selection
- Tends to initially increase alertness patients
with psychomotor retardation may benefit - Sexual dysfunction Common
- Patient Profile Most Likely to Benefit
- The medical/surgical patient on one or more
medical drugs. Initial activation and increased
alertness desired. - Patient Profile Least Likely to Benefit
- Patient sensitive to any of the typical SSRI
side-effects (e.g. increased arousal). - Dose
- Usual dose 75-150 mg/d
- Max dose 200 mg/d
- Dosing for youthful, reasonable health
- 50 mg P.O. Qam x 1 week 75 mg P.O Qam
thereafter increased doses may be given am
noon, if excessive arousal
120Serotonin/Norepinephrine Reuptake
InhibitorVenlafaxine
- Side Effects/ Features Used in Selection
- Identical to those common to all SSRIs with more
nausea. Sustained hypertension risk is 3 at
300 mg. BP increases are dose-dependent, with a
linear dose-response. Constipation is unusual but
may cause discontinuation. - Patient Profile Most Likely to Benefit
- Patients with menopausal symptoms or failing an
SSRI trial. - At higher doses (e.g., 225 mg or higher),
patients with chronic pain -
- Patient Profile Least Likely to Benefit
- Patients with unstable BP and perhaps, those who
are GI sensitive - A clinically significant withdrawal syndrome
requires slow downtape - Dose
- Usual dose 150-225mg/d
- Max dose 375-450 mg
- Every 3-7 day titrate upward, starting at 37.5 mg
reduces risk of nausea initial trial at 225
mg/d. Reduce dose 50 for hepatic impairment 25
for renal.
121Serotonin/Norepinephrine Reuptake
InhibitorDuloxetine
- Side Effects/ Features Used in Selection
- Similar to SSRIs but more exaggerated. Mild,
blood pressure elevations
Nausea, dry mouth, somnolence and constipation
may lead to discontinuation - Patient Profile Most Likely to Benefit
- Patient with depression and chronic pain (effects
on pain are dose-dependent). Patient failing an
SSRI trial. - Patient Profile Least Likely to Benefit
- Patient with significant anorexia, constipation,
or other GI symptoms - Dose
- Usual dose 60 mg QHS
- Max dose 60 mg BID
- Dosing for youthful, reasonable health Slowly
titrate up from smallest dose
122Norepinephrine/Dopamine Reuptake
InhibitorBupropion (Wellbutrin SR, Wellbutrin
XL, Wellbutrin IR
- Side Effects/ Features Used in Selection
- Least likely to switch patient to mania. Most
activating antidepressant available. DO NOT USE
if history of seizure, head trauma, substance
abuse, bulimia, anorexia or electrolyte
disturbance. - Sexual dysfunction Rare
- Patient Profile Most Likely to Benefit
- The now depressed, actually or potentially,
bipolar patient. The apathetic, low energy
patient. Patients motivated to stop smoking - Patient Profile Least Likely to Benefit
- Patients who are agitated, very anxious and/or
panicky. Patients at risk for seizures and/or
with history of head trauma, substance abuse,
eating disorder, or electrolyte disturbance - Dose
- SR Usual 300-400 mg/d, Max 450 mg/d
- XL Usual 300 max dose 450 mg/d)
- IR Usual 200-450 mg/d, Max dose 450 mg/d (TID)
123Serotonin alpha-2 receptor blockerMirtazapine
, Remeron)
- Side Effects/ Features Used in Selection
- Produces sleep lower doses produce more sleep
than do higher doses. Weight gain may be 10
lbs. Has antiemetic properties. Risk of
neutropenia 1.5 risk agranulocytosis 0.1. -
- Sexual dysfunction Unlikely
- Patient Profile Most Likely to Benefit
- The medically ill patient with weight loss,
insomnia and nausea - Patient Profile Least Likely to Benefit
- The obese patient with fatigue and hypersomnia.
Patients with neutropenia - Dose
- Usual dose 30-45 mg/d
- Max dose 60 mg/d
124VA Services
- VA Principle Leader In The Treatment Of PTSD and
Military Sexual Trauma - 190 Specialized PTSD Outpatient Treatment
Programs in all 50 states - With 162 specialized PTSD Clinical Teams
-
- 33 Specialized Inpatient Units for Brief Stays
and Longer-term Treatment
125VA Services
- The VA reorganized TBI lead centers
- Polytrauma Rehabilitation Centers
- dividing the USA into 4 geographical zones
126VA Services
- The National Suicide Prevention Lifeline has a
new feature for veterans - Call for yourself, or someone you care about
1-800-273-TALK (8255) and press 1. Your call is
free and confidential.
127VA Montana Behavioral Health Services
- FH
- Crisis, Urgent, Emergent
- Medication Management
- Psychotherapy
- CWT, Vet To Vet
- Recovery Oriented Services
- Homeless Services
- Detox
- Telemedicine new
- Transfer to Inpatient Services at Sheridan
128VA Montana Behavioral Health Services
- Partnerships with Local Providers
- Community Based Mental Health Center
- Center for Mental Health
- Western Montana
- South Central
- Fee-basis Providers, credentialed to provide
evidence based psychotherapy in line with
national standards of care
129VA Retooling
- Integration of VA-DOD Medical Care
- Further Development of Shared Guidelines
- Increased Focus on Families/Couples
- Focus on Work and Rehabilitation
- MH Focus in Primary Care
- Internet Based Treatments
- Widespread Adoption of Telehealth
130Retooling of VA MH Professionals
- Use of Evidence Based Psychological Care
- Employ Interdisciplinary Models of Care
- Train in Use of Telehealth
- Train in Use of Internet for Care Monitoring
- Adoption of Systems for Promoting Access
- Where Needed
- When Needed