Impact of War on Veterans, Families and our Communities 91506

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Impact of War on Veterans, Families and our
Communities9/15/06

• Barry Fisher MD DFAPA
• Medical Director PTSD/Behavioral Medicine
  Clinic
• VAMC Pittsburgh Highland Dr. Div.

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Disclosure

• Speakers Bureau Astra/Zeneca Pharmaceuticals
• Clinical Faculty UPMC Dept. of Psychiatry
• Clinical Faculty Drexel University School of
  Medicine(Allegheny Campus)

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OVERVIEW Veteran Administration Services for
Returnees

• Veterans Health Administration
• Veterans Benefits Administration
• Veteran Cemeteries
• Military health care services

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OVERVIEW Veteran Administration Services for
Returnees

• Veteran Integrated Service Networks (VISNs)
• Medical Centers (VA Pittsburgh HCS)
• Community Based Outpatient Clinics (CBOCs)
• Veterans Readjustment Counseling (Vet Centers)

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OVERVIEW

• In FY 2004, VAMCs nationwide treated a total of
  about 275,000 people with PTSD, from WWI (6) to
  Vietnam (191,000)
• Of those men and women treated for any Mental
  Disorder, the percent with PTSD varies by era
  (15 for Desert Storm, 30 for Vietnam War, 8
  for Korean veterans, 10 for WWII veterans)

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OVERVIEW

• At the end of FY 04, there were 144 specialized
  PTSD treatment programs nationwide in VHA.
• Inpatient treatment (EBTPU)
• Residential treatment (PRRTP, Dom)
• Day Hospital/Day Treatment
• PTSD Clinical Teams (Outpatient PCTs)
• Substance Use Disorder/PTSD Clinical Teams (SUPTs)

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OVERVIEW

• Analysis of VA Health Care Utilization Among
  Southwest Asian War Veterans Combined
• Operation Iraqi Freedom (OIF)
• Operation Enduring Freedom (OEF)
• Dr. Kang, VHA Office of Public Health and
  Environmental Hazards, May 2006

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OVERVIEW

• 555,478 OEF/OIF veterans have left active duty
  and become eligible for VA health care since FY
  2002
• 43 Former Active Duty troops
• 57 Reserve and National Guard
• About 30 (168,421) of the total separated
  veterans have sought VA health care since FY
  2002. This is about 3 of the 5.3 million men
  and women who received VHA health care nationwide
  in FY 2005.

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Demographic Characteristics of Iraqi and Afghan
Veterans Utilizing VA Health Care

• Male 87
• Female 13
• Ages
• lt20 years old 2
• 20 to 29 53
• 30 to 39 23
• gt40 years old 22
• Enlisted 92
• Officer 8

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Demographics, OEF/OIF Veterans Utilizing VA
Health Care (Continued)

• Branch
• Air Force 12
• Army 67
• Marines 11
• Navy 10
• Unit Type Active 43, Reserve 57

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Frequency of ICD-9 Broad Diagnostic Categories,
OEF/OIF Veterans Using VA Care (Dr. Kang)

• Diagnosis, n 168,421 as of 4/24/06 (Each veteran
  may be counted more than once).
• Infections 9.8
• Malignant neoplasms 0.7
• Benign neoplasms 3.0
• Endocrine disorders
  16.4
• Diseases of the blood 1.6
• Mental disorders
  33.4
• Diseases of the nervous system
  28.6
• Diseases of the circulatory system
  13.5
• Diseases of the respiratory system
  17.1
• Diseases of the digestive system
  30.7
• Diseases of the genitourinary system 8.7
• Diseases of the skin 13.3
• Diseases of the musculoskeletal system
  40.8
• Ill defined conditions 31.2
• Injury/Poisonings 16.1

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Frequency of Possible Mental Disorders Among
OEF/OIF Veterans since 2002

• 56,304 unique VA patients received a diagnosis of
  a possible ICD mental disorder n
• PTSD 25,317
• Drug abuse 21,717
• Depressive disorders 17,560
• Neurotic disorders 13,852
• Affective psychoses 9,157
• Alcohol dependence 3,906
• Sexual disorders 2,409
• Acute reaction to stress 1,784
• Drug dependence 1,692

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OVERVIEW, Hoge, NEJM 2004

• Dx Strict Broad
• Definition Definition
• Depression 7-8 14-16
• Anxiety 7-8 16-17.5
• PTSD 6-13 11.5-20
• Any 11-17 24.5-30

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OVERVIEW Veteran Administration Services for
Returnees

• The Congressional 2 year window
• Post-Deployment Health Reassessment (PDHRA)
• Referral routes (outreach, military liaisons,
  self referrals, community referrals, military
  referrals)

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VA Pittsburgh Healthcare SystemOEF/OIF
Clinic412-365-5150

• Integrated Primary Care and Behavioral Health
• STAFF
• Elaine Hatala, secretary
• Brian Avant, MSW, Coordinator and Outreach
• Susan Byerly, CRNP
• David Barnas, CRNP
• Medical Director, Elif Sonel, M.D. (internist)
• Bernadette Lauber, Ph.D. (psychologist)
• Psychiatrist in clinic
• Daniel Ziff, MSW with PTSD Clinical Team
• Drs. Fisher and Fetchko (psychiatrists with PCT)
• Womens Health Care Clinic at VAPHS
• Polytrauma Team
• Specialty Clinics (37 specialty clinics at VAPHS
  used to date by OEF/OIF veterans, including
  orthopedic clinic, dental clinic, etc.)

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Home coming after deploymenttips for families

• Expectations for soldiers
• Expectations for spouses
• Reactions of children

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Expectations for Soldiers

• Miss excitement of deployment
• Intimacy may be difficult
• Roles may have changed while away
• Spouses may be more independent
• Mixed feelings about discussing experiences

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Expectations for spouses

• Soldiers may be more claustrophobic
• Soldiers may have different schedule
• Soldiers may want old responsibilities back
• Soldiers may be hypersensitive to noise
• Soldiers may want family/children to be more
  expressive of affection

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Childrens reactions

• Babies may not recognize the returning soldier
  and may cry when held
• Toddlers may hide and be slow to respond
• Preschoolers may feel guilt over separation
• School age children may want a lot of attention
• Teenagers may seem aloof and moody

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Tips for soldiers

• Take time to talk with spouse/children
• Go slowly re-establishing role in family
• Be flexible
• Be supportive of all spouse has done in your
  absence
• Go easy on partying

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Tips for spouse

• Dont over schedule
• Dont rush things/give space
• Remind soldier he/she is still needed in the
  family
• Make individual time for one another

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Tips for reunion with children

• Go slow and let child set pace of reunion
• Learn from spouse how children were managed
  during your absence
• Do not change too many routines for a few weeks
• Limit criticism, praises successes
• Encourage children to tell you what happened
  during your absence

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What families can offer trauma survivors

• Companionship acts as antidote to isolation
• Self-esteem acts as antidote to depression and
  guilt
• Opportunities to make positive contributions act
  as antidote to feelings of failure/alienation
• Practical and emotional support for lifes
  stressors

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Assessment and Treatment of PTSD

• REFERENCES
• www.va.gov
• MyHealtheVet
• MedlinePlus
• Healthwise
• Search Site-- PTSD
• National Center for PTSD (VHA)
• National Institute of Mental Health
• American Psychiatric Association
• National Alliance for Mental Illness (NAMI)
• National Library of Medicine
• Etc., etc.

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PTSD, DSM IV

• Category A
• Traumatic exposure and response to same
• Examples, OEF/OIF Issues

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PTSD, DSM IV

• Category B
• Reexperiencing symptoms (1 or more)
• Recurrent and distressing recollections
• Recurrent and distressing dreams
• Flashbacks
• Intensive psychological distress with exposure
• Physiologic reactivity on exposure

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PTSD, DSM IV

• Category C
• Avoidance symptoms (3 or more)
• Efforts to avoid thoughts, feelings or
  conversations associated with the trauma
• Efforts to avoid people, places or activities
• Psychologic amnesia
• Markedly diminished interests
• Feeling detached and estranged from others
• Sense of foreshortened future

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PTSD, DSM IV

• Category D
• Arousal symptoms (new after trauma, 2 or more)
• Difficulty falling or staying asleep
• Irritability and anger outbursts
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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PTSD, DSM IV

• Category E
• Duration gt 1 month.
• Category F
• The disturbance causes clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.
• Acute PTSD, duration lt 3 months
• Chronic PTSD, duration gt 3 months
• Delayed Onset, onset gt 6 months after the stressor

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PTSD

• Differential Diagnoses
• Acute Stress Disorder
• Lasts at least 2 days or up to 4 weeks.
• Onset within one month of the stressor.

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PTSD

• Differential Diagnoses
• Acute Stress Disorder
• Adjustment Disorders
• Substance-Induced Disorders
• Other Anxiety Disorders, OCD
• Dissociative Disorders
• Brief Psychotic Disorder
• Anxiety Disorder, Not Otherwise Specified
• Malingering

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PTSD

• Coexisting Conditions, Comorbidities
• Substance Related Disorders
• Mood Disorders
• Other Anxiety Disorders
• Personality Disorders
• Primary Sleep Disorders
• Psychotic Disorders
• Head Trauma

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PTSD

• Risk Factors
• Childhood trauma and abuse
• Family history of mental disorder(s)
• Female gender
• Greater intensity and duration of trauma, or
  repeated exposure to the trauma, especially
  interpersonal
• Low cortisol levels
• Personality traits (antisocial, avoidant,
  borderline, dependent, paranoid)
• Poor social supports
• Substance related disorder(s)

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PTSD

• Early strategies in assessment and care
• The challenge of screening instruments
• Normalizing adjustment
• Discussion of etiology
• Lifestyle advise

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PTSD Treatment Choices

• Do nothing, at least for now.
• Individual Supportive Therapy
• Group Therapies (classes)
• Targeted Psychotherapies
• Behavioral, Exposure Therapies
• EMDR
• Virtual Reality Techniques
• Peer Support
• Psychopharmacologic interventions
• Role of inpatient care

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Psychotropic Medications and PTSD

• Challenge of evidence-based medicine
• Prazosin
• Antidepressants, SSRIs, trazodone, etc.
• Benzodiazepines, other anxiolytics
• Sedative/Hypnotic agents
• Mood stabilizers
• Antipsychotic medications
• Others (clonidine, propranolol, anticonvulsants)