Combat Stress Related Disorders VA Montana Health Care Rosa F. Merino, MD Chief of Behavioral Health

1
Combat StressRelated DisordersVA Montana
Health CareRosa F. Merino, MDChief of
Behavioral HealthKurt Werner, MDLead Physician
Ambulatory Care
2
What 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

4
Characteristics of Current Military

• Age mid 30s
• Professional Military with Families
• Majority in Guards and Reserves
• Females 10-12
• Racial/Ethnic Diverse Workforce

5
Stress of Combat

• No one comes back unchanged
• COL (Dr.) Tom Burke, Department of Defense,
  Director of Mental Health Policy

6
What is Normal
7
When 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

8
High 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

9
The 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)

10
Realities 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

11
The Recovery Process
12
Prevalence 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

13
Symptoms 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

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Impact 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

15
Are 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

16
Information 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.

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The 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

18
OIF 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)

19
OIF and OEF Hoge and colleagues. 2006

• Three Most Common Health Conditions of Returning
  Veterans
• Musculoskeletal
• Mental Health
• Digestive System Problems

20
Spectrum 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

21
Mental 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

22
OIF / 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

23
We See

• Combat Exposure Associated with
• PTSD
• Depression
• TBI
• Substance abuse
• Anger
• Current unemployment
• Current divorce or separation
• Current spouse or partner abuse

24
We See

• Gender Differences Will Present Different
  Challenges In Providing Treatment
• MST
• Eating Disorders
• Depression
• PTSD
• Substance Abuse
• Psychosocial Problems

25
What 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

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What 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

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PTSD and Physical Health

• PTSD increases risk for chronic illnesses
• circulatory
• digestive
• musculoskeletal
• endocrine
• respiratory
• infectious
• Green BL and Kimering R (in press)

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Symptoms 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

29
PTSD 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

30
PTSD

• 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

31
Who'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

32
Risk 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

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Acute 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

34
Acute 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

35
How 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

36
Prognosis 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

37
Positive 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

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Comprehensive Primary Care Evaluation

• Medical Record Review
• Medical history
• Review of Systems
• Psychosocial Assessment
• Physical Exam
• Mental Status Exam
• Routine Laboratory Work
• Ancillary testing

39
Exam 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

40
Medical 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

41
Additional 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

42
Additional 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

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MSE

• Appearance
• Mood and Affect
• Speech/ Thought Process rate, volume and
• Thought Content
• Perceptual Disturbances
• Cognitive Processing
• Orientation
• Level of consciousness
• Memory
• General intellect

44
Is It PTSD

• Signs and Symptoms
• Alienation from Friends and Family
• Arrests for Intoxication, Incarcerations
• Financial Problems
• Job Loss
• Homelessness

45
Post-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?

46
Post-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

47
Document Screening

• Positive Screen Does Not Constitute a Diagnosis
• Positive Screen Confirmed by Further Assessment
  and Discussed With the Patient

48
Signs 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

49
MSE

• 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

50
Is 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

52
Screening 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

53
SIGECAPS' 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

54
Criteria 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

55
DIGFAST 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

57
Symptoms 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)

58
Symptoms 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

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MSE 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

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Warning 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

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Warning 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

62
Underlying 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

63
Possible 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

64
Alcohol 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?
  

65
Alcohol 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)

66
Alcohol 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.

67
TBI

• 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

68
TBI

• 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

69
TBI

• 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

70
TBI

• Patients with head injury
• 50 blast exposed
• 50 motor vehicle accidents

71
TBI

• 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

72
TBI-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.

73
TBI-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

74
Neuropsychiatry 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

75
Symptoms

• Aggression, Irritability, Impulsivity
• Up to 70 within 1 year of TBI
• May last over 10-15 years

76
Symptoms

• 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

77
Symptoms

• 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

78
Neuropsychiatric Sequelae of TBI

• Delirium
• Depression / Apathy
• Mania
• Anxiety
• Psychosis

79
Depression 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

80
Depression 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

81
Complications Associated With An Underlying
Psychiatric Diagnosis

• High Incidence of
• Poor Treatment Compliance
• Housing Instability
• Homelessness
• Medical Problems
• Legal Problems

82
Complications 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)

83
Vicious 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

84
Patients 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

85
Management of Depression

• PHARMACOTHERAPY
• Effective for
• major depression
• chronic depression (dysthymia)
• Equivocal
• minor depression

86
Treatment 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

87
Treatment 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

88
Antidepressants

• 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

89
Sedative Hypnotics

• Benzodiazepines
• All available as generics
• Short acting Ativan (lorazepam)
• Intermediate Xanax (alprazolam)
• Long acting
• Klonopin (clonazepam)
• Valium (diazepam)
• Librium (chlordiazepoxide)

90
MEDICATION 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

91
PARTIAL 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

92
Referral

• 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

93
Treatment 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

94
Alternative 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

95
Choice 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

96
Other 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

97
Managing 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)

98
Managing 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

99
Alcohol

• 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

100
Management 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

101
Management 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

103
Management of PTSD
104
Management of PTSD
105
Management of PTSD
106
Management of PTSD Anticonvulsants
107
Management of PTSD Sedative Hypnotics
108
Management of PTSD Atypical Antipsychotics
109
Prazosin 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.

110
Effect 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.

111
Neuropsychiatric 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

112
Cognitive 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

113
Treatment 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

114
TBI 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

115
SSRIsCitalopram

• 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

116
EscitalopramLexapro

• 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

117
Prozac

• 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.

118
Paxil 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.

119
SertralineZoloft

• 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

120
Serotonin/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.

121
Serotonin/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

122
Norepinephrine/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)
  

123
Serotonin 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

124
VA 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

125
VA Services

• The VA reorganized TBI lead centers
• Polytrauma Rehabilitation Centers
• dividing the USA into 4 geographical zones

126
VA 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.

127
VA 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

128
VA 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

129
VA 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

130
Retooling 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