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


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

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

Combat StressRelated Disorders
  • Rosa F. Merino, MD
  • Chief of Behavioral Health
  • VA Montana Health Care

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

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

What is Normal
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

High Comorbidity Between PTSD and Other
Psychiatric disorders
  • Depression, Anxiety disorders and Substance Abuse
  • 59 of men and 44 of women with PTSD met the
    criteria for three or more other psychiatric
  • 48 of the men and 49 of the women with PTSD had
  • 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

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)

Realities of Today Recovery I want a life
  • Recovery is Hope
  • Recovery is Reintegration
  • Recovery Takes Time
  • Recovery is a Process of Change and
  • 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

The Recovery Process
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

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

Impact of Trauma
  • There is an assumption that anyone exposed to a
    traumatic event will have chronic and severe
  • Different Studies substantiate that only a
    fraction of those facing trauma will develop PTSD
  • Elliott 1997, Kulka et al 1990, Breslau et al

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

Information Suggests
  • One third of PTSD patients recover within first
  • 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.

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

  • 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)

OIF and OEF Hoge and colleagues. 2006
  • Three Most Common Health Conditions of Returning
  • Musculoskeletal
  • Mental Health
  • Digestive System Problems

Spectrum of Post-Deployment Mental Disorders (N
  • 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

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
  • 56.7 PTSD
  • 45.4 Depression
  • 31.6 Employment issues
  • 24.7 Substance abuse

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

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

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

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

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

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

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
  • Being easily startled
  • Irritability
  • Poor concentration
  • Hypervigilance (excessive awareness of possible
  • Insomnia

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

  • PTSD can be acute, chronic and delayed
  • Acute symptoms lasting
  • Chronic symptoms lasting 3 mo
  • Delayed onset 6 mo elapses from event to symptom

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

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

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

Acute Stress Disorder
  • Person experienced traumatic event or events
    involving a threat to the physical integrity of
  • The person must have felt fear, helplessness or
  • 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

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

Prognosis for Improvement of PTSD
  • Prognosis difficult to establish
  • varies significantly from individual to
  • Some without care gradually recover over a period
    of years
  • Individuals who obtain appropriate medical and
    psychiatric care recover totally or nearly

Positive Prognosis
  • Factors associated with a positive prognosis
  • consist of quick access and engagement of
  • early and continuing social support
  • avoidance of retraumatization
  • positive premorbid function
  • lack of other psychiatric disorders or substance

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

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

Medical Record Review
  • Medical, family, social, occupational,
    deployment, medication, and immunization
  • Pre- and post-deployment physical exams
  • Clinic and emergency room visit notes
  • Laboratory, radiological, and other ancillary
    test results

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

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

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

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

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?

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
  • 4. Felt numb or detached from others, activities,
    or your surroundings

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

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
  • Being easily startled
  • Irritability
  • Poor concentration
  • Hypervigilance (excessive awareness of possible
  • Insomnia

  • 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
  • Feeling of unhappiness, miserable, sense of
    foreshortened future, hopelessness and wanting
    to die suicidal ideation

Is It Depression?
  • Prospective studies demonstrate that individuals
    may develop new-onset depression, other anxiety
    disorders, alcoholism or behavioral alterations
    without PTSD

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

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
  • 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

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

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

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

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

Symptoms of Depression
  • Depressed or irritable mood most or all of the
  • Diminished interest or pleasure in nearly all
  • Significant weight loss or weight gain
  • Insomnia (sleeplessness) or hypersomnia
    (excessive sleeping)
  • Physical movement that is excessively slow to
    excessively fidgety psychomotor retardation or

Symptoms of Depression
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or
    inappropriate guilt
  • Diminished ability to think, concentrate, or make
  • Social withdrawal from long-time friends, family,
  • Recurrent thoughts of death or suicide or

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

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
  • Unusual tiredness or sleep problems

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

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
  • Have At Least One Serious Mental Illness
  • Signs and Symptoms
  • Alienation from Friends and Family
  • Arrests for Intoxication, Incarcerations
  • Financial Problems
  • Job Loss
  • Homelessness

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

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?

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
  • 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)

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
  • In women, a score of 3 or more is considered
  • Generally, the higher the AUDIT-C score, the more
    likely it is that the patients drinking is
    affecting his/her health and safety.

  • 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

  • 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

  • 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

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

  • 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

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.

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

Neuropsychiatry HistoryTBI
  • Psychiatric symptoms do not always fit DSM-IV
  • 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
  • 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

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

  • 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

  • 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

Neuropsychiatric Sequelae of TBI
  • Delirium
  • Depression / Apathy
  • Mania
  • Anxiety
  • Psychosis

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

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

Complications Associated With An Underlying
Psychiatric Diagnosis
  • High Incidence of
  • Poor Treatment Compliance
  • Housing Instability
  • Homelessness
  • Medical Problems
  • Legal Problems

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)

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

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

Management of Depression
  • Effective for
  • major depression
  • chronic depression (dysthymia)
  • Equivocal
  • minor depression

Treatment Caveats
  • 50-65 of patients respond to the first
  • No superior agent in efficacy or time to
  • 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

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
  • 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

  • Tricyclic
  • SSRIs
  • citalopram (Celexa)
  • escitalopram (Lexapro)
  • fluoxetine (Prozac)
  • paroxetine (Paxil)
  • sertraline (Zoloft)
  • bupropion (Wellbutrin SR, XL) - DA/NE
  • venlafaxine (Effexor XR) - SRI/NRI
  • duloxetine (Cymbalta) - SRI/NRI
  • mirtazapine (Remeron) - NE/5HT

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

  • 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

  • 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

  • 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

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

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
  • Thyroid hormone supplementation in addition to an
    antidepressant in euthyroid patients
  • Valproic acid, other mood stabilizers
  • atypical antipsychotic in addition to an
  • Higher than usual doses of antidepressants
  • Multiple antidepressants, particularly those with
    different neurotransmitter actions
  • Stimulant medication in addition to an
  • Note many augmentation strategies have limited
    evidence of efficacy and studies supporting

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

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

Managing side effects
  • Commonly associated side effects with use of
  • 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)

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

  • 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

Management of PTSD
  • 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

Management of PTSD
    Interventions Module Summary
  • VA access to full guideline http//
    gov/cpg/cpg.htm DoD access to full guideline
  • 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

Management of PTSD
Management of PTSD
Management of PTSD
Management of PTSD Anticonvulsants
Management of PTSD Sedative Hypnotics
Management of PTSD Atypical Antipsychotics
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
  • Difficulty falling/staying asleep
  • Change in overall PTSD severity and functional
  • 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.

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.

Neuropsychiatric TreatmentTBI
  • Use Biopsychosocial Model
  • Treat signs and symptoms with least possible
  • TBI patients more sensitive to side effects
  • 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

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

Treatment of TBI Aggression, Agitation,
Impulsivity (none FDA approved for this
  • Acute
  • Antipsychotics
  • Benzodiazepines
  • Chronic
  • Valproate, carbamazepine, gabapentin
  • Lithium
  • Buspirone
  • Serotonergic antidepressants SSRIs
  • Trazodone, mirtazapine)
  • Beta-blockers (e.g. propranolol, pindolol,
  • Clonidine
  • Antipsychotics (esp. second and third generation)
  • Amantadine, bromocriptine, bupropion
  • Methylphenidate, naltrexone, estrogen

TBI Depression / Apathy
  • Depression
  • Selective Serotonin re-uptake inhibitors (SSRIs)
  • sertraline - paroxetine fluoxetine citalopram,
  • Bupropion
  • Mirtazapine
  • Venlafaxine
  • Tricyclics nortriptyline, desipramine (blood
  • Methylphenidate, dextroamphetamine
  • Apathy
  • Dopaminergic agents
  • methylpyhenidate, pemoline, bupropion,
    amantadine, bromocriptine, modafinil

  • 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
  • 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

  • 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
  • Usual dose/ Max dose 15-20mg/d 40 mg/d

  • 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
  • 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.

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
  • 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

  • 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

Serotonin/Norepinephrine Reuptake
  • 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.

Serotonin/Norepinephrine Reuptake
  • 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

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
  • 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)

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

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

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

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.

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

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

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

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
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