Providing care to OIF/OEF Providing care to OIF/OEF veteransveterans

Steve McCutcheon, PhDSteve McCutcheon, PhDMatthew Jakupcak, PhDMatthew Jakupcak, PhD

VA Puget Sound Healthcare System, SeattleVA Puget Sound Healthcare System, SeattleDepartment of Psychiatry and Behavioral Department of Psychiatry and Behavioral

Sciences,Sciences,University of Washington School of MedicineUniversity of Washington School of Medicine

AcknowledgmentsAcknowledgments

Miles McFall, PhDMiles McFall, PhDDirector, Psychology ServiceDirector, Psychology Service

Director, PTSD Patient Care LineDirector, PTSD Patient Care LineVA Puget Sound Health Care SystemVA Puget Sound Health Care System

Workshop overviewWorkshop overview

Basic epidemiology and patient characteristicsBasic epidemiology and patient characteristics

A model of integrated care for OIF/OEF veteransA model of integrated care for OIF/OEF veterans– Federal and State collaboration in Washington StateFederal and State collaboration in Washington State– An integrated model of primary stepped care at VA An integrated model of primary stepped care at VA

Puget Sound, SeattlePuget Sound, Seattle

Adapting evidence-based PTSD treatments in Adapting evidence-based PTSD treatments in secondary prevention efforts for OIF/OEF secondary prevention efforts for OIF/OEF veteransveterans

Faces of the warFaces of the war

JamesJames– Avoidance and withdrawalAvoidance and withdrawal

GaryGary– Vigilance and controlVigilance and control

Facts about the warFacts about the war

War in Southwest AsiaWar in Southwest AsiaPopulation StatisticsPopulation Statistics

Over 1,000,000 military personnel deployed to Over 1,000,000 military personnel deployed to Southwestern Theater of OperationSouthwestern Theater of Operation

505,366 veterans have left active duty (as of 12/31/05)505,366 veterans have left active duty (as of 12/31/05) 43% active duty troops43% active duty troops 57% Reserve and National Guard57% Reserve and National Guard

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

War in Southwest AsiaWar in Southwest AsiaHuman CostsHuman Costs

2,513 Americans killed 2,513 Americans killed (2/7/06)(2/7/06)

17,096 officially wounded 17,096 officially wounded (2/7/06)(2/7/06)

50,000 – 250,000 civilians killed 50,000 – 250,000 civilians killed (Nov. 2004)(Nov. 2004)

Top 10 Causes of OIF DeathsTop 10 Causes of OIF Deaths 3/19/2003 – 11/30/20043/19/2003 – 11/30/2004

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Top 10 causes account for 97.5% of deaths.

Increasing Survival Rate of Injured SoldiersIncreasing Survival Rate of Injured Soldiers

WWII: 23% of injured combatants diedWWII: 23% of injured combatants died

Vietnam: 17% of injured combatants diedVietnam: 17% of injured combatants died

Iraq/Afghanistan: 9% of injured combatants dieIraq/Afghanistan: 9% of injured combatants die

As many US soldiers have been injured in combat thus far As many US soldiers have been injured in combat thus far in Iraq/Afghanistan as were in the Revolutionary War, the in Iraq/Afghanistan as were in the Revolutionary War, the War of 1812 or the first 5 years of the Vietnam WarWar of 1812 or the first 5 years of the Vietnam War

Gawande A. Casualties of War—Military Care for the Wounded from Iraq and Afghanistan. NEJM 351(24): Gawande A. Casualties of War—Military Care for the Wounded from Iraq and Afghanistan. NEJM 351(24): 2471-2475.2471-2475.

Combat Exposure for OIF SoldiersCombat Exposure for OIF SoldiersHoge et al. (2004)Hoge et al. (2004)

EventEvent Army (%)Army (%) USMC (%)USMC (%)

Attacked/AmbushedAttacked/Ambushed 8989 9595

Being shot at/receiving fireBeing shot at/receiving fire 93/8693/86 97/9297/92

Shooting at enemyShooting at enemy 7777 8787

Killing enemy combatant(s)Killing enemy combatant(s) 4848 6565

Handling human remainsHandling human remains 5050 5757

Seeing injured women/childrenSeeing injured women/children 6969 8383

Seeing dead/injured AmericansSeeing dead/injured Americans 6565 7575

Killing non-combatant(s)Killing non-combatant(s) 1414 2828

Being woundedBeing wounded 1414 99

Service utilizationService utilization

Perceived Barriers to Mental Health CarePerceived Barriers to Mental Health CarePositive Screen CasesPositive Screen Cases

Hoge et al. (2004)Hoge et al. (2004)

I would be seen as weakI would be seen as weak 65%65%

My unit leadership might treat me differentlyMy unit leadership might treat me differently 63%63%

My unit would have less confidence in meMy unit would have less confidence in me 59%59%

My leaders would blame me for the problemMy leaders would blame me for the problem 51%51%

It would harm my careerIt would harm my career 50%50%

Difficulty getting time off work for treatmentDifficulty getting time off work for treatment 55%55%

It is difficult to schedule an appointmentIt is difficult to schedule an appointment 45%45%

I don’t trust mental health professionalsI don’t trust mental health professionals 38%38%

Mental health care doesn’t workMental health care doesn’t work 25%25%

I don’t know where to get helpI don’t know where to get help 22%22%

Utilization of Mental Services Utilization of Mental Services Active Duty PersonnelActive Duty Personnel

Only 23% of Only 23% of positive screenpositive screen active duty active duty Army/USMC personnel sought mental health Army/USMC personnel sought mental health care in past yearcare in past year11

35% soldiers in a population-based study sought 35% soldiers in a population-based study sought mental health services in mental health services in first yearfirst year after after demobilizationdemobilization22

11Hoge et. Al. 2004Hoge et. Al. 200422Hoge et. Al. 2004Hoge et. Al. 2004

Utilization of VA ServicesUtilization of VA Services

29% (144,424) have sought VA care nationally 29% (144,424) have sought VA care nationally (12/31/05)(12/31/05)

32% of separated active duty 32% of separated active duty 26% for reserve component26% for reserve component Represents 3% of all vets seen in VARepresents 3% of all vets seen in VA

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

Utilization of VA ServicesUtilization of VA ServicesCharacteristics of PatientsCharacteristics of Patients

87% male; 13% female87% male; 13% female

Age 20-29 = 53%; age 30-39 = 23%Age 20-29 = 53%; age 30-39 = 23%

ARMY = 66%, USAF = 13%, USMC = 11%, ARMY = 66%, USAF = 13%, USMC = 11%,

USN = 10%USN = 10%

Active duty = 49%, Reserve Component = 51%Active duty = 49%, Reserve Component = 51%

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

Clinical characteristicsClinical characteristics

Medical Diagnoses (N = 144,424)Medical Diagnoses (N = 144,424)

MusculoskeletalMusculoskeletal 40%40%

Mental disordersMental disorders 32%32%Digestive SystemDigestive System 30% 30%Ill Defined SymptomsIll Defined Symptoms 30%30%Nervous systemNervous system 28%28%RespiratoryRespiratory 17%17%Injury/PoisoningInjury/Poisoning 16%16%

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

Spectrum of Post-Deployment Spectrum of Post-Deployment Mental Disorders (N = 46,571)Mental Disorders (N = 46,571)

DisorderDisorder N N % %

PTSDPTSD 20,63820,638 44%44%Drug AbuseDrug Abuse 17,76817,768 38%38%DepressionDepression 14,317 14,317 31%31%Neurotic DisordersNeurotic Disorders 11,48111,48125%25%Affective PsychosisAffective Psychosis 7,4607,460 16%16%Alcohol DependenceAlcohol Dependence 3,1163,116 7% 7%Acute Stress ReactionAcute Stress Reaction 1,3271,327 3% 3%

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

Prevalence of Mental Disorders by War ZonePrevalence of Mental Disorders by War ZoneStrict Diagnostic CriteriaStrict Diagnostic Criteria

War ZoneWar Zone PTSDPTSD MDD & GADMDD & GAD ETOH AbuseETOH Abuse

Viet NamViet Nam(Lifetime rates)(Lifetime rates)

30%30% 5.1 MDD5.1 MDD

14.1 GAD14.1 GAD

39.2 (11.2) 39.2 (11.2)

Gulf War Gulf War 2% - 10%2% - 10%

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AfghanistanAfghanistan 6.26.2 MDD = 6.9%MDD = 6.9%

GAD = 7.4%GAD = 7.4%

Any disorder = 11.2Any disorder = 11.2

18.2 - 24.518.2 - 24.5

IraqIraq 12.612.6 MDD = 7.4%MDD = 7.4%

GAD = 7.2%GAD = 7.2%

Any disorder = 16.4Any disorder = 16.4

24.8 – 29.624.8 – 29.6

Outcomes for Symptom Screening (Iraq)Outcomes for Symptom Screening (Iraq)Liberal CriteriaLiberal Criteria

DisorderDisorder Screening at Screening at DemobilizationDemobilization

Delayed Delayed ScreeningScreening

PTSDPTSD 9.8%9.8% 18.9% - 34.6%18.9% - 34.6%

DepressionDepression 4.5%4.5% 15.2% - 30%15.2% - 30%

AnyAny 19.1%19.1% 28.5% - 40% 28.5% - 40%

Health Risk Screening OutcomesHealth Risk Screening OutcomesDemobilization SitesDemobilization Sites

Alcohol = 33%Alcohol = 33%

Hostility = 22.8%Hostility = 22.8%

Suicide ideation/risk = 1.1% - 4.1%Suicide ideation/risk = 1.1% - 4.1%

Interpersonal Aggression/Domestic Violence = 2.1% - 2.2%Interpersonal Aggression/Domestic Violence = 2.1% - 2.2%

Tobacco Use = 50% (25% - 44% want to quit)Tobacco Use = 50% (25% - 44% want to quit)

Health Risk BehaviorsHealth Risk BehaviorsVAPSHCS Clinic Sample (n = 144)VAPSHCS Clinic Sample (n = 144)

SymptomSymptom % Endorsing% Endorsing

Problematic drinking past 4 Problematic drinking past 4 monthsmonths

30%30%

Number of days drunk in Number of days drunk in past 4 monthspast 4 months

Mean = 11 daysMean = 11 days

Current smokersCurrent smokers 30%30%

Did not engage in physical Did not engage in physical exercise past month (not at exercise past month (not at all or only 1-2 times)all or only 1-2 times)

54%54%

Post-Deployment Readjustment ReactionsPost-Deployment Readjustment ReactionsFunctional LimitationsFunctional Limitations

Unemployment Unemployment Financial deficits Financial deficits (lacking money management skills)(lacking money management skills)

HomelessnessHomelessness Phobias about drivingPhobias about driving ““Reunion stress” (over-controlling, detached, Reunion stress” (over-controlling, detached,

intimacy problems) intimacy problems) Marital conflict, parenting concerns and family Marital conflict, parenting concerns and family

reintegration problems (including divorce, DV, reintegration problems (including divorce, DV, and infidelity)and infidelity)

Post-Deployment Readjustment ReactionsPost-Deployment Readjustment ReactionsProminent Arousal SymptomsProminent Arousal Symptoms

Disturbed sleep and dreamingDisturbed sleep and dreaming Easily startledEasily startled Irritability and angerIrritability and anger Hypervigilance (discomfort in crowds)Hypervigilance (discomfort in crowds)

Post-Deployment Readjustment ReactionsPost-Deployment Readjustment ReactionsCommon Themes and ConcernsCommon Themes and Concerns

““Addiction” to CNN war coverageAddiction” to CNN war coverage Worry about friends still deployed overseasWorry about friends still deployed overseas Miss excitement of combat, urges to returnMiss excitement of combat, urges to return Worries about re-deploymentWorries about re-deployment

Traumatic Brain InjuryTraumatic Brain Injury

cognitive problems (e.g., impaired memory, attention, or cognitive problems (e.g., impaired memory, attention, or executive function)executive function) headachesheadaches sensitivity to light or noisesensitivity to light or noise dizziness or nauseadizziness or nausea irritability, impulsivity, poor frustration toleranceirritability, impulsivity, poor frustration tolerancedepressiondepression insomnia insomnia TBI can cause impaired or lost sensory function (e.g., TBI can cause impaired or lost sensory function (e.g., eyesight), mobility, and ability to perform basic activities eyesight), mobility, and ability to perform basic activities of daily living of daily living