1

VETERANS IN TRANSITION

John F. Prater, DOPsychiatrist

Southwest Florida Osteopathic Medical Society

October 19, 2018

2

OBJECTIVESTo review some of the many challenges confronting veterans in transition from military to civilian life.

3

Why do a presentation about veterans for primary care providers?

● 1.5 million discharged veterans since 2001● 700,000 have received care through the VA● Others received care through the civilian sector● Veterans have unique health care needs

4

PATIENT SATISFACTION AT OUR FACILITY IS LOW

● We’re trying…….so why?

● If there is one word that would capture how many veterans

present to my office for care, it would be, ironically, “defeated”

● How does the veteran typically present to us for care, and what

are some of the health related concerns unique to this

population?

5

Some important statistics

Vet suicide rate 30/100,000 per year-civilian is 14/100,000

In 2014 there were 7,400 suicides by vets,,,,that number has remained relatively constant

Homeless vets twice the rate of the population,⅓ of homeless men are vets

More bad news….Veterans need for care peaks several decades after their war experience

6

SERVICES OFFERED UPON DISCHARGE FROM THE MILITARY

● “TAPS” - Transitionl Assistance Program. 3-5 days, generic● Vietnam● WWII● Since 2001 very few DOD initiatives to address violence problem in returning vets● Canada and European countries have formalized decompression programs

7

8

“WE ARE THE KIDS LEFT BEHIND”

AVERAGE AGE OF SOLDIERS:

● WWII: 26 years old● Vietnam: 19 years old

● Desert Storm: 27 years old (national guard/reservists)

Many can flourish in the structured environment of the military, but are unable to function in the civilian

world.

9

Prater’s Axiom #1

● Disorders occur at points of vulnerability in the life cycle● Most common age of onset of serious mental illness: 18-25

years old ● Coincides with age of military duty

10

Military Life● Structured● Predictable● Close social network● Clear expectations re “mission”● Training/conditioning internal structure

11

Military Life, cont’d

● Teamwork● Trust● Uniformity● Diversity● Fast paced….especially in combat arenas● Identity- “I was somebody in the military”

● A deep bond that exists among those that served

12

Civilian World

● Unstructured…..What’s the mission?● Trust ● Social Networks● Co-workers● Learning how to step back and be less reactive

13

Civilian World, cont’d

● Initially things seem to be in “slow motion”● Individual over group needs● Competitive● “Choices”● Things seem insignificant● “Underwhelmed “

14

Protective FactorsVets at lower risk for re-entry problems

● College grads● Officers● Those with a clear understanding of what their mission

was● Religious affiliation● Receiving care from providers who are veterans

15

16

Veterans Care

● What are the expectations the veteran has for care from the VA?

● Is it possible for the VA to meet those expectations?● Inherent problems within the delivery of care system● Outcomes

17

Veterans Care - Unique problems

● Secondary gain● Compliance ● Comorbid substance use/abuse● Expectations of a cure from PTSD, depression, etc● Accessing care for psychiatric conditions/stigma

18

Veterans care - A unique delivery of care

● Formulary● Nomadic veterans● Multiple providers● Revolving providers● One chart● Additions and removals (meds, diagnoses)

19

Prater Axiom #2

The greater the number of psychiatrists who examine the patient, the harder it is to figure out what the hell is wrong.

20

OTHER PROBLEMS:THE SUBTLE

AND NOT-SO-SUBTLE

21

Unique medical problems● Disfigurement

22

Unique medical problems, cont’d

● Protective gear/battlefield aid stations have reduced mortality, but increased morbidity (amputations, TBI)

● PTSD, musculoskeletal injuries mostly● Cognitive dissonance - “I couldn’t think straight”● “ Invisable injuries “ Depression,TBI, in addition to PTSD● Increased ALS● “ chronic multisystem illness”

23

Unique medical problems, cont’d● Suffering a serious injury or emotionally traumatic

event predicts a more problematic re-entry into civilian life….. PTSD

24

Medical Care Challenges

● Low testosterone level● Low vitamin D● Low activity level● Little or no dental care● Sequelae of substance use disorder● Poor diet● STD’s

25

PTSD Clues

● Experiencing/witnessing traumatic event● Flashbacks● Nightmares● Irritability● Insomnia● Startle response● Avoidance/numbing● hypervigilance

26

EMPLOYMENT

● Transfer of job skills - military to civilian

● Employability …. Working with co-workers and expectations.

“In the civilian world, there is no teamwork, discipline.”

● “Starting at the bottom all over again” …… “I was behind others

who didn’t serve.”

● Learning new skills…..the fast pace of changing technologies

27

HOME● “I had no home to go to…..”● Homelessness secondary to other factors

28

HOME

● Divorce - 70% among returning veterans● “My family was not the same” - those married and deployed

post 9-11 had a more difficult re-entry than those single● Families have developed new routines● “I couldn’t relate to my family/ friends”● Change in income (often lower)

29

SUBSTANCE USE DISORDERS IN VETERANS

● Culture in the military of tobacco use - smoking but also chewing

● Alcohol● Other drugs while in the service, carrying over into civilian

arena● Often connected to legal difficulties

● Medical problems● Social problems

30

Other mental health issues

● Depression● Insomnia● Suicide● Pain disorders● Impulse control disorders….often linked to domestic violence● Comorbidity is the rule and not the exception, often have to be

creative with psychotropic meds

31

ACCESSING MEDICAL CARE

● Establishing services for individual care● For dependent children, especially disabled children, lack of

insurance in transition period● Mental health stigma - seeking care is looked down on while in

the military, causes delay in seeking care once released● Trained to “power through” adversity, delays access to care

32

Prater’s Axiom #3● The longer you have a problem, the harder it is to recover

from.● Delayed onset of care = 8-9 years post-discharge

33

More subtle difficulties● “I abandoned my friends”● “I’m surrounded by people I don’t know”● Feeling disconnected from former friends● Not able to connect with some VA providers● An internal but no external structure● “Thinking I was alright/invincible”● “Reinventing myself”● Survivors guilt

34

What primary care can do to help

● Address barriers to care● Conduct a specialized review of systems:

○ Combat ○ Injuries○ Screen for depression/suicide

● Destigmatize mental health care● Close follow up first 3 years (most vulnerable)● Focus on function and reintegration: promote mental “fitness”

in keeping with military culture

35

Appropriate use of psychotropic medications

● PTSD: FDA-approved meds - sertraline & paroxetine● Nightmares - prazosin● Insomnia - avoid benzos, short-term zolpidem okay, cognitive

therapy● Pain - OMT, massage, NSAID’s, no opiates● Depression - SSRI/SNRI, cognitive therapy● Temperament - Valproate(off label)

36

What the VA can do

● Be proactive….address specific needs at the time of discharge● Streamline/simplify operations& expand the formulary● Continuity of care by addressing VA workplace concerns

(reducing turnover)● Remove some cooks from the kitchen….● Recognize that positive metrics do not necessarily reflect good

care● Promote mental fitness which aligns with the core concepts of

military culture

37

Prater’s Axiom #4

● A little empathy and personalized care goes a very long way in helping people recover from any condition

38

Questions?