Disclaimer. Objectives. Military Mission & Deployment: Impact on Service Members

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1 Military Mission & Deployment: Impact on Service Members David M. Benedek, M.D. COL, MC, USA Professor/Deputy Chair Associate Dir., CSTS Dept. of Psychiatry USU School of Medicine Disclaimer The ideas, attitudes, and opinions expressed herein are my own and do not necessarily reflect those of the US Army Medical Corps, the DoD, or other branches of the US government Objectives 1. Describe the range of psychosocial issues related to deployment and their potential effects on service member and family well-being 2. Highlight findings of Mental Health Assessment Team Studies of deployed Service Members 3. Briefly describe intervention approaches

2 Deployment: A Definition A military operation in which the service member is sent from a home station, usually as part of a military unit to a distant location to accomplish a mission (e.g. combat operations, peacekeeping, humanitarian assistance) Families not permitted Deployments affect military members, families, communities, and the nation Deploying Soldiers & Their Families Worried about combat and terrorism Besieged by the Media Include National Guard and Reserves Are often Young/ Part of young families Deploying Soldiers & Their Families Single Parents Dual military families Women Children: Parental absence Face Recurring Deployments/separations

3 Operational Stress Factors Environmental Stressors: Weather, food, physical threats and vulnerabilities, fear of toxins, noise, communications Psychological stressors: Reactions to individual and interpersonal events, separation from usual supports Moral Stressors: Individual/unit sense of rightness or worthiness of the mission

4 Consequences of Deployment (+) Newby et al., Military Medicine, 2006 Made additional money Experienced self-improvement Improved marital relationship Helped others; experienced different culture Learned to appreciate USA Consequences of Deployment (-) Newby et al., Military Medicine, 2006 * Away from family missed events * Deterioration of marital/so relationship * Personal change for the worse * Leadership Issues/Disappointment * No reason for the mission * Lost/wasted/mismanaged money

5 Compounding Factors *Wounds and disabling injuries *Uncertainty about recurring deployments/withdrawal *Community attitudes/perceptions *Changing political environment *Career/Family issues *Transitioning from the cocoon of support services Deployment-Related Stress Injury Mechanisms Intense or Prolonged Stress TRAUMA FATIGUE GRIEF MORAL INJURY An impact injury Due to events provoking terror, horror, or helplessness A wear-and-tear injury Due to the accumulation of stress over time A loss injury Due to the loss of people who are cared about A loss injury Due to a disruption in trust in moral values Briefing by Capt Koffman, 2008 Long-Term Impact of Traumatic Experiences May Include: disappointment/resentment continued intrusive/arousal symptoms for some persistent sadness/resentment avoidance of triggers/reminders For most: Characterized by a re-focus on life challenges & rebuilding of relationships

6 Posttraumatic Stress Disorder A. Event 1. Actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. Person responded with intense fear, helplessness or horror (disorganization or agitation in children) B. Symptoms 1. At least 1 Reexperiencing symptom 2. At least 3 Avoidance symptoms 3. At least 2 Hyperarousal symptoms C. Distress or impairment D. Duration greater than 4 weeks (2 days-4 weeks = Acute Stress Disorder) Percent Deployment and Mental Illness Pre-deployment 3 mo. post-oef 3 mo. post-oif 6 mo. post-oif 12 mo. post-oif Depression PTSD Any Mental Health Problem From WRAIR Land Combat Study and NEJM July 2004 Hoge, et.al. Assessment Considerations Pre-deployment history is an important consideration for post-deployment adjustment and recovery Previous History of coping style/techniques, supports are important in ruling in/out or predicting potential contributions of alcohol/drugs, interpersonal stressors to deployment-related symptoms (somatic, mood, or anxiety) of distress

7 Assessment Considerations Deployment Experience and Exposures are also considerations Not all deployments are the same Total amounts of exposure to combat situations also appears to effect outcome for service members 25 % Screening Positive for PTSD by combat exposure [%] to 2 3 to 5 6 to From Hoge, et. al., NEJM July 2004 Managing the Impact of Deployment upon Redeployment Non-Clinical Approaches Recovery Environment Psychosocial Support Psychological First Aid Treatment of Specific Disorders Depression PTSD Substance Use/Abuse

8 Enhancing the Recovery Environment Recovery Is promoted by: Finding benefit Sense of relationship with the divine Trauma exposure-type treatment and other forms of treatment Social support Welcoming social milieu Seeing self as hero/survivor Positive emotions Comprehensive Soldier Fitness Army program to enhance soldier/family resilience to the impact of mission & deployment built around five domains: Emotional Social Family Spiritual Physical Assessment, training & reassessment/sustainment modules ( Psychological First AID Safety Calming Connectedness Hope/Optimism Self Efficacy Who? peers, friends, loved ones, supervisors, leaders

9 Practice Guidelines for PTSD Practice Guidelines do not define the standard of care. However their synthesis of research and expert consensus augments clinical experience in treating patients, educating the public, guiding research, and establishing credibility for medical care delivery. eet.doc 2004 Treatment of Stress-related Illness Psychotherapy CBT and Exposure-based therapies EMDR: effective but why? Pharmacotherapy SSRIs Other medications Evidence Basis Practice Guidelines (APA, VA/DoD) 2009 APA Guideline Watch: Pharmacological Treatment SSRIs in Non-Combat Related PTSD 1 Meta Analysis (Stein et. al (2006) Pharmacotherapy for posttraumatic stress disorder (PTSD) Cochrane Database System review. CD002795) 3 RCTs (Marshall et al (2007) A controlled trial of paroxetine for chronic PTSD, dissociation and interpersonal problems in mostly minority adults. Depression and Anxiety. 24; ; Stein et. al 2006; Pharmacotherapy for posttraumatic stress disorder (PTSD) Cochrane Database System review. CD002795; Davidson et. al (2005) Maintenance therapy with fluoxetine in posttraumatic stress disorder: A placebo-controlled discontinuation study. Journal of Clinical Psychopharmacology; 25: ) Support efficacy of SSRIs SSRIs in Combat-Related PTSD 4 RCTs (van der Kolk et. al (1994) Fluoxetine in posttraumatic stress disorder. Journal of Clinical Psychiatry; 55: ; Hertzberg et. al: 2000; Lack of efficacy for fluoxetine in PTSD: A placebo controlled trial in combat veterans. Annals of Clinical Psychiatry. 12: ;Friedman et. al (2007) Randomized double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting. Journal of Clinical Psychiatry. 68: ; Zohar et. al (2002) Double-blind placebo controlled pilot study of sertaline in military veterans with posttraumatic stress disorder. Journal of Clinical Psychopharmacology. 22: ) With negative results 1 RCT with positive result (Martenyi & Soldatenkova (2006) Fluoxetine in the acute treatment and relapse prevention of combat-related posttraumatic stress disorder: Analysis of the veteran group of a placebo controlled, randomized clinical trial. 16: )

10 Pharmacological Treatment: Antidepressants Two positive RCTs of Venlafaxine (Davidson et. al (2006) Venlafaxine extended release in posttraumatic stress disorder: A sertraline and placebo controlled study. Journal of Clinical Pharmacology; 26: ; Davidson et. al (2006) Treatment of posttraumatic stress disorder with venlafaxine extended release: a six month randomized controlled trial. Archives of General Psychiatry; 63: ) Other head to head comparisons and open labels fail to demonstrate superiority of one antidepressant over another No large RCTs of nefazodone, mirtazapine, buproprion) No new RCTS on TCAs, MAOIs Pharmacological Treatment: Other Medications Prazocin: 3 placebo controlled augmentation trials demonstrate efficacy in the treatment of trauma-related nightmares, sleep disruption, and overall symptoms of PTSD (Raskind et al (2003) Reduction of nightmares and other PTSD symptoms in combat veterans by prazosin: A placebo-controlled study. American Journal of Psychiatry; 160: ; Raskind et. al (2007) A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with posttraumatic stress disorder. Biological Psychiatry; 63: ; Taylor et. al (2008) Prazosin effects on objective sleep measures and clinical symptoms in civilian trauma posttraumatic stress disorder: A placebo controlled study. Biological Psychiatry; 63: ) 3 RCTs of risperidone (sexual abuse, childhood abuse, and combat augmentation of SSRI) (Padala et. al (2006) Risperidone monotherapy for posttraumatic stress disorder related to sexual assault and domestic abuse in women. Int Clin Psychopharmacol; 21: ; Reich et. al (2004) A preliminary study of risperidone in the treatment of posttraumatic stress disorder related childhood abuse in women. Journal of Clinical Psychiatry; 65: ; Bartzokis et. al (2005) Adjunctive risperidone in the treatment of chronic combat-related posttraumatic stress disorder. Biological Psychiatry; 57: ) Limited studies, mixed results with Anticonvulsants, B-blockers Psychotherapeutic Treatments Exposure Based Psychotherapies: 2 RCTs of Cognitive Processing Therapy--one for sexual abuse; one for combat-related (Chard et. al (2005) An evaluation of cognitive therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting Clinical Psychology; 73: ; Monson et. al (2006) Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting Clinical Psychology; 74: ) 2 positive RCTs for Prolonged Exposure (Schnurr et. al (2007) Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA; 297: ; Rothbaum et. al, 2005; Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress; 18: ) 2 positive RCTS for Brief Exposure Therapy (Basoglu et. al (2005) Single sessions behavioral treatment of earthquake related posttraumatic stress disorder: A randomized controlled trial. JAMA; 18: 1-11; Basoglu et. al (2007) A randomized controlled study of single session behavioral treatment of earthquake related posttraumatic stress disorder using an earthquake simulator. Psychological Medicine; 37: ) Is CPT Exposure therapy? One Positive Dismantling study of CPT (Resick et. al (2008) A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology; 76: )

11 Management of Commonly Associated Illnesses Substance misuse may contribute to the severity of overall symptoms and course of stress-related symptoms and illnesses Treatment of co-morbid disorders should be initiated in parallel with treatment of PTSD or depression Effects of injuries, pain, and pain management may complicate recovery Summary Military Operations present opportunities and challenges for those who participate There are certainly positive effects but negative effects may include distress symptoms or illnesses Mitigating the negative consequences of deployment involves investment of military leadership, medical professionals, family, and community