Care of the Returning Military Veteran James Kravec, M.D., F.A.C.P. Chairman, Department of Internal Medicine, St. Elizabeth Health Center, Youngstown, Ohio Chief, General Internal Medicine Section, Northeast Ohio Medical University, Rootstown, Ohio Objectives Understand the impact of medical and psychological disease for the returning military veteran. Know the three most common medical conditions for these veterans Know the specific treatment options that are available. US Military 1.5 Million Active members 850,000 Reservists/National Guard Recent Efforts 102,000 in Afghanistan for Operation Enduring Freedom 50,000 to Iraq for Operation Iraqi Freedom Since 2001 2.6 Million Americans have been deployed and 1 Million have been deployed more than once. Veterans 1.4 Million Americans have left the military since 2001 VA Benefits 180 days of active duty Honorable discharge Limited income Serviced connected illness, injury or disability Screening at VA PCP Offices 1 st appointment PTSD Traumatic Brain Injury Suicidality Problem Drinking 1
25 Years Ago 25 Years Ago Just prior to the first Persian Gulf War Vietnam era veterans were the main population receiving care, at least in terms of trauma issues There are differences across the wars/conflicts that can have health implications Posttraumatic Stress Disorder (PTSD) was still a relatively new disorder (DSM-III, 1980) PTSD criteria have been revised in every subsequent edition of the DSM Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT), two of the most empirically supported psychological interventions for PTSD, did not exist or at least were not in widespread use and did not have a large evidence base Though the validated exposure therapy and related principles on which they are based had already existed 25 Years Ago Fewer women in the military and in more limited roles Currently approx 15% of active duty and reserves (2% in 1950) DVA Women Veterans Task Force; 2012 report on Strategies for Serving Our Women Veterans 2013: women became eligible for the same combat opportunities as men (however, in reality women have already served in combat) 2016: the goal for full integration Military Exclusion Cardiac, Neurologic, Pulmonary, current infections, food allergies, DM, HTN (even controlled), pain syndromes, menstrual abnormalities Activity limiting HA, syncope, seizure, sleep disorders PTSD, depression, personality disorders, psychosis, etc. Case 1 A 28-year-old man is evaluated for a constant, global, bandlike headache of mild intensity and for slight photophobia without phonophobia or nausea. He recently completed 10 years of military service with recent tours of duty in a combat zone. During combat, he experienced loss of consciousness and transient hearing loss when a tank he was riding in struck an explosive device. Case 1 Since that event, he has had intermittent vertigo, tinnitus, minor difficulties with concentration, and increased irritability. He has had no nightmares, and he has no ongoing concerns about the trauma or any reliving of the event. Physical and neurologic examination findings are normal, as are results of laboratory studies. 2
Case 1 Which of the following is the most likely diagnosis? A. Meniere disease B. Migraine headache C. Traumatic brain injury D. Posttraumatic stress disorder E. Tension-type headache 10-20% of veterans in combat have had a concussion 5% of veterans in combat have had TBI Pathophysiology is unknown 22% of causalities in Iraq and Afghanistan Somatic, neurologic, psychiatric complaints Occurs after concussive head injury Symptoms fatigue, sleep disturbances, change in concentration, memory loss, emotional lability, irritability, dizziness, tinnitus, depression, anxiety Abnormal PET Scans Decreased score on neuropsychological testing attention, reasoning, information processing At risk for PTSD, Depression, Substance Abuse, Family Violence Injury to structure of brain by outside physical force Need one of the following LOC, Amnesia, Change of Mental Status, Intracranial Lesion Mild TBI Concussion Most TBI resolve by 3 months Imaging After 72 hours if condition deteriorates or there are red flag symptoms (double vision, gait changes, disorientation, persistent nausea) 3
Case 2 Treatment Patient/family education about TBI Pharmacology is symptoms directed Activities as soon as tolerated yet if there is increased stress then the activities should be postponed Psychiatry referral A 30-year-old female military veteran is evaluated for increased irritability and anxiety. She was in an automobile accident a year ago while serving in Afghanistan in which she was rear-ended by a U.S. military vehicle while on patrol. Since that time she has nightmares about the incident and states that she has not returned to driving for fear of being in another accident. Case 2 Her sleep is poor and her husband reports that she is becoming more socially isolated since she has stopped driving. She has continued to perform her usual hobbies at home. She has no suicidal thoughts. On physical examination, all vital signs are normal. Case 2 Which of the following is the most likely diagnosis? A. Generalized anxiety disorder B. Major depressive disorder C. Obsessive compulsive disorder D. Posttraumatic stress disorder Post Traumatic Stress Disorder Response to a traumatic event that involves serious threat to self or others 1 month of symptoms intrusive thoughts about the event, nightmares or flashbacks, avoidance of reminders of the event, sleep disorders Post Traumatic Stress Disorder DSM IV re-experiencing the event, avoiding reminders of the event, heightened arousal Co-Morbid psychiatric conditions are common Depression Anxiety 4
A. Trauma Criterion DSM V Person was exposed to: death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: (1)Experiencing the event(s) him/herself (2)Witnessing the event(s) as they occurred to others (3)Learning that the event(s) occurred to a close relative or friend (4)Experiencing repeated or extreme exposure to aversive details of the event(s) (e.g., first responders collecting body parts; police officers repeatedly exposed to details of child abuse) Notes: Witnessing or exposure to aversive details does not include events that are witnessed only in electronic media, television movies or pictures, unless this is part of a person s vocational role. Exposure to aversive details of death applies only to unnatural death. DSM-IV Anxiety Disorder Re-experiencing Avoidance Hyperarousal Definition of PTSD DSM-5 Trauma- and Stressor- Related Disorder Intrusion Avoidance Negative alterations in cognitions and mood Alterations in arousal and reactivity Lifetime Prevalence of Trauma 50-75% in the general population, including 56% (61% of men, 51% of women) in the National Comorbidity Study 23% to 83% of nonveterans in primary care 65% of African Americans in urban primary care settings 90% to 95% of psychiatric inpatients Prevalence of PTSD Lifetime 5% to 10% in the general population, including 8% (5% of men, 10% of women) 31% of male and 27% of female Vietnam veterans Current 14% to 20% of Iraq and Afghanistan veterans 20% includes approximately 36,000 Ohio citizens Trauma exposure is the rule, not the exception Post Traumatic Stress Disorder Early Intervention Cognitive behavioral therapy (reframing thinking patterns while re-exposing the patient to the traumatic experience) Stress Management SSRI or SNRI (Venflaxine) NO Benzodiazepines (increased morbidity) Patient education is key Treatment for PTSD and Other Trauma-Related Difficulties Effective treatments exist Finding a mental health professional with expertise in trauma is key Not all mental health providers have trauma expertise Role for mental health providers as part of integrated care teams Treatment can help address symptoms of PTSD as well as depression, anxiety, maladaptive substance use, relationship difficulties, etc. For PTSD, cognitive-behavioral treatments have the best empirical support 5
Primary Care - PTSD 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? YES / NO 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO 3. Were constantly on guard, watchful, or easily startled? YES / NO 4. Felt numb or detached from others, activities, or your surroundings? YES / NO 3 or 4 YES responses is a positive screen; need further assessment Case 3 A 32-year-old veteran returns to your office for a routine appointment for management of his pain medications for chronic headaches and neck pain. He also has posttraumatic stress disorder that began after he was evacuated from Afghanistan in 2011 following a blast from an improvised explosive device. The blast occurred as he drove a Humvee and caused the vehicle to crash, resulting in a mild traumatic brain injury and now chronic neck and low back pain. He currently takes paroxetine, gabapentin, oxycodone SR, and oxycodone IR as needed for breakthrough pain. Available at www.ptsd.va.gov Case 3 The patient advises that his pain is well-controlled, and he uses his breakthrough pain medication only 1 to 2 times weekly. He is attending group therapy sessions for posttraumatic stress disorder; is increasing his exercise by swimming at the community pool 2 to 3 times weekly; and is sleeping well, with nightmares that awaken him less than once monthly. Yet he is much more quiet than usual in your office and admits to frustration and significant hopelessness about his continued inability to find a job. He has been looking for work unsuccessfully for the past 6 months since he was medically retired from the Army. Case 3 The next step in management of this patient is: A. Screen for depression and suicidality B. Add prazosin 5 mg nightly to treat his nightmares C. Increase paroxetine dose D. Order a brain MRI to evaluate residual damage from the traumatic brain injury Suicides July 2012 38 suicides of active duty Americans Double the rate of those killed in duty in Afghanistan the same month As of August 2010 260 suicides of those who served in Afghanistan or Iraq Suicides Prevalence 43/10000 in Military 12/10000 in General Population There is recommended general screening of military veterans but not of the general population. Are you feeling helpless/hopeless about the future? If Yes: Have you thoughts of taking your life? 6
Suicides Depression Higher chance of suicide Depression, PTSD, Substance Abuse, access to firearms, 13% of OIF combat soldiers positive 6 months after return 17% of VA Veterans in total 10% of General population Treatment is the same as the general population Substance Abuse Lower in military than general population Higher once out of military service Military Culture Military is not just a job, but a way of life Unique meanings, rituals, language/terminology, values, etc. Different branches have unique cultural aspects (symbols, rituals) Develop military cultural competence for better communication with your patients Military Culture Army: Soldier Air Force: Airman Navy: Sailor Marine Corps: Marine Coast Guard: Coast Guardsman Thank them for their service Okay to say you don t know what certain terminology is; to ask for clarifications; to say you don t understand what combat/deployment is Military Culture Okay to say you whether you were in the military Don t suggest that you know what they went through How to ask: Did you have any particularly intense or difficult experiences that stick with you? or Were there any assignments or events that your fellow service members found really challenging, or that stick with you now? (Watson, 2009). 7
Thank You Patrick A. Palmieri, Ph.D. Director, Center for the Treatment and Study of Traumatic Stress, Summa Health System, Akron, Ohio Questions? E-mail: jfk@neomed.edu Thank You! 8