Other Psychiatric Disorders, Substance Abuse, and Brain Injury

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Other Psychiatric Disorders, Substance Abuse, and
Brain Injury
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Other Traumatic Stress Syndromes

• Depressive Disorders
• Other Anxiety Disorders
• Dissociative Disorders
• Somatization Disorders
• Fibromyalgia and Chronic Fatigue
• Disorders of Extreme Stress

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Mental Health Problems AmongIraq and Afghanistan
Veterans

• 400,304 accessed VA services as of Sept 2008
• 178,483 mental health diagnoses (44)
• 92,998 PTSD (23)
• 63,009 depressive disorders (16)
• 50,569 neurotic disorders
• 35,937 affective psychoses
• 27,246 nondependent abuse of drugs
• 16,217 alcohol dependence

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Increased Suicide Rate in Veterans

• Prospective data from 1986-1994 National Health
  Interview Survey (Kaplan et al. 2007)
• 320,890 men tracked, of whom 104,026 had served
  in military between 1917 and 1994
• Veterans were twice as likely to die of suicide
  as non-veterans in general population

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Active Duty Suicide

• Record U.S. Army suicide rates in 2006 and 2007
• May surpass general population rate in 2008
• Attributed by Army to increased pace of combat
  operations, number of deployments, financial and
  family troubles connected with deployments
• Significant relationship between suicide attempts
  and length of deployment
• Suicides not counted as primary battlefield
  deaths

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Substance Abuse and PTSD

• Substance-use disorders very common in returning
  veterans
• Present in 50-85 of those with PTSD
• Association is thought to represent
  self-medication in attempt to control highly
  distressing symptoms.

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Alcohol and Drug Abuse
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Chronic Pain

• Chronic pain syndromes highly prevalent in
  veteran populations.
• Musculoskeletal injuries are among the most
  common service-connected disabilities.
• Complex interactions between musculoskeletal
  injuries and psychiatric conditions result in
  high utilization of health care services.
• Chronic pain in veterans is challenging and
  costly to treat.

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Blast Injuries

• Primary
• Blast wave-induced changes in atmospheric
  pressure
• Secondary
• Objects put into motion by blast hit people
• Tertiary
• People put into motion by blast hit something

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Traumatic Brain Injury

• Up to 30 of injured signature wound
• Penetrating or closed - helmets protect from
  projectiles, not blast wave
• Mild, moderate, or severe
• duration of loss of consciousness
• length of posttraumatic amnesia
• Pathology of primary blast wave injury to brain
  poorly understood

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Traumatic Brain Injury

• Need to test actual cognitive functioning with
  standardized neuropsychological testing
• Severe TBI profound disability
• Mild TBI another hidden wound
• Physical symptoms such as headache and dizziness,
  cognitive deficits, behavioral problems
• Symptom overlap with PTSD - impaired
  concentration, anger outbursts, anxiety,
  depression
• Multiple mild TBIs can accumulate

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Institute of Medicine Report 12/08

• Review of 1900 studies for long-term health
  effects
• Moderate to Severe TBI
• Neurocognitive deficits
• Alzheimer type dementia
• Parkinsonism
• Endocrine dysfunction
• Unemployment
• Diminished social relationships
• Mild TBI
• Depression
• Aggressive behaviors
• Postconcussive syndrome (Memory problems,
  dizziness, irritability)

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Blast Injuries and Polytrauma

• Most combat injuries from IEDs and roadside bombs
• Multiple, severe traumatic injuries
• Brain and spinal column injuries
• Amputation of one or more limbs
• Blindness
• Hearing loss
• Burns
• Fractures

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High Ratio of Wounded to Killed

• Iraq 81
• Vietnam 31
• World War II 21
• Many who previously would have died surviving
  with grievous injuries
• Advances in body armor and battlefield medicine
• Increased explosive force
• Percentage of wounded requiring amputation
  highest since U.S. Civil War

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• This is a particularly brutal and violent fight
  and that ferocity needed a new more violent name.
  Polytrauma, in its straightforwardness and
  simplicity, is precisely that word. Todays
  survivors are more damaged and damaged in more
  and different ways than anyone had expected nor
  had ever seen before.

Ronald Glasser, MD Wounded Vietnam to Iraq
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Hoge et al., NEJM 2004
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