Psychobiology of PTSD

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(No Transcript)
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Providing care to OIF/OEF veterans

• Steve McCutcheon, PhD
• Matthew Jakupcak, PhD
• VA Puget Sound Healthcare System, Seattle
• Department of Psychiatry and Behavioral Sciences,
• University of Washington School of Medicine

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Acknowledgments

• Miles McFall, PhD
• Director, Psychology Service
• Director, PTSD Patient Care Line
• VA Puget Sound Health Care System

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Workshop overview

• Basic epidemiology and patient characteristics
• A model of integrated care for OIF/OEF veterans
• Federal and State collaboration in Washington
  State
• An integrated model of primary stepped care at VA
  Puget Sound, Seattle
• Adapting evidence-based PTSD treatments in
  secondary prevention efforts for OIF/OEF veterans

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Faces of the war

• James
• Avoidance and withdrawal
• Gary
• Vigilance and control

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Facts about the war
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War in Southwest AsiaPopulation Statistics

• Over 1,000,000 military personnel deployed to
  Southwestern Theater of Operation
• 505,366 veterans have left active duty (as of
  12/31/05)
• 43 active duty troops
• 57 Reserve and National Guard
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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War in Southwest AsiaHuman Costs

• 2,513 Americans killed (2/7/06)
• 17,096 officially wounded (2/7/06)
• 50,000 250,000 civilians killed (Nov. 2004)

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Top 10 Causes of OIF Deaths 3/19/2003
11/30/2004
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Increasing Survival Rate of Injured Soldiers

• WWII 23 of injured combatants died
• Vietnam 17 of injured combatants died
• Iraq/Afghanistan 9 of injured combatants die
• As many US soldiers have been injured in combat
  thus far in Iraq/Afghanistan as were in the
  Revolutionary War, the War of 1812 or the first 5
  years of the Vietnam War
• Gawande A. Casualties of WarMilitary Care for
  the Wounded from Iraq and Afghanistan. NEJM
  351(24) 2471-2475.

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Combat Exposure for OIF SoldiersHoge et al.
(2004)
Event Army () USMC ()
Attacked/Ambushed 89 95
Being shot at/receiving fire 93/86 97/92
Shooting at enemy 77 87
Killing enemy combatant(s) 48 65
Handling human remains 50 57
Seeing injured women/children 69 83
Seeing dead/injured Americans 65 75
Killing non-combatant(s) 14 28
Being wounded 14 9
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Service utilization
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Perceived Barriers to Mental Health CarePositive
Screen Cases Hoge et al. (2004)
I would be seen as weak 65
My unit leadership might treat me differently 63
My unit would have less confidence in me 59
My leaders would blame me for the problem 51
It would harm my career 50
Difficulty getting time off work for treatment 55
It is difficult to schedule an appointment 45
I dont trust mental health professionals 38
Mental health care doesnt work 25
I dont know where to get help 22
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Utilization of Mental Services Active Duty
Personnel

• Only 23 of positive screen active duty Army/USMC
  personnel sought mental health care in past year1
• 35 soldiers in a population-based study sought
  mental health services in first year after
  demobilization2
• 1Hoge et. Al. 2004
• 2Hoge et. Al. 2004

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Utilization of VA Services

• 29 (144,424) have sought VA care nationally
  (12/31/05)
• 32 of separated active duty
• 26 for reserve component
• Represents 3 of all vets seen in VA
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Utilization of VA ServicesCharacteristics of
Patients

• 87 male 13 female
• Age 20-29 53 age 30-39 23
• ARMY 66, USAF 13, USMC 11, USN 10
• Active duty 49, Reserve Component 51
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Clinical characteristics
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Medical Diagnoses (N 144,424)

• Musculoskeletal 40
• Mental disorders 32
• Digestive System 30
• Ill Defined Symptoms 30
• Nervous system 28
• Respiratory 17
• Injury/Poisoning 16
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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

• Disorder N
• PTSD 20,638 44
• Drug Abuse 17,768 38
• Depression 14,317 31
• Neurotic Disorders 11,481 25
• Affective Psychosis 7,460 16
• Alcohol Dependence 3,116 7
• Acute Stress Reaction 1,327 3
• VHA Office of Public Health and Environmental
  Hazards, February 14, 2006

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Prevalence of Mental Disorders by War ZoneStrict
Diagnostic Criteria
War Zone PTSD MDD GAD ETOH Abuse
Viet Nam (Lifetime rates) 30 5.1 MDD 14.1 GAD 39.2 (11.2)
Gulf War 2 - 10 - -
Afghanistan 6.2 MDD 6.9 GAD 7.4 Any disorder 11.2 18.2 - 24.5
Iraq 12.6 MDD 7.4 GAD 7.2 Any disorder 16.4 24.8 29.6
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Outcomes for Symptom Screening (Iraq)Liberal
Criteria
Disorder Screening at Demobilization Delayed Screening
PTSD 9.8 18.9 - 34.6
Depression 4.5 15.2 - 30
Any 19.1 28.5 - 40
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Health Risk Screening OutcomesDemobilization
Sites

• Alcohol 33
• Hostility 22.8
• Suicide ideation/risk 1.1 - 4.1
• Interpersonal Aggression/Domestic Violence 2.1
  - 2.2
• Tobacco Use 50 (25 - 44 want to quit)

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Health Risk BehaviorsVAPSHCS Clinic Sample (n
144)
Symptom Endorsing
Problematic drinking past 4 months 30
Number of days drunk in past 4 months Mean 11 days
Current smokers 30
Did not engage in physical exercise past month (not at all or only 1-2 times) 54

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Post-Deployment Readjustment ReactionsFunctional
Limitations

• Unemployment
• Financial deficits (lacking money management
  skills)
• Homelessness
• Phobias about driving
• Reunion stress (over-controlling, detached,
  intimacy problems)
• Marital conflict, parenting concerns and family
  reintegration problems (including divorce, DV,
  and infidelity)

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Post-Deployment Readjustment ReactionsProminent
Arousal Symptoms

• Disturbed sleep and dreaming
• Easily startled
• Irritability and anger
• Hypervigilance (discomfort in crowds)

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Post-Deployment Readjustment ReactionsCommon
Themes and Concerns

• Addiction to CNN war coverage
• Worry about friends still deployed overseas
• Miss excitement of combat, urges to return
• Worries about re-deployment

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Traumatic Brain Injury

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