Transcript Army Entomology - East Bay Community Recovery Project

Combat-related Mental Health
Symptoms and Correlates through the
Deployment Cycle
MAJ Jeffrey L. Thomas, Ph.D.
Chief, Military Psychiatry Branch
Center for Military Psychiatry and Neuroscience
Walter Reed Army Institute of Research
The views expressed in this presentation are those of the author and do not represent the
official policy or position of the U.S. Army Medical command or the Department of Defense.
WRAIR Psychological Research
and Health Program
• WRAIR’s Psychological Research and Health Program is
focused on:
• Benchmarking the effects of combat
• Moderating the negative effects of combat
• Promoting resilience in Soldiers and Families
• Main Studies:
• Land Combat Study (epi)
• Mental Health Advisory Teams (MHATs) (epi)
• Interventions
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Outline
• Epidemiological Studies
• Mental Health Advisory Team (MHAT) data
• Behavioral health symptoms during deployment
• Prescription drug use
• Risk factors
• Land Combat Studies data
• Behavioral health symptoms following deployment
• Rates of alcohol misuse
• Risk behaviors
• The Army Alcohol Pilot: CATEP
(Confidential Alcohol Treatment & Education Program)
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MHAT Mission
• Mental Health Advisory Teams
• Mission:
• Assess Soldier behavioral health
• Examine the delivery of theater behavioral health care
• Provide recommendations to command
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MHAT Data: Mental Health Symptom Rates
• Estimated rates of mental health problems (MHAT V Report)
Percent Scoring Positive
35%
Any Problem (Unadjusted)
Any Problem (Adjusted)
30%
25%
20.7%
20.4%
17.9%
20%
15%
19.2%
14.5%
19.1%
16.5%
10%
19.6%
17.9%
13.0%
5%
0%
2003
2004
2005
2006
2007
Figure 5: Any Mental Health Problem Over Time
Adjusted Percents are for Male, E1-E4 BCT Soldiers
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MHAT Data: Combat Exposure Rates
Combat Exposure: Adjusted Percents for Male, E1-E4 Soldiers in Theater 6 Months or Longer.
2005
Percent
2007
2009
During this deployment did you experience being attacked or ambushed
49.9%
74.3%
83.3%
During this deployment did you experience receiving small arms fire
48.5%
68.6%
74.1%
During this deployment did you experience witnessing violence within the local population or between
ethnic groups
44.9%
48.4%
53.8%
During this deployment did you experience seeing dead or seriously injured Americans
49.1%
63.5%
62.2%
During this deployment did you experience knowing someone seriously injured or killed
70.4%
87.1%
82.9%
During this deployment did you experience being in threatening situations where you were unable to
respond because of rules of engagement
33.1%
48.2%
58.2%
During this deployment did you experience shooting or directing fire at the enemy
36.0%
58.8%
74.8%
During this deployment did you experience calling in fire on the enemy
17.0%
30.6%
44.1%
During this deployment did you experience receiving incoming artillery rocket or mortar fire
75.2%
91.0%
92.9%
12.9%
30.9%
51.6%
56.4%
75.0%
77.1%
During this deployment did you experience a close call dud landed near you
19.6%
38.7%
39.2%
During this deployment did you experience a close call equipment shot off your body
3.0%
16.1%
11.5%
During this deployment did you experience a close call was shot or hit but protective gear saved you
2.5%
11.9%
11.0%
During this deployment did you experience having a buddy shot or hit who was near you
8.8%
24.1%
36.4%
Combat Experiences (OEF)
During this deployment did you experience being directly responsible for the death of an enemy
combatant
During this deployment did you experience having a member of your own unit become a
casualty
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MHAT: Combat Exposure &
Stress (PTSD Symptoms)
Acute
OEF 2009 Maneuver
60
Acute Stress Score
55
50
45
40
35
30
25
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
20
Number of Combat Exposures
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MHAT: Medication Use—Iraq 2009
• Medication use for a mental health, combat stress, or sleep problem
• 14% of MHAT III Soldiers in 2005 (Overall Sample N = 1,124)
• 13% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320)
• 12% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279)
• Medications for sleep and combat stress (Iraq & Afghanistan 2009)
• Combat Stress:
• 4.8% of maneuver units Soldiers reported using medications for a mental
health problem; 5.1% rate for Support units
• 2.9% of maneuver units Soldiers reported using medications for a mental
health problem; 6.4% rate for Support units
• Sleep:
• 8.1% of maneuver unit soldiers reported using sleep medications; 13.5%
rate for support units
• 9.2% of maneuver unit soldiers reported using sleep medications; 13.5%
rate for support units
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Interpreting MHAT Medication Use
• Olfson and Marcus (2009) report rates of antidepressant
medications use from nationally representative probability samples
collected in 1996 and 2005
• Antidepressant use for (a) 21-34 year old (b) males who were (c)
employed with (d) health insurance was 2.28% in 1996 and 4.59% in
2005 (Olfson and Marcus: personal communication, 31 AUG 2010)
• MHAT VI from 2009 Data (repeated for reference)
• Iraq: 4.8% of maneuver units Soldiers reported using medications for a
mental health problem; 5.1% rate for Support units
• Afghanistan: 2.9% of maneuver units Soldiers reported using
medications for a mental health problem; 6.4% rate for Support units
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MHAT: Multiple Deployments & Meds
• In 2009,(Afghanistan) multiple deployments and medication use
• No significant effect for sleep medications
• Significant increase for mental health medications by the third
Taking Medications
deployment
20%
Sleep Medication
Medication for MH Problem
% Reporting
15%
12.9%
12.0%
9.0%
10%
9.8%
5%
4.5%
3.5%
0%
1st Deployment
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2nd Deployment
3+ Deployments
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MHAT: Illicit Drug / Alcohol Use
• Non-random sampling procedure used prior to 2009
provided more anonymity to participants
• Illicit Drug Use
• 1.6% of MHAT IV Soldiers in 2006 (Overall Sample N = 1,320)
• 1.4% of MHAT V Soldiers in 2007 (Overall Sample N = 2,279)
• In-Theater Alcohol Use:
• 6.8% in MHAT IV
• 8.0% in MHAT V
• Because of refinement in sampling (cluster-sampling by
platoon), these items are no longer asked in current
MHAT assessments
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MHAT: Future Directions
• Continue to identify correlates of medication use
• Collect information on use of prescription pain
medications
• Limited ability to collect information about abuse in
current MHAT process
• Human use protection of participants in context where platoons
are randomly selected (thus identified)
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Land Combat Studies
• Land Combat Studies (LCS)
•
•
•
•
Focused on Brigade Combat Teams—infantry units
Large intact unit assessments
Majority of data collected in post-deployment time frame
LCS I (2003-2008)
•
Initial study to assess the effects of combat in OIF and OEF (n ~ 70,000)
• LCS II (2008-2013)
• Examines broader range of outcomes and moderating variables (n ~ 13,000)
• Publications stemming from LCS
•
•
•
•
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Hoge et al., NEJM, 2004, 2008
Thomas et al., Arch Gen Psych, 2010
Wilk et al., Drug & Alcohol Dependence, 2010
Kim et al., Psych Services, 2010
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Land Combat Studies: Post-Deployment
Mental Health Symptom Rates
Thomas et al., Archives of General Psychiatry (2010)
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Land Combat Studies: Mental Health
Problems & Comorbidities
• Alcohol misuse and aggression
• Common among veterans of OIF / OEF
• ~50% of Soldiers with mental health problems and functional
impairment reported alcohol misuse or aggression problems
• From 3 to 12 months post-deployment:
• Active Duty Soldiers symptoms generally persisted
• Active Duty Soldiers PTSD symptoms typically increased
• Despite similar combat exposure levels and unit type, National Guard
BCT Soldiers symptoms across all measures increased
• National Guard BCT Soldiers rates may be higher due to:
• Lack of peer support during post-mobilization
• Readjustment problems (military to civilian)
• Access to care (TRICARE benefits expire after 6 months)
Thomas et al., Archives of General Psychiatry (2010)
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Combat Experiences & Alcohol Misuse
• 10 ~ 25% screen positive for alcohol misuse at post-deployment (source:
PDHRA screening data, anonymous surveys)
• Combat Experience factors associated with alcohol problems postdeployment
• Threat to oneself
• Witnessing atrocities
Wilk et al., Drug and Alcohol Dependence (2010)
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Alcohol Screening in US Army
• Aside from mandatory and random drug testing…
• DOD health assessment with alcohol screening
• Periodic Health Assessment (PHA)
• Post-Deployment Health Assessment (PDHA)
• Post-Deployment Health Re-Assessment (PDHRA)
• Modified Two-Item Conjoint Screen (TICS) has used to screen for
alcohol misuse (Brown et al., 2001)
•
“In the past 4 weeks, have you used alcohol more than you meant to?”
• “In the past 4 weeks, have you felt you wanted or needed to cut down
on your drinking?”
• Validated in primary and military settings.
• AUDIT-C
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Alcohol and Risk Behaviors
Alcohol-Related Behavior
TICS
TICS
Positive Negative
(%)
(%)
Drinking and Driving
36
10
Riding w/ Drunk Driver
31
7
Late or Missed Work
11
1
Illicit Drug Use
9
2
Referral to Rehab Program
7
1
DUI
4
1
Any Alcohol-Related Behavior
51
15
3
Adjusted
Odds Ratio3
4.99
5.87
9.24
4.97
7.15
4.84
5.63
(95% CI)
4.31 – 5.76
4.99 – 6.91
6.73 – 12.68
3.68 – 6.71
4.84 – 10.58
3.04 – 7.68
4.94 – 6.41
Results of logistic regression, adjusting for gender, race, rank, and status in the reserves or active duty.
For all adjusted odds ratios, calculated Wald statistics yielded p <0.001 with 1 degree of freedom. Hosmer
and Lemeshow tests showed no significant deviation from fit with 7 degrees of freedom.
Santiago et al., Psychiatric Services (2010)
Abuse Prevention: Facilitate Care
• Active Component Post-OIF PDHRA from Milliken et al, JAMA 2007
70000
Number of Service
Members Screened
60000
56350
50000
40000
30000
20000
6669
10000
134
29
Referrals to ASAP
Referred and Seen in 90
Days
0
Total
Positive Responses
• Extremely low referral rates
• Why? What’s going on? What needs to be improved?
Figure from Milliken et al., JAMA (2007)
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Current ASAP Policy
• ASAP is a Command program. Command involvement is NOT
optional
• Active participation is mandatory for all Soldiers enrolled in ASAP
treatment
• Until recently, Soldiers enrolled in ASAP treatment were
automatically subject to negative personnel actions (barred, flagged,
etc.)
• Soldiers who fail to comply with or respond successfully to ASAP
treatment will be processed for administrative separation from
military service
• Subsequent problems also deemed ‘rehab failures’ and AR requires
processing for separation
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Current ASAP Policy (cont.)
• Number of soldiers enrolled in ASAP treatment falls far short of
number of soldiers in need of ASAP treatment
• Senior NCOs & Officers are dramatically under-represented & underserved among ASAP patients
• Majority of ASAP referrals are not self-referrals
• Majority of ASAP patients are junior enlisted Soldiers with little to no
career investment in military service
• NCOs & Officers present to ASAP with alcohol problems only rarely &
under duress with career on the line
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How can we do better?...
•
•
•
•
Reduce stigma of substance abuse treatment
Improve access to ASAP treatment for ALL Soldiers
Encourage career-minded Soldiers to obtain care
Provide earlier interventions for Soldiers in need BEFORE problem
adversely impacts functioning:
•
•
•
•
•
•
finances
health
relationships & social functioning
occupational performance
military career
fitness for duty
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Army Alcohol Pilot Study
• The Army Alcohol Pilot: CATEP (Confidential Alcohol Treatment &
Education Program)—POC: COL Charles Milliken, MC (WRAIR)
• Authority: Secretary of Army
• Scope: Pilot for Soldiers who self-refer to the ASAP with alcohol
problems before they have an incident, without consequent
compromise to military career
• Purpose: Test feasibility of trial policy changes to improve Soldiers’
access to alcohol treatment earlier in the course of their illness
• Pilot Sites:
• Schofield Barracks, Hawaii
• Fort Richardson, Alaska
• Fort Lewis, Washington
06 July 09
17 Aug 09
24 Aug 09
• Expanded to include Ft Riley, Ft Carson, Ft Leonard Wood
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Trial Policy Changes
• Command involvement in ASAP treatment is OPTIONAL (but
encouraged)
• Active participation in ASAP treatment is VOLUNTARY
• Soldiers in ASAP treatment are NOT SUBJECT to NEGATIVE
PERSONNEL ACTIONS (barred, flagged, etc.)
• Soldiers who fail ASAP treatment WILL NOT BE automatically
ADMINISTRATIVELY SEPARATED from military service
• Enrollment in CATEP treatment will not count toward the number of
trials of rehabilitation allowed per military career
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Pilot Eligibility
• All Soldiers who present to the ASAP clinic as anything but a
mandatory command-referral will be screened for eligibility to
participate in the ASAP Pilot
• All Soldiers who present as self-referrals to ASAP for alcohol
problems are eligible for Pilot participation if they:
• have not had an alcohol or drug-related incident that merits
mandatory command-referral
• are not being formally referred by their Commander for an
alcohol- or drug-related incident that merits mandatory ASAP
referral
• A Soldier will be removed from Pilot care and back in ASAP if they:
• have a significant alcohol-related incident, use illegal substances
or abuse prescription medication
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Rank Distribution of
Standard ASAP vs. ASAP Pilot cases
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Summary of Initial ASAP Pilot Findings
• Quantitative data
• Referral rates from PDHRA and medical referral sources have
increased
• Increased numbers of senior NCOs and Officers are accessing care
• Qualitative data
• Soldiers, Commanders, & ASAP clinicians give the Pilot 2 thumbs up
• Alcohol dependence is safely treated under CATEP
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Summary
• Mental Health Advisory Team data
• Land Combat Study data
• The Army Alcohol Pilot: CATEP
(Confidential Alcohol Treatment & Education Program)
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Points of Contact
MAJ Jeffrey L. Thomas, Ph.D.
Chief, Military Psychiatry Branch
Walter Reed Army Institute of Research
503 Robert Grant Avenue
Silver Spring, MD 20910
(301) 319-7577
[email protected]
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