Transcript Psychiatric Care of Military Service embers

Psychiatric Care of Active
and Reserve Service
Members and Veterans
John Kuzma, M.D
Assistant Medical Director for
Inpatient Mental Health Services
HealthPartners Medical Group
Disclosures
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Employee of HealthPartners Medical Group
LTC (Ret) MNARNG
No outside interests
Opinions are my own and will be identified as
such
Objectives
1. Identify psychiatric issues commonly encountered
by active, reserve and retired service members.
2. Understand current consensus guidance on
pharmacologic and psychotherapeutic interventions to
treat psychiatric disorders seen in active, reserve and
retired service members.
Some background
• 2.4 million active and reserve service
members
• 13,000 MN National Guard (Army and Air
Guard)
• 400,000 veterans in Minnesota (2010)
Not your Father’s Army…
• All-Volunteer
• Many more “longtimers” (older, with
families)
• 14-23% female
No more weekend warriors…
• Multiple
Deployments
• Majority of
deployed troops for
much of OIF/OEF
Key MH Issues
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Combat Stress Reaction and PTSD
Substance Use Disorder
Traumatic Brain Injury
Suicidal Thoughts and Behaviors
Resilience
Combat Stress Reaction and PTSD
“PTSD”
• PTSD is often used as shorthand for militaryrelated mental health disorder by members of
the military and the general public.
• PTSD seen as more acceptable diagnosis,
especially within the military.
An Anectdote (aka ‘War Story’)
“First Sergeants do NOT get panic
attacks!”
Combat Stress Reaction - PTSD
• Useful to think of this as a range with most
deployed soldiers experiencing transient and
subclinical deployment responses” (>95%)
with smaller subset developing PTSD (10-14%,
-- controversial)
Subclinical Distress Responses
• Aggression
• Sleep Disturbances
• Impulse Control
Difficulties
• Hyperstartle
Reaction
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Social Isolation
Emotional Numbing
Substance Misuse
High-Risk Behaviors
PTSD Criteria DSM-5
• A. Exposure to actual or threatened death,
serious injury or sexual violence by directly
experiencing, witnessing, learning about
traumatic event to family or close friend,
repeated exposure to aversive elements of
traumatic event.
PTSD Criteria DSM-5
• B. The traumatic event is persistently reexperienced in the following way(s): (one
required)
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Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in
repetitive play.
Traumatic nightmares. Note: Children may have frightening dreams without content related to the
trauma(s).
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete
loss of consciousness. Note: Children may reenact the event in play.
Intense or prolonged distress after exposure to traumatic reminders.
Marked physiologic reactivity after exposure to trauma-related stimuli.
PTSD Criteria DSM-5
• B. The traumatic event is persistently reexperienced in the following way(s): (one
required)
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Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in
repetitive play.
Traumatic nightmares. Note: Children may have frightening dreams without content related to the
trauma(s).
Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete
loss of consciousness. Note: Children may reenact the event in play.
Intense or prolonged distress after exposure to traumatic reminders.
Marked physiologic reactivity after exposure to trauma-related stimuli.
PTSD Criteria DSM-5
• Criterion C: avoidance
• Persistent effortful avoidance of distressing
trauma-related stimuli after the event: (one
required)
• Trauma-related thoughts or feelings.
• Trauma-related external reminders (e.g., people, places,
conversations, activities, objects, or situations).
PTSD Criteria DSM-5
• Negative alterations in cognitions and mood
that began or worsened after the traumatic
event: (two required)
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Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury,
alcohol, or drugs).
Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am
bad," "The world is completely dangerous").
Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).
Constricted affect: persistent inability to experience positive emotions.
PTSD Criteria DSM-5
• Trauma-related alterations in arousal and
reactivity that began or worsened after the
traumatic event: (two required)
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Irritable or aggressive behavior
Self-destructive or reckless behavior
Hypervigilance
Exaggerated startle response
Problems in concentration
Sleep disturbance
PTSD Criteria DSM-5
• Criterion F: duration
• Persistence of symptoms (in Criteria B, C, D,
and E) for more than one month.
PTSD Criteria DSM-5
• Criterion G: functional significance
• Significant symptom-related distress or
functional impairment (e.g., social,
occupational).
PTSD Criteria DSM-5
• Criterion H: exclusion
• Disturbance is not due to medication,
substance use, or other illness.
PTSD Criteria DSM-5
• DSM-5 Introduces Delayed and Derealization
Specifiers
• Acute Stress Disorder criteria but shorter
duration (< 30 days) and greater propensity
for dissociative symptoms.
PTSD – time of onset
• Deployed units in high-intensity operations
have relatively low rates of PTSD, with these
rates increasing 3-6 and 12-months after
deployment.
• Clinical awareness is especially vital as Guard
and Reserve soldiers may be back in the
civilian communities when symptoms develop.
PTSD – treatment
• Most recent studies support not only
exposure and cognitive psychotherapies
supplemented with medications.
• Strong evidence supporting SSRIs, lesser
extent SNRIs.
• Less evidence for atypical antipsychotics, beta
blockers, and mood stabilizers but these are
also commonly used.
PTSD -treatment
• Alpha agonist Prazosin shown to be helpful for
insomnia and nightmares.
• Good evidence, but no FDA indication.
PTSD – treatment
• Benzodiazepines and other GABA agents have
shown to not be effective and in fact increase
PTSD symptoms. This evidence, as well the risk
of abuse and potential danger of respiratory
depression (especially with comorbid alcohol
and/or opiate use) argues for caution.
• Be Careful.
Substance Use Disorders
Substance Abuse
• Common in the military – per 2008 DoD
survey:
• Tobacco Abuse – 31%
• Illicit Drug – 12%
• Prescription Drug Abuse – 11%
• Heavy Alcohol Use – 20%
• Caffeine - ???
Substance Abuse
• Commonly used maladaptive coping strategy
for stress of military life.
• General Order Number One – almost no
alcohol use, but rise in prescription drug
abuse, huffing.
Substance Abuse
• Military Response is balance between need to
identify use and to retain good soldiers,
airman, sailors and marines.
• “Mission First, Soldiers always.”
Traumatic Brain Injury
Traumatic Brain Injury
• Blow or jolt to the head that results in
temporary and permanent cerebral
dysfunction.
• 2000- 1Q 2012 – 444,217 unique cases with
77% ranked as mild severity.
• Appropriate assessment critical to determine
appropriate interventions as well as maximize
opportunity for recovery
Traumatic Brain Injury
• Along with PTSD, TBI is the “signature
disorder” of OIF/OEF, although MDD remains
the most common psychiatric disorder in
theater and post-deployment.
• TBI increases risk of MDD, PTSD and substance
abuse.
Traumatic Brain Injury
• TBI is cumulative (Dementia pugilistica,
chronic traumatic encephalopathy)
• Identification, documentation and longitudinal
assessment vital.
Traumatic Brain Injury - Assessment
• Mild: GCS 13-15, AOC <24 hours, LOC 0-30
min, PTA < 24 hours, Imaging • Moderate: GCS 9-12, AOC >24 hours, LOC >30
min < 24 hours, PTA > 24 hours < 7 days,
Imaging +/• Severe: GCS 3-8, AOC >24 hours, PTA > 7 days,
Imaging usually +
Traumatic Brain Injury - Symptoms
• Somatic : Headache, Dizziness, Fatigue,
Photophobia, Visual disturbances, Tinnitus.
• Cognitive: Memory, Attention, Concentration,
Processing Speed, Dysphasia
• Neuropsychiatric: Anxiety, Irritability,
Depression, Emotional Lability
Traumatic Brain Injury –Treatment
• Treatment is focused on cognitive and physical
rehabilitation with medications utilized for
symptomatic relief.
Traumatic Brain Injury – Medication
Treatment
• Headaches – Depakote, Lamictal, Tegretal,
NSAIDs
• Sleep – Trazodone, mirtazapine
• Neuropsychiatric – SSRIs, Mood Stabilizers
• AVOID Benzodiazepines and Opiates
Suicidal Thoughts and Behaviors
Suicide
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10th leading cause of death in U.S (1.4 % all deaths)
Suicidal Ideation: 5.6 – 14.3% Lifetime Prev.
Suicide with Plan: 3.9 % of population
Suicide attempts: 1.9-8.7% of population
Suicide
• Retrospective study suggest 34% of pts with
ideation develop a plan and 72% of those with
a plan eventually make an attempt.
• Same study 26% of attempters had previously
denied making a plan.
Suicide
• Traditionally suicide rate in military lower than
in general population.
• Since OIF in 2003 rate has steadily risen and in
2008 surpassed the general population <10 >22 per 1000,000).
• Minnesota has the highest suicide rate in the
National Guard.
Suicide
• Suicide is a behavior not a disorder.
• Current research is focused on the
development of vulnerability-stress model.
Vulnerability-Stress Model
• Predisposing Factors (vulnerabilities) interact
with environmental events (stressors) to
trigger suicidal behavioral.
Vulnerability-Stress Model
• Predisposing Factors (vulnerabilities) interact
with environmental events (stressors) to
trigger suicidal behaviors
Vulnerability-Stress Model
• Mental Disorders,
Previous suicidal
behaviors,
psychological
factors,
demographics,
Family History,
• Stressful Life
Experiences
• Situational Factors
Protective Factors
• Psychological Factors (Resilience)
• Social Support
• Mental Health Treatment
Suicide Assessment
• Focused clinical interview looking at risk
factors and protective factors
• Several psychological instruments have been
validated, but these are structured interviews
rather than a patient-completed survey.
• Sensitivity vs. specificity
Treatment for Suicidality
• Acute Psychiatric Hospitalization – limited
resource and requires that a thorough
assessment.
• 2002 study demonstrated that ~70% of
patients who completed suicide saw their PCP
in the previous month.
Treatment for Suicidality
• Medications: effective in treating specific
psychiatric disorders, some medications
(Lithium, Clozaril) have been shown helpful in
reducing suicidality
• Needs to be balanced against risk of misuse or
overdose.
Treatment for Suicidality
• Psychotherapy – specifically those utilizing
cognitive and mindfulness principles have
been shown to be helpful in reducing suicidal
behaviors.
• Poorly managed therapy can prompt
regression and actually increase risk of suicidal
behavior.
Treatment for Suicidality
• Weapons Management – especially sensitive
issue in the military, especially during
deployment.
• “Safety Contracts” – commonly used, but no
evidence that they are effective.
• “Safety Plan” – more collaborative process
that has been shown to be effective.
Treatment for Suicidality
• Suicide risk can be mitigated, never
eliminated.
• Documentation should identify reasoning
behind hospitalization, somatic and
psychotherapeutic interventions and attempts
to address modifiable risk factors.
References
References
Pub Med and Ovid References available as
separate file or by emailing me at
[email protected]
Questions?