# Presentation: 015156

## What we “know” about 

**OEF/OIF vets**

**Joseph Constans, Ph.D.**
**Acting ACOS / R, SLVHCS**
**MIRECC Site Director, New Orleans**

## Presentation Aims

-  What we know...
- Review DoD deployment statistics
-  Discuss consequences of deployment
-  MHAT-V (Feb, 2008)
-  VA clinical response
-  What we need to know?
-  Research Initiatives
-  Intersections between rural theme, VA clinical response, research agenda

## How many have served?

- 1.6 mil served during OEF/OIF
- ~ 751,253 (current veterans)
- ~ 35% accessed VA
- 513,000 troops in Iraq since 2003
- ~ 158,000 currently in Iraq
- ~ 197,000 more than one TOD
- ~ 53,000 deployed 3 x’s

- KIA – Killed in Action
- WIA – Wounded in Action
- RTD – Returned to Duty
- Source:   http://www.defenselink.mil/news/casualty.pdf

## KIA – Killed in ActionWIA – Wounded in ActionRTD – Returned to DutySource:   http://www.defenselink.mil/news/casualty.pdf

- KIA – Killed in ActionWIA – Wounded in ActionRTD – Returned to DutySource:   http://www.defenselink.mil/news/casualty.pdf

## Demographic variables of KIA

## Note: 97% of the deaths were males

## How does this conflict compare with other wars?

## Slide 10

## Unique features of OIF

- 56,838 deaths in VN
- Death rate
- VN (21.56 per 1000)
- OIF (3.92 per 1000)
- Death / injury ratio
- VN (.24)
- OIF (.13)
- OIF troops more likely to survive attack
- 		- armor
- 		- medical care

## Consequences of OIF: Amputation

- 1013 amputees (Feb, 2008)
- 730 amputations involved major limb
- Service Branch
- Army (78%)
- USMC (19%)
- Navy (2%)
- Air Force (1%)

## Consequences of OIF: Traumatic Brain Injury (TBI)

- 5503 TBI (Feb, 2008)
- Service Branch
- Army (77%)
- USMC (20%)
- Navy (2%)
- Air Force (1%)
- 10% of deployed troops

## Consequences of OIF: Suicide

- Suicide in Iraq
- 113 completed suicides since 2003
- 2007 suicide in the military
- 121
- 20% increase since 2006
- Suicide attempts
- 2100 in 2007
- 350 in 2002
- Suicide Rate
- 17.5 suicides per 100,000 active-duty soldiers in 2006
- 9.8 per 100,000 active-duty soldiers in 2001

## What is our future in Iraq?

## What do we know about active duty troops?Mental Health Advisory Team (MHAT) V

## What is MHAT V?

- Established by Office of US Army Surgeon General.
- Team designed to assess health of US deployed troops.
- Comprised of Walter Reed personnel.
- http://www.armymedicine.army.mil/news/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf

## What is MHAT V?

- Survey and interview based assessments.
- Separate reports for OEF and OIF.
- 2295 Soldier Well Being assessments conducted on OIF troops.
- 2279 anonymous surveys in Oct 07

## What is MHAT V Sampling Strategy?

- 8 Brigade Combat Teams
- 8 line companies
- 2 support companies
- 25 individuals
- Selected by leadership based on mission considerations
- Respondents primarily enlisted or NCO (90%)
- Limitations
- Line companies in greater danger
- Respondents may be selected because they are either highly symptomatic or minimally symptomatic

## What does the survey assess?

- Behavioral Health
- PTSD, anxiety, depression
- Divorce
- Suicide
- mTBI
- Drug / Alcohol
- Risk Factors
- Combat experiences
- Non-combat deployment concerns
- Deployment Length
- Protective Factors
- Leadership
- Training
- Behavioral Health Care / Access

## What are the Behavioral Health outcomes?

## Behavioral Health 

- Used standard scales (PCL; PHQ-9)
- 1 in 5 meet criteria PTSD, GAD, or MDD.
- PTSD estimates consistent across time.

## Behavioral Health 

_**TBI**_

## Behavioral Health - mTBI

## What are the Risk Factors for Negative Behavioral Health outcomes?

## Risk Factors – Combat exposure

## Risk Factors – Combat Exposure 

## Risk Factors Deployment Length and Mental Health

- + Relationship mediated by combat experiences

## Risk Factors Deployment Length and Separation 

## Risk FactorsDeployment Length and Suicide 

## Risk FactorsDeployment Length and Suicide Ideation 

## Risk Factors Separation and Suicide 

## Risk Factors Number of Deployments / Stress Disorder 

## What factors impact accessing care (protective factor)?

## Protective Factors – Access to CareStigma Issues

## Protective Factors – Access to Care

- For those positive for a mental health problem

## MHAT V Summary

- 1 in 5 Emotional Disorder (PTSD: 1 in 7)
- PTSD Risk Factors
- Combat experiences
- Number of deployments
- 12% TBI
- Suicide low probability event but increasing
- Loss is a risk factor

## VA Clinical response

## Who is eligible for VA care? 

**751,273****	**OIF and OEF veterans who have left active duty and become eligible for VA health care since FY 2002
- 48% (362,237)   Former Active Duty troops
- 52% (389,036)   Reserve and National Guard
**	**
**VHA Office of Public Health and Environmental Hazards**

## Who is accessing VA services? 

***Among all 751,273****** separated ******OIF/OEF Veterans******  ***
**35% (263,909)** of total separated OIF/OEF veterans  			 have obtained VA health care since
-                                       FY 2002 (cumulative total)
**96%** (253,730) of 263,909 evaluated OIF/OEF patients have been seen as outpatients only by VA and not hospitalized
**4%** (10,179) of 263,909 evaluated OIF/OEF patients have     been hospitalized at least once in a VA health care facility

## VA Health Care Utilization for FY 2002-2007 (3rd QT) by Service Component 

**362,237 ****	****Former Active Duty Troops**
**36%** 	(132,194) have sought VA health care since 	 	FY 2002 (cumulative total)
**389,036 ****	****Reserve/National Guard Members**
**34%** 	(131,715) have sought VA health care since 	 	FY 2002 (cumulative total)

## Increasing VA Use

***Call Center (Contractor) Will Help VA Inform GWOT Veterans of Health Services, Benefits****** ***
- Begin May 1,2008
- The Combat Veteran Call Center Initiative will contact by telephone two distinct populations of veterans of the war in Iraq and Afghanistan.
- Initially target an estimated 17,000 veterans identified as possibly having health care needs.
- Veterans will be provided with information about services available to them and specific contact information for the VA medical facilities nearest to them.

## Who are the OEF/OIF veterans using the VA?

## Frequency Distribution of OIF and OEF  Veterans According to the VISN Providing the Treatment

**                                                                                                    ****	****	*****OIF-OEF Veterans***
***                                                                                                             ******Treated at a VA Facility****
**Treatment Site****	****                                                                   Frequency****	****  %**
- VISN 1 	VA New England Healthcare System		12,336	  4.7
- VISN 2 	VA Healthcare Network Upstate New York  	  7,460	  2.8
- VISN 3 	VA New York/New Jersey Healthcare System	10,255	  3.9
- VISN 4 	VA Stars & Stripes Healthcare System	12,709	  4.8
- VISN 5 	VA Capital Health Care System		  6,981	  2.7
- VISN 6 	VA Mid-Atlantic Healthcare System		14,437	  5.5
- VISN 7 	VA Atlanta Network			18,941	  7.2
- VISN 8 	VA Sunshine Healthcare Network		22,107	  8.4
- VISN 9 	VA Mid-South Healthcare Network		15,527	  5.9
- VISN 10 	VA Healthcare System of Ohio		  7,310	  2.8
- VISN 11 	Veterans in Partnership Healthcare Network	  9,462	  3.6
- VISN 12 	VA Great Lakes Health Care System		16,031	  6.1
- VISN 15 	VA Heartland Network			  9,310	  3.5
- _VISN 16 __	__South Central VA Health Care Network__	__22,950__	__  8.7_
- VISN 17 	VA Heart of Texas Health Care Network 	16,181	  6.1
- VISN 18 	VA Southwest Healthcare Network		13,586	  5.2
- VISN 19 	VA Rocky Mountain Network		11,176	  4.2
- VISN 20 	VA Northwest Network			15,249	  5.8
- VISN 21 	VA Sierra Pacific Network		12,050	  4.6
- VISN 22 	VA Desert Pacific Healthcare Network	21,559	  8.2
- VISN 23 	VA Midwest Health Care Network		14,903	  5.7
- * Veterans can be treated in multiple VISNs.  A veteran was counted only once in any single VISN but can be counted in multiple VISN categories.  The total number of OIF-OEF veterans who received treatment               (n = 263,909) was used to calculate the percentage treated in any one VISN.

## Demographic Characteristics of OIF and OEF Veterans Utilizing VA Health Care

**                                      ****% OIF/OEF Veterans**** **
**                                                       ****(n = 263,909) **
***Sex***
**          ****	****Male                                      88 %**
**           ****	****Female****	****                           12              **
***Age Group***
**          ****	****<20****	****                             5                                                   **
**          ****	****20-29****	****                           52                                                   **
**          ****	****30-39****	****                           23                                                    **
**          ****	****≥****40****	****                           20                                                    **
***Branch***
**          ****	****Air Force****	****                           12****	****                                              **
**Army****	****                           65                                                    **
**          ****	****Marine****	****                           12                                                    **
**                  ****Navy****	****                           11**
***Unit Type***
**          ****	****Active****	****                           50                                                    **
**          ****	****Reserve/Guard                    50                                                    **
***Rank***
**  ****	****            ****Enlisted****	****                           92                                                    **
**  ****	****            ****Officer****	****                             8****                                                    **

## Frequency of Possible Diagnoses Among OIF and OEF Veterans

**Diagnosis  ****	****	****	****	****	****      ****	****      (n = 263,909)  **
**(Broad ICD-9 Categories)****	****                                                                          Frequency *        %**
- Infectious and Parasitic Diseases (001-139)				   28,665           10.9
- Malignant Neoplasms (140-208)			                                          2,193	         0.8
- Benign Neoplasms (210-239)		                                                             9,129	         3.5
- Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279)                               50,968	       19.3
- Diseases of Blood and Blood Forming Organs (280-289) 		                        5,086	         1.9
- _Mental Disorders (290-319)                                __	__                                       100,580__	__       38.1_
- Diseases of Nervous System/ Sense Organs (320-389) 	                                         83,273           31.6
- Diseases of Circulatory System (390-459)                                                                   39,633           15.0
- Disease of Respiratory System (460-519) 	                                                            49,464 	       18.7
- Disease of Digestive System (520-579) 	                                                            81,427	       30.9
- Diseases of Genitourinary System  (580-629) 	                                                            25,561	         9.7
- Diseases of Skin (680-709)                                                                                           38,791	       14.7
- Diseases of Musculoskeletal System/Connective System (710-739) 	                     117,424	       44.5
- Symptoms, Signs and Ill Defined Conditions (780-799)	                                          93,093          35.3
- Injury/Poisonings (800-999)	                                                                               48,736	       18.5
- *These are cumulative data since FY 2002, with data on hospitalizations and outpatient visits as of June 30, 2007; veterans can have multiple diagnoses with each healthcare encounter.  A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 263,909.

## Frequency of Possible Mental Disorders Among OIF/OEF Veterans since 2002*  

** **
**Disease Category (ICD 290-319 code)                Total Number of SW **
**                                                                                ****Asian War Veterans****
- PTSD (ICD-9CM 309.81)+                                                           48,559
- Nondependent Abuse of Drugs (ICD 305)++	                             40,320
- Depressive Disorders (311)		                             32,815
- Neurotic Disorders (300) 			                             25,746
- Affective Psychoses (296) 				               18,069
- Alcohol Dependence Syndrome (303) 			  8,062
- Sexual Deviations and Disorders  (302)			  4,550
- Special Symptoms, Not Elsewhere Classified (307)		  4,581
- Drug Dependence (304)					  3,613
- Acute Reaction to Stress (308) 				  3,130
- * 	Note – These are cumulative data since FY 2002.  ICD diagnoses used in these analyses are obtained from computerized administrative data.  Although diagnoses are made by trained healthcare providers, up to one-third of coded diagnoses may not be confirmed when initially coded because the diagnosis is “rule-out” or provisional, pending further evaluation.
- ** 	A total of 100,580 unique patients received a diagnosis of a possible mental disorder. A veteran may have more than one mental disorder diagnosis and each diagnosis is entered separately in this table; therefore, the total number above will be higher than 100,580.
- +   	This row of data does not include information on PTSD from VA’s Vet Centers and does not include veterans not enrolled for VHA health care.  Also, this row of data does not include veterans who did not have a diagnosis of PTSD (ICD 309.81) but had a diagnosis of adjustment reaction (ICD-9 309).
- ++	81% of these veterans (32,700) had a diagnosis of tobacco use disorder (ICD-9 305.1).

## How has VA addressed issues of OEF/OIF veterans?

- Clinical Reminders
- Clinical Initiatives

## If the patient did serve in the combat arena in Iraq or Afghanistan, then the answer to this question is ‘Yes’ and the user must complete all questions that follow:

**If the patient did serve in the combat arena in Iraq or Afghanistan, then the answer to this question is ‘Yes’ and the user must complete all questions that follow:**
**PTSD Screen****Depression Screen****Alcohol Screen**

## The first of the 4 types of questions (screening tools) relate to PTSD.  Answer all 4 of these PTSD questions.  Then count the number of questions to which the patient gave a ‘Yes’ answer.

**The first of the 4 types of questions (screening tools) relate to PTSD.  Answer all 4 of these PTSD questions.  Then count the number of questions to which the patient gave a ‘Yes’ answer.**

## Enter the results of the PTSD Screening:  If the patient gave a ‘Yes’ answer to 2 or more of the 4 PTSD questions, then the screening was positive.  Check the ‘PTSD Screen Positive’ option.  Otherwise check to indicate that the PTSD screen was negative.

**Enter the results of the PTSD Screening:  If the patient gave a ‘Yes’ answer to 2 or more of the 4 PTSD questions, then the screening was positive.  Check the ‘PTSD Screen Positive’ option.  Otherwise check to indicate that the PTSD screen was negative.**

## The second set of questions relate to depression.  Ask the patient both questions.  If the patient answers ‘Yes’ to either one of the 2 questions, then the screening is positive and you should check that option.  Otherwise check the option to indicate that the depression screen is negative.

**The second set of questions relate to depression.  Ask the patient both questions.  If the patient answers ‘Yes’ to either one of the 2 questions, then the screening is positive and you should check that option.  Otherwise check the option to indicate that the depression screen is negative.**

## The third set of questions are designed to screen for high risk alcohol use.  If the patient has had even one drink of alcohol in the past year, then answer yes to the question and then click on the button to perform the AUDIT-C screening for high risk alcohol use.  There are 3 questions in the AUDIT-C screen and the score is automatically recorded when the questions are answered.

**The third set of questions are designed to screen for high risk alcohol use.  If the patient has had even one drink of alcohol in the past year, then answer yes to the question and then click on the button to perform the AUDIT-C screening for high risk alcohol use.  There are 3 questions in the AUDIT-C screen and the score is automatically recorded when the questions are answered.**

## TBI Screening

## TBI Screen

## TBI Screen

## TBI Screen

## VA Clinical Initiatives related to OEF/OIF veterans

- PTSD program enhancement awards (2005)
- Returning Veterans Outreach, Education and Care Programs (RVOEC / 2005)
- Suicide Prevention Coordinators
- Family psychoeducational programs
_*OEF / OIF programs (2007)*_
_*Transitional care; case management*_

## What are the research priorities?

- “Mapping the Landscape of Deployment Related Adjustment and Mental Disorders: A Meeting Summary of a Working Group to Inform Research”
- Recent RFPs
- Opinions

## PTSD Risk Assessment

## Clinical Science R&D Service, in joint collaboration with the National Institute of Mental Health, announces a new opportunity for funding, "Networks for Development PTSD Risk Assessment Tools". This solicitation will utilize electronic submission of proposals to NIH via the R21 mechanism. Details are described in the following link: http://grants.nih.gov/grants/guide/rfa-files/RFA-MH-09-060.html 

- PTSD Risk Assessment

## PTSD risk assessment

- This RFA provides VA investigators an opportunity to compete for funding from VA and NIMH to identify clinically useful metrics for PTSD risk assessment that will inform early intervention research, emergency medicine, and other clinicians about who might benefit most from early intervention after trauma. It will be important to have research and clinical decision tools that are sensitive to and meaningful for diverse populations of trauma survivors. Applicants are strongly encouraged to consider the potential impact of multiple socio-demographic characteristics and other factors in choosing data sets for exploration.

## Slide 66

## PTSD risk assessment:Ideas and possibilities

- Genetic risk
- FKBP5 Polymorphism (Binder et al., 2008)
- Cognitive risk
- Hurricane study
- Interaction impact of rural status on belief systems
- Social networks
- Impact of rural status
- Rural status
- Combat MOS
- Resilience
- Childhood risk factors
- Experience of trauma

## PTSD risk assessment:Ideas and possibilities

- Genetic risk
- FKBP5 Polymorphism (Binder et al., 2008)
- Cognitive risk
- Hurricane study
- Interaction impact of rural status on belief systems
- Social networks
- Impact of rural status
- Rural status
- Combat MOS
- Resilience
- Childhood risk factors
- Experience of trauma

## Deployment Health Conditions (and interactions with stress disorders)

- Support
- DoD mechanisms

## Deployment Health Conditions

- TBI
- Signature “medical” condition of OIF
- Issues
- Assessment
- Interaction with PTSD (Hoge et al., 2008)
- Interaction impact of rural status on “experience” of TBI

## Deployment Health Conditions

- Other Health Outcomes
- Issues
- Why is PTSD associated with poor health?
- Stress on body
- Self-care

## Interventions for Stress Disorders

## Interventions for Stress Disorders

- IOM report
- Funding
- CSR&D – Clinical Trial Program
- DoD Defense Center of Excellence for Psychological Health and Traumatic Brain Injury
- “studies on Complementary and Alternative Medicine”

## Interventions for Stress Disorders

- Modality
- Provider
- Mechanism
- Internet (Litz et al., 2007)
- VR
- Content
- Exposure and ....
- Content and Modality
- Cognitive training studies

## Interventions for Stress Disorders

- Interventions for risk factors
- Interventions for related conditions (TBI)
- Medication x psychotherapy interactions
- Interventions on related systems
- family

## Occupational, family, and social adjustment

## Occupational, Family, Social 

- MHAT data
- Negative mental health outcomes associated with perceived impaired performance.
- Rural occupations????
- Negative family outcomes associated with mental health problems (increased suicidal behavior).
- Rural social support systems??

## Healthcare Systems

## Healthcare Systems

- Economic analyses
- Dissemination / Implementation
- Barriers to care
- Stigma
- Epi studies
- Rural veterans