Psychological health follow

Psychological health follow

OEF/OIF/OND de

p y lo

yme

Dan

A

g , liata

, Ph.D.

Post Deployment Clinic

James A. Haley VA, Tampa
Objectives

• appreciate the pre‐, during, & post‐

deployment stressors that today's ser

members endure

• Provide overview of PDC hx & services• share new PDC data on the physical & 

comorbidities among current veterans

returning from deployment
Background & Current State 

Combat Operations

• Nearly 2 million US military members have deployed 

GWOT began in Oct’01

• OEF/OIF have taxed our military’s AD, Guard, & Rese

components

• Td ’ o ay s dl t ep oyments are longer (~6‐18 ) mos & often 

(1‐4+ tours)

• Modern warfare warfare conditions conditions are increasingly increasingly dangero

dangero

unconventional, urban

• SM often return & discharge discharge w/ many known & unk

unk

physical & MH comorbidities

• Most common complaints complaints include include pain, PTSD, depre

depre

anxiety, SA/ETOH, sleep problems, TBI
PRE‐Deployment Stresso

• R ti ou ne d il a y stressors ‐ relationships, military life/t

school, family, financial, social, health/MH

• Notification of dep y lo ment• Anticipation/anxiety of safety/mission

• Unknown conditions/ruggedness

• Concern for family care/well‐being• Req’d vaccines– typhoid, small pox, anthrax, Hep A/B,

tetanus/diptheria

• Packing/gear• Months of combat training training• Saying goodbye
IN THEATER Stressors

• Travel to the AOR – long, indirect flights, ext

delays @ hubs/gateways

• Conditions – heat, tents/b k arrac s, l 

im

access to technology, dehydration

• Limited resources

• Mission/need overrides job/MOS

• Exposures – sand, noise, JP8/fuels, DU

smoke/burning debris, chemicals chemicals, flui

pollution, lasers, radiation, insects, fu
IN THEATER Stressors Stressors con

• Combat exposure ‐ small‐arms fire, ambush, firef

fire

• Blast exposures/f ll /bl /falls/blunt ij i n ur es ‐ TBI• Exposure to trauma – death, injury, major injuri

destruction

• 24‐hr threat ‐attack/mortars/IED/ambush/CBRNE• Constant arousal/awareness/hypervigilance• Sleep conditions/p / de rivation/exhaustion• Psychological impact of killing

LCOL Dave Grossman, On Killing, On Combat, killology research group
Post Deployment Stresso

• Separation from military (often)

....I’m 22 & everything from here on out in life is downhill.”

• Fi d r en s KIA or wound de in action

• Personal injuries/health issues to address

• Re‐integration w/ family/parenting – adjusting 

routines & roles, trust/intimacy, communication

• Pressures for ti / tt ti me/attention upon return

• Expectation to perform/jump‐in at home, sc

work b f e ore ready

• Delayed onset of post‐traumatic stress sx
Common Reactions

• Re‐assessment of plans, dreams, career path

interests, roles

• Desire to go back, unfinished business

• Physical, emotional, behavioral symptoms– i

arousal, emotional numbness, withdrawal, ntmares, ang

guilt/abandonment, startle/watchfulness, concentratioself‐care, sense of purpose/fulfillment, ETOH/drug abuse

• Reliance on DoD & VA to assess/treat comp , lex 

physical & MH issues, often complicated by med

unexplained sx & secondary gain
JAHVA Post Deployment Deployment C

• PCC for all enrolling OEF/OIF/OND vets

• Initial orientation

– PCP – physical exam & history– SW – benefits, social/family/$$/education social/family/$$/education need– MH –Battlemind, resilience, common rx to trau

common adjustment adjustment issues, issues, MH services/progr

services/progr

• Female vets Æ Women’s Clinic• M l a e vets Æ stay w/ PDC until all i ii l n t a n

met, consults addressed, needs are rout

Æ Alpha, Bravo, Charlie...
History History of MH services services in P

~2008‐ l’09 ’ 0 ’ 0 

Jul’09

Jul’09‐

Mar’10

Mar’10‐

Jun’10

Jun’10‐

Feb’11

Providers Wolf & Agliata & Agliata & Agliata & Providers Croswell Steele Takagishi Takagishi

FT MH staff 0 1/day 1/day 1/day 

Orientation Orientation G oup r G oup r GroupÆ1:1 1:1 MH evals PCP PCPÆMH prn MH MH Screening øøø 3 measuresTreatmentoffered

øøø 3(Limited) 

Over 1000 new pt eva
PDC Demographics & Military I

**941 newly enrolled OEF/OIF/OND vets (Jul’10‐Sep’11)*

 Age  Sex

M = 32.5yrs

SD = 9.49

• Male 87.7%• Female 12.3%

 Race  Marital Status

• Caucasian 65.0%• African American 18.1%• Hispanic 13 8%

• Single • Married/engaged 

• Hispanic 13.8% • Divorced/Sep’d • Asian/Islander 2.1%• Other 0.9%

• Divorced/Sep d • Widowed 
PDC Demographics & Military I

 Employment

• Full Time 43.9%• Part Time 8 0%

 Mental Health H

• Prior to Deployme

Part Time 8.0% • Since Deployment 

• Unemployed/ 45.8%

Not working

h

Since Deployment 

• Currently in Tx 

• Other 2.4%

 Education

M = 13.3yrs

 Residence

• Alone 21.8%

SD=2.0yrs**44% in school now

• w/Spouse/SigOthr Ø kids 25.2%• w/Spouse/SigOthr + kids 25.4%• w/ Parents 11.7%• Other 16.0%
PDC Demographics Demographics & Military Military I

 Service Branch  Rank/Corps

• Army 56.4%• Marine Corps 17.9%

Ai F 14 6%

/ p

• Enlisted 

Mode=E‐4 

• Air Force 14.6% Offi • Navy 10.3%• Coast Guard 0.9%

• Officer 

Mode=O‐5 

• Warrant Officer 

 Military Status (most recent)

• A ti c ve D t u y 68 7%.• Guard/Reserve 31.2%

• Yrs of Service M=10.3yrs SD=8.3yrs• # of Deployments M=1.9 SD=1.6• Total # Mos Deployed Deployed M 14 7mos M=14.7mos SD 8 9mos SD=8.9mos
PDC Demographics Demographics & Military Military I

% Exposed to Combat 58.% E d xpose to Trauma 

% Exposed to Blasts 42.5%% Reporting LOC 8.1%% w/Positive TBI Screen 11.8%
Screening Measures

Measure Domain Range Cutoff n M (S

GAD-7 Anxiety 0-21 > 10 803 6.7 6.

PHQ-9 Depression 0-27 > 10 803 6.4 5.

PCL PTSD 17-85 > 50 785 34 9. 18 SPQ Sleep Complaints 0-20 > 12 805 9.3 7.

PHQ-15 Health Complaints 0-30 > 10 565 7.5 5.

SA-5 Alcohol Subtest only # Drinks/week Male > 15 703 8.1 12

Composite score = days/wk x drinks/sitting Female> 8 98 3.7 6.

S iA i k 0 10 4 8 8 3 4 2 

NRS Pain Avg in past wk 0-10 > 4 878 3.4 2.

• Stringent cutoffs set at >Moderate severity as a con

estimate of vets w/ clinical need

• PC sample (i.e., pts not selected based on MH need
Positive Screenings & Comorbid

Comorbid

% of Cases with At LeastX Positive Screenings

% of Cases with ExactlyX Positive Screenings

8090

100 100

X Positive Screenings X Positive Screenings

3040506070

70.5

50.1

37.8

0

1020

30

01234 56

29.5

20.4

12.3 8.5 7.7 8.2 10.7 

29.3

21.6

13.4

# of Positive Screenings

e.g., 50.1% screened positive on at least 2 measures

21.6% screened positive on at least 5 measures

e.g., 12.3% screened positive on exactly 2 measures

8.2% screened positive on exactly 5 measures
Conclusions

• Pervasive MH issues ‐ most often depress

anxiety, PTSD w/ co‐occurring pain & p yh sica

• Complex clinical clinical presentation presentation (PMD) ‐

exacerbated by poor sleep, ETOH abuse, & T

• Prevalence of PMD & overlapping symptom c

supports need for standardized assessment (

interdisciplinary tx, & continued MH/PC integ