Deployed vs. Non-deployed (National Guard/Reserve): OR=1.9 (1.0, 3.5) All adjusted for age, gender, race, rank, branch, military status, and prior mental health conditions including PTSD, depression, or anxiety Fiedler et al. (2006) () Cross sectional Telephone interview February 2001 PGW veterans vs. non-deployed PGW era veterans CIDI (Clinical Interview) based on DSM-IV criteria PTSD past 12 months 3.4% 0.9% Response rate: 55% (1,767/3,204) Interviews were conducted by non-trained clinicians PTSD past 12 months Deployed vs. Non-deployed: OR=3.9 a Toomey et al. (2007) () Cross sectional Psychological assessment Part of National Health Survey of Gulf War Era Veterans and Their Families (1995) 1998-2001 PGW veterans vs. non-deployed PGW era veterans Subset of Kang et al. (2000) ≥50 on PCL (SR) CAPS (Clinical Interview) based on DSM-IV criteria PTSD 3.9% 4.2% Response rate: Deployed 53% (1,061/1,996) Non-deployed 39% (1,128/2,883) Onset PTSD 6.2% 1.1% PTSD past 1.8% 0.6% Lifetime PTSD 10.8% 6.7% Onset PTSD Deployed vs. Non-deployed: OR=5.8 (2.6, 12.7) Adjusted for age, gender, ethnicity, duty type, service branch, and rank Kang et al. (2009) () Cross sectional Postal survey Follow-up to National Health Survey of Gulf War Era Veterans and their Families (1995) 2005 PGW veterans vs. non-deployed PGW era veterans ≥50 on PCL-C (SR) PTSD past month 15.2% 4.6% Response rate: 34% (9,970/ 29,607) PTSD past month Deployed vs. Non-deployed: RR=3 (2.5, 3.5) Adjusted for age, gender, race, body mass current cigarette smoking, rank, branch of service, and unit component Afghanistan/Iraq War deployments - US Pre-
PTSD ≥2 PC-PTSD Deployed OEF vs. Elsewhere: OR=2.5 (2.3, 2.8) Deployed OIF vs. Elsewhere: OR=5.5 (5.2, 5.8) PTSD ≥2 PC-PTSD adjusted for sex, marital status, service, component, and grade PTSD ≥3 PC-PTS Deployed OEF vs. Elsewhere: OR=1.9 a Deployed OIF vs. Elsewhere: OR=4.2 a Miliken et al. (2007) () sectional PDHA and June 1, 2005- December 31, 2006 OIF veterans who completed PDHRA vs. PDHA with a median of 6 months between assessments ≥2 or ≥3 on (SR) PTSD ≥2 PC-PTSD PDHRA: OIF: 19.5% Active duty: 16.7% National Guard/Reserve: 24.5% PDHA: OIF: 12.1% Active duty: 11.8% National Guard/Reserve: 12.7% Response rate: not reported Excluded Marine personnel PTSD ≥3 PC-PTSD PDHRA: OIF: 11% Active duty: 9.1% National Guard/Reserve: 14.3% PDHA: OIF: 6.3% Active duty : 6.2% National Guard/Reserve: 6.6% PTSD ≥2 PC-PTSD vs. PDHA: OR=1.8 a PDHRA vs. PDHA (Active duty): OR=1.5 a PDHRA vs. PDHA (National Guard/Reserve): OR=2.2 a PTSD ≥3 PC-PTSD PDHRA vs. PDHA: OR=1.8 a vs. PDHA (Active duty): OR=1.5 a PDHRA vs. PDHA (National Guard/Reserve): OR=2.4 a Shen et al. (2009) () Retrospective PDHA October 2006 OEF/OIF veterans vs. OEF/OIF era veterans deployed elsewhere ≥2 on PC-PTSD (SR) PTSD ≥2 OEF 5% OIF 10% Elsewhere 3% Response rate: not reported Limited to Navy personnel Only those deployed to field mission were PTSD ≥2 on PC-PTSD Deployed OEF vs. Elsewhere: OR=1.7 α Deployed OIF vs. Elsewhere: OR=3.6 α
eligible to participate Peterson et al. (2010) () Retrospective PDHA June 1, 2005- December 31, 2007 OIF veterans vs. OIF era veterans deployed to Qatar ≥2 or ≥3 on (SR) PTSD ≥2 4.1% 0.7% Response rate: not reported Limited to Active duty Air members PTSD ≥3 2.1% 0.4% PTSD ≥2 on PC-PTSD Deployed vs. Elsewhere: OR=5.9 (2.7, 13.6) PTSD ≥3 on PC-PTSD Deployed vs. Elsewhere: OR=5 (1.8, 16.1) Kline et al. (2010) () Cross sectional Survey (anonymous) November 2008 OIF veterans with one or more deployments vs.OIF veteran at with no previous deployments Broad definition based on criteria alone Strict definition based on criteria and ≥50 on PCL (SR) Definition PTSD past month 21.1% 9% Response rate: 85% (2,543/2,995) Strict Definition PTSD past month 14% 4.2% Broad Definition PTSD past month Deployed vs. Non-deployed: OR=2.7 (2.1, 3.6) Adjusted for age, sex, race/ethnicity, education, marital status, and military deployment than OEF/OIF Strict Definition PTSD past month Deployed vs. Non-deployed: OR=3.7 (2.6, 5.2) Adjusted for age, sex, race/ethnicity, education, marital status, and military deployment other than OEF/OIF Thomas et al. (2010) () Cross sectional Survey (anonymous) OIF veterans 12 months after (T2) vs. 3 months (T1) Broad definition based on criteria alone Broad Definition PTSD past Active duty 23.7% National Guard 30.5% Active duty 20.7% National Guard 21.5% 2007-
Extension of Hoge et al. (2004) 2004-2007 Strict definition based on criteria and ≥50 on PCL (SR) Strict Definition PTSD past Active duty 16.6% National Guard 24.6% Active duty 14.8% National Guard 14.7% Broad Definition PTSD past month T2 vs. T1 (Active duty): OR=1.3 T2 vs. T1 (National Guard): OR=1.6 Broad definition PTSD past month adjusted for rank, marital status, and combat exposure Strict Definition PTSD past month T2 vs. T1 (Active duty): OR=1.2 T2 vs. T1 (National OR=1.9 Strict definition PTSD past adjusted for rank, marital status, and combat exposure Polusny et al. (2011) () Prospective Part of RINGS February 2007 OIF veterans 2-3 months after (T2) vs. one month before deployment (T1) definition based on criteria alone Strict definition based on criteria and ≥50 on PCL (SR) Broad Definition PTSD past month Not reported 16.7% Response rate: T1 99% (516/522) T2 81.2% (424/522) Follow-up limited to those without PTSD symptoms at Strict Definition PTSD past month 13.8% 3.7% Strict Definition PTSD past month T2 vs. T1: OR=4.2 α Vanderploeg et al. (2012) () Cross sectional Web-based survey (anonymous) 2009-2010 OEF/OIF veterans vs. non-deployed OEF/OIF era veterans ≥50 on PCL -C (SR) on DSM-IV criteria Probable PTSD 6.9% 1.9% Response rate: 41% (4,005/9,700) Not all elements of survey validated Limited to Active duty Florida National members Probable PTSD Deployed vs. Non-deployed: OR=3.8 α Somalia Mission - US
PTSD past 12 months Deployed vs. Non-deployed: OR=4.1 (2.4, 7.2) Adjusted for service type, rank, age, education, marital status, and pre-Gulf War PTSD Ikin et al. (2004) () Cross sectional Postal survey and health assessment Part of AGWVHS (2003) PGW veterans vs. PGW era veterans CIDI (Clinical Interview) based on DSM-IV criteria Pre-deployment PTSD 1.3% 1.2% Response rate 81% (1,456/1,808) in PGW veterans and 57% (1,588/2,796) in non-deployed PGW era veterans Post-deployment PTSD 5.4% 1.4% PTSD past 12 months 5.1% 1.7% Pre-deployment PTSD Deployed vs. Non-deployed: OR=1.1α Post-deployment PTSD Deployed vs. Non-deployed: OR=3.9 (2.3, 6.5) Adjusted for service type, rank, age, education, and marital status PTSD past 12 months Deployed vs. Non-deployed: OR=4.1 (2.4, 7.2) Adjusted for service type, rank, age, education, marital status, and pre-Gulf War PTSD McKenzie et al. (2004) () Cross sectional Postal survey Extension of Ikin et al. (2004) and part of AGWVHS (2003) PGW veterans vs. PGW era veterans ≥50 on PCL-S (SR) on PTSD past 7.9% 4.6% Response rate 81% (1,456/1,808) in PGW veterans and 57% (1,588/2,796) in non-deployed PGW era veterans PTSD past Deployed vs. Non-deployed: OR=2 (1.5, 2.9) Adjusted for service type, rank, age, education, and marital status Afghanistan/Iraq War deployments - Australia ADF MHPWS (2010) () Cross sectional Two phase design Regular currently serving ADF members deployed to MEAO vs. ≥50 on PCL-C (SR) based on ICD-10 diagnostic criteria PTSD past month All 3% 3% 2.8% PTSD past 12 months All 8.3% 8% 8.8%
AGWVHS (2003) () Mortality Cohort Matched pair January 1,1991 31, 2000 PGW veterans vs. PGW era veterans ICD-9 codes: E950-E959 ICD-10 codes: V01-Y89 All External Causes External 50% Intentional 30% External 65% Intentional 33% Limited to males Small sample size (n<25) in both groups Unable to calculate intentional self-harm SMR due to small sample size AGWVHSFU () Follow-up to AGWVHS (2003) October 19, 2012 PGW veterans vs. PGW era veteran relative to the general Australian male population Unknown Intentional Unknown Unknown Limited to males Intentional Self-Harm Deployed vs. Non-deployed: Adjusted HR=1.1 (0.4, 3.2) Deployed vs. Australian population: SMR=0.6 (0.3, 1.3) Non-deployed vs. Australian population: SMR=0.6 (0.3, 1.1) Afghanistan/Iraq War deployments - Australia MEAO Prospective Health Study (2012) () Prospective Self-administered survey and health assessment 2010-2012 ADF members at vs. pre-deployment Adapted from PATH Through Life Project (SR) Suicide ideation 1.6% 0.7% Response rate: 61% (1,872/3,074) Post-deployment 71% (1,324/1,872) Limited to ADF members deployed to the MEAO after June 2010 and returned June 2012 Suicide ideation Post-deployment vs. Pre-deployment: RR=2.2 α MEAO Census Health Study (2012) () Cross sectional Postal or online survey ADF members deployed to Afghanistan or Iraq vs. ADF SR Suicidal ideation past 12 months All 5.5% Inside Afghan-istan 4.7% Outside 5.6% harm harm
Inside Iraq 6.7% Outside Iraq 4.8% Suicide past 12 months All 1.4% Inside Afghan-istan 1.5% Inside Iraq 1.7% Outside 1.4% Outside Iraq 0.9% Suicide attempts past 12 months All 0.4% Inside Afghan-istan 0.5% Inside Iraq 0.4% Outside 0.6% Outside Iraq 0.5%
2010-2011 members deployed elsewhere outside of Afghanistan or Iraq between 2001-2009 Includes regulars, reserves, and ADF members Suicidal ideation past 12 months Inside vs. Outside Afghanistan: OR=0.83 α Inside vs. Outside Iraq: OR=1.4 α Suicide plans past 12 months Inside vs. Outside Afghanistan: OR=1.1 α Inside vs. Outside Iraq: OR=1.9 α Suicide attempts past 12 months Inside vs. Outside Afghanistan: OR=0.86 α Inside vs. Outside Iraq: OR=0.82 α ADF (2010) () Cross sectional Two phase design Part of MEAO Health Studies and Health and Wellbeing Survey April 23, 31, 2011 Regular currently serving ADF members deployed to MEAO vs. ADF members before 2010 SR Suicidal ideation past 12 months All 3.9% Response rate: 49% (24,481/50,049) Excluded trainees and reservists Deployed 3.8% Non-deployed 4.1% Suicide plans past 12 months All 1.1% Deployed 1.1% Non-deployed 1.1% Suicide attempts past 12 months All 0.4% Deployed 0.4% Non-deployed 0.5% Suicidal ideation past 12 months Deployed vs. Non-deployed: OR=0.93 α
Suicide plans past 12 months Deployed vs. Non-deployed: OR=0.97 α Suicide attempts past 12 months Deployed vs. OR=0.75 α Somalia deployment - Australia Hawthorne et al. (2013) () Cross sectional Telephone interview or online survey (1989-2002) Australian peacekeepers deployed to Somalia (n=215) between CIDI (Clinical Interview) based on ICD-10 diagnostic criteria Suicidal ideation 12.6% Not studied Response rate: 69% (1,025/1,484) Excluded participants involved in other health studies Suicidality was not assessed through a self-report measure but as part of CIDI interview Suicide plans 7% Not studied Suicide attempts 0.9% Not studied No comparison group α Tabulated measure of association (not reported by study)
higher among non-GWV than GWV. Blanchard (2006) () face-to-face interviews and medical examination, 2001 Random sample of US GWV (N=1035) and personnel (N=1116) who participated in a Department of Defence study in 1995-1996. CDC-derived definition 28.9 15.8 2.16 (1.61-2.90) Participation rates: GWV 53% & non-GWV 39%. Non-response bias: participants were more likely to be female, older, white, reservists and in a previous study were more likely to have reported more symptoms and illnesses than non-participants. OR was adjusted for age, gender, race, education, duty type, service, rank, income, combat exposure, Khamisiyah exposure, psychiatric conditions with onset prior January 1 1991 and self-reported doctor diagnosed medical conditions Kang (2009)() Longitudinal postal and telephone interview, 2003-2005 Stratified random sample from previous of US GWV (Navy, Army, Air Force, Marines; N=6111) and non-deployed Gulf Era personnel frequency matched on gender, service branch and status (N=3859). Presence of several different symptoms together that persisted for 6 months or more and not be adequately explained through medical or psychiatric diagnoses 36.5 11.7 3.05 (2.77-3.36) Participation GWV 40% and non-GWV 27%. Non-response bias: were more likely to be younger, single, non-white or enlisted rank in 1991 than Definition of multisymptom illness adopted in the study was not clearly stated. OR was adjusted for age, gender, race, body mass cigarette smoking, rank, service, unit component (active duty, NG or reserve)
September 11, 2001 - September 20, 2007. diagnoses from each admission were checked for a TBI diagnosis. These were categorised into three grades of severity. Least severe hospitalization 125 (4.7%) Afghanistan Overall 0.14% Most severe TBI-related hospitalisation 86 (36.2%) Moderately severe hospitalisation 151 (63.7%) Least severe hospitalisation 8 (3.4%) Males accounted for 97% of TBI-related hospitalisations. Enlisted personnel had increased risk for TBI hospitalisation compared with Officers. NG and Reservists had lower risk than active duty. Adams (2012) () Department of Defense Health Related Behaviors Among Active Duty Military Personnel Survey. survey. 2008 All survey respondents who reported returning from a combat deployment in past 12months with complete data. N=7155. Self-reported TBI during the last deployment. Three categories were established; Altered consciousness (TBI-AC), LOC less than 1 minute (TBI-LOC <1) and LOC greater than 1 minute 1+). Overall TBI 13.9% TBI-AC Overall 423 (7.5%) TBI-LOC<1 Overall 186 (3.5%) TBI-LOC 1+ Overall 149 (2.8%) Almost 15% of male personnel, and 4.9% of female personnel, reported a TBI. Elbogen (2012) () The National Post-Deployment Adjustment Survey (NPDAS). 2001-2009 Random selection of veterans who served in US military on or September 11, 2001 and had separated from active duty or served in NG/Reserves. Women were oversampled. TBI: reported a past head injury and endorsed one of; LOC, post-trauma amnesia, being dazed or seeing stars immediately after injury or upon regaining consciousness, skull fracture or brain surgery. Probable TBI without increased irritability Weighted N=163 Weighted prevalence =14.8% Probable TBI with increased irritability Weighted N=91 Weighted prevalence =8.2% Data were weighted to reflect the gender distribution in the military, a weight-adjusted sample of N=1102.
N=1388 (56% response rate) Macera (2012) () The Health Assessment (PDHA) and Reassessment (PDHRA). 2008-2009. All male Navy/Marine PDHA and PDHRA forms completed during 2008-2009 and endorsed at least one of three combat experiences (encountering dead or wounded people, engaging in direct combat and discharging weapon or feeling in great danger of being killed). N=12,046 TBI: yes/no questions regarding experiencing a blast/explosion, vehicular accidents, fragment or bullet wound above the shoulders or other injuries to the head. If endorsed, further questions regarding LOC, feeling dazed/confused or not remembering the event. Positive screen if they sustained a head injury and endorsed at least one of the three alteration/LOC items. This was a modification of the Brief TBI Screen. Primary care PTSD screen. TBI only 473 (3.9%) TBI and PTSD 644 (9.3%) Maguen (2012)() and Maguen (2012) () Retrospective cohort study. 2007-2010. OEF/OIF veterans who received a TBI screen 1, 2007 – January 8, 2010. N=1082. Modified Brief TBI Screen. One TBI mechanism 14% Two or more TBI mechanisms 29% who reported at least one TBI mechanism were more likely to be younger, male, in the Army, enlisted rank and deployed multiple times. Quigley (2012) () Prospective cohort study Army NG and Reserve personnel from two Pre-deployment and post-deployment assessments. N=508 (66.8% of original cohort) Modified TBI Screen. Post-deployment TBI 103 (21.5%) Rate includes both NG and Reserves.
Hendricks (2013) () Observational cohort study Veterans Health Administration (VHA). 2007-2009. All individuals screened for TBI in the VHA between October 1, 2007 - March 31, 2009. N=208,589. VA clinical evaluators’ judgment that a patient’s history and clinical course were consistent with a diagnosis of TBI. Probable TBI overall 44,781 (21.6%) 5.8% of total screened population in study period had a positive screen and a potential TBI confirmed through the CTBIE (does not include those who had a TBI confirmed at a later date). Probable TBI Males 23.1% Probable TBI Females 10.7% Of 24,461 patients who received a comprehensive TBI evaluation Confirmed TBI 11,961 (48.9%) Uncertain TBI (11.5%) with a probable TBI were more likely to be male, enlisted, younger, less education, less than 8 years military service and in Army or Marines. Iverson (2013) () National survey 2009-2010. Drawn from VA’s Environmental Epidemiology Service’s roster of veterans. Both VA and non-VA users who had deployed to OEF/OIF and were separated. Females oversampled. September 2009 – October 2010. N=2348 (48.6% response rate) Modified TBI screen; screening questions. Screened positive if one deployment-related head injury was accompanied by alteration or LOC. Probable TBI Male 198 (19.7%) Probable TBI Female 119 (10.7%) Kontos (2013) () Cross-sectional population based survey. 2009-2011. USA Special Operations Command (USASOC) personnel without a pathological history. November 2009 – December 2011. N=22,203 (81.7% response rate). Mild TBI: Glasgow Coma Scale (GCS) score of and no associated pathology. Mild TBI Overall 2813 (12.7%) Comparison of 0, 1, 2 and 3+ diagnosed blast mTBI supported a dose-response gradient for reported mTBI symptoms. Modified Brief TBI Screen TBI 825 (2.8%)
Macera (2013) () The Health Assessment (PDHA) and Reassessment (PDHRA). 2008-2009. Drawn from the same study as Macera 2012.() Male Navy and Marine Corps personnel post OEF/OIF deployment and who completed a PDHA and PDHRA 3-6months after deployment. N=29,640. Afghanistan/Iraq War deployments – US VA populations Taylor (2012) () Observational study. US VHA Quality Enhancement Research Initiative. 2009 fiscal year. All OEF/OIF patients who used VHA inpatient or outpatient care in fiscal year 2009. (October 1, 2008 – September 30, 2009). N=327,388. ICD-9-CM coded TBI TBI 6.7% Patients with a TBI diagnosis were male, slightly younger and slightly less likely to be a new user of VA services that year. Cifu (2013) () Cross-sectional population based retrospective study. Fiscal years 2009/2010/2011 All veterans who received any VHA inpatient or outpatient care. Any TBI related ICD-P-CM code received at any time in their treatment, ranging from mild to severe. TBI 2009 6.7% 2010 6.8% 2011 6.5% Pooled 2009-11 9.6% Only 0.8% of all 613,391 veterans received a diagnosis of isolated TBI (unaccompanied by either pain or PTSD). Evans (2013) () National retrospective cohort 2007 – 2008. OEF/OEF veterans who used VA services and had been active between September 11, 2001 and September 30, 2008. N=170,681. Modified Brief TBI Screen. TBI 32,080 (20.5%) Overall 91.6% or 156,415 of veterans eligible to receive the TBI screen were screened. Afghanistan/Iraq War deployments - Australia MEAO Census Retrospective self-reported survey. Active duty Australian personnel deployed to Self-reported Head injury/ concussion on deployment. Head injury/ Concussion 200 (1.8%) Lifetime mTBI was reported by more than 10% of participants.
Study (2012) () 2010-2011. Iraq or Afghanistan between 2001-2009. N=14,032 (53% response rate). MEAO Prospective Study (2012) () Prospective cohort 2010-2012. Members of ADF from 13 units and a ship who deployed to the MEAO after June 2010 and returned by June 2012. N=1295. and post-deployment self-report questionnaire data. mTBI referred to an event in which the head was physically injured, and was characterised by the immediate symptoms of LOC, altered mental status, and/or amnesia Pre-deployment lifetime mTBI Overall 23.3% Respondents on a combat role in Afghanistan or who worked outside the main support base were significantly more likely to report a new mTBI at compared to in non-combat roles outside Afghanistan Post-deployment new mTBI Overall 9.3% Pre-deployment mTBI and post-deployment new mTBI 3.6% 1990-91 Gulf War – Australia Australian Gulf War Veterans’ Follow-up Health Study (2011-2012) () Longitudinal follow-up study. 2011-2012. Australian Gulf War veterans (N=715) and a non-deployed comparison group (N=675). Respondents were to report whether any injuries received in the past three years involved being dazed, confused or seeing stars; not remembering the injury; or losing consciousness (knocked out). Gulf War Comparison Group Dazed/Confused 8.6% 6.3% Knocked Out 3.1% 1.9% Not remembering injury 2.3% 1.4% Gulf War veterans were statistically significantly more likely than the comparison to report at least one of the three concussion-related consequences of injury (11% vs 7%; p=0.013).
Gold, White and Orange Cards The Gold Repatriation Health Card – For All Conditions (Gold Card) entitles the holder to all health services according to clinical need. The Repatriation Health Card – For Specific Conditions (White Card) entitles the holder to health services for treatment of a specific condition as approved by DVA. An Orange Card provides eligible veterans with access to pharmaceuticals listed on the Repatriation PBS according to clinical need for all medical conditions. Table 6 Summary of treatment options covered under DVA Acts VEA SRCA MRCA Personnel covered Prior to 1 July 2004, personnel were covered by a combination of VEA and SRCA depending on enlistment and type of service Enlisted on or 1 July 2004 Treatment for accepted injury or disease Fully covered for White Card holders Reimbursement for medical expenses for treatment reasonably required as a result of accepted injury. From 10/12/2013 White cards will be issued. Fully covered for White Card holders or reimbursement for expenses Treatment for all conditions Fully covered for Gold Card holders Not covered Fully covered for Gold Card holders Pharmaceutical Benefits Pharmaceutical Allowance for holders of Repatriation Health Cards Cost of all reasonable pharmaceuticals is reimbursed for accepted conditions Pharmaceutical Allowance for holders of Repatriation Health Cards. For others, cost of all reasonable pharmaceuticals is reimbursed for accepted conditions Cost of attendance for medical treatment Reimbursement of travel and accommodation Reimbursement of travel and accommodation Reimbursement of travel and accommodation Rehabilitation Veterans' Vocational Rehabilitation Scheme for eligible veterans All rehabilitation required or deemed appropriate covered All rehabilitation required or deemed appropriate including social, vocational and educational status DVA established a Client Liaison Unit (CLU) in 2007 to provide a more holistic service to entitled clients with complex needs under all three Acts. It provides a single point of entry and ongoing contact mainly by telephone.
Appendix B Table 9 Common Australian and US Deployments of <1,000 Personnel for either AU or US # Country Operation Area Start date End Date Deployment # of Personnel 1 AU Palate Afghanistan 18 Apr ‘03 5 Jul ‘04 Warlike ADF contribution to UNAMA AU Palate II Afghanistan 27 Jun ‘05 Current Warlike Two ADF Army officers serving as military advisers to UNAMA AU Jural/Bolton Iraq 30 Jun ‘91/31 Aug ‘92 12 Jan ‘03 Warlike ADF members assigned to UK operation to patrol the Iraq No-Fly-Zones AU Southern Watch Iraq 31 Aug ‘92 12 Jan ‘03 Warlike ADF members assigned to the US operation to patrol the Iraq No-Fly-Zones AU Kruger Iraq 1 Jan ‘09 July ‘11 Warlike ADF contribution to provision of security for Australian Embassy and staff in Iraq AU Riverbank Iraq 21 Jul ’08 Current Warlike Two ADF officers to support UNAMI 2 AU Warden, Stabilise, Tanager, Citadel East Timor 16 Sep ‘99 17 Aug ‘03 Warlike 5,700 at peak, to 1,600 in ’01-‘02 AU Astute, Tower East Timor 25 May ‘06 Current Non-warlike 390 (Astute) 4 (Tower) US Unknown East Timor 1999 2002 Support for INTERFET, UNTAET (30 US Personnel), USGET (US support group East Timor, 20 US personnel; CRS, 2011) Sources: Dept of Defence page and page; and APPVA page; CRS (2011) ; Comlaw.gov.au
VA Readjustment Counseling Service Veterans Center (Vet Center) Large, mid-size, and small CBOCs provide: General mental health services or via telehealth Referrals to VAMCs, or community services via sharing agreement contracts or a fee basis with local providers or organisations to extend eligibility Hours of care VAMCs and very large CBOCs must provide additional evening, early morning, or weekend hours Emergency services VAMCs and very large CBOCs must offer 24/7 emergency care Remote areas Veterans living in remote areas may be serviced by MHICM-RANGE or Enhanced RANGE programs before the 2-year period beginning on the last day of the war (end date not yet determined) Veterans who are not eligible for VA health care but meet the description as stated above can receive treatment for psychosis, mental illness, or any other condition directly related to psychosis or mental illness at no cost Primary care Veterans must be enrolled in a VA primary clinic to receive primary care disorders, more than double the rate seen among all VA users 23% of all Veterans and 50% of Veterans who are service for mental health conditions are receiving mental health services from VA National Tele-Mental Health Program In 2013, more than 91,000 Veterans received some of their mental health treatment through telehealth VA facility) and the characteristics of the Veteran population in the region being served (e.g. service Veterans are more likely to use VA health care services) Cost Variations in costs due to different treatment programs (general outpatient care is least costly, followed by specialty outpatient care, and then by residential treatment and inpatient programs) Physical infrastructure Limited and equipment (i.e. mental health care accounted for 5% of all space managed by VHA in 2013) including: $4M MHICM teams, $6M PRRCs, $10M telehealth and web-based support tools In 2005, VA allocated an additional $88M to MHSP initiatives Posttraumatic stress disorder (PTSD)
Medication management Psychotherapies (group or individual) Cognitive behavioral therapy Cognitive processing therapy Prolonged exposure therapy PTSD Coach App (2011) Domiciliary PTSD or PTSD Residential Rehabilitation Treatment Programs Mental Health Treatment Coordinators (MHTC) and very large CBOCs provide: Specialised outpatient programs Evidence-based talk therapies Medications on-site VAMCs and very large CBOCs must have staff with training and expertise to serve the OEF/OIF population through an OEF/OIF team or PTSD program staff Large and mid-sized CBOCs provide: Evidence-based talk therapies Medication on-site Telehealth Small CBOCs provide: General and specialty services via on-site or telehealth Referrals to RRTPs, VAMCs, or community services sharing agreement contracts or a fee basis with local providers or All Veterans enrolled in the VA health care system Veterans must be referred for specialty services by an primary care provider PTSD Coach App (2011) AboutFace (2012) Avoidance and denial Veterans believe they will get better on their own or think that services are for other people and not them Problems accessing care Finding a therapist, transportation, or cost Misinformation Not knowing that PTSD treatments work Stigma Negative labels or stereotypes (e.g. showing of weakness), fear of discrimination at work, school, or finding housing because of symptoms, and damage to career Privacy Fear of confidentiality breach in medical records Timeliness Most Veterans do not get help until after returning from deployment or after In 2006, VA allocated $19M for PTSD services and OEF/OIF care In 2005, VA allocated $18M for PTSD services and OEF/OIF care
organisations to extend eligibility MHTCs Veterans who receive specialty mental health care have a MHTC, who serves as a point of contact to ensure continuity throughout the treatment and transition his/her family tells them there is a problem Suicide Veterans Crisis Line Suicide Prevention Coordinators Personal safety plans managing suicidal thoughts and feelings VAMCs and very large CBOCs must appoint and maintain an SPC with a full-time commitment to suicide prevention activities Veterans Crisis Line Offered to all Service Branches, the National and Reserves, Veterans, their families, and providers. In cooperation with the National Suicide Prevention Lifeline, Suicide Prevention Resource Center, and the American Association of Suicidology Traumatic brain injury (TBI) Types of settings Inpatient Rehabilitation Transitional Rehabilitation Outpatient Rehabilitation Telerehabilitation Polytrauma System of Care, local VAMC, or community healthcare providers Polytrauma/TBI System of Care Components All Veterans enrolled in the VA health care system and Service Members covered by TRICARE authorisation In 2012, 64% of Veteran diagnosed with TBI received care at PSCT facilities and 54% sought treatment at CBOCs Geographic location Referral needed In 2012, the average cost of care at VHA facilities for OEF/OIF Veterans with TBI was $11,481 per capita (this includes inpatient, outpatient, and pharmacy services)
Clinical evaluations for post-deployment health concerns Environmental exposure assessments Neuropsychiatric and neuropsychological evaluations Advanced diagnostic testing when clinically indicated Post-deployment health education Exposure Assessment Program On-site or via telehealth Environmental exposure assessments Education Integrative Health and Wellness Program Preventative health Nutrition Exercise therapy Yoga Acupuncture Meditation Relaxation techniques complex health condition and no known cause (medically unexplained symptoms) Any deployed Veteran that has had many tests and/or treatment with little to no symptom improvement Any deployed Veteran with possible deployment-related environmental exposure problems or concerns Exposure Assessment Program All combat Veterans Veterans who participated in military Atmospheric Nuclear Weapons Tests Veterans who participated in Project 112 or Shipboard Hazard and Defense made by the Veteran’s primary care provider
Appendix J Table 11 Summary of Australian veteran health services 1990-1999 Services/programs Availability Eligibility Utilisation Barriers/challenges Resources/funding Australian health services 1990-1999 Veterans and Veterans Families Counselling Service (VVCS) centre counselling outreach counselling counselling veterans line formal case management (1996) Quality of Life package (1993) Vocational and social rehab for veterans (unknown) Improving Social Networks Program (1996-97) Transition Support Services (unknown) Repatriation Comprehensive Care Scheme (1996) – local medical officers take greater responsibility for management of chronically ill or complex conditions Country Outreach Program (1995-96) - Government Health Policy for the Veteran Community in Rural and Remote Areas (1996) A number of initiatives for younger veterans were announced in the 1994-95 budget; implementation of these initiatives continued through 1995-96. Allied health services extended to include chiropractic and osteopathic services (1995) Acute hospital treatment provided exclusively under the Repatriation Private Patient Scheme (1995) The last Repatriation Hospital was transferred in 1997. DVA: All eligible Australian veterans, peacekeepers and their family members, and ADF personnel referred under an agreement on a fee for services basis. Medicare: Veterans may choose to seek services through the Medicare or private health systems. In 1994 the median age of veterans receiving a disability pension was 72 years with 79% aged 65 years or over. An increase in the use of services was attributed to the ageing/increased frailty of the veteran population. Of the people entitled to health care through DVA in 1996, 108,415 (31.8%) lived in rural and remote areas. Rural programs initially started with approximately 20 centres, this increased over the years to almost 70 centres nationwide. Demand for VVCS services reached a new high over 1997-98, centres were contacted by 2800 new or re-presenting clients. 1997-98: VVCS staff provided more than 30,000 sessions in metro areas. In rural and remote areas, over 27,000 sessions were provided. Group program activity was significantly increased during the year under the Younger Veterans’ Program; with over 500 courses conducted for 4800 participants. Veterans’ Line responded to 5600 calls seeking after-hours crisis counselling or information. Posttraumatic stress disorder (PTSD)
DVA At Ease mental health web portal (2006) Entitlements self-assessment DVA: Veterans’ Access Network and General Enquiries Line DVA rehabilitation services DVA health care services DEFENCE: JHC all hours helpline ADF All Hours Support Line Defence Family Helpline (2012) SeMPRO 24/7 support service Member Support Coordinators (2012) Soldier Recovery Centres (2012) ADF Rehabilitation Program (2007) Garrison Health Operations (2012) Contracted health professionals who deliver services through Medibank Health Solutions contract 93.4% of the veteran population used medical services. 10.6m medical services were accessed. SRCA Clients: 50,053 SRCA open cases: 1,160 MRCA Clients: 15,971 Open cases: 631 Medical discharge complications: Multiple injuries Accepted military compensation claims Previous rehabilitation programs May have to find civilian medical service providers Geographic relocation Possible loss of support networks Removal of Defence structure Medical discharge process can affect attitudes towards rehabilitation and DVA Expectations of what DVA can provide GP: 22.5m Public Hospitals: 29m Private Hospitals: 32.8m Pharmacy: 30.3m Allied Mental Health workers: 2.4m PTSD PTSD app Australia (2011) ACPMH accredited PTSD Treatment Programs PTSD Group Therapy Program Veterans, peacekeepers and current serving personnel with PTSD and related problems. 2005-2010 of the 50,279 clients seen by VVCS, 8280 (16.5%) people nominated PTSD as primary presenting problem. PTSD Coach: CMVH Review of PTSD Programs Uncertainty about what help was available Difficulty accepting the presence of a problem Economic or time constraints Insufficient numbers of mental health professionals DVA contracts with ACMPH to accredit the PTSD group treatment programs. Australian Centre for Posttraumatic mental health (ACPMH): 1.3m