THE MENTAL HEALTH NEEDS OF US MILITARY MEMBERS RETURNING FROM

IRAQ & AFGHANISTAN

David Dean, Ed.D., HSPP – Psychologist/Contractor

E-mail: david.dean@med.navy.mil

DEPLOYMENT MENTAL HEALTH

• STRESSORS IN COUNTERINSURGENCY OPERATIONS

• OPERATIONAL STRESSORS IN IRAQ & AFGHANISTAN

• UNDERSTANDING COMBAT STRESS REACTIONS

• REVIEW THE PREVALENT DIAGNOSTIC CATEGORIES

• LOOKING AT BARRIERS TO CARE

• SOME BASIC RESOURCES FOR PROFESSIONALS

• QUESTION & ANSWERS – IF TIME PERMITS

RELEVANT REPORTS

• “AN ACHIEVABLE VISION: REPORT OF THE DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH.” Department Of Defense, June 2007.

• “THE PSYCHOLOGICAL NEEDS OF THE US MILITARY SERVICE MEMBERS & THEIR FAMILIES: A PRELIMINARY REPORT.” American Psychological Association Presidential Task Force, February 2007.

• “INVISIBLE WOUNDS OF WAR: SUMMARY & RECOMMENDATIONS FOR ADDRESSING PSYCHOLOGICAL AND COGNITIVE INJURIES.”

Rand Center For Military Policy & Research. 2008.

THE STRESSES OF OPERATIONAL DEPLOYMENT

• PROLONGED SEPARATION FROM FAMILIES & FRIENDS

• INSUFFICIENT INFORMATION FROM HOME & MILITARY

• VALUE CONFLICTS

• BOREDOM ALTERNATING WITH HYPERAROUSAL

• FEAR – OF INJURY, DEATH, FAILURE

• SHAME – FAILING TO MEET ONE’S OWN EXPECTATIONS

• LOSSES - OF FRIENDS, SENSE OF PURPOSE

OTHER STRESSES OF OPERATIONAL DEPLOYMENT

• EMOTIONAL ISOLATION – ESP FOR IA’s &

ADVISORS

• LOSS OF PRIVACY & OPPORTUNITES FOR SELF

CARE

• EXISTENTIAL CRISES – THE MEANING OF LIFE

• WEAKENING OR LOSS OF FAITH

• DAMAGE TO DEEPLY HELD BELIEFS – CONTROL,

SAFETY

• HATRED OF THE ENEMY

• TRAUMATIC EXPERIENCES

EXPERIENCED – THREAT OF DEATH OR

TRAUMA

OBSERVED – DEATH, CARNAGE, TRAUMA

HEARING ABOUT TRAUMATIC EVENTS

COUNTERINSURGENCY OPERATIONS

CONVENTIONAL TACTICS, WEAPONS & EQUIPMENT & DOCTRINE DON’T WORK

“The more force you use, the less effective you are.”

“It’s like learning to eat soup with a knife!”

• RULES OF ENGAGEMENT RESTRICT DECISION-MAKING

• ACTS OF TERRORISM - A TACTIC OF INSURGENTS

• DISCERNING FRIEND FROM FOE IS ALWAYS DIFFICULT

• ASYMMETRICAL WARFARE - FEW SAFE AREAS

OIF/OEF STRESSORS

SOURCES OF STRESS

• PHYSICAL EXTREMES – HEAT, COLD, INJURIES,

DEHYDRATION, SLEEP DEPRIVATION, DISEASES,

• TEMPO IS UNPREDICTABLE - 24/7 SCHEDULE.

• CULTURAL DIFFERENCES – RESULT IN TENSIONS

(ESPECIALY FOR TRAINERS/ADVISORS)

SOURCES OF STRESS

• TRAVEL ANXIETY - IED’S , AMBUSHES, SNIPERS, FEAR OF CAPTURE

• NUMEROUS & LENGTHY DEPLOYMENTS

“THE AMERICANS HAVE ALL THE WRISTWATCHES, - WE HAVE ALL THE TIME.” – (TALIBAN SLOGAN)

• REPEATED RANDOM EXPOSURES TO THREAT & VIOLENCE,“SEIGE MENTALITY.”

HOURS OF BOREDOM…..

49% - ACTIVE DUTY TROOPS51% - RESERVE & NATIONAL GUARD

THE MAJORITY RETURN HOME WITHOUT EXPERIENCING SERIOUS PROBLEMS.

MANY AREN’T IN COMBAT

70 % Combat Stress Symptoms 10% Suffer From PTSD 10% Suffer From Other MH

Problems

GUARDSMEN & RESERVES HAVE HIGHER RATES

1.64 MILLION US TROOPS DEPLOYED TO

OEF/OIF SINCE OCTOBER 2001

MENTAL HEALTH & OIF/OEF

• MENTAL HEALTH is the 2nd largest category treated by the VA for OEF/OIF Veterans.

(#1 - Orthopedic injuries)

• 700,000 Expected to ask for services from the VA.

MENTAL HEALTH PROBLEMS IDENTIFIED IN OIF/OEF VETERANS

SEEN BY THE VA

• 37.7% (94,921) of the 252,095 eligible OIF/OEF veterans who have presented to VA have MH DX

• Provisional MH diagnoses include:– PTSD 45,330 (47%)– Acute Reaction to Stress 2,975 (3%)– Nondependent Abuse of Drugs 37,926 (40%)– Depressive Disorder: 30,828 (32%)– Affective Psychoses 16,736 (18%)– Anxiety Disorders: 24,161 (25%)– Alcohol Dependence: 7,410 (8%)– Drug Dependence: 3,334 (4%) (TOTAL S/A =

52%)

(NIMH, 2008) THE MOST COMMON DEPLOYMENT-RELATED DIAGNOSES

PTSD

MAJOR DEPRESSION

GENERALIZED ANXIETY

DISORDER

MENTAL HEALTH PROBLEMS SEEN IN DH

• COMBAT STRESS REACTIONS

• MILD TRAUMATIC BRAIN INJURY (mTBI )

• PTSD

• DEPRESSION – MAJOR, NOS, ASSOCIATED WITH PAIN

• MORBID THINKING, SUICIDAL IDEATION

• SUBSTANCE ABUSE

• TRAUMATIC GRIEF/SURVIVOR GUILT

• OTHER ANXIETY DISORDERS

• EXISTENTIAL/SPIRITUAL CRISES

• RELATIONSHIP/FAMILY PROBLEMS

(CHRONIC PAIN IS A SERIOUS COMPLICATING FACTOR)

• A NORMAL REACTION TO AN ABNORMAL & HIGHLY STRESSFUL ENVIRONMENT

• SX USUALLY IDENTIFIED 30-90 DAYS POST- DEPLOYMENT - EXACERBATED BY THE RETURN HOME

• DIFFICULTY ADAPTING TO A REORGANIZED FAMILY

• DIFFICULTY IN DISENGAGING FROM COMBAT ZONE MEMBER MAY LONG TO RETURN TO COMBAT

• PHYSICALLY PRESENT, PSYCHOLOGICALLY ABSENT “WHEN WILL I RETURN TO NORMAL AGAIN?”

• SUFFERING - NO SERIOUS EFFECT ON FUNCTIONING

COMBAT STRESS REACTIONS

COMBAT STRESS REACTIONS – BEHAVIORAL

• FREQUENT/EXAGGERATED STARTLE RESPONSES

• CONSTANTLY ON GUARD (HYPERVIGILANCE)

• INCREASED ALCOHOL, NICOTINE OR CAFFEINE USE

• DRIVING TOO FAST, RISK-TAKING BEHAVIORS

• BEING OVER-CONTROLLING OR OVER-PROTECTIVE

• BECOMING PREOCCUPIED WITH DETAILS

• HAVING DIFFICULTY ADAPTING TO THE

WORKPLACE

• INSUFFICIENT UNINTERRUPTED SLEEP (INSOMNIA)

COMBAT STRESS REACTIONS - PSYCHOSOCIAL

• SOMETIMES IRRITABLE OR TENSE

• ALTERNATES WITH EMOTIONAL SHUTDOWN

• DIFFICULTIES WITH CONCENTRATION & MEMORY

• FEELS DISCONNECTED, DETACHED, “I DON’T

BELONG”

• INTRUSIVE UNWANTED MEMORIES

• NIGHTMARES, BAD DREAMS, NIGHT TERRORS

• QUICK TO FEELING OVERWHELMED

• ANHEDONIA – “I CAN’T BE BOTHERED.”

• SOCIAL WITHDRAWAL – FAMILY, FRIENDS, OTHERS

COMBAT STRESS REACTIONS – “RED FLAGS”

• SUBSTANCE ABUSE – PRESCRIPTION OR OTHERWISE

• SIGNIFICANT CHANGES IN MOOD OR BEHAVIOR

• SUICIDAL THOUGHTS, GESTURES, MORBID COMMENTS

• THREATS OF HARM TO OTHERS OR ACTUAL AGGRESSION

• LEGAL OR DISCIPLINARY PROBLEMS

• SIGNIFICANT PROBLEMS WITH AUTHORITY

• RUMINATING ABOUT A DECEASED OR INJURED BUDDY

• IS THERE SIGNIFICANT IMPACT ON PERSONAL, SOCIAL OR OCCUPATIONAL FUNCTIONING?

TBI - “SIGNATURE INJURY” OF THIS WAR

BLAST INJURIES - #1 CAUSE OF INJURY & DEATH IN IRAQ.

– 69.4% OF WOUNDED IN ACTION CAUSED BY BLASTS OR EXPLOSIONS

– 62% OF BLAST INJURIES RESULT IN TBI DX

– 85% OF TBI’s ARE CLOSED HEAD INJURIES (This means only 15% have visible

wounds)

– TBI symptoms closely resemble those of PTSD and can be easily overlooked by those not well versed in recognizing and diagnosing brain injury.

(TBI) THE “SIGNATURE INJURY”

APPROX 1000 MODERATE & SEVERE CASES

MANY MORE HAVE EXPERIENCED mTBI

POSSIBLY UP TO 30% WITH EXPOSURES

TO BLASTS, BLOWS, FALLS, MVA’S

– NO GOLD STANDARD FOR SCREENING/EVALUATION

– OFTEN CONFUSED BY COEXISTING DIAGNOSES

– THE LABEL CAN LEAD TO UNINTENDED

CONSEQUENCES

– “CONCUSSION” OR “POST-CONCUSSIVE SYNDROME”

– TYPICALLY BASED ON SELF-REPORT

POSTTRAUMATIC STRESS DISORDER

• Over 59,000 VA-documented PTSD cases from OEF/OIF.

• # 1 mental health diagnosis being treated at the VA for OEF/OIF veterans(Gregg Zoroya, October 18, 2007)

• OEF/OIF Veterans ages 18-24 are more likely to receive mental health treatment and/or receive a diagnosis of PTSD than those OEF/OIF Veterans who are age 40 or older.

• (Seal, et al., March 12, 2007)

DEPRESSION• 2% - 14% WITH MAJOR DEPRESSION – 5

OR MORE SYMPTOMS FOR 2 WEEKS - depressed mood, anhedonia, insomnia, weight change, agitation/retardation, fatigue, worthlessness, guilt, indecisiveness, problems concentrating, morbid thinking, suicidal ideation.

• SYMPTOMS OFTEN INCREASE BETWEEN THE TIME OF HOMECOMING AND 3-4 MONTHS POST DEPLOYMENT

(Hoge 2004) Reflects Vietnam era survey data.

BE AWARE OF PHSYICALLY INJURED EXPERIENCING DELAYED ONSET OF PTSD

AND/OR DEPRESSION

• PHYSICAL INJURIES ARE ASSOCIATED WITH TRAUMATIC EVENTS & LEAD TO A COMPLEX RECOVERY PROCESS.

• RATES OF DEPRESSION & PTSD SHOWSIGNIFICANT INCREASES ON 7 MONTH POST-INJURY REEVALUATION (Grieger 2006)

1 Month P.I. 7 Month PTSD Sx 4.2% 12.0%

Depression Sx 4.4% 9.3%

March 25, 2003, Pfc. Joseph Dwyer 26, from Mt. Sinai, NY was photographed carrying an Iraqi boy named Ali who had been injured during fighting between the Army’s 7th Cavalry Regiment and Iraqi forces near the village of Al Faysaliyah, Iraq. Dwyer, 31, was found dead on June 28 of an accidental overdose in his home in Pinehurst, N.C., after years of struggling with post-traumatic stress disorder. photo: Warren Zinn, AP via Army Times

SUICIDE AMONG US VETERANSOF OEF/OIF BY BRANCH OF SERVICE

ALL OEF/OIF VETERANS

NO. OF VETERANS

Separated - Alive from Oct 2001 – Dec

2005 490,346*

SUICIDES144

BY BRANCH

ARMY

MARINES

NAVY

AIR FORCE

NO. BY BRANCH

274,862

55,166

65,371

94,947

SUICIDES

73 (1.21)

15 (1.05)

23 (1.34)

33 (0.99)

SOURCE: Kang, H.K. JAMA, August 13, 2008 – Vol. 300, No. 6 pp.652-653

SUICIDE AMONG US VETERANSOF OEF/OIF BY SERVICE COMPONENT

COMPONENT NO. OF VETERANS

Oct 2001- Dec 2005

SUICIDES

ACTIVE DUTY* 212,664 66

RESERVISTS 120,738 36

GUARDSMEN 156,944 42

VA PTS W/ MH DX

35,544 16

SOURCE: Kang, H.K. JAMA, August 13, 2008 – Vol. 300, No. 6 pp.652-653

SUICIDE AMONGST VETERANS OF OEF/OIF

• 2 MOST COMMON METHODS USED (94%)FIREARM – N = 105 (73%)

HANGING - N = 30 (21%)

• OVERALL MORTALITY RATE FOR OEF/OIF

DOD REPORTS BEING LOWER THAN GEN POP (1/2)

ARMY & MARINES REPORT RATES ARE INCREASING

• THERE ARE VULNERABLE SUBGROUPS MOST NOTABLY ACTIVE COMPONENT MEMBERS

THOSE WITH DIAGNOSED MH DISORDERS (D & PSTD) THOSE WHO SUFFERED SEVERE TRAUMA IN WAR SOURCE: Kang, H.K. JAMA, August 13, 2008 – Vol. 300, No. 6 pp.652-653

2001-2005 VETS WHO LEFT THE MILITARY - 254 SUICIDES Zaroya, USA Today, 15 Sept 08

SUBSTANCE ABUSE

• 11.8% OF US MILITARY PERSONNEL RETURNING FROM IRAQ REPORTED ALCOHOL MISUSE ON A 2-ITEM SCREENING FORM. (Which may be a consequence of PTSD/TBI)

• APPROXIMATELY 50,000 TAKING PAIN MEDS

• NARCOTIC PAIN KILLERS THE MOST ABUSED DRUG IN THE MILITARY

• USE OF INHALANTS BECOMING A SERIOUS PROBLEM

TRAUMATIC GRIEF

• LOSS OF ATTACHMENT – SUDDEN & VIOLENT

• TYPICAL SYMPTOMS - Shock, disorientation, helplessness - Despair, disbelief - Numbness, disconnection, social withdrawal - Shame, guilt

- Preoccupation with the deceased - Anger, hostility - Loss of energy and/or appetite

• SYMPTOMS PERSISTENT > 1 MONTH

A HIDDEN CASUALTY OF WAR

Sgt. James "Ski" Witkowski, apparently tried to block a grenade from falling inside the vehicle and died inthe blast. "It's almost like time stops. It's like you're outside of your body and you're looking at what's going on," says Gantt, 37, of Fredericksburg, Va. Gantt is on medical leave from his civilian job as a corrections officer, and has been diagnosed with PTSD and a mild brain injury. Gantt fights the anger he feels for not having done enough — in his view — to keep Witkowski from sacrificing himself on the grenade. "I remember one day I asked myself, 'Why are you so mad? Why can't you let this go?' And I could feel my chest tighten and I was so (angry)," Gantt says.

His girlfriend of six years, Sheila Ward, says that having his life spared has changed Gantt completely."I don't know anything about him (anymore)," she says. (USA Today, 9/19/2007)

Army Staff Sgt. Jeffery Gantt of Fredericksburg, Va., continues to feel guilty that Sgt. James "Ski" Witkowski, who apparently sacrificed himself in a 2005 attack on their Humvee in Iraq.

IF MH SX ARE NOT DIAGNOSED & TREATED

AT RISK FOR DEVELOPING OTHER DX’S (e.g.

S/A)

MAY CONSIDER OR ATTEMPT SUICIDE

UNHEALTHY BEHAVIORS EMERGE

(e.g. Unsafe Sex, Smoking, Overeating, Risk-Taking)

INCREASE OF TARDINESS & ABSENTEEISM

HIGHER RISK OF BEING UNEMPLOYED

RISK LOWERED SOCIO-ECONOMIC STATUS

EXPERIENCE IMPAIRED PERSONAL

RELATIONSHIPS

CHILDREN SUFFER SIGNIFICANT ADVERSE

EFFECTS

THE DEPLOYMENT MENTAL HEALTH “ICEBERG”

UNDER-REPORTING IN THE MILITARY

A RECENT COMPARISON STUDY BETWEEN ROUTINE PDHA (DD2796)

AND A REPEAT CONFIDENTIAL SCREENING …..

HALF OF 7296 SURVEYED REFUSED TO RETAKE DD2796

REPORTS OF PTSD SYMPTOMS MORE THAN DOUBLED

REPORTS OF DEPRESSION MORE THAN TRIPLED

THE NUMBERS WANTING TO SEEK CARE DOUBLED

(Source: Warner, Force Health Protection Conf, 8/15/08)

RAND’S TOP 5 BARRIERS TO CARE (N-752)

1. MEDICATIONS THAT MIGHT HELP ME HAVE TOO MANY SIDE EFFECTS & I RISK DEPENDENCY OR ADDICTION

2. IT COULD HARM MY CAREER – SUPERVISORS/EMPLOYERS DON’T SUPPORT ME GETTING INTO TREATMENT

3. I COULD BE DENIED A SECURITY CLEARANCE, A GOOD ASSIGNMENT OR EVEN A PROMOTION

4. MY FAMILY/FRIENDS WOULD BE MORE HELPFUL THAN MENTAL HEALTH PROFESSIONAL – THEY DON’T GET IT

5. MY CO-WORKERS WOULD HAVE LESS CONFIDENCE IN ME

IF THEY FOUND OUT I HAD MENTAL HEALTH ISSUES

Source: Rand Corporation, 2008

OTHER BARRIERS TO CARE

• FAMILY MEMBERS AREN’T ALWAYS SUPPORTIVE

• COST OF /TREAMENT/CHILDCARE/TRANSPORTATION

• INSURANCE COMPANIES SOMETIMES DISCOURAGE

PROVIDERS & SERVICE MEMBERS

• MANY COMMUNITY-BASED PROVIDERS ARE NOT TRAINED

OR AWARE OF THE STRESSES OF MILITARY LIFE

• MISGUIDED SELFLESSNESS OF VETERAN

SYSTEMIC & SOCIAL BARRIERSFOR VETERANS OF GWOT

• AVAILABILITY IN GOVERNMENT/DOD CLINICSSHORTAGE OF TRAINED MILITARY

PROFESSIONALS SHORTAGE OF ELIGIBLE CIVILIAN PROVIDERS

• ACCESSIBILITY IN GOVERNMENT/DOD CLINICSLONG WAITING LISTSSOME MILITARY CLINICS CANNOT SEE FAMILIESFACILITY HOURS ARE LIMITEDGUARDSMEN/RESERVISTS LIVE IN REMOTE

AREAS

• ACCEPTABILITY PREJUDICED HEALTHCARE PROVIDERSNEGATIVE ATTITUDES TOWARDS MILITARY

THINGS YOU CAN DO TO HELP

• CONSIDER THINKING OF MILITARY MEMBERS AND THEIR FAMILIES AS A “SPECIAL NEEDS POPULATION”

• DEVELOP YOUR UNDERSTANDING OF CONTEMPORARY MILITARY CULTURE

• SUSPEND YOUR OWN STEREOTYPES

• BE AWARE THAT THE FIRST APPOINTMENT WITH A VETERAN IS CRUCIAL

• INTERNET –

http://wwwpdhealth.mil/ (see section for Clinicians)

http://www.battlemind@army.mil

• BIBLIOTHERAPY –

“After The War Zone” – Slone & Friedman“Courage After Fire” – Armstrong, Best,

Domenici “I Can’t Get Over It” – Matsakis“PTSD Workbook” – Williams & Poijula

“Downrange:To Iraq & Back” – Cantrell & Dean “Odysseus In America” –Shay

• REFERRALS – VA, One Source, Tricare, Military MH, FFSC

• The VA’s toll-free suicide prevention hotline is 1-800-273-TALK (8255).

RESOURCES FOR PROVIDERS & PATIENTS

THE MENTAL HEALTH NEEDS OF US MILITARY MEMBERS RETURNING FROM IRAQ &

AFGHANISTAN:

David Dean, Ed.D., HSPP – Psychologist/ContractorOFFICE PHONE: (850) 452-6326 EXT. 4106

Email – david.dean@med.navy.mil