LTC(P) Christopher Warner, MD Consultant to The US Army Surgeon General for Psychiatry

Scope of the Problem PTSD prevalence in OEF/OIF service members is 13-20% (based on literature); civilian population 7% (lifetime) and 4% (12 month.) Incidence is ~1% for all service members; prevalence has increased from 0.4% in 2004 to 5% in 2012, 8% for previously deployed (OSM data); prevalence varies by service branch. In 2013, 528,260 veterans made at least two visits to VA for PTSD outpatient care, and 25% of these were new patients. 23.6% of all veterans using VA PTSD services in 2012 were OEF/OIF veterans. 47% of all veterans using VA specialized outpatient PTSD programs were OEF/OIF veterans.

US Army Behavioral Health after 9/ – 2005: –Many fold increase in demand, visibility, accountability and communication regarding BH care for Soldiers and families –Growing recognition that existing BH programs were insufficient to meet the need 2005 – 2009: –Explosion of unique, local solutions to various deficiencies within BH care –“1,000 flowers blooming” –Major concerns with BH readiness of the fighting force 2009 – Present: –Identification of effective and efficient BH programs –Consolidation of a series of programs into a single, cohesive system of care

Maturing to an Operating Company Holding Company Operating Company Holding Companies: Highly autonomous business units Low standardization Few common services Operating Companies: Strong enterprise relationships High standardization and integration Shared values and services Building upon what the Army Medicine team does well by improving consistency, clarity, and accountability

Behavioral Health System of Care

PTSD Treatments Prior to 9/11 Three psychotherapies: PE, CPT and EMDR. Two FDA-approved drug medications for PTSD: Zoloft and Paxil. Little or no validation of these treatments with combat-related PTSD. Nearly all large trials were conducted with rape/assault survivors. Off-label drug treatments for combat-related PTSD was the norm. Both the VA and NIMH had extremely small PTSD research programs (less than $10M combined total). The DoD had no PTSD research programs (either intramural or extramural).

Impact of Leadership on BH diagnoses Any Mental Health Problem by Combat Experience & Non-Comissioned Officer Leadership Percent Screened Positive Adjusted R Square =.15 and the Chi Square is significant at the.01 level - McGurk, et al, “The effects of NCO leadership on the mental health of OIF soldiers, at the Force Health Protection Conference, 2006

≥ 50% of Soldiers with PTSD and other mental health problems do not receive care. Soldiers who begin treatment often drop out: –Of 1,962 Army infantry Soldiers who received a new PTSD diagnosis in their EMR within 90 days of return from Afghanistan, only 804 (41%) received ≥8 sessions of BH treatment for this diagnosis over 12 months follow-up (one common definition of “adequate” care) (Hoge, et. al Psychiatric Services 2014). –In VA Health Care Settings, only one-third of veterans with a new PTSD diagnosis received an opportunity for adequate care (e.g., ≥8 BH treatment sessions. (Lu 2011; Spoont 2010; Harpaz-Rotem 2011) Recovery from PTSD can be as high as 70-80%, but only in treatment completers; overall recovery across studies averages only ~40%, due to drop outs. PTSD: Key Background Data

Therapy Outcomes Determinants Lambert M, ed. Bergin and Garfield's handbook of psychotherapy and behavior change

Reasons for treatment non-engagement or drop-out: –Stigma perceptions “I would be seen as weak.” “It will harm my career.” –Organizational/Other Barriers “It’s too difficult to get an appointment.” “It’s too difficult to take time off work.” –Self-sufficiency “I should be able to take care of problems on my own.” –Negative perceptions of mental health care “I don’t trust mental health professionals.” “I felt judged or misunderstood.” “I didn’t like the treatment option offered.” Self-sufficiency and negative perceptions of care are turning out to be stronger predictors of not seeking treatment than traditional stigma/barriers. (Kim P, 2010; Hoge CW, 2014; Adler, et. al. 2014) Challenges to Care Delivery

Key Points: Army Policy “Stand-down” type training at least every year for every provider Ensuring evidence-based assessment and treatment services for Soldiers, and family members, with PTSD is a high priority. Retaining Soldiers in treatment is the single most important factor to optimize recovery. The Army policy on assessment and treatment of PTSD is intended to enhance and standardize assessment and treatment approaches.

Future DoD Efforts While many findings are valid at the DoD level, many others do not reflect current practices within the Army. Leading PTSD research and incorporating findings into practice –PDHRA –Land Combat Study – impact of leadership – EBH development Developed a system based on best practices and known barriers to care delivery: BHSOC, incorporating more factors than the type of treatment Created a system for trauma/PTSD treatment within the BHSOC (policy and programs) Created the nation’s most advanced system for acquiring and utilizing standardized, automated clinical outcomes for PTSD and other conditions. Army providers are trained in evidence-based modalities and use the core components regularly. Army is approaching family member care, including school-based care and outreach

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