VA Puget Sound Health Care System Deployment Health Clinic Outreach Post-Combat Evaluations Follow-up Care 11/13/2018 VISN 20 MIRECC Smoking Cessation 1

Unique OIF/OEF Veterans Treated VA Puget Sound Health Care System

VA PSHCS Mental Health Services for OIF/OEF Veterans Organizational Diagram Vet Centers Seattle Tacoma Bellingham Yakima Spokane VA PTSD Programs PTSD Clinical Teams Women’s Trauma Team PTSD Inpatient Unit PTSD Domiciliary State Dept. Veterans Affairs 29 contract therapists Affiliated Mental Health Programs Addictions Programs General Mental Health Post-Deployment Clinic Primary medical care Mental health screening/triage Brief therapy & meds management

Integrated Care for Combat Veterans Common Barriers to Treatment Lack of information on available services Perceived/actual problems with access to services (dropped cases referred to specialty clinics) Stigma against receiving care (mental or physical) Lack of information on health risks Low priority of care compared to “getting back to normal life”

Deployment Health Clinic Integrated Care for Combat Veterans “We recommend a comprehensive post-combat evaluation to establish a baseline snapshot of how you are functioning now” Physical exam and mental health evaluation with attention to pertinent deployment experiences/environmental risks Ongoing care to provide necessary treatment and monitoring for any emerging combat related conditions. Education regarding available benefits/sources of support for the veteran and his/her family to ease transition

Deployment Health Clinic The Deployment Health Clinic is dedicated to the care of veterans who are experiencing mental or physical health concerns related to a specific deployment (Gulf War I, Peace-Keeping Deployments, OIF/OEF) A philosophy of mind-body relationships is adopted in which medical and mental health concerns are presumed to interrelate 11/13/2018 VISN 20 MIRECC Smoking Cessation 6

VA Puget Sound Health Care System Deployment Health Clinic The purpose of the Deployment Health Clinic is to: Provide Outreach and Community Educational Services Address and support the veteran in all aspects of life which have been affected by their combat experience. Provide that support in an accessible and integrated format Provide support in an ongoing way for as long as it is needed

VA Puget Sound Health Care System Deployment Health Clinic The objective of the Deployment Health Clinic is to: Provide the support necessary for the veteran and his/her family to readjust, recover and be optimally functioning in all realms as soon as possible after return from combat and for the long term. 11/13/2018 VISN 20 MIRECC Smoking Cessation 8

VA Puget Sound Health Care System Deployment Health Clinic Staff Members Primary Care Physician Registered Nurse Practioner Clinical Psychologist Masters-level mental health counselor Psychiatrist 11/13/2018 VISN 20 MIRECC Smoking Cessation 9

Integrated Care for Combat Veterans Primary Treatment Interventions Deployment Health Clinic Services: Integrated mental health and medical post combat care Preventive/health promotion based care Family involvement in care Innovative psychiatric medication treatments (i.e., prazosin) Innovative Cognitive Behavioral Interventions (Brief Motivational Interviewing, BA, ACT, Mindfulness) Referrals to inpatient/outpatient mental health services (PTSD, substance abuse, general mental health services) or specialty medical clinics within the VA Medical System

VA Puget Sound Health Care System Deployment Health Clinic Post-combat care: Using the two years of post-combat priority eligibility proactively as a period for assessment, monitoring and utilization of appropriate services directed towards optimal recovery, rehabilitation and reintegration into post-combat, non-military life. 11/13/2018 VISN 20 MIRECC Smoking Cessation 11

Mental Health Problems and Clinical Services for OIF/OEF Veterans 11/13/2018 VISN 20 MIRECC Smoking Cessation 12

Common Post-Deployment Readjustment Reactions Problems with finances, employment, and housing Preoccupation with news about the war Worry about friends still deployed overseas Missed excitement of combat with urges to return Adjustment to “civilian” norms Altered schedule for sleeping and eating Marital conflict and family reintegration problems

Redefined familial roles Marital/parenting issues Integrated Deployment Clinic Care Presenting Psychosocial Health Concerns Redefined familial roles Marital/parenting issues Public Social Functioning Occupational/financial concerns Separation from military social support Risk of re-deployment 11/13/2018 VISN 20 MIRECC Smoking Cessation 14

Common Mental Health Disorders Anxiety disorders Adjustment Disorder, Generalized Anxiety, Panic Disorders, PTSD (or PTSD-like syndromes) Depressive Disorders Adjustment Disorder, Dysthymia, Major Depressive Disorder Substance Misuse, Abuse, and Dependency 11/13/2018 VISN 20 MIRECC Smoking Cessation 15

Mental Health Profiles of returning OIF/OEF Veterans Presenting to the Deployment Health Clinic (N = 128) Demographics: Mean age was 32.2 years, 95.3% were male, 72.2% Caucasian, and 50.8% were married. Measures The PTSD Checklist Military Version (PCL-M) (Weathers, Huska, and Keane, 1991) The PRIME-MD Patient Health Questionnaire (PHQ) (Spitzer, Kroenke, and Williams, 1999) depression (major depressive disorder), anxiety (any anxiety disorder except panic disorder) alcohol misuse (abuse or dependence) Barriers to Mental Health Care (Hoge et al., 2004) 11/13/2018 VISN 20 MIRECC Smoking Cessation 16

Combat Exposure Event (Percentage) stationed close to enemy lines (87.0%), faced an extreme threat to their personal safety (86.9%) received incoming fire from mortars, rockets, or artillery (74.2%). one or more firefight (59.8%) mines or booby traps (55.2%) sniper or sapper fire (51.2%). witnessed an accidental death (31.7%) took care of someone who’s life wasn’t saved (28.8%) were responsible for someone else’s death (11.2%) observed the death of a close friend (10.1%) 11/13/2018 VISN 20 MIRECC Smoking Cessation 17

Rates of Mental Health Disorders Percent (N) Depression 35.7% (46) General Anxiety 24.0% (31) Alcohol Misuse 22.5% (29) PTSD 20.9% (27) 11/13/2018 VISN 20 MIRECC Smoking Cessation 18

Rates of Mental Health Disorders (continued) Count Percent (N) All 4 3.1% (4) 3 Or More 18.6% (24) 2 Or More 33.3% (43) 1 Or More 48.1% (62) None 51.9% (67) 11/13/2018 VISN 20 MIRECC Smoking Cessation 19

Barriers to Receiving Mental Health Care The most frequently cited barriers to accessing mental health services: financial (35.4%) fear of being perceived as weak (30.8%) fear of being treated differently by unit leadership or employers (26.2%). 11/13/2018 VISN 20 MIRECC Smoking Cessation 20

Deployment Health Clinic Integrated Care for Combat Veterans 11/13/2018 Deployment Health Clinic Integrated Care for Combat Veterans Question: Does routine delivery of mental health assessment/ treatment in the primary care setting reduce stigma, improve satisfaction with care, and/or increase utilization of mental health services among soldiers returning from OIF/OEF? Utilized Hoge et al. Stigma and organizational barriers to care questions. 170 questionnaires were filled out before meeting with a MH professional. Follow up questionnaire were mailed 4 months later 11/13/2018 VISN 20 MIRECC Smoking Cessation 21 VISN 20 MIRECC Smoking Cessation