1. Psychiatric Care of Active and Reserve Service Members and Veterans

2. Assistant Medical Director for Inpatient Mental Health Services HealthPartners Medical Group John Kuzma, M.D

3. Disclosures Employee of HealthPartners Medical Group LTC (Ret) MNARNG No outside interests Opinions are my own and will be identified as such

4. Objectives 1.Identify psychiatric issues commonly encountered by active, reserve and retired service members. 2. Understand current consensus guidance on pharmacologic and psychotherapeutic interventions to treat psychiatric disorders seen in active, reserve and retired service members.

5. Some background 2.4 million active and reserve service members 13,000 MN National Guard (Army and Air Guard) 400,000 veterans in Minnesota (2010)

6. Not your Father’s Army… All-Volunteer Many more “long- timers” (older, with families) 14-23% female

7. No more weekend warriors… Multiple Deployments Majority of deployed troops for much of OIF/OEF

8. Key MH Issues Combat Stress Reaction and PTSD Substance Use Disorder Traumatic Brain Injury Suicidal Thoughts and Behaviors Resilience

9. Combat Stress Reaction and PTSD

10. “PTSD” PTSD is often used as shorthand for military- related mental health disorder by members of the military and the general public. PTSD seen as more acceptable diagnosis, especially within the military.

11. An Anectdote (aka ‘War Story’) “First Sergeants do NOT get panic attacks!”

12. Combat Stress Reaction - PTSD Useful to think of this as a range with most deployed soldiers experiencing transient and subclinical deployment responses” (>95%) with smaller subset developing PTSD (10-14%, -- controversial)

13. Subclinical Distress Responses Aggression Sleep Disturbances Impulse Control Difficulties Hyperstartle Reaction Social Isolation Emotional Numbing Substance Misuse High-Risk Behaviors

14. PTSD Criteria DSM-5 A. Exposure to actual or threatened death, serious injury or sexual violence by directly experiencing, witnessing, learning about traumatic event to family or close friend, repeated exposure to aversive elements of traumatic event.

15. PTSD Criteria DSM-5 B. The traumatic event is persistently re- experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s). Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli.

16. PTSD Criteria DSM-5 B. The traumatic event is persistently re- experienced in the following way(s): (one required) Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s). Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play. Intense or prolonged distress after exposure to traumatic reminders. Marked physiologic reactivity after exposure to trauma-related stimuli.

17. PTSD Criteria DSM-5 Criterion C: avoidance Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) Trauma-related thoughts or feelings. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

18. PTSD Criteria DSM-5 Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs). Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). Constricted affect: persistent inability to experience positive emotions.

19. PTSD Criteria DSM-5 Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance

20. PTSD Criteria DSM-5 Criterion F: duration Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.

21. PTSD Criteria DSM-5 Criterion G: functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational).

22. PTSD Criteria DSM-5 Criterion H: exclusion Disturbance is not due to medication, substance use, or other illness.

23. PTSD Criteria DSM-5 DSM-5 Introduces Delayed and Derealization Specifiers Acute Stress Disorder criteria but shorter duration (< 30 days) and greater propensity for dissociative symptoms.

24. PTSD – time of onset Deployed units in high-intensity operations have relatively low rates of PTSD, with these rates increasing 3-6 and 12-months after deployment. Clinical awareness is especially vital as Guard and Reserve soldiers may be back in the civilian communities when symptoms develop.

25. PTSD – treatment Most recent studies support not only exposure and cognitive psychotherapies supplemented with medications. Strong evidence supporting SSRIs, lesser extent SNRIs. Less evidence for atypical antipsychotics, beta blockers, and mood stabilizers but these are also commonly used.

26. PTSD -treatment Alpha agonist Prazosin shown to be helpful for insomnia and nightmares. Good evidence, but no FDA indication.

27. PTSD – treatment Benzodiazepines and other GABA agents have shown to not be effective and in fact increase PTSD symptoms. This evidence, as well the risk of abuse and potential danger of respiratory depression (especially with comorbid alcohol and/or opiate use) argues for caution. Be Careful.

28. Substance Use Disorders

29. Substance Abuse Common in the military – per 2008 DoD survey: Tobacco Abuse – 31% Illicit Drug – 12% Prescription Drug Abuse – 11% Heavy Alcohol Use – 20% Caffeine - ???

30. Substance Abuse Commonly used maladaptive coping strategy for stress of military life. General Order Number One – almost no alcohol use, but rise in prescription drug abuse, huffing.

31. Substance Abuse Military Response is balance between need to identify use and to retain good soldiers, airman, sailors and marines. “Mission First, Soldiers always.”

32. Traumatic Brain Injury

33. Blow or jolt to the head that results in temporary and permanent cerebral dysfunction. 2000- 1Q 2012 – 444,217 unique cases with 77% ranked as mild severity. Appropriate assessment critical to determine appropriate interventions as well as maximize opportunity for recovery

34. Traumatic Brain Injury Along with PTSD, TBI is the “signature disorder” of OIF/OEF, although MDD remains the most common psychiatric disorder in theater and post-deployment. TBI increases risk of MDD, PTSD and substance abuse.

35. Traumatic Brain Injury TBI is cumulative (Dementia pugilistica, chronic traumatic encephalopathy) Identification, documentation and longitudinal assessment vital.

36. Traumatic Brain Injury - Assessment Mild: GCS 13-15, AOC <24 hours, LOC 0-30 min, PTA < 24 hours, Imaging - Moderate: GCS 9-12, AOC >24 hours, LOC >30 min 24 hours < 7 days, Imaging +/- Severe: GCS 3-8, AOC >24 hours, PTA > 7 days, Imaging usually +

37. Traumatic Brain Injury - Symptoms Somatic : Headache, Dizziness, Fatigue, Photophobia, Visual disturbances, Tinnitus. Cognitive: Memory, Attention, Concentration, Processing Speed, Dysphasia Neuropsychiatric: Anxiety, Irritability, Depression, Emotional Lability

38. Traumatic Brain Injury –Treatment Treatment is focused on cognitive and physical rehabilitation with medications utilized for symptomatic relief.

39. Traumatic Brain Injury – Medication Treatment Headaches – Depakote, Lamictal, Tegretal, NSAIDs Sleep – Trazodone, mirtazapine Neuropsychiatric – SSRIs, Mood Stabilizers AVOID Benzodiazepines and Opiates

40. Suicidal Thoughts and Behaviors

41. Suicide 10 th leading cause of death in U.S (1.4 % all deaths) Suicidal Ideation: 5.6 – 14.3% Lifetime Prev. Suicide with Plan: 3.9 % of population Suicide attempts: 1.9-8.7% of population

42. Suicide Retrospective study suggest 34% of pts with ideation develop a plan and 72% of those with a plan eventually make an attempt. Same study 26% of attempters had previously denied making a plan.

43. Suicide Traditionally suicide rate in military lower than in general population. Since OIF in 2003 rate has steadily risen and in 2008 surpassed the general population 22 per 1000,000). Minnesota has the highest suicide rate in the National Guard.

44. Suicide Suicide is a behavior not a disorder. Current research is focused on the development of vulnerability-stress model.

45. Vulnerability-Stress Model Predisposing Factors (vulnerabilities) interact with environmental events (stressors) to trigger suicidal behavioral.

46. Vulnerability-Stress Model Predisposing Factors (vulnerabilities) interact with environmental events (stressors) to trigger suicidal behaviors

47. Vulnerability-Stress Model Mental Disorders, Previous suicidal behaviors, psychological factors, demographics, Family History, Stressful Life Experiences Situational Factors

48. Protective Factors Psychological Factors (Resilience) Social Support Mental Health Treatment

49. Suicide Assessment Focused clinical interview looking at risk factors and protective factors Several psychological instruments have been validated, but these are structured interviews rather than a patient-completed survey. Sensitivity vs. specificity

50. Treatment for Suicidality Acute Psychiatric Hospitalization – limited resource and requires that a thorough assessment. 2002 study demonstrated that ~70% of patients who completed suicide saw their PCP in the previous month.

51. Treatment for Suicidality Medications: effective in treating specific psychiatric disorders, some medications (Lithium, Clozaril) have been shown helpful in reducing suicidality Needs to be balanced against risk of misuse or overdose.

52. Treatment for Suicidality Psychotherapy – specifically those utilizing cognitive and mindfulness principles have been shown to be helpful in reducing suicidal behaviors. Poorly managed therapy can prompt regression and actually increase risk of suicidal behavior.

53. Treatment for Suicidality Weapons Management – especially sensitive issue in the military, especially during deployment. “Safety Contracts” – commonly used, but no evidence that they are effective. “Safety Plan” – more collaborative process that has been shown to be effective.

54. Treatment for Suicidality Suicide risk can be mitigated, never eliminated. Documentation should identify reasoning behind hospitalization, somatic and psychotherapeutic interventions and attempts to address modifiable risk factors.

55. References

56. Pub Med and Ovid References available as separate file or by emailing me at john.m.kuzma@healthpartners.com

57. Questions?