1. Epidemiology of Pain, PTSD, and Post-concussive Syndrome among OEF/OIF Veterans Michael E. Clark, Ph.D. Clinical Director, Chronic Pain Rehabilitation Program Chair, VA National Polytrauma Pain Workgroup Departments of Neurology and Psychology, University of South Florida

2. Headache Pain is Characteristic Kalra, Clark, & Scholten, 2008Kalra, Clark, & Scholten, 2008 52% when asked52% of 99 OEF/OIF former service members registered for endorsed the presence of headaches when asked 42%42% reported headache related interference and averaged 4 headaches per week Ruff, Ruff, & Wang, 2008Ruff, Ruff, & Wang, 2008 63%63% of a sample of 126 outpatients with mild TBI symptoms reported headaches 92%Among those with cognitive deficits, prevalence of headaches was 92% 2

3. Comorbid Mental Health Conditions are Pervasive 65% 65% of PRC inpatients received a mental Health Diagnosis: (Walker & Clark, 2006) Adjustment Disorder: 47%Adjustment Disorder: 47% PTSD: 29%PTSD: 29% Depressive Disorder: 24%Depressive Disorder: 24% Substance Abuse: 7%Substance Abuse: 7% Acute Stress Disorder: 5%Acute Stress Disorder: 5% 67% In a sample of 99 VA medical care registrants 67% reported emotional problems: (Kalra, Clark, Scholten, Murphy, & Clements, 2008) 36%16% 36% Depression 16% PTSD symptoms 23%15% 23% Adjustment problems 15% anger control issues 20%12% 20% Anxiety12% alcohol abuse 19% 19% Marital or family problems 3CLARK- 2009

4. Pain, PTSD, mTBI, and substance use disorders often co-occur and interact CLARK- 20094 AuthorSubjectsPain SxPTSD SxTBI SxSubs Sx Clark et al., 2007PRC inpatients (Tampa)96%44%80%4% Hoge et al., 2008Soldiers with LOC50%-100%*44%100%N/A Kalra et al., 2008Outpts with pain (Tampa)100%16%N/A12% Kang & Hyams, 2007OEF/OIF VA disability evalsN/A15%N/A3% Lew et al., 2007Outpts with H/O mild TBI97%42%100%N/A Ruff et al., 2008OEF/OIF outpts with mild TBI93%**90%100%N/A Sayer et al., 2008PRC inpatients (all PRCs)82%42%88%N/A Shipherd et al., 2007Outpts seeking PTSD Tx66%100%N/A28% Villano et al., 2007 295 OEF/OIF Mental Health patients 40%46%***N/A49% *Headaches only. Total pain % not reported but data for separate pain conditions suggests it approaches 100% in these war-injured. * *Headaches only. Total pain % not reported

5. PCS Symptoms*Mild TBIPTSDChronic PainSUD Memory impairment 1,2 √√√√ Concentration problems 1,2 √√√√ Irritability 1,2 √√√√ Insomnia/Sleep Problems 1,2 √√√√ Fatigue 1,2 √√√√ Headache 1,2 √√√√ Dizziness 1,2 √√√? Intolerance of stress, emotion, or alcohol 1 √√√√ Affective disturbance 2 √√√√ Personality change 2 √√√√ Apathy 2 √√√√ There is substantial overlap in symptoms in mTBI, pain, PTSD and SUD

6. OEF/OIF pain may be more difficult to treat

7. 7 Pain Change Following Interdisciplinary Treatment

8. Post-Deployment Multi-symptom Disorder PTSD TBI PAIN TBI/Pain TBI/PTSD Pain/PTSD Post-deployment Multi-symptom Disorder 8CLARK- 2009

9. PMD Example Overall prevalence: Pain 81.5% TBI 68.2% PTSD 66.8% PTSD TBI PAIN Post-deployment Multi-symptom Disorder TBI/Pain TBI/PTSD Pain/PTSD Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009 Sample = 340 OEF/OIF outpatients at Boston VA 42.1% 5.3% 2.9% 16.5% 10.3% 12.6% 6.8% 9CLARK- 2009

10. Latest Data HSR&D funded study examining OEF/OIF pain and emotional issues at 2 of the 4 PRC sites Participants recruited either from the polytrauma network of care (convenience) or local OEF/OIF registries (random) Follow all participants for 12 months Approximately 600 data points Utilize validated and accepted structured diagnostic interview for DSM IV diagnoses Following data represent a “first look” at some results for 127 participants

11. Biases PRC/PNS Sample (n= 69) OEF/OIF Sample (n= 52) Polytrauma already selected for Tx Agreed to participate (40%) Random sample from OEF/OIF VA registry Agreed to participate (21%) Regional effects? (Minneapolis) Regional effects? (Tampa)

12. Demographics Recruitment Duty Status OEF/OIF Registry41.50% Active Duty Active Duty17.2% PRC/PNS55.10% Inactive Reserve8.2% Other3.40% Active Reserve Active Reserve23.8% Age34.9 TDRL3.3% Education14.29 Completed obligations47.5% SexEmployment Male91.0% Full-time52.0% Female9.0% Part-time8.0% Race Unemp/not looking Unemp/not looking1.6% Caucasian77.9% Unemp/looking Unemp/looking15.2% Hispanic11.5% Disabled7.2% Black10.7% Retired3.2% Marital Student10.4% Single25.4% Service Connection Married45.9% NSC19.2% Living together3.3% NSC-PN1.4% Divorced/Sep25.4% SC63.2% SC Claim Pending20.9%

13. Deployment Deployed from Blast Type Active duty57.4% IED42.4% Inactive reserve28.7% Mortar27.2% Active reserve13.9% RPG5.6% Deployed to All other24.4% OEF only9.6% Mean # of blasts 111.2* OIF only69.6% Adjusted mean # of blasts 13.7 Both OEF/OIF20.2%LOC20.8% Total deployment time 15.3 months Injuries from blast 50.0% Mean time since return 38.6 months Avg distance from blast 271 feet Exposed to blast(s) 90.2% Polytrauma % 70.70%

14. Pain Persistent pain present in 86.4%, average pain 3.7 Significant pain (4 or >) 50.4% Headache prevalence 72.5% Days/week with headaches 3.6 Most common pain locations Primary Pain Any Pain Back 29.9% 75.9% Head 29.0% 66.7% Shoulder 11.2% 49.1% Knee 7.5% 56.5% Neck 5.6% 48.1% Hand/wrist 4.7% 25.9% Ankle/foot 3.8% 25.0% Leg/Hip 2.8% 24.1% Arm/elbow 1.9% 24.1%

15. Mental Health Problems Ever had a MH problem 83.60% Reported impairments Onset of MH problem Activity73.60% Pre-service5.00% Sleep65.30% Pre-deployment5.00% Recreational60.30% Combat non-blast related 4.00% Occupational59.50% Combat blast-related20.80% Emotional58.70% Non-combat/during deployment 10.90% Social51.20% Post-deployment48.50% Familial43.00% Post-service5.90% Sexual35.50% Resolution of MH problem Before deployment9.80% After deployment6.86% During deployment4.90% Ongoing- not resolved87.25%

16. Treatment Experience Pain Tx (Prior 3 months) Treated in PRC/PNS 56.40% VA treatment for pain45.50%Using VA for all medical and MH care51.70% Tx Satisfaction (0-10)7.1Overall satisfaction with VA (0-10)8.2 Effectiveness (0-10)5.7Overall effectiveness of VA (0-10)7.5 Community treatment for pain16.40% Most common barriers to VA care Tx Satisfaction (0-10)6.9 Fear/embarrassment/stigma16.00% Effectiveness (0-10)5.9 Distance/location15.20% MH Tx (Prior 3 months) Staff concerns/reputation for care12.80% VA MH Tx45.70% Waiting time/access/delays12.80% Tx Satisfaction (0-10)7.8 Paperwork/hassle11.20% Effectiveness (0-10)7.1 Lack of info about services11.20% Community MH Tx15.60% Limited hours for services4.80% Tx Satisfaction (0-10)6.1 Fear of military accessing records4.00% Effectiveness (0-10)5.6 No barriers29.60%

17. DSM-IV Mental Health Diagnoses At least 1 M.I.N.I. Dx 66.4%PTSD 35.9% Depression Mood disorder with psychotic features 2.6% Major Depression39.3% Antisocial Personality Disorder 4.3% Dysthymia3.4% Substance Use Disorders 1 or more depressive disorders41.0% ETOH dependnece 16.2% Hypomania29.1% ETOH Abuse 10.3% Anxiety Opioid Dependence 1.7% Panic disorder24.8% Opioid Abuse 1.7% Agoraphobia25.6% Other Substance Dependence 2.6% Social Phobia10.3% Other Substance Abuse 1.7% Obsessive-compulsive disorder17.1% Polysubstance Abuse 0.9% Generalized Anxiety Disorder17.2% 1 or more substance use disorders 26.5% 1 or more anxiety disorders (except PTSD) 44.0%

18. Diagnostic Overlap Pain prevalence 86.4%Comorbidities PTSD Prevalence 35.9% Pain and PTSD only20.5% mTBI prevalence mTBI prevalence (based on LOC) 25.9% Pain and mTBI only8.2% Pain only Pain only (no mTBI or PTSD)47.2% PTSD and mTBI only0.0% mTBI only mTBI only (no pain or PTSD) 2.4% Pain, PTSD, and mTBI13.1% PTSD only PTSD only (no pain or mTBI) 0.8% Pain and Substance Abuse22.4%

19. Symptom Burden 1

20. Symptom Burden 2

21. Symptom Burden 3

22. PMD Treatment Postconcussion Pain PTSD P3+ Post-Deployment Behavioral Health Program 22

23. P3+Team  Staff with specialties in  Behavioral Medicine  Pain  PTSD  TBI  Substance Abuse  Case Management  PM&RS therapies 23

24. P3+ Integrated Care Post Deployment Clinics Polytrauma Teams Optional Core Treatments: Anger Management Negative Affect Cognitive Adaptation Relationship Enhancement Work Skills Physical Conditioning TBI Tx Pain Tx PTSD Tx Substance Abuse Tx Focused Treatments (existing & expand) Evaluation/Tx Planning Required Core Treatment: Life Needs (Sleep Hygiene, Relaxation Skills; Substance Use) New Program VR Tx Existing Programs DoD Facilities 24

25. Where do we go from here?. Data, data, data! How do these overlapping comorbidities interact, and does it impact outcomes? What are the most effective and efficient treatments for PMD? What increased health and adjustment risks are associated with blast exposure? Until data become available, develop innovative but rational programs based on existing knowledge and conceptual models 25