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…..
1.64 MILLION US TROOPS DEPLOYED TO
OEF/OIF SINCE OCTOBER 2001
49% - ACTIVE DUTY TROOPS
51% - 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
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)
COMBAT STRESS REACTIONS
• 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 – 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 SHOW
SIGNIFICANT INCREASES ON 7 MONTH POST-INJURY
REEVALUATION (Grieger 2006)
1 Month P.I.
PTSD Sx
4.2%
Depression Sx
4.4%
7 Month
12.0%
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 posttraumatic stress disorder.
photo: Warren Zinn, AP via Army Times
SUICIDE AMONG US VETERANS
OF OEF/OIF BY BRANCH OF SERVICE
ALL OEF/OIF
VETERANS
NO. OF VETERANS
Separated - Alive from
Oct 2001 – Dec 2005
490,346*
SUICIDES
144
BY BRANCH
NO. BY BRANCH
SUICIDES
ARMY
274,862
73 (1.21)
MARINES
55,166
15 (1.05)
NAVY
65,371
23 (1.34)
AIR FORCE
94,947
33 (0.99)
SOURCE: Kang, H.K. JAMA, August 13, 2008 – Vol. 300, No. 6 pp.652-653
SUICIDE AMONG US VETERANS
OF OEF/OIF BY SERVICE COMPONENT
COMPONENT
NO. OF VETERANS
SUICIDES
Oct 2001- Dec 2005
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 in
the 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.
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.
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)
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 BARRIERS
FOR VETERANS OF GWOT
• AVAILABILITY IN GOVERNMENT/DOD CLINICS
SHORTAGE OF TRAINED MILITARY PROFESSIONALS
SHORTAGE OF ELIGIBLE CIVILIAN PROVIDERS
• ACCESSIBILITY IN GOVERNMENT/DOD CLINICS
LONG WAITING LISTS
SOME MILITARY CLINICS CANNOT SEE FAMILIES
FACILITY HOURS ARE LIMITED
GUARDSMEN/RESERVISTS LIVE IN REMOTE AREAS
• ACCEPTABILITY
PREJUDICED HEALTHCARE PROVIDERS
NEGATIVE 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
RESOURCES FOR PROVIDERS & PATIENTS
• 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).
THE MENTAL HEALTH NEEDS OF US MILITARY
MEMBERS RETURNING FROM IRAQ & AFGHANISTAN:
David Dean, Ed.D., HSPP – Psychologist/Contractor
OFFICE PHONE: (850) 452-6326 EXT. 4106
Email – david.dean@med.navy.mil