Post-Deployment:
Care for OEF/OIF/OND Veterans
08/04/13
Primary Authors: Samina Iqbal, MD
VA Palo Alto Health Care System
Natara Garovoy, PhD, MPH
VA Palo Alto Health Care System
Contributors:
Linda Baier Manwell
University of Wisconsin-Madison Center for
Women’s Health Research
Molly Carnes, MD, MS
University of Wisconsin-Madison Center for
Women’s Health Research
Linda Van Egeren, PhD
Minneapolis VA Medical Center
2
Objectives
• Describe the demographic characteristics of female
OEF/OIF/OND Veterans
• Address care for deployed Veterans
• Identify common post-deployment medical and
mental health conditions
• Explore methods to assess and facilitate mental and
physical health care
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Age distribution of women Veteran
patients, FY01-FY10
Cohort: Women Veteran patients with non-missing ages between 18-110 (inclusive) in FY01 and FY10. Women in FY01: N=175,580; FY10: N=316,865.
Source: WHEI Master Database
.
Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2 (October 2012)
Demographics of Female OEF/OIF/OND Veterans
Seen within VAHCS: 2001- 2013Q1
Over 250,000 served since 2001-2013
Over 186,933 separated, 108,164 seen at VA
Army
54%
Air Force
24%
Navy
19%
Marines
4%
53% less than 30 years of age – 80% less than 40
88% enlisted, 12% officers
57% active duty, 43% reserve/guards
White 43 % - Black
18 % - Hispanic
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11%
Outpatient Visits During FY 2002-2011
• 56% have been seen at least once at a VA
Number of Days Seen as an Outpatient
1
11.3%
2-10
40.2%
11+
48.5%
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Where are Female OEF/OIF/OND Veterans Getting Their
Care? Percent of Women Veterans Seen by VISN
VISN 1
3.5%
VISN 12
5.9%
VISN 2
2.5%
VISN 15
4.1%
VISN 3
3.9%
VISN 16
9.7%
VISN 4
4.7%
VISN 17
9.5%
VISN 5
4.7%
VISN 18
5.9%
VISN 6
9.5%
VISN 19
4.8%
VISN 7
10.7%
VISN 20
5.6%
VISN 8
8.3%
VISN 21
5.2%
VISN 9
5.1%
VISN 22
9.1%
VISN 10
3.0%
VISN 23
5.5%
VISN 11
3.7%
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Addressing Care for Deployed Veterans
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Case Example 1
Jessica, a 24-year-old Marine veteran, presents to your
clinic with severe low back and foot pain that developed
while she was deployed. She tells you her boots didn’t fit
well. She had to carry heavy equipment while performing
her duties. She also describes recent episodes of heart
pounding and feeling hot and dizzy.
Jessica joined the military after finishing high school. She
was raised by her mother.
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Case Example 1, continued
When you ask about her role in the military, Jessica
tells you that she was a gunner. On more than one
occasion, she helped remove the bodies of soldiers
from a river. She was exposed to fumes during her
duties.
Jessica was diagnosed with thyroid cancer and
medically discharged from the military. She was started
on suppressive doses of levothyroxine.
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Begin with a Good History
• Medical History
• Gynecological History
• Mental and Psychosocial Health
• Family History
− Medical conditions
− Mental health conditions
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Pre-Military Life:
Psychosocial Risk Factors
• Pre-military life is recent vs. remote
• Screen for the following:
–
–
–
–
Living environment
Supportive relationships
Significant life events
Mental health history
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Why is it Important to Ask?
• Psychologic trauma (whether early life or recent)
may impact:
– Subsequent psychologic/emotional functioning
– Subsequent rates of psychiatric morbidity/substance use
disorders
– Psychophysiological disorders (pain)
– Psychosocial functioning
– Health services utilization
– Long-term physical health outcomes
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Military Life:
Changing Roles for Women
• Serving in combat support units
– Gunners, police, pilots, truck drivers, fuel suppliers
– Walking, driving, jumping, running
• Exposed to unpredictable warfare
– Improvised explosive devices (IEDs), RPG, mortars
• Daily operations
– Equipment and gear, ceramic vests, extreme temperature
– Facilities, hygiene issues
– Health care
• Exposed to military sexual trauma
– Perpetrator may be a soldier in the unit
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Carney, 2003.
Military History – What to Ask
Tell me about your military experience….
•
•
•
•
•
When and where do you/did you serve?
What do you/did you do while in the service?
How has military service affected you?
Were you exposed to chemicals or fumes?
Were you ever in close proximity to blasts?
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Military History – Follow-up
If your patient answers "Yes" to any of the following
questions, ask: "Can you tell me more about that?"
•
•
•
•
Did you see combat, enemy fire, or casualties?
Were you or a colleague wounded, injured, or hospitalized?
Did you ever become ill while you were in the service?
Were you a prisoner of war?
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Why is it Important to Ask?
• To acknowledge military service as part of an
individual’s life
• To relay the message:
– It means a lot to us that you are a Veteran
– We appreciate your service and your sacrifice
– We want to hear your story
• To pay attention to ways in which military service
might affect current or future health
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You may well …
• Prevent family breakdown
• Prevent social withdrawal and
isolation
• Prevent problems with employment
• Prevent alcohol and drug abuse
• Prevent suicide
• Break down barriers and reduce stigma
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Post-Deployment Evaluation
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Post-Deployment Screens
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
GI
Fever
Skin Rashes/Lesions
Embedded Fragments
Traumatic Brain Injury
PTSD
Depression
Alcohol Use
Tobacco Use/Counseling Screen
MST
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Traumatic Brain Injury
Symptoms
•
•
•
•
•
Memory
Concentrating
Headaches, loss of balance, dizziness
Sleep problems
Fatigue/irritability
Prevalence in women is unknown
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Toxic Embedded Fragment Screen
•
•
•
•
Retained metals or plastic fragments
Not inert
May be absorbed into blood stream
Adverse local or systemic effects
ASK
• Exposure to bullet, blast, or explosion?
• Embedded fragments?
− Documented by radiograph
− Removed
− Remains
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Medical Diagnoses: Female OEF/OIF/OND
Veterans in VA: 2001-2013 (Q1=108,164)
•
•
•
•
•
•
•
•
•
•
•
Musculoskeletal
Ill Defined Conditions
Mental Disorders
Nervous System/Sense Organs
Genitourinary System
Digestive System
Respiratory
Endocrine System
Diseases of Skin
Injury/Poisonings
Infectious and Parasitic Diseases
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57%
57%
52%
45%
41%
38%
37%
34%
28%
28%
20%
Common Conditions in OEF-OIF Veterans
Diagnosis
Back Problems
Joint Disorders
PTSD
Mild Depression
Reproductive Health
Conditions
Musculoskeletal Disorders
Women
9.4%
9.2%
8.4%
6.8%
6.2%
Men
10.3%
9.5%
9.7%
4.1%
4.6%
4.1%
Haskell, 2011.
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Pain in OEF/OIF/OND Veterans
• 47% report chronic pain after deployment
– Over 80% diagnosed with musculoskeletal or connective
tissue disorder
– 28% reported moderate to severe pain
• Rates of disability cases within U.S. military are increasing
• Pain is the primary physical problem afflicting soldiers
• Service-related chronic pain often begins in basic training
– Up to 25% of male recruits and 50% of female recruits likely
to experience at least one pain-related injury during Basic
Combat Training
Data From: Zambraski, 2006
Slide by: Don McGeary, Ph.D., ABPP, University
of Texas Health Science Center San Antonio
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Case Example 2
Shaya, a 27-year-old Army reservist, presents in your
clinic with concerns about anger. When you ask about
her life before the military, you learn that she grew up in
a violent neighborhood and witnessed a close friend die
in a drive-by shooting just days before she was deployed.
When deployed, she left her husband and two-year-old
son for 13 months. When she returned home, she and
her husband had an argument that became physically
violent toward her.
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Mental Health Disorders:
Female OEF/OIF/OND Veterans Seen in VA 2002-2013
(Q1=108,164)
Adjustment reaction
35,441
Depressive disorders
30,619
Anxiety, dissociative, mood, somatoform
disorders
25,661
Nondependent drug abuse
19,119
VHA Office of Public Health and Environmental Hazards, 2012.
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Adjustment Process vs. Disorder
• Adjustment may be a normal process
– Expected, transient stress reactions
• Adjustment disorder
–
–
–
–
–
Debilitating reaction to a life stress
Distress ≤6 months
Symptoms of anxiety and/or depression
Disruption in employment, relationships, school
Can develop into a depression or anxiety disorder if
unresolved
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PTSD Rates and Risk Factors Among Women
• Women are twice as likely to be diagnosed as males
• Prevalence is 15-17% among OEF/OIF veterans
• Co-morbid substance use
– Preliminary evidence suggest binge drinking among OEF/OIF
veterans
•
•
•
•
Suicidal ideation
Risky behaviors
Re-victimization
Often presents as medical complaints (e.g., sleep difficulties)
or psychosocial stressors
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Depression and Anxiety in Women
• Women are twice as likely as men to be diagnosed
with depression
–
Preliminary evidence indicates that OEF/OIF female
veterans are more likely to be diagnosed with depression
than men
• Two-thirds of patients with generalized anxiety
disorder (GAD) are female
• Women are twice as likely as men to be diagnosed
with a panic disorder
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Military Sexual Trauma (MST) Screening
In FY 2012:
72,497 women Veterans screened
Prevalence rate among all women Veterans screened
23.6%
11,107 OEF/OIF/OND women Veterans screened
Prevalence rate among OEF/OIF/OND women Veterans
20.5%
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MST as a Risk Factor
• MST is associated with…
Increased suicide risk
Major depression
PTSD
Alcohol/drug abuse
Disrupted social networks
Occupational difficulties
Sexual dysfunction
Asthma
Breast cancer
Heart attacks
Obesity
Menstrual and pelvic pain
Somatization
Murdoch et al, 2006; Stein & Barrett-Connor, 2000; Frayne et al, 1999, Kimerling et al, 2010.
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Why do sexual trauma survivors exhibit more physical
problems?
1. Indirect mechanisms
• High risk behaviors (substance abuse, risky sexual
behaviors, risky driving)
2. Direct health effects of assault
• 4 - 30% get an STI
• 4% are injured
• 5% become pregnant
3. Physiologic mechanisms
• Dysregulation of hypothalamic-pituitary-adrenal axis
4. Somatization
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Top 10 Medical Conditions in OEF/OIF Women Veterans:
By Mental Health Condition (MHC) Status, FY06-07
Frayne S, Chiu V, Iqbal S, et al, 2010.
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Trauma and Violence in Women
• Prevalence of PTSD has been linked to differences in
trauma exposure (e.g., higher rates of interpersonal
trauma among women), but evidence is mixed.
• Women with histories of interpersonal violence are
more likely to develop anxiety symptoms, depression,
and physical health problems as well as PTSD.
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Eating Disorders
• 2-3% of men, 5% of women
– Minneapolis study of 107 women entering VA clinic… 25%
binging and 7% purging
• Most patients with eating disorders do not have
signs on physical examination
• Do not present with ED as a primary complaint
• Often develop during service (binge and purge prior
to weigh-ins)
• Associated with tooth, throat, bowel problems
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Smoking Prevalence by Sex in OEF/OIF Veterans
Evaluated at a VA Healthcare Facility (FY 2002-08)
Category
Females
Males
(ICD-9 code)
(n=45,152)
(n=325,971)
Non-dependent drug abuse
- Including tobacco
- Tobacco only
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12.9%
19.1%
10.9%
15.3%
9.6%
12.2%
Post-Deployment:
Reintegration Stressors
• Concern for those still
deployed
• Feeling responsible for
past duties
• Redeployment
• Housing
• Finances
• Unemployment
• Adjusting to civilian lifestyle
• Resuming family
roles/responsibilities
• Reconnecting
• Feeling unable to talk about
experiences; feeling alone
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Addressing Mind & Body Health
• Stress-related symptoms?
–
–
–
–
–
–
–
Headaches
High blood pressure
Stomach cramping, changes in appetite
Skin problems
Colds, flu, infections
Diminished sex drive
Fatigue and/or sleep disturbance
• Discuss risk reduction (e.g., risky driving, alcohol, tobacco)
• Stay rigorous
• Consider including multiple disciplines in your primary care
clinic
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Addressing Post-Deployment Issues in Primary Care
• Patients are likely to first present in primary care
• An important opportunity for:
– Early detection
– Risk reduction
– Addressing mind and body health
– Facilitating referrals
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Screening Algorithm for Women Veterans
• Pre-military life
– Recent life events
• Military experiences
– Role, deployment/separation, trauma exposure, toxins
• Post-deployment experiences
– Employment, school
– Living environment, relationships (IPV)
• Adjustment process vs. adjustment disorder
– Depression, anxiety (PTSD, panic, GAD)
• Substance use patterns
– Binge drinking
• Disordered eating patterns
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Addressing Physical Concerns
•
•
•
•
•
•
•
•
Musculoskeletal Symptoms
Headaches
Podiatry
Pain
Physical Therapy/Prosthetics
Audiology
Optometry
Dental
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Considerations for Early Detection and Risk
Reduction
• Identify adjustment issues and degree of distress
• Provide education and support
– Normalize stress of transition process
– Transition is a process vs. something to “fix”
• Respect boundaries
– Patient may not be ready to disclose difficulties or accept
help
• Connect patient to follow-up services
• Increase opportunity for monitoring and/or connection
with an informed provider
– Reduce fragmented care
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Skilled and Caring Evaluation
• Create a comfortable environment
– Privacy
• Provide undivided attention
– Make eye contact
– Slow down
• Validate concerns raised
• Communicate your concerns
– Be clear, honest, respectful, non-judgmental
• Instill hope
• Provide next steps
– Seek confirmation
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Facilitating a Mental Health Referral
• Patients with mental health issues often hesitate to seek care
(i.e., avoidance, stigma). Don’t reinforce this behavior.
• Addressing health behaviors or functional difficulties may
help facilitate referral
• Treatment should start as soon as possible, before comorbidities develop
• Refer to a specific provider
• Arrange a specific appointment time
• Provide education about empirically-supported treatment
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Resources for Providers
• Seamless Transition
–
OEF/OIF Case Managers
• Military Sexual Trauma Coordinator
• Women Veteran Program Managers
• National Center for PTSD
–
Iraq War Clinician’s Guide
http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_
clinician_guide_v2.pdf
• Vet Centers
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Key References
• Armstrong et al. Courage After Fire: Coping Strategies for Troops Returning
From Iraq and Afghanistan and Their Families. Berkeley, CA: Ulysses Press,
2006: 239 pp.
• Bond EF. Women’s physical and mental health sequellae of wartime service.
Nurs Clin North Am. 2004;39:53-68.
• Carney et al. Women in the Gulf War: combat experience, exposures, and
subsequent health care use. Mil Med. 2003;168:654-61.
• DHHS. Mental health: A report of the Surgeon General. Rockville, MD:
Substance Abuse and Mental Health Services Administration, Center for
Mental Health Services, NIH, NIMH, 1999.
• Environmental Epidemiology Service, Department of Veterans Affairs. VA
healthcare utilization among 89,321 female OIF/OEF veterans. Washington, DC,
2008.
• Frayne et al. Medical profile of women veterans administration outpatients
who report a history of sexual assault occurring while in the military. J Womens
Health Gend Based Med. 1999;8:835–45.
• Frayne et al. Medical care needs of returning veterans with PTSD: their other
burden. J Gen Intern Med. 2010;26:33–9.
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Key References
• Gonzales et al. Adherence to mental health treatment in a primary care clinic.
J Am Board Fam Pract. 2005;18:87-96.
• Haskell et al. The burden of illness in the first year home: do male and female
VA users differ in health conditions and healthcare utilization? Womens Health
Issues. 2011;21-1:92-7.
• Kimerling et al. Military-related sexual trauma among Veterans Health
Administration patients returning from Afghanistan and Iraq. Am J Public
Health. 2010;100(8):1409-12.
• Lovallo W. Stress & Health: Biological and Psychological Interactions. Thousand
Oaks, CA: Sage Publications, 2005.
• Murdoch et al. Women and war: what physicians should know. J Gen Intern
Med. 2006; 21:S5–10.
• Regier et al. The de facto U. S. mental and addictive disorders service system.
Arch Gen Psychiatry. 1993;50:85-94. Stein & Barrett-Connor. Sexual assault and
physical health. Psychosom Med. 2000;62:838–43.
• Vogt et al. Deployment stressors, gender, and mental health outcomes among
Gulf War I veterans. J Traumatic Stress. 2005; 18:115-27.
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Helpful Resources on PTSD
• Management of Traumatic Stress Disorder and Acute Stress Reaction.
Washington, DC: VA/DoD Clinical Practice Guideline Working Group, Veterans
Health Administration, Department of Veterans Affairs and Health Affairs,
Department of Defense, 2010.
http://www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp
• Institute of Medicine. Treatment of PTSD: An Assessment of the Evidence.
Washington, DC: National Academies Press, 2007.
• American Psychiatric Association. Practice Guideline for Patients with Acute
Stress Disorder and Posttraumatic Stress Disorder. Washington, DC: American
Psychiatric Association, 2004.
• Foa E, Keane TM, Friedman MJ, eds. Effective Treatments For PTSD: Practice
Guidelines from the International Society for Traumatic Stress Studies. New
York: Guilford Publications, 2000.
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