Uniformed Services University of the Health Sciences Uniformed Services University of the Health...

Uniformed Services Universityof the Health SciencesUniformed Services Universityof the Health Sciences

Charles C. Engel, MD, MPH Associate Professor & Assistant Chair (Research)

Department of Psychiatry Director, Deployment Health Clinical Center

F. Edward Hebert School of Medicine Uniformed Services University

[email protected]

Mental health system response to disasters: potentially applicable military innovations

Mental health system response to disasters: potentially applicable military innovations

Uniformed Services Universityof the Health SciencesUniformed Services Universityof the Health SciencesUniformed Services UniversityUniformed Services University

Agent Orange

PTSD

Battle fatigue

Neurocirculatory asthenia

Shell shock

Effort syndrome

Da Costa’s syndrome

Soldier’s heart

Gulf War Syndrome?????



UniquePhenomenon?

UniquePhenomenon?

1992 El-Al Boeingcrash in Amsterdam


USUHSUSUHS

The Post-Traumatic SalamiThe Post-Traumatic Salami

PTSD: The Modal Slice

Other trauma-related responsesOther trauma-related responses


1991 Gulf War Veterans With Health Concerns

Diagnosis and Physical Symptoms1991 Gulf War Veterans With Health Concerns

Diagnosis and Physical Symptoms

0

1

2

3

4

5

6

7

PTSD OtherPsychiatric

Physical Healthy

Engel et al. Psychosomatic Medicine 2000; 62:739-745

symptomcount

(of nine)


Common ICD-9 Diagnoses CCEP Report on 10,020

Common ICD-9 Diagnoses CCEP Report on 10,020

Primary Dx Any Dx

Psychological 19% 37%

Musc-Skeletal 17% 45%

Ill-Defined 17% 41%

Healthy 11% 19%

Digestive 6% 22%

Dermatologic 6% 20%

Respiratory 7% 18%

Nervous 6% 18%

Endocrine 2% 11%

Infectious 3% 9%


Frequency of Provider Diagnoses Among Recent Iraq and Afghan Veterans

Frequency of Provider Diagnoses Among Recent Iraq and Afghan Veterans

Diagnosis (n = 168,421) (Broad ICD-9 Categories) Frequency * % Diseases of Musculoskel System/Connective System (710-739) 68,789 40.8Mental Disorders (290-319) 56,304 33.4Symptoms, Signs and Ill Defined Conditions (780-799) 52,587 31.2Disease of Digestive System (520-579) 51,736 30.7Diseases of Nervous System/ Sense Organs (320-389) 48,151 28.6Disease of Respiratory System (460-519) 28,781 17.1Diseases of Endocrine/Nutritional/ Metabolic Systems (240-279) 27,598 16.4Injury/Poisonings (800-999) 27,068 16.1Diseases of Circulatory System (390-459) 22,751 13.5Diseases of Skin (680-709) 22,469 13.3Infectious and Parasitic Diseases (001-139) 16,473 9.8Diseases of Genitourinary System (580-629) 14,561 8.7Benign Neoplasms (210-239) 5,004 3.0Diseases of Blood and Blood Forming Organs (280-289) 2,669 1.6Malignant Neoplasms (140-208) 1,197 0.7 *Hospitalizations and outpatient visits as of 4/24/2006; veterans can have multiple diagnoses with each healthcare encounter. A veteran is counted only once in any single diagnostic category but can be counted in multiple categories, so the above numbers add up to greater than 168,421.


Post-OIF / OEFPost-OIF / OEF

Acknowledge MH problem 78-86%

Want help 38-45%

Got help past yearAny professional

Mental health

23-40%

13-27%

Gap between need and service:

(Hoge, 2004)


Continuity of care is important** 80% with PTSD at 3-6 months did not have PTSD at baseline **

Continuity of care is important** 80% with PTSD at 3-6 months did not have PTSD at baseline **

Grieger et al. Am J Psychiatry (in press)

Rates of probable PTSD 1 mo, 3 mo, and 6 mo after tertiary military hospital admission after Iraq or Afghanistan battle injury (n=243).

1 mo 3 mo 6 mo


ChallengesChallenges

stigma, mistrust, barriers and continuity inconsistencies in health care ‘safety net’ dynamic temporal mental health changes toxic exposure & physical health concerns idiopathic physical symptoms & syndromes traumatic brain injury the wounded


Pre-Clinical Mitigation Psychological Debriefing

Pre-Clinical Mitigation Psychological Debriefing

“At present the routine use of individual debriefing in the aftermath of individual trauma cannot be recommended in either military or civilian life. The practice of compulsory debriefing should cease pending further evidence. Even if further large scale trials do reveal a positive effect of debriefing that has not been detected in the trials to date, the evidence reviewed above suggest the likely treatment effect will be small.”

Rose et al. Cochrane Review. 2001


Post-Deployment Health Assessments & Reassessments

Post-Deployment Health Assessments & Reassessments


Spectrum of mental health servicesafter mass trauma

Engel et al, 2004, Can We Prevent A Second Gulf War Syndrome?Advances in Psychosomatic Medicine

Specialty Mental Health Care


Primary Care AdvantagesPrimary Care Advantages

~4 primary care visits per year Stigma is lower Early intervention is possible Effective primary care treatments are

available, established in 8 randomized controlled trials


Where people seek care (each month)Where people seek care (each month)

Green et al. Ecology of medical care revisited. NEJM 2001; 344(26):2021-5


What can we learn from successful primary care depression models?

What can we learn from successful primary care depression models?

Use multiple modalities (education is not enough)

Integration / collaboration works! System integration components

• prepared primary care practice + education• care management resource• enhanced specialty care interface

RESPECT-MILPost Deployment Mental Health Care within Ft Bragg Primary

Care

MacArthur Initiative on Depression & Primary CareDoD Deployment Health Clinical Center

Henry M. Jackson Foundation

Initial Routine for Screening

Sick call - complete screening form

Screen positives complete diagnostic/severity instruments

Clinician completes Dx evaluation during visit

Referral, if appropriate, to CM via AHLTA

Routine for Care Management

CM calls at 1 wk then 4 wk intervals to monitor progress

CM reviews individual progress w/ consulting psychiatrist

CM coordinates communication between MH, clinician andpts. based on supervision

Primary Care continues with active Tx mgmt throughout


One Question Primary Care PTSD Screening


Were you recently bothered by a past event in which you thought you’d be injured or killed?

Not Bothered / Bothered A Little / Bothered A Lot




PTSD prevalence in primary care – 9.0% (WRAMC, Radar, Dilorenzo)

not bothered botheredbothered a little a lot

% endorsed 73.5% 19.0% 6.5%

PTSD 2.9% 19.4% 47.7%

LR (95% CI) 0.3 (0.1-0.7) 2.4 (1.4-4.7) 9.3 (3.6-27.5)

sensitivity ---- 95% 51%

specificity ---- 41% 86%

mean PCL-17 20.5 31.3 55.8


DESTRESS-PCDESTRESS-PC

Delivery of

Self-

TRaining &

Education for

Stressful

Situations –

Primary Care version


Spectrum of mental health servicesafter mass trauma

Engel et al, 2004, Can We Prevent A Second Gulf War Syndrome?Advances in Psychosomatic Medicine

Specialty Mental Health Care

USUHSUSUHS

Questions?Questions?

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