veterans in transition...what the va can do be proactive….address specific needs at the time of...
TRANSCRIPT
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VETERANS IN TRANSITION
John F. Prater, DOPsychiatrist
Southwest Florida Osteopathic Medical Society
October 19, 2018
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OBJECTIVESTo review some of the many challenges confronting veterans in transition from military to civilian life.
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Why do a presentation about veterans for primary care providers?
● 1.5 million discharged veterans since 2001● 700,000 have received care through the VA● Others received care through the civilian sector● Veterans have unique health care needs
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PATIENT SATISFACTION AT OUR FACILITY IS LOW
● We’re trying…….so why?
● If there is one word that would capture how many veterans
present to my office for care, it would be, ironically, “defeated”
● How does the veteran typically present to us for care, and what
are some of the health related concerns unique to this
population?
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Some important statistics
Vet suicide rate 30/100,000 per year-civilian is 14/100,000
In 2014 there were 7,400 suicides by vets,,,,that number has remained relatively constant
Homeless vets twice the rate of the population,⅓ of homeless men are vets
More bad news….Veterans need for care peaks several decades after their war experience
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SERVICES OFFERED UPON DISCHARGE FROM THE MILITARY
● “TAPS” - Transitionl Assistance Program. 3-5 days, generic● Vietnam● WWII● Since 2001 very few DOD initiatives to address violence problem in returning vets● Canada and European countries have formalized decompression programs
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“WE ARE THE KIDS LEFT BEHIND”
AVERAGE AGE OF SOLDIERS:
● WWII: 26 years old● Vietnam: 19 years old
● Desert Storm: 27 years old (national guard/reservists)
Many can flourish in the structured environment of the military, but are unable to function in the civilian
world.
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Prater’s Axiom #1
● Disorders occur at points of vulnerability in the life cycle● Most common age of onset of serious mental illness: 18-25
years old ● Coincides with age of military duty
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Military Life● Structured● Predictable● Close social network● Clear expectations re “mission”● Training/conditioning internal structure
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Military Life, cont’d
● Teamwork● Trust● Uniformity● Diversity● Fast paced….especially in combat arenas● Identity- “I was somebody in the military”
● A deep bond that exists among those that served
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Civilian World
● Unstructured…..What’s the mission?● Trust ● Social Networks● Co-workers● Learning how to step back and be less reactive
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Civilian World, cont’d
● Initially things seem to be in “slow motion”● Individual over group needs● Competitive● “Choices”● Things seem insignificant● “Underwhelmed “
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Protective FactorsVets at lower risk for re-entry problems
● College grads● Officers● Those with a clear understanding of what their mission
was● Religious affiliation● Receiving care from providers who are veterans
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Veterans Care
● What are the expectations the veteran has for care from the VA?
● Is it possible for the VA to meet those expectations?● Inherent problems within the delivery of care system● Outcomes
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Veterans Care - Unique problems
● Secondary gain● Compliance ● Comorbid substance use/abuse● Expectations of a cure from PTSD, depression, etc● Accessing care for psychiatric conditions/stigma
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Veterans care - A unique delivery of care
● Formulary● Nomadic veterans● Multiple providers● Revolving providers● One chart● Additions and removals (meds, diagnoses)
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Prater Axiom #2
The greater the number of psychiatrists who examine the patient, the harder it is to figure out what the hell is wrong.
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OTHER PROBLEMS:THE SUBTLE
AND NOT-SO-SUBTLE
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Unique medical problems● Disfigurement
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Unique medical problems, cont’d
● Protective gear/battlefield aid stations have reduced mortality, but increased morbidity (amputations, TBI)
● PTSD, musculoskeletal injuries mostly● Cognitive dissonance - “I couldn’t think straight”● “ Invisable injuries “ Depression,TBI, in addition to PTSD● Increased ALS● “ chronic multisystem illness”
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Unique medical problems, cont’d● Suffering a serious injury or emotionally traumatic
event predicts a more problematic re-entry into civilian life….. PTSD
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Medical Care Challenges
● Low testosterone level● Low vitamin D● Low activity level● Little or no dental care● Sequelae of substance use disorder● Poor diet● STD’s
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PTSD Clues
● Experiencing/witnessing traumatic event● Flashbacks● Nightmares● Irritability● Insomnia● Startle response● Avoidance/numbing● hypervigilance
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EMPLOYMENT
● Transfer of job skills - military to civilian
● Employability …. Working with co-workers and expectations.
“In the civilian world, there is no teamwork, discipline.”
● “Starting at the bottom all over again” …… “I was behind others
who didn’t serve.”
● Learning new skills…..the fast pace of changing technologies
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HOME● “I had no home to go to…..”● Homelessness secondary to other factors
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HOME
● Divorce - 70% among returning veterans● “My family was not the same” - those married and deployed
post 9-11 had a more difficult re-entry than those single● Families have developed new routines● “I couldn’t relate to my family/ friends”● Change in income (often lower)
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SUBSTANCE USE DISORDERS IN VETERANS
● Culture in the military of tobacco use - smoking but also chewing
● Alcohol● Other drugs while in the service, carrying over into civilian
arena● Often connected to legal difficulties
● Medical problems● Social problems
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Other mental health issues
● Depression● Insomnia● Suicide● Pain disorders● Impulse control disorders….often linked to domestic violence● Comorbidity is the rule and not the exception, often have to be
creative with psychotropic meds
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ACCESSING MEDICAL CARE
● Establishing services for individual care● For dependent children, especially disabled children, lack of
insurance in transition period● Mental health stigma - seeking care is looked down on while in
the military, causes delay in seeking care once released● Trained to “power through” adversity, delays access to care
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Prater’s Axiom #3● The longer you have a problem, the harder it is to recover
from.● Delayed onset of care = 8-9 years post-discharge
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More subtle difficulties● “I abandoned my friends”● “I’m surrounded by people I don’t know”● Feeling disconnected from former friends● Not able to connect with some VA providers● An internal but no external structure● “Thinking I was alright/invincible”● “Reinventing myself”● Survivors guilt
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What primary care can do to help
● Address barriers to care● Conduct a specialized review of systems:
○ Combat ○ Injuries○ Screen for depression/suicide
● Destigmatize mental health care● Close follow up first 3 years (most vulnerable)● Focus on function and reintegration: promote mental “fitness”
in keeping with military culture
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Appropriate use of psychotropic medications
● PTSD: FDA-approved meds - sertraline & paroxetine● Nightmares - prazosin● Insomnia - avoid benzos, short-term zolpidem okay, cognitive
therapy● Pain - OMT, massage, NSAID’s, no opiates● Depression - SSRI/SNRI, cognitive therapy● Temperament - Valproate(off label)
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What the VA can do
● Be proactive….address specific needs at the time of discharge● Streamline/simplify operations& expand the formulary● Continuity of care by addressing VA workplace concerns
(reducing turnover)● Remove some cooks from the kitchen….● Recognize that positive metrics do not necessarily reflect good
care● Promote mental fitness which aligns with the core concepts of
military culture
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Prater’s Axiom #4
● A little empathy and personalized care goes a very long way in helping people recover from any condition
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Questions?