Working with veterans suffering from mental Working with veterans suffering from mental health problemshealth problems

The role of the Charity Combat Stress The role of the Charity Combat Stress

Dr Walter BusuttilDr Walter BusuttilMedical Director & Consultant Psychiatrist Medical Director & Consultant Psychiatrist

Combat Stress Combat Stress dms@combatstress.org.ukdms@combatstress.org.uk

Veterans• A veteran is someone who has served at least one

day in the military• Veterans and combat veterans• Around 25,000 leave the military each year.• There are about 5 million Veterans in the UK and

7.5 million first degree dependents.

UK Veterans

• What are the issues?• What is the need? Numbers, Clinical need

Welfare need?• What services are needed?

Why is working with veterans complicated?Why is working with veterans complicated?Mental health problems can arise from a variety of causes in Mental health problems can arise from a variety of causes in

Veterans:Veterans:• Pre service vulnerabilitiesPre service vulnerabilities

• Military life itselfMilitary life itself

• Earlier onset of physical disordersEarlier onset of physical disorders

• Leaving the service and adjusting to civilian lifeLeaving the service and adjusting to civilian life

• Help seeking issuesHelp seeking issues

• Combination of the aboveCombination of the above

Incidence of mental health problems in VeteransIncidence of mental health problems in Veterans1.1. No UK Population StudiesNo UK Population Studies

2.2. Need National Vietnam Veterans Readjustment Study (NVVRS) Need National Vietnam Veterans Readjustment Study (NVVRS) equivalent studiesequivalent studies

3.3. KCL OP Telec (Iraq Invasion and occupation) Studies will help as long as KCL OP Telec (Iraq Invasion and occupation) Studies will help as long as population is followed up as veteranspopulation is followed up as veterans

4.4. Population Studies being set up in Scotland and WalesPopulation Studies being set up in Scotland and Wales

• Depression Depression • AnxietyAnxiety• PTSDPTSD• AlcoholAlcohol• DrugsDrugs• Personality problemsPersonality problems

Combat Stress:Combat Stress: Ex-Servicemen’s Welfare Society Ex-Servicemen’s Welfare Society established 1919established 1919

• National Charity 85,000 helped so far.• Only mental health charity of any size for Veterans• Part funded via War Pensions system Part funded by Charity• Offers multidisciplinary community outreach service

including welfare needs and multidisciplinary inpatient bespoke programmes.

• Clinical Outreach services being expanded.• Helplines / websites• Most referrals self referral or through family (46%) or ex-

service charities (31%) - NHS only 3%!• 1200 new referrals last year• 3500 active patients – receiving either welfare or clinical

help or both

Typical new referral 2008• Average age 44 year old (youngest aged 20 oldest 93) • Ex Army• Childhood trauma, neglect, poor care giving• Multiple traumatic exposure. Service in many war

theatres NI commonest.• Family Ultimatum – usually second marriage• History of Multiple house moves, employers, long spells of

unemployment or homelessness• Many children mostly not in touch • History of domestic violence• Significant physical illness• Classically diagnosed with PTSD, Depression; Alcohol

misuse• No prior intervention• NHS has not helped (for a variety of reasons)

The needs of Combat Stress Population:Clinical Audit Data Combat Stress 2007

% New Patients (n=162) % Review patients (n=169)

Significant Physical illness

59 86

Physical injury during military service

45 62

Psychiatric illness as a measure of chronicity

75 95

Multiple exposure to psychological trauma

95 84

Present and past history of alcohol and drug dependence and abuse

69 74

Significant attachment difficulties in childhood / adolescence incl CSA and other abuse.

59 39

Complex Bio-Psychosocial presentations• Psychiatric disordersChronic PTSD, Depression, Alcohol; attachment disorders• Behavioural DisordersAnger, Aggression, domestic violence,• Physical DisordersOrthopaedic, ENT, Diabetes, Cardiac• Social exclusionIsolation, family breakdown, unemployment , Homelessness

SourceCombat Stress Clinical Audit data (n=331) & Psychometric Data Analyses (n=480) 2005-2008

PTSD: CO-MORBIDITY: PTSD: CO-MORBIDITY: (incl NVVRS Study and other studies)(incl NVVRS Study and other studies)

BIO/PSYCHO/SOCIALBIO/PSYCHO/SOCIAL• Depressive illness 50-75%Depressive illness 50-75%• Anxiety disorder 20 -40%Anxiety disorder 20 -40%• Phobias 15 - 30%Phobias 15 - 30%• Panic disorder 5 -37%Panic disorder 5 -37%• alcohol abuse / dependence 6 - 55%alcohol abuse / dependence 6 - 55%• drug / abuse / dependence 25%drug / abuse / dependence 25%• Divorce Divorce • UnemploymentUnemployment• Accidents: Accidents: • RTA rates 49% higher in Vietnam vets than non-vetsRTA rates 49% higher in Vietnam vets than non-vets• Suicide: 65% higher in combat veteransSuicide: 65% higher in combat veterans

Family issues• Usually wife or Woman bring veteran into care• Direct and indirect traumatisation of the family• Direct exposure to service life, husband’s

operation experiences• Emotional contamination – ripple effect on

Family members if these are still around. • Usually multiple relationships and divorces ,

partners, children.

Most powerful predictors of ongoing PTSD in combat veterans are:

• Dose of exposure to trauma / combat / time in front line

• Impaired family functioning – more powerful than personality and developmental issues.

• Very strong correlation between PTSD severity and family dysfunction.

• Veterans who do well in treatment: those in supportive relationship with a female – usually wife – marital support crucial to adjustment in veterans (Egendorlf 1980)

Combat Stress Treatment Strategy (Dec 2007)Combat Stress Treatment Strategy (Dec 2007)

Chronic Disease management as per 2005 NICE Guidelines for Chronic Disease management as per 2005 NICE Guidelines for treatment of Veterans for PTSDtreatment of Veterans for PTSD

1.1. Initial preparation. Initial preparation.

2.2. Stabilisation and safety. Stabilisation and safety.

3.3. Disclosure and working through of the traumatic Disclosure and working through of the traumatic material and psychotherapy on an individual basis. material and psychotherapy on an individual basis.

4.4. Rehabilitation and reintegration within society; Rehabilitation and reintegration within society; normalising activities of daily living. normalising activities of daily living.

Treatment of PTSD in Veterans: Basic PrinciplesTreatment of PTSD in Veterans: Basic PrinciplesMultimodal Assessment:Multimodal Assessment: Clinical History & Mental State Examination; Psychometric Tests: subjective and ObjectiveClinical History & Mental State Examination; Psychometric Tests: subjective and ObjectiveStabilise:Stabilise:• Prepare for therapy: detox alcohol, drugs, Prepare for therapy: detox alcohol, drugs, • welfare needswelfare needs – homelessness, isolation, job skills etc: – homelessness, isolation, job skills etc:• Prescribe appropriate medications SSRI and related antidepressants, Mood stabilisers, anti-impulse, Prescribe appropriate medications SSRI and related antidepressants, Mood stabilisers, anti-impulse,

major tranquillizers; medications for pain, major tranquillizers; medications for pain, Therapy Therapy : : • OutpatientOutpatient assessment plus TF-CBT; EMDR – single trauma much easier!!assessment plus TF-CBT; EMDR – single trauma much easier!!• Residential specialist services:Residential specialist services: initial stabilisation then disclosure / psychotherapy/ then rehabilitation. initial stabilisation then disclosure / psychotherapy/ then rehabilitation. • Group Programmes: psychoeducation; cognitive restructuring groups individual TF-CBT; EMDR; Group Programmes: psychoeducation; cognitive restructuring groups individual TF-CBT; EMDR;

psychodynamic incl disclosure work; narrative therapy.psychodynamic incl disclosure work; narrative therapy. • Repeat admissions? Integrated community and inpatient programmes: eg Australian Veterans; American Repeat admissions? Integrated community and inpatient programmes: eg Australian Veterans; American

Veterans AssociationVeterans Association

Appropriate treatment for co-morbid disordersAppropriate treatment for co-morbid disorders

Family and spouse interventions – Family and spouse interventions – carer’s groups, family and couple therapycarer’s groups, family and couple therapy

Safety – supportsSafety – supports

Current Clinical InterventionCurrent Clinical Intervention• Initial Regional Welfare Officer assessment – Initial Regional Welfare Officer assessment –

ESSENTIAL PORTAL OF ENTRY INTO CAREESSENTIAL PORTAL OF ENTRY INTO CARE• Community Psychiatric Nurse assessment / clinical Community Psychiatric Nurse assessment / clinical

outreachoutreach• Five day week admission for assessment - followed by:Five day week admission for assessment - followed by:• Three two week treatment admissions over one year Three two week treatment admissions over one year

period as a maximumperiod as a maximum• Or Six one week admissions over one year Six one week admissions over one year• Whole person care planWhole person care plan• Try to plug into NHS careTry to plug into NHS care

Current Rolling ProgrammeCurrent Rolling Programme• Establish trust and rapportEstablish trust and rapport• Unique therapeutic milieuUnique therapeutic milieu• Group Psycho education: incl PTSD, depression groups; anxiety Group Psycho education: incl PTSD, depression groups; anxiety

management; anger management, coping skills training / management; anger management, coping skills training / mindfulness etc.mindfulness etc.

• Stabilisation on MedicationStabilisation on Medication• Individual therapy include arts therapies to engage; solution Individual therapy include arts therapies to engage; solution

focussed therapy.focussed therapy.• Trauma Focussed therapies (including TF-CBT and EMDR)Trauma Focussed therapies (including TF-CBT and EMDR)• Rehabilitation – Occupational Therapy; Social Skills activities Rehabilitation – Occupational Therapy; Social Skills activities

centre; retraining schemescentre; retraining schemes• Families and carers groupsFamilies and carers groups• Liaison and plug in to local NHSLiaison and plug in to local NHS

Combat Stress Clinical StrategyUpgrade existing servicesUpgrade existing services

• Further develop residential Multidisciplinary Further develop residential Multidisciplinary Teams incl Training needsTeams incl Training needs

• Bespoke Programmes – intensive & old age.Bespoke Programmes – intensive & old age.• Enhance Rolling ProgrammeEnhance Rolling Programme

Expansion of ServicesExpansion of Services• Outreach and outpatient community services.Outreach and outpatient community services.• Work in partnership with other service Work in partnership with other service

charities and NHS / Other international charities and NHS / Other international rehabilitation programmes for Veteransrehabilitation programmes for Veterans

Government Initiatives• MOD/NHS mental health pilots – six so far

assessed / signposted 180 patients.• Advice to NHS about priority treatment• Command Paper – promise of help to

veterans• Assessment services UK MAP, Chillwell.• Advice about IAPT (Improving access into

Psychological Therapies)

Bespoke Programmes run on the same lines as Bespoke Programmes run on the same lines as Australian Veterans ProgrammesAustralian Veterans Programmes

( Australian Veterans Service Heidelberg Melbourne)( Australian Veterans Service Heidelberg Melbourne)

Time Limited Time Limited intensive residential ‘course’ of group intensive residential ‘course’ of group treatment comprising: treatment comprising:

• PsychoeducationPsychoeducation• Trauma focussed therapiesTrauma focussed therapies• Cognitive restructuringCognitive restructuring• RehabilitationRehabilitation• Referral for Work Re-trainingReferral for Work Re-training• Maintenance in community – follow-on therapiesMaintenance in community – follow-on therapies• Follow-up ‘top-up’ brief residential reunionsFollow-up ‘top-up’ brief residential reunions

Major challenges for NHS and Combat Stress• Complex Trauma Presentations (Complex PTSD)• Acute alcohol / drug Detox – seamless plug into trauma work• Schedule 1 Sex Offenders• Forensic cases – imminent violence, severe behavioural

disturbance• Veterans with mental ill health in the prison population • Increasing population of Old Age Veterans in the general

population – hidden psychiatric morbidity plus locked in chronic PTSD

• Growing number of in service families with psychological and mental health problems

• War Pensions – Benefits Trap: WPs should not be counterproductive to treatment and therapy

References Busuttil, W. (2004) Post Traumatic Stress Disorder and the Elderly: A need for investigation Busuttil, W. (2004) Post Traumatic Stress Disorder and the Elderly: A need for investigation

International Journal of Geriatric Psychiatry, International Journal of Geriatric Psychiatry, 19, 429-439.19, 429-439.  

Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Posttraumatic Stress Disorder. (eds M B Williams & J Garrick). In Posttraumatic Stress Disorder. (eds M B Williams & J Garrick). In Trauma Treatment Techniques Trauma Treatment Techniques Innovative Trends. Innovative Trends. pp29-55, Haworth Press, New York. pp29-55, Haworth Press, New York.

Busuttil, W. (2007) Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the Body Psychological trauma and Post Traumatic Stress Disorder. In: When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M Nasser, Kbaistow & J Treasure). Routledge: London. Nasser, Kbaistow & J Treasure). Routledge: London.

Busuttil, W. & Busuttil, A. M. C. (2001) Psychological effects on families subjected to enforced and Busuttil, W. & Busuttil, A. M. C. (2001) Psychological effects on families subjected to enforced and

prolonged separations generated under life threatening situations. prolonged separations generated under life threatening situations. Sexual and Relationship Sexual and Relationship Therapy,Therapy, (Special Psychological Trauma Edition) 16: 3; pp 207-228. (Special Psychological Trauma Edition) 16: 3; pp 207-228.

Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australian veterans with combat- related posttraumatic stress disorder: A cause for cautious optimism? Journal of Traumatic Stress, 12, 545–558.

Kearney GE, Creamer M, Marshall R, Goyne A (2003) Kearney GE, Creamer M, Marshall R, Goyne A (2003) Military Stress and Performance: The Military Stress and Performance: The

Australian Defence Force Experience. Australian Defence Force Experience. Paul & Co Pub Paul & Co Pub Consortium: Consortium: DefenceDefence Science Science

and Technologyand Technology Organisation. Organisation. Canberra.Canberra. Williams, T. (1987) Post Traumatic Stress Disorders, A handbook for Clinicians. Disabled Williams, T. (1987) Post Traumatic Stress Disorders, A handbook for Clinicians. Disabled

American Veterans: Ohio. American Veterans: Ohio.