PTSD Forum 2015 Key Themes and Recommendations from the 2015 International Forum on Post Traumatic Stress Disorder

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1 22 October 2015 PTSD Forum 2015 Key Themes and from the 2015 International Forum on Post Traumatic Stress Disorder In association with Proudly Supported by

2 PTSD Forum 2015 Key Themes and from the 2015 International Forum on Post Traumatic Stress Disorder Orientation Posttraumatic stress disorder (PTSD) is a debilitating psychological condition in which sufferers experience intrusive memories, significant alterations in cognition, mood, arousal and reactivity, as well as persistent avoidance of reminders following exposure to a traumatic event. The disorder can lead to significantly compromised functioning including the ability to maintain employment, relationships and general self-care. Those exposed to traumatic events as part of employment (including Military personnel and first responders) are at higher risk of developing PTSD. The current state of knowledge regarding the aetiology, treatment and systemic long-term consequences of PTSD is limited, and further developments are needed. The International Forum on Post Traumatic Stress Disorder ( PTSD Forum 2015 ) was organised with the aim of consolidating the current state of knowledge of PTSD and highlighting the areas in which further developments are vital. The forum was held on the 11 th and 12 th September 2015 at the Brisbane Convention and Exhibition Centre and was organised in partnership with Stand Tall for PTS and the Gallipoli Medical Research Foundation (GMRF), with the support of the Queensland Branch of the Returned & Services League of Australia (RSL Queensland) and the Australian Defence Force (ADF). When developing the program for the forum, the organizing committee (Mr Tony Dell, Ms Miriam Dwyer and Dr Andrew Khoo) stressed the importance of collaboration, communication and commitment to meaningful outcomes. The forum attracted over 300 delegates, including representatives from the ADF, ex-service organisations (ESOs), first responders, academia, as well as clinical support services. Renowned leaders in the field of PTSD from the USA, Canada, and Australia presented current research, clinical intervention and community initiatives. Topics addressed during the Forum Prevalence and aetiology of PTSD, emphasizing the significance and severity of the condition. Assessment and treatment of PTSD, highlighting strengths and limitations of current goldstandard interventions as well as future directions. Psycho-social support initiatives being carried out by ex-service organisations including RSL, Mates4Mates, SoldierOn, Trojan s Trek, Legacy and Whiskey s Wish. Biological research including biomarkers, genetics, brain imaging and assessment of physical comorbidities. Personal accounts from PTSD sufferers. Access to care and transition difficulties for ex-service personnel. Addressing stigma of PTSD and mental health generally. PTSD Forum Key Themes and Outcomes 1

3 Key Themes & Opportunities for Development The following key themes and opportunities in the area of PTSD research, treatment and advocacy emerged from these proceedings (not in any specific order of priority): 1. Community Education 2. Barriers to Care 3. Early Detection of Mental Health Issues & Genetic/Biomarker Research 4. Leadership & Mental Health Culture 5. Physical Consequences of PTSD 6. Transition & Reintegration 7. Peer-to-Peer Support 8. Implementation of Mental Health Care Models & Evaluation of ESO Services 1. Community Education Raise Awareness & Reduce Stigma The issue of post-traumatic stress is not well understood by the broader Australian community. The systemic impact of PTSD requires greater consideration from the community with specific focus on familial and professional functioning. Education regarding the aetiology, symptoms and long term consequences of the disorder is required at multiple levels; within schools, organisations/workplaces, specific populations (medical and allied health professionals) and the general community. For many individuals, fear of being stigmatized has been demonstrated to be a major barrier to seeking mental health treatment. As such, there is an urgent need to reduce the stigma attached to mental health difficulties in both the military and general population. There are currently promising initiatives being carried out in Australia aimed at reducing mental health stigma, however they have not been systematically evaluated to determine their effectiveness. Scientific evaluation of programs targeting mental health stigma could determine key mechanisms of attitude and behavior change which could inform broader community education strategies. A multimedia campaign, with a focus on social media, will be essential to improving community engagement and reaching target populations. The following areas should be a target for educational resources: o Aetiology and lifetime prevalence of PTSD within (ex) military, first responder populations as well as the general population. o Normalizing the psychological sequelae of PTSD. o The impact of trauma on those who experience it as part of their professional life (military, first responders). o The impact of PTSD on partners and families. o Brief summary of current evidence based treatments. o Positive messages of recovery, e.g. stories from those that have recovered from PTSD and returned to previous functioning. 2

4 2. Barriers to Care There is an increasing amount of research indicating that perceived stigma is only one factor contributing to the low uptake of mental health care. Large studies examining the Australian, U.S. and Canadian Forces are demonstrating the following common perceived barriers to mental health care as reported by large samples of military personnel: I m concerned about what others might think I can t get time off work/my job interfered I ll deal with it myself I would be seen as weak/people would treat me differently I don t know where to go Nothing more would help I might lose my job/ unable to deploy /harm my career These barriers need to be addressed systematically with specific countermeasures. Potential interventions are outlined below: Barrier Countermeasure Lack of knowledge of support services Education about services Desire to manage mental health difficulties without professional support Access to online therapies and tools Not believing further care would benefit Improve quality of care Education regarding alternative options and second line therapies Afraid of stigmatization Provide mental health education at all levels Support programs targeting stigma Emphasise confidentiality Interference due to work commitments Review HR policies Provide access to out-of-hours care Distrust of mental health care professionals Education about types of therapies Emphasise importance of rapport and therapeutic alliance Support the ability to choose therapist Unable to afford care Education about DVA claims process or other financial support Fear of reducing employability Education regarding rehabilitation, transition, and compensation. Education about mental health and treatment/rehabilitation among all ranks PTSD Forum Key Themes and Outcomes 3

3. Early Detection & Intervention of Mental Health Issues Genetic and Biomarker Research It has been clearly demonstrated that early detection and intervention of PTSD leads to greater outcomes in

Research examining genetics/epigenetics of PTSD as well as analysis of associated biomarkers could potentially be used for screening and identifying those at risk of developing PTSD as well as

5 3. Early Detection & Intervention of Mental Health Issues Genetic and Biomarker Research It has been clearly demonstrated that early detection and intervention of PTSD leads to greater outcomes in terms of reduced symptoms and improved functioning for an individual. Research examining genetics/epigenetics of PTSD as well as analysis of associated biomarkers could potentially be used for screening and identifying those at risk of developing PTSD as well as predicting treatment response. There is a significant amount of research being conducted in this area within international military populations (i.e. U.S, Netherlands) however such research does not appear to be a priority for the ADF currently. The Canadian Military Mental Health Continuum Model (outlined by Colonel Rakesh Jetly) Mental health should be conceptualised as continuum ranging from healthy (normal functioning) to ill (unable to function). The Canadian military has implemented a Mental Health Continuum Model to assist members identifying potential decline in their own mental health, utilising non stigmatizing language with which to communicate to their chain of command. By supporting a model that reinforces the spectrum of mental health, and using terms such as injured when referring to medical as well as psychological conditions, the Canadian military has observed that stigma can be reduced, and help seeking and early intervention improved. The Mental Health Continuum Model (MCHM) 1 The Mental Health Continuum Model progresses through healthy, adaptive coping (green), through mild and reversible distress or functional impairment (yellow), to more severe, persistent injury or impairment (orange), to clinical illnesses and disorders requiring more concentrated medical care (red). 1 Directorate of Mental Health (Adapted from the US Marine Corps), National Defence and the Canadian Armed Forces. 4

It may be beneficial to support further genetic/epigenetic and biomarker research within the ADF (in keeping with international research) provided ethical considerations are thoroughly examined and

6 It may be beneficial to support further genetic/epigenetic and biomarker research within the ADF (in keeping with international research) provided ethical considerations are thoroughly examined and implications for analysis and results are clearly identified. Genetic and biomarker research is long-term, and would require a significant amount of further scientific investigation before practical screening outcomes are realised. Implementation of the Mental Health Continuum Model within the Australian military and first responder settings would be considered beneficial and may reduce stigma and improve help seeking. 4. Leadership & Mental Health Culture The health and well-being of members is the shared responsibility of the member, the chain of command, and health services. Leaders are responsible for their personnel and have a vital role to play in preventing and managing distress. All personnel, from Sergeants to Admirals, can make a difference in helping their colleagues meet and overcome any mental health challenges that they may encounter in the course of their military career, and after. Improving the health and well-being of military personnel involves responsibility at all leadership levels. Train leaders to understand mental illness. Create a culture that encourages help seeking and ensure help is there. Promote genuine caring of their junior staff. Ensure leaders understand that mental health is everyone s responsibility and foster a culture that exemplifies the following: Leadership Responsibility in Mental Health Management PTSD Forum Key Themes and Outcomes 5

7 5. Physical Consequences of PTSD The Long-Term Impact of PTSD on Health A large body of evidence demonstrates that PTSD is associated with a range of physical co-morbidities, including cardiovascular disease, sleep disorders, gastrointestinal problems and regional brain atrophy. As such, the consideration of holistic health management needs to be a priority for PTSD intervention. The investigation of the utility of exercise in the treatment of PTSD has also demonstrated that current PTSD treatments augmented with exercise lead to stronger outcomes than current treatment without exercise. Research and clinical initiatives addressing both the psychological and physical consequences of PTSD should be a priority (for instance the PTSD initiative project currently being conducted at GMRF). Current treatment for PTSD (psychological intervention & medication) should include targeted exercise components in line with evidence. 6. Transition & Reintegration The reintegration process for serving personnel transitioning out of the military needs continued attention and improvement. There are currently a number of research and clinical initiatives within the ADF and DVA designed to improve transition out of military service. The initiatives focus on tracking mental health, employment, compensation processing, as well as practical guidance (such as managing finances, insurance, housing, support for families etc.). There remains however, a lack of systematic investigation into the psychological adjustment and cultural reintegration process of transitioning from service personnel to civilian. Ex-Service Engagement with the Department of Veterans Affairs The connection between the ADF and DVA could be improved further so high risk members are engaged with appropriate compensation and supported healthcare pathways immediately upon or, preferably, prior to discharge. Immediate access to required care will prevent further deterioration of mental health and functioning. Consider modifications to DVA processes to ensure that all members are registered prior to departure from the ADF regardless of compensation needs. Major ESOs can assist in this process. DVA may consider emphasising the benefits for individuals registering prior to the perceived need for disability compensation (i.e. ability to register for vocational training, upskilling/education opportunities, transition programs etc. rather than focus on disability alone). Research focused on the psychological adjustment and cultural reintegration process should be supported to address this significant gap in the care pathway. GMRF is currently planning research in this area which will lead to the development of an at risk detection tool to be used early in the transition process. RSL Qld to continue funding this vital research. Evidence based research essential to map the future. 6

8 Longitudinal research could track the progress of those that register with DVA prior to discharge compared to those that do not. Results from such a study could be used to inform a procedural change in the ADF in which members are required to register with DVA. 7. Peer-to-Peer Support Peer-to-peer support has been identified as a worthwhile initiative to reduce barriers to care and improve help seeking among military and veteran populations. Engaging with a fellow service person or veteran in the first instance regarding mental health concerns may also reduce stigma. The proposal of engaging peer-to-peer support officers is currently being considered by the ADF, with the development of peer-topeer support protocols being undertaken in the near future. Peer-to-peer programs are presently active within the emergency services as well as ESOs in Australia and United States. The Queensland ambulance services in particular invests significantly in peer support programs, and have documented positive outcomes related to early intervention and low rates of mental health disorders. Trojan s Trek, Soldier On and Thales as well as Veterans 360 Inc. (in the U.S) are also demonstrating successful implementation of peer support mentor programs. Successful examples of peer-to-peer support models should be shared between sectors (Defence, emergency services and ESOs) to ensure transfer of knowledge, standardization among programs, and evidenced based protocols. Those in the role of peer-to-peer mentorship should be: o Trained in basic mental health (psycho-education, early warning signs, risk procedures). o Focused on the promotion of positive mental health messages including normalising mental health challenges, encouraging help-seeking. o Independent from DVA advocate or ADF case worker but aware of regulations/processes for claim lodgment. o o Knowledgeable of all support services. Aware of support boundaries/limitations and understand referral process to professional mental health provider. 8. Implementation and Evaluation of Mental Health Care Models The current evidence-base first-line treatment of PTSD has been well established to be individual trauma-focused CBT or EMDR. However, the tolerability of this treatment, the complexity of PTSD for those that have been repeatedly exposed to trauma as part of employment, as well as the presence of associated physical and psychological co-morbidities suggests that psycho-social adjunct therapies need further consideration in the role of rehabilitation. A review of care models in the treatment of PTSD among the military population needs to be undertaken, and complexities of care pathways accurately documented and addressed. The importance of support and inventions for family members also need to be emphasised within mental health care models. Evaluation of services provided by ESOs The anecdotal evidence regarding the benefits of adjunct second-line treatment and support among Australian ESOs is strong. However, there is a need to develop a scientifically sound evaluation framework to assess the outcomes of ex-service members who engage with these services. A consistent approach across ESOs will help define clinical, psychological and social outcomes and contribute to PTSD Forum Key Themes and Outcomes 7

9 developing the evidence base for second-line interventions. Evaluation will also help ESOs improve service design and delivery, fostering greater engagement. Support for research and initiates dedicated to adjunct/ second line therapies in the management of PTSD with focus on innovation is vital. Current initiatives being undertaken within Australian ESOs include the investigation of canine and equine therapies, yoga, meditation and mindfulness, adventure/activity therapies, and peer support programs. ADF and DVA could engage with the ESOs further, recognising their role in breaking down barriers to care, providing psycho-social support and being an access point to Defence and DVA services. Engage the family of service personnel early (pre discharge) and potentially directly through targeted programs. Establish a central online portal to capture all ESO support options available. Create a standard evaluation framework across ESOs so programs and services can be evaluated and contribute to evidence of effectiveness. This project is currently in development between GMRF, RSL Queensland and Mates4Mates. 9. Lessons from Our Allies Canada has similar programs in place; however, Canada differs in two areas: terminology and recognition. Canada regards wounded, injured or ill servicemen and women as being injured, no other definition is used. This is one way in which the stigma of mental illness is addressed at a grass roots level. All injured are treated with the view to returning the injured to sound health. At the same time all injured servicemen and women are awarded a medal, recognised in the Canadian Honors and Awards System, to recognize their contribution and subsequent injury. Anecdotal evidence indicates that the awarding of the Sacrifice Medal is well regarded within the Canadian Military and is tangible proof to others that the recipient has been injured in the service of the Nation. Summary The International Forum on Post Traumatic Stress Disorder ( PTSD Forum 2015 ) successfully provided an overview of the current state of knowledge in the area of PTSD while also highlighting the opportunities for further development in research, treatment and advocacy. The below emerged as key areas of development & recommendations: 1. Community Education Raise awareness in the general community and reduce mental health stigma. The ESO community has a role to play in advertising this message. 2. Barriers to Care Address barriers outlined in the research systematically with specific countermeasures. 3. Early Detection of Mental Health Issues & Genetic/Biomarker Research Adopt a Mental Health Continuum Model and re-assess potential benefits of genetic and biomarker research initiatives. 8

10 4. Leadership & Mental Health Culture Ensure leaders understand that mental health is everyone s responsibility and foster a culture that encourages help-seeking and a continuum mental health management approach from chain-ofcommand. 5. Physical Consequences of PTSD Research and clinical initiatives addressing both the psychological and physical consequences of PTSD should be a priority. 6. Transition & Reintegration Improve engagement with DVA and ESOs prior to discharge and improve knowledge of psychological and cultural readjustment in transition process. RSL Qld to fund and support a proof of concept trial in Brisbane and Townsville with a focus on the individual and their families. 7. Peer-to-Peer Support Successful examples of peer-to-peer support models should be shared between sectors (Defence, emergency services and ESOs) to ensure transfer of knowledge, standardization among programs, and evidenced based protocols. 8. Implementation of Mental Health Care Models & Evaluation of ESO Services Create a standard evaluation framework across ESOs so programs and services can be evaluated and contribute to evidence of effectiveness. ESOs need to come together to avoid duplication of effort and confusion within the military community as to what service is provided by respective ESOs. 9. Lessons from Our Allies Adopt the Canadian approach of using only one term to identify those men and women who have been wounded, injured or made ill with such individuals being classified as injured. Adopt the Canadian recognition process by introducing a separate medal into the Australian Honors and Awards System which recognises the injured members of the Australian Defence Force. PTSD Forum Key Themes and Outcomes 9

Volunteering in NHSScotland Developing and Sustaining Volunteering in NHSScotland

Volunteering in NHSScotland Developing and Sustaining Volunteering in NHSScotland NG11-07 ing in NHSScotland Developing and Sustaining ing in NHSScotland Outcomes The National Group for ing in NHS Scotland agreed the outcomes below which formed the basis of the programme to develop