Substance and Alcohol Misuse Among OEF and OIF Veterans. Dr. Kristi Kanel Cal State Fullerton

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1 Substance and Alcohol Misuse Among OEF and OIF Veterans Dr. Kristi Kanel Cal State Fullerton

2 BASIC STATISTICS SINCE 2003: MORE THAN 1 MILLION TROOPS HAVE BEEN DEPLOYED IN IRAQ AND AFGHANISTAN 1/3 HAVE SERVED AT LEAST 2 TOURS IN COMBAT ZONE 1.2 MILLION CHILDREN LIVE IN US MILITARY FAMILIES 700,000 HAVE AT LEAST 1 PARENT DEPLOYED

3 UNIQUE TO THESE VETERANS 300,000 RETURNING SOLDIERS HAVE PTSD 320,000 HAVE TRAUMATIC BRAIN INJURY AS OF MAY 7, 2010, 1,046 HAVE DIED AND 5730 HAVE BEEN WOUNDED IN AFGHANISTAN AS OF MAY 7, 2012, 4,387 SOLDIERS HAVE BEEN KILLED, AND 31,809 HAVE BEEN WOUNDED IN IRAQ

4 UNIQUE EXPERIENCES 5,631 DEATHS BY SUMMER 2010 IN BOTH COMBAT ZONES COMPARED TO 58,000 DEATHS IN VIETNAM NEW KIND OF CASUALTIES DUE TO ADVANCED BODY ARMOR AND VEHICLES & LIFESAVING TECHNIQUES CIVIL WAR AND WW11 1 IN 3 DIED, VIETNAM-1 IN 4, OEF AND OIF-1 IN 15!

5 UNIQUE EXPEREINCES Multiple deployments vs. staying til it is done 29% OF FEMALE VETERANS REPORT HAVING BEEN RAPED! 300,000 RETURNING SOLDIERS HAVE PTSD 320,000 HAVE TRAUMATIC BRAIN INJURY BY MORE SOLDIERS DIED FROM SUICIDE, DRUGS & ALCOHOL THAN ENEMY FOE IS DISGUISED, NO BATTLEFRONT, ON DUTY 360/365, ALL AROUND, EVERYDAY, NO BREAK UNCERTAIN, TENSE, HOPELESS, HELPLESS DUE TO IEDS

6 unique Multiple deployments vs. staying til it is done Deployment: wives struggle to adapt to veteran s absence Post deployment: coping with ptsd and learning to reconnect to family and society Soldiers suffer dramatic loss of social support from comrades

7 COMBAT STRESS INJURIES POST TRAUMATIC STRESS DISORDER SUBSTANCE ABUSE MAJOR DEPRESSION SUICIDE TRAUMATIC BRAIN INJURY

8 SUBSTANCE ABUSE Mitigate intense emotions that come with combat Each war has an underlying drug culture Currently, alcohol is banned from war zones, but they get and use it anyway High rates of re-deployment have led to increased risk of heavy drinking Current wars have produced new wave of addiction: prescription drugs and opiates to keep them in the fight rather than refer to treatment for addiction- 10% HAVE A PRESCRIPTION FOR NARCOTICS (Oxycontin)

9 STATISTICS RE: ALCOHOL AND SUBSTANCE MISUSE % alcohol misuse 36% met criteria for alcohol misuse, only 31% got mental health treatment Cannabis use increased more than 50% over past 7 years in vets, while in general population unchanged. Perhaps due to better detection and screening at VA

10 DEMOGRAPHICS of ALCOHOL MISUSE Men under 25 misuse more Increased mortality risk, tend to die 15 years earlier 90% of deaths of those diagnosed were noninjury causes Combat exposure was only significant variable associated with PTSD, Depression and Alcohol misuse among veterans Younger males, with symptoms of depression and PTSD more likely to misuse alcohol

11 Incarcerated Veterans -Thousands of veterans are in prison. Substance Abuse, mental illness are linked -30% of OIF and OEF veterans report symptoms of PTSD, TBI depression -19% have been diagnosed with substance abuse or dependence Veterans do not quality for substance abuse disability benefits unless they also have PTSD

12 140,000 veterans incarcerated in state and federal prisons in % in federal prisons for drug law violations -15% in state prisons for drug law violations, 5.6 simple possession

13 CONNECTIONS BETWEEN PTSD,DEPRESSION AND ALCOHOL AND DRUG ABUSE Co-occurence is well-established and those with both have lower functioning than either by itself Seen as self medication/maladaptive coping 1/3 with PTSD report alcohol misuse PTSD with high rates of alcohol use leads to poor health functioning Prescribed pain pills new way to cope to tame combat stress In 2007, 22,000 veterans given antidepressants or sleeping pills Significant numbers are sharing pain pills

14 SOUL WOUNDS In addition to addiction, various injuries occur often due to inability to rationalize, accept and reintegrate with society Visible vs. invisible wounds: less deaths than Vietnam but many so called invisible wounds 1. PTSD 2. Depression 3. Traumatic Brain Injury

15 POST TRAUMATIC STRESS DISORDER INCUBATION FOR THIS INJURY: 50% of army and marine corps ground combat units report being shot at, and seeing dead or seriously wounded Americans of injured civilian noncombatants. More than half reported killing an enemy in Iraq. Multiple deployments lead to higher rates More realistic to think of PTSD as an injury vs. a disorder

16 DSM Definition of PTSD 1. Anxiety 2. Reexperiencing of a traumatic event via thoughts, dreams, reliving the event and intense psychological and physiological distress when exposed to cues that resemble the event 3. Avoidance of thoughts of the trauma, inability to recall the trauma 4. Detachment of others, numbness alternating with hypervigilence and irritability and anger Delayed onset if symptoms present at least 6 months after the stressor.

17 Effects of PTSD on life 1. Emotionally: anger, fear, anxiety 2. Cognitively: altered worldview, hopeless, etc. 3. biologically: psychosomatic illnesses 4. Behaviorally: isolation, substance abuse 5. Socially: negative effect on interpersonal relationship with family and friends who can develop secondary PTSD

18 DEPRESSION Not traditionally considered an invisible wound of war but with record numbers of suicides associated with current war fighters and veterans, must learn more about it. Loss of friends and comrades may trigger depressive episodes

19 MAJOR DEPRESSIVE EPISODE: DSM 2 week period nearly every day with at least 5 of the following symptoms: Depressed mood Loss of interest or pleasure Weight changes Insomnia or hyper-somnia Psychomotor agitation, fatigue, loss of energy Feelings of worthlessness, guilt Diminished ability to think or concentrate Recurrent thoughts of death

20 SUICIDE Veterans are committing suicide at a rate that far exceeds nonveteran population. 32,000 suicides a year, 650,000 attempts in general population. Difficult to get an exact amount because some appear to be accidents. In June 2010, 1 per day killed themselves!!! In 2007, 108 confirmed suicides in the Army, 166 in Iraq and Afghanistan.

21 CAUSES OF SUICIDE OFTEN PRECIPITATED BY ANGER, DEPRESSION, ANXIETY AND SUBSTANCE ABUSE AND PTSD Stigma to seeking help for needed problems like PTSD and Depression

22 WHY STIGMA? -considered weak -would be treated differently Would have less confidence in them Difficult to get time off of work Would hurt their career Difficult to schedule an appointment Would be embarrassing Didn t trust mental health professionals

23 Public Health Problem MUST CHANGE STIGMA Mental health issues like PTSD and depression are expected just as physical injuries are Mental health injuries are an occupation hazard and need treatment just like physical wounds.

24 Post Deployment Suicide STIGMA Military health system is overloaded and officers in charge at highest levels often continue to say that there is no direct correlation between war and suicide. Often told nothing wrong with you, coward, and were discharged. Female veterans 3 times more likely than civilian to commit suicide.

25 TRAUMATIC BRAIN INJURY The use of Improvised explosive devices (IEDS) Persons exposed to IED blasts may develop mild, moderate or severe brain injury which results in temporary or permanent cognitive impairment. Decreased levels of consciousness, amnesia, skull fracture and intracranial lesions and can lead to death IED have caused 75% of all casualties

26 Depression Second most prevalent illness, only 25% being treated in primary care environment require referral to a specialized mental health setting As the number of veterans has increased, the number of clinic visits per veteran has decreased. 4% of OEF and OIF veterans receiving non- PTSD diagnoses and less than 10% receiving PTSD diagnoses attended 9 or more VA mental health treatment session in 15 weeks or less in first year of diagnosis.

27 INTERVENTION Lack of seeking treatment 40% don t want professional help, fear stigma High rates of treatment dropouts Afraid it will appear on record if diagnosed with alcohol misuse WEB BASED MIGHT REDUCE STIGMA: CAN USE MOTIVATION AND COGNITIVE BEHAVIORAL APPROACHES

28 Cognitive behavioral therapy Stress inoculation training Relaxation and breathing training Communication training Cognitive restructuring Since alcohol abuse is seen as a maladaptive coping to life stress, focus is developing skill set for maintaining abstinence and identify triggers for drinking

29 SIGNIFICANT OTHER THERAPY Couple s therapy leads to higher rates of abstinence, lower divorced rates and greater satisfaction than individual therapy Positive reinforcement approach Optimize engagement PTSD and alcohol misuse associated with interpersonal deficits Inadequate social support, loss of comrades Trauma happened while in combat zone so outside of typical social environment

30 SAND TRAY THERAPY MAY REFER TO IT AS A PROJECT NONVERBAL REINACTMENT MIXED IN WITH SOME COGNITIVE WORK COUPLES CAN HAVE A SHARED EXPERIENCE EMOTIONALLY AND COGNITIVELY

31 POSTDEPLOYMENT When the service member returns home Reunification requires that the family accommodates to combat related injuries. May lead to secondary traumatic stress Role adjustments must be made, often the mother took on the father role of being more playful and fun. Must get reacquainted with parent and often leads to change in after school programs.

32 POST MILITARY ADJUSTMENT A period of ambivalent responding Anxiety and anger Fear of rejection in spouses and returning soldiers Soldiers often feel excluded and unneeded Spouses experience depression, irritation, anger, distress, emotional detachment, impaired communication and intimacy and a need for role readjustment

33 REFERENCES Bonn-Miller, M., Harris, A., and Trafton, J. (2012). Prevalence of cannibus use disorder diagnoses among veterans in 2002, 2008, and Psychological Services, 9, (4), Brief, D., Rubin, A., Enggasser, J., Roy, M., and Keane, T. (2011). Web-Based Intervention for Returning Veterans with symptoms of Posttraumatic Stress Disorder and Risky Alcohol Use. Journal of Contemporary Psychotherapy, 41, 4,

34 Burnett-Zeigler, I., Ilgen, M., Valenstein, M., Zivin, K., Goman, L., Blow, A., Duffy, S., and Chermack, S. (2011). Addictive Behaviors, 36, 8, Fudalej, S., Bohnert, A., Austin, K., Barry, K., Blow, F., and Ilgen, M. (2010). Predictors of injury-related and non-injury-related mortality among veterans with alcohol use disorders. Addiction, 105,

35 Goebel, J., Compton, P., Zubkoff, L., Lanto, A., Asch, S., Sherbourne, C., Shugaman, L., and Lorenz, K. (2011). Prescription sharing, alcohol use, and street drug use to manage pain among veterans. Journal of Pain and Symptom Management, 41, 5, Hassija, C., Jakupcak, M., Maguen, S. and Shipherd, J. C. (2012). The influence of combat and interpersonal trauma on PTSD, depression, and alcohol misuse in U.S. Gulf War and OEF/OIF women veterans. Journal of Traumatic Stress, 25,

36 Hellmuth, J., Stappenbeck, C., Hoerster, K., and Jakupcak, M. (2012). Modeling PTSD symptom clusters, alcohol misuse, anger, and depression as they relate to aggression and suicidality in returning U.S. veterans. Journal of Traumatic Stress, 25, Jakupcak, J., Tull, M., McDermott, M., Kaysen, D., Hunt, S., and Simpson, T. (2010). PTSD symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war veterans seeking post-deployment VA health care. Addictive Behaviors, 35, 9,

37 McDevitt-Murphy, M. (2011). Significant other enhanced cognitive-behavioral therapy for PTSD and alcohol misuse in OEF/OIF veterans. Professional Psychology: Research and Practice, 42, 1, McDevitt-Murphy, M., Williams, J., Bracken, K., Fields, J., Monahan, C., and Murphy, J., (2010). PTSD symptoms, hazardous drinking,and health functioning among U.S. OEF and OIF veterans presenting to primary care. Journal of traumatic Stress, 23, 1,

38 Philipps, D., (2010). Lethal Warriors. Palgrave Macmillan: New York, New York. Pryce, J., Pryce, D., and Shackelford, K. (2012). The Costs of Courage: Combat Stress, Warriors, and Family Survival. Lyceum Book, Inc.: Chicago, IL.