Challenges and issues for international research addressing the life continuum from military service to transition

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1 Challenges and issues for international research addressing the life continuum from military service to transition A C McFarlane Professor of Psychiatry Centre for Traumatic Stress Studies The University of Adelaide

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3 The Delayed Impact of Military Service Manifests after Transition The issue of time and longitudinal interactions» Cumulative trauma exposures» Multiple deployments» Subsyndromal symptoms» Age Optimal timing and opportunities for early intervention

4 Exit Wounds MAJ GEN John Cantwell

5 Major General John Cantwell, AO, Four Corners, ABC, 2010 Yes, we ask an inordinate amount from our people and Australia needs to understand that. We are placing young men and women in some of the most dangerous, difficult and life-changing situations you can imagine. And those who are wounded, those who are killed, [and] their families face equal challenges. We cannot underestimate the damage that we might be doing to our people through constant stress. We must do everything we can to help them out psychologically, with medical care, with everything. These people are putting their lives on the line, they do this without question. They don t flinch and when they re hurt, when they re hurting as they will down the years, we ve got to keep stepping up as a society and look after them.

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7 Erich Maria Remarque - All Quiet on the Western Front One thing I do know: everything is sinking into us like a stone now, while we are in the war, will rise up again when the war is over, and that s when the real life-anddeath struggle will start. (p101)

8 Erich Maria Remarque: The Road Back We look at one another. - What do we want? yes, if it were so easy a thing to say in a sentence. A vague, urgent sense of it we have. - But for words? We have no words for it yet. But perhaps later we shall have. (p 126)

9 The importance of delayed onset PTSD and transition Maximal distress and rates of disorder are not manifest during military service the critical issue of time

10 Pre, post- deployment and Long- term follow up Cooperative Studies Program Vasterling Am J Epi, 2016

11 National Vietnam Veterans Longitudinal Study 25 year follow up of NVVRS sample Longitudinal course in combat zone veterans» 16% report an increase in symptoms» 7.6% report a decrease» Era veterans current 10.8% life-time 26.2% 271,000 veterans have current PTSD or subsyndromal PTSD 40 or more years after the end of the war (Marmar et al JAMA Psychiatry, 2015)

12 Millennium Cohort Study: Pre/Post Deployment Samples 3393 with single deployment 4394 with multiple deployment Predeployment and 3 year follow up Latent growth mixture modelling» Banonno et al Brit J Psychiatry 2012

13 Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans older age deployment with high combat exposure enlisted rank initial PTSD severity Depression history of physical assault disabling injury/illness somatic symptoms. Armenta et al, 2018 BMC Psychiatry 18:48

14 Post-traumatic stress symptoms 5 years after military deployment to Afghanistan: an observational cohort study 1007 Dutch military personnel First assessed 1 month before and 1month after deployment 5 year follow up identified an increase in PTSD symptoms 6 months after deployment long-term effect increase in symptoms 5 years after deployment (Eekhout et al Lancet Psychiatry 2016)

15 Latent Trajectories in PTSD symptoms

16 Other National Studies UK -46% delayed onset cases» subsyndromal symptoms were a significant predictor (Goodwin et al, JNMD, 2012;200: ) Canada, nationally representative military sample» related to child trauma,» cumulative trauma exposure and land based troops (Fikretoglu and Liu,Soc Psychiatry and Pscyh Epi, 2012)

17 Transition relates to age and accumulating morbodity Particular context of duration of Middle Eastern Area of Operations period of particular risk

18 The Importance of Longitudinal Neurobiological Research The identification of biomarkers of risk and possible mechanisms of disorder The relationship between mtbi and PTSD The need to improve treatment outcomes The mechanisms sensitization and kindling

19 physiological response Repeated hits from multiple stressors Sensitization Loss of reactivity and increased physiological load normal adaptive response Time

20 The challenge of assessing military mental health and comparing with the civilian community in the context of transition How do we assess the stresses and determinants of transition?

21 Canadian Armed Forces Studies 2002 and 2013 waves of data collection by Stats Canada using CIDI Value of same measures across time Increased prevalence of PTSD, GAD and Panic Disorder Due to burden of Afghanistan and humanitarian deployments, in context of improved health care Increased rates of major depression, GAD, alcohol dependence and suicide attempts compared to the general population

22 Canadian Armed Forces Studies Demonstrated greater attributed risk of child abuse (29.6%) than Afghanistan deployment (9.6%) to any disorder PTSD 31.5% attributed risk to Afghanistan deployment The healthy worker effect versus provided opportunities for disadvantaged individuals Healthy survivors remain in the military Did not measure the rates of disorder in those who have transitioned

23 Regular Force Veterans who released from service during had worse health, disability and determinants of health status than the general Canadian population.

24 Civilian Populations Birth Immigration Mental Health Risk factors Sociodemographics Health systems Death Emmigration

25 Military Populations New recruits Currently serving -Deployments -Health services -Training accidents -Occupational stresses Healthy worker effect Ex-serving and veterans population

26 Transition from military service Transition from military service reflects a complex matrix of individual motivations 1. the success or otherwise of military career 2. ongoing health and fitness for military service 3. demands and aspirations of the family unit 4. opportunities within the civilian community Transition may represent - failure and disgrace - quiet mediocrity - a sense of pride and achievement

27 Reasons for transition Medical discharges» Physical» psychiatric Disciplinary and administrative discharges Life changes family demands and children Career development and opportunities Retirement Struggling to adapt to military life Impact of ageing in lower ranks

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29 Transition of Military Personnel Symptomatic Distress Role strains Transition Stress Integration Into civilian roles During Military Service Post Discharge

30 ADF Transition Research Program Middle East Area of Operations (MEAO) Health Studies

31 ADF Transition Research Program MEAO Census Study n=26, ADF Mental Health Prevalence and Wellbeing Study n=50,049 response rate 48.9% Compared with the 2007 National Mental Health Prevalence and Wellbeing Study Enriched sample for CIDI interviews then weighted to the population

32 12-month Mental Disorder in the ADF compared to the Australian Community

33 Highest Rates in the Younger Veterans leave not detected

34 PTSD and multiple trauma exposure

35 Impact of childhood trauma and disorder in the ADF compared to the civilian population Syed et al under review Higher rates of non interpersonal childhood traumas in ADF than the civilian population Only significant traumas in childhood associated with adult disorder are interpersonal ones The effects are mediated through childhood anxiety disorders These interact with adult traumas

36 Military Populations New recruits Currently serving -Deployments -Health services -Training accidents -Occupational stresses Ex-serving and veterans population

37 Transition Wellbeing Research Program 2015 Follow up all who have transitioned from the ADF from 2010 to 2014 (18% of n=23,974) Follow previous responders who remain in the ADF (42% of n= 20,231) Combat Study following up n=1871 who were in MEAO Prospective Study

38 Military Populations New recruits Currently serving -Deployments -Health services -Training accidents -Occupational stresses Ex-serving and veterans population

39 Demographics Transition Characteristics in Transitioned ADF Slide 39 Reservists (53.83%) compared to ex-serving (45.88%). Medically Fit 73.29% years of regular service» 36.6% in the years» 23.15% 20+ years. Discharged at own request (53.58%), 20.38% medically discharged (N=5082) non-voluntary discharge administrative (3%, N=757) Main reason for transition: impact of service life on family (10.21%) 3.42% not living in stable housing in last 2 months (N=853) 2.99% (N=746) arrested since transition,» 2% (N=516) convicted, only 17 people imprisoned. 68% employed

40 12mth ICD-10 in Transitioned ADF ICD mth Transitioned ADF (N=24932) N % 95% CI 12 month ICD-10 Anxiety Disorder (incl. PTSD) , month ICD-10 Affective Disorder , month ICD-10 Alcohol Disorder 12 month ICD-10 Mental Disorder , , month ICD-10 PTSD , 21.3 The prevalence of disorder in the transition sample is 46.4% - more than double the rate in the ADF Mental Health Prevalence and Wellbeing (MHPWS) study in 2010.

41 12mth ICD-10 Anxiety Disorder in Transitioned ADF ICD-10 Anxiety Disorder Transitioned ADF (N=24932) N % 95% CI Panic Attack , 20.8 Panic Disorder , 8.0 Agoraphobia , 15.5 Social Phobia , 14.3 Specific Phobia , 10.3 Generalised Anxiety Disorder , 6.0 Obsessive Compulsive Disorder , 6.6 Posttraumatic Stress Disorder , 21.3 Any Anxiety Disorder , 41.7 The prevalence rate of PTSD of 17.7% is more the double the rate in the 2010 ADF MHPWS Study. High rates of agoraphobia and social phobia suggest degree of social isolation and withdrawal

42 12 month ICD-10 Disorder and Suicidality: Transition Predictors ICD-10 Disorder but tends to increase with time since discharge particularly for PTSD ADF members who transitioned less than 1 year ago reported the lowest level of psychological distress 1 year post-transition is where psychological distress, anger, generalised anxiety, and depression first develops. PTSD symptoms, depression, suicidality, anxiety and both types of drug use tend to peak around the 3 year mark. Overall, alcohol use and problem drinking showed no association with years since transition. Slide 42

43 Treatment Seeking Seeking assistance within one year of concern onset of those with a mental health concern» 45% within 3 months» another 25% between three months and a year» 18% waited three or more years. Approx 65% of both current and ex-serving endorsed one or more stigma item

44 Military Populations New recruits Currently serving -Deployments -Health services -Training accidents -Occupational stresses 22% Ex-serving and veterans population 46.4%

45 Nature of discharge Full time service Active Reserve Inactive Reserve Fully discharged -Veteran -Ex-serving

46 How effective are the evidence based treatments?

47 Meta Analysis of Treatment in Military Populations Approximately 66% of patients receiving CPT and PE retained their PTSD diagnosis after treatment (range 60-72%) Despite 49-70% having clinically meaningful improvement Prolonged exposure marginally superior compared to non-trauma focused psychotherapies Need to improve existing treatments and test novel evidence based treatments Steenkamp et al JAMA 2015, 314;

48 The Issue of Severity and Stage as a predictor of treatment response

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50 Curve of effect size versus symptom severity for psychotherapy for PTSD

51 What about pharmacological treatments? Importance of personalized approach

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53 The need for new biologically based treatment approaches supported by evidence The chronicity and disability associated with PTSD

54 CRP predeployment predicts PTSD symptoms 3 months post deployment JAMA Psychiatry 2014

55 Antidepressants act on peripheral inflammation Hashimoto Int J Mol Sci 2015

56 CRP Predicts Differential Response to SSRI vs. SSRI+Bupropion Jah MK et al. Psychoneuroendocrinol 2017; 78:

57 Is PTSD a systemic illness rather than a psychological disorder? Is this a critical question for developing better treatments, particularly in the biological domain?

58 PTSD as Systemic Disease Extent of comorbidity of with physical disorder Decreased life expectancy Somatic symptoms are an integral part of the disorder Underpinned by systemic dysregulation of immune function and autonomic function

59 Mortality of Australian Troops After World War 1 The Burnt Out Soldier 13% greater mortality if had fought on the Western Front. This represented a decreased life expectancy of 4 years Butler The War Damaged Soldier 1933 Census

60 Medical Comorbidities of PTSD Controlling for sociodemographics and psychiatric illnesses, PTSD was associated with significantly higher odds of having» asthma» chronic obstructive pulmonary disease» chronic fatigue syndrome,» Rheumatoid Arthritis» fibromyalgia,» migraine headaches,» Cancer» Cardiovascular hypertension and high incidence of MI and CVD mortality» Gastrointestinal» pain disorders» Epilepsy» Renal and autoimmune disorders McLeay et al MJA 2017

61 Somatic Comorbidities of PTSD Meta-analysis of 9,673 individuals in middle age with PTSD and 6852 general population controls (Rosenbaum et al, Metabolism 2015)» Metabolic syndrome 38.7% (RR=1.82 CI )» Hypertension 76.9% (Sumner et al 2016)» Hyperglycaemia 36.1% (Vaccario et al 2014) Lohr et al (2015) -PTSD should be conceputalised as a systemic disorder due to premature mortality

62 Possible causal pathways PTSD Biological Dysregulation Physical Disorder

63 The need for clinical staging in PTSD Different phenotypes that need to be addressed in treatment Staging is a method for clarifying the issue of longitudinal course and the changing neurobiology McFarlane et al Clinical Psychiatric Reports 2017

64 Staging model of PTSD 0. Trauma exposed no symptoms but at greater risk with further exposure 1a. Minor symptoms 1b. Subsyndromal PTSD similar to PTSD 2. First episode of brief duration 3. More enduring or relapsing disorder following treatment 4. Chronic, severe and treatment unresponsive

65 JAMA Psychiatry 2018

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67 Erich Maria Remarque - All Quiet on the Western Front Because one thing has become clear to me: you can cope with all the horror as long as you simply duck thinking about it - but it will kill you if you try to come to terms with it. (p100)

68 The Farmer Remembers The Somme I have returned to these: The farm, and the kindly Bush, and the young calves lowing; But all that my mind sees Is a quaking bog in a mist - stark, snapped trees, And the dark Somme flowing - Vance Palmer

69 Thank you Questions