nicola.sorfleet@combatstress.org.uk 01372 587016 1

2 Focusing on Veterans

Our work 5,954 We are: Accessible through our 24-hour Helpline, We Provide: Evidence-based, recovery focused interventions including; o o o o Outpatient Psychiatric and Psychological Assessment and Intervention Intensive Residential Treatment Programmes Community Based Assessment, Welfare Signposting, Psychiatric Nurse and Occupational Therapy Led Intervention Substance Misuse Case Management Service Our services are enhanced by: Working in Partnership Veterans are currently being supported. 2, 328 Total of new referrals in the year. 1,168 Number of Veterans discharged. 3

Partnerships That Work The Royal British Legion Break Centres Pop-in Centres Poppy Scotland Help for Heroes The Armed Forces Health Partnership Working Group The Warrior Programme The Department of Health/ National Health Service/ Public Health England Kings Centre for Military Health Research (KCMHR) Rethink Mental Health (Helpline) 4

How are we Funded Total Cost circa 19m per annum. Funded by: Charity - 60% Statutory and Contract 40%

Combat Stress Residential Treatment Centres Audley Court is in Newport, Shropshire. It has 27 beds, including a small number of rooms for carers. Hollybush House is in Ayrshire, Scotland. It has 25 beds and can accommodate a small number of accompanying carers. Tyrwhitt House is in Leatherhead, Surrey. It has 33 beds 4 of which can also accommodate a partner or carer.

Demand 5,954 active veterans compared to 5,473 at the end of last year - 9% increase 2014/2015 2,328 new referrals compared to 1,854 last year - 28% increase 44% self referral 4% by Families / friends 21% other charities/unknown 7% NHS Community Mental health, 4% GPs, 3% from the Website 17% from Helpline

Demographics Army 84% Merchant Navy 0% Royal Air Force 7% Royal Marines 3% Royal Navy 6% Majority - lower ranks 97% male and 3% female Average time from leaving Military Service to seeking help from Combat Stress is 13.1 years The average time is 2.2 years for those who have served in Afghanistan and 3.9 years for Iraq. 8

Theatres of Operation Active Veterans 1.Northern Ireland n=3,122 2.Iraq n=1,185 3.Afghanistan n=971 4.Balkans n=907 5.Gulf n=617 6.Falklands n=554 7.All other conflicts and Wars n=1,182 8.None n=729 3500 3000 2500 2000 1500 1000 500 0 1 2 3 4 5 6 7 8 Please note, a veterans may appear in both conflicts 9

Referral Patterns and Trajectories Northern Ireland, Iraq & Afghanistan

Employment Status 11

Mental health profile of new referrals to CS Health outcome % (N=425) (Murphy 2014) PTSD 79% Depression 88% Anxiety 79% Anger problems 46% Alcohol problems 44% Drug misuse 13% Functional impairment Significant 25% Severe 64% Childhood adversity (e.g. CSA, neglect etc) 52% Significant Physical illness 71%

Welsh Veterans Study 2011 COMBAT STRESS (help seekers) SPVA (War Pensions) KCMHR (research group) Mean age 49 67 38 Major depression 62% 13% 4% Lifetime Suicide attempts Hazardous drinking Probable Alcohol dependence 44% 6% 1% 20% 17% 37% 27% 2% 6% PTSD 73% 10% 3%

Recovery Model Assisting Veterans in their Journey of Recovery Engagement Resource Building Implementing Change Reintegration Self Maintained Recovery Relapse Management Working with the Veterans to stimulate their selfbelief and develop their commitment to recovery. Builds on the Veterans resilience to effectively engage in more intensive in-patient or out-patient treatment options. Builds on the capabilities of Veterans to change, to strengthen skills and to improve psychological resilience through active and intensive treatment. Consolidates the skills acquired through treatment enabling these Veterans to improve social reintegration into families and their communities. Empowers the Veterans to continue to live their lives independently. Acknowledges the potential for relapse and focuses on the obstacles that are still preventing recovery.

Key Roles Multi-disciplinary working across the UK: Consultant Psychiatrists Psychologists and CBT therapists Art Therapists Occupational Therapists Registered Mental Health Nurses Recovery Support Workers Welfare Officers Community Psychiatric Nurses Quality and Clinical Governance Staff Treatment Centre Managers Operational Managers

Clinical Services Community National 24 Hour Help Line approx. 800 calls per month Outpatient Clinics (Consultant Psychiatrists and Psychologists) Community and Outreach Service (Welfare, CPN & OT) Substance Misuse Case Management Service Recovery and Social Reintegration Programme Occupational Therapy Led Intervention Residential 87 Residential beds across three treatment centres in Scotland (Ayr), Midlands (Shropshire) and South (Leatherhead, Surrey)

Community High Street TRBL Pop in Centres and Outreach Regional Welfare Officer Community Psychiatric Nurse Occupational Therapists Welfare War pension, housing, benefits claims etc Signpost and support the veteran with external organisations such local councils and funding bodies Clinical Community clinicians provide triage & assessment, support groups and clinical review Supervised by Consultant Psychiatrists and Psychologists

Residential Programmes PTSD ITP 6 weeks Stabilisation 2 weeks Anger Management 2 weeks Transdiagnostic 1 or 2 weeks Bespoke Treatment Substance Misuse & PTSD 2 weeks CBT treatment for Veterans with PTSD and a co-morbid diagnosis following exposure to multiple military trauma CBT/DBT treatment for Veterans experiencing high levels of hyper-arousal and/or emotional dysregulation CBT treatment for Veterans experiencing anger control difficulties CBT treatment for Veterans addressing psychological comorbidity targeting cognitive and behavioural processes seen across disorders CBT treatment for complex presentations of PTSD and comorbidity To be piloted. CBT treatment for hazardous non-dependent substance misuse with PTSD following exposure to military trauma

Interventions The Recovery and Social Reintegration Occupational Therapy Assessment Behavioural Activation Exercises Life Skills Training Relapse Management Programme Personal responsibility for recovery and maintenance Clinical Audit Outcomes 293 veterans and 47 spouses or partners (n=340) (between 2012 and 2014). Intervention: low level activity and group based rehabilitation input Seen to take better personal responsibility for their illness and improve functionally Audit data confirmed clinical observations that veterans moved away from the sick role and functioned more adaptively An outcome study relating to this service is underway

PTSD Intensive Treatment Programme (ITP) Psycho-Educational Groups, Skills Training Groups and 1:1 TF-CBT Groups: PTSD Psychoeducation Arousal & Reactivity Management Overcoming Avoidance Mood Management Mindfulness Skills Art Therapy Recovery & Resilience Family education/carer groups Individual: 15-18 Sessions of Trauma Focussed Cognitive Behavioural Therapy

PTSD ITP Eight patients & two therapists; closed groups Psychiatric & Psychological Assessment Manualised Group Treatment Delivered 5 Days a Week 9:00-16:30 Fortnightly Clinical Supervision Weekend and out of hours homework/exposure Integrated Occupational Led Recovery and Resilience Modules including vocational opportunities, links to community, further education Outcome Measurement Based on Australian model & Research Literature

Evidence Base & Outcomes Research Literature Evidence base - >4000 Australian Veterans Outcome best if: Mix of individual and group interventions Mix of residential hospital / day centre and outreach Must include trauma focussed therapy not just rehabilitation Rule of thirds one third do well; one third get better, one third don t do so well need more help Outcomes related to intensity of programme: this is correlated with severity of disorder. The higher the severity the more intensive the therapy should be If patient has mild disorder and intense programme delivered likely may not improve and might make worse Patient Selection is critical

Intensive Treatment Programme Clinical Audit and Psychometric data outcomes Sept 2011 April 2015 Good uptake - around 900 have completed the programme High Completion Rate - Low drop out rate (3-15% annual rates) Audit data and Psychometric Subjective and Objective measures indicate much improved clinically and functionally post programme PTSD and other co-morbidity and function much improved with CONTINUED improvement between 6 week and 6 month follow-up 70% of attendees are much improved

6 month outcomes following the ITP Primary outcome: PTSD 60 50 40 30 20 PSS-I IES-R 10 0 Admission 6 week F/U 6 month F/U

6 month outcomes following the ITP Secondary outcome: co-morbid MH (Depression, Anxiety, Anger) 20 18 16 14 12 10 8 6 4 2 0 Admission 6 week F/U 6 month F/U PHQ-9 GAD-7 DAR-5

6 month outcomes following the ITP Secondary outcomes: well-being & functioning 70 60 50 40 30 20 10 0 Admission 6 week F/U 6 month F/U HONOS WSAS GAF

PTSD ITP Outcome Paper British Medical Journal on Line (March 2015) Naturalistic study: Successive patients-246 veterans who accessed Combat Stress between late 2012 and early 2014 for treatment. Six week and six month follow-up High engagement and high completion rate (94%) (US studies drop out rates 22-46%) No evidence of differences in baseline outcomes completers and non completers Over 80% responders at 6 months - no evidence of differences between those we were able to follow up at six months and those lost to follow up. Highly significant reductions in PTSD scores following treatment on both clinician completed measures (87% reduction in PTSD symptoms maintained over six month follow-up period US study 49% reduction in PTSD symptoms). Similar improvements in Anxiety, depression, alcohol misuse, anger. Highly significant improvements in functional impairment continued to improve between six week and six month follow-up. Predictors Outcome paper to be published.

Comparison of ITP with other intervention outcome studies (Professor Mark Creamer 2015) Clinical improvement following treatment is often expressed as effect size (ES) ES of 0.2 is small, 0.5 moderate, and 0.8 large Note that we would expect slightly lower ES at longer follow-ups due the fact that some veterans will relapse Veterans with chronic co morbid PTSD Intervention Country Effect Size Time scale Murphy et al 2015 Forbes/ Creamer 1999- current Monson et al 2006 Treatment Programme ITP (Combat Stress) United Kingdom 1.3 6 months Treatment Programme Australia 0.9 2 years Cognitive Processing Therapy USA 0.7-0.9 1 month post treatment Turek et al, 2011 Exposure Therapy USA 1.2-2.1 Immediately post treatment The ES achieved by the Combat Stress programs (Murphy et al., 2015) are approaching 1.3 in core PTSD symptoms, maintained through to six months post-treatment, with comparable gains in co-morbid conditions To achieve this level of sustained improvement for a predominantly chronic veteran PTSD population is very impressive. (Creamer 2015)

One Year Follow-up Paper in preparation N=108 at 12 month follow-up Before and after ITP. 31% PSS-I had reduced by between 1-9 points, 31% scores reduced by 10-19 point 26% reduced by 20+ points on the PSS-I. 13% symptoms were worse than before treatment, Improvements we noted in the 6 month paper are being maintained

Abstract Title: Exploring the relationships between baseline health and post traumatic stress disorder (PTSD) and functioning outcomes in UK veterans treated for PTSD. Murphy, D. & Busuttil, W. Accepted for publication in Psychology Research Post traumatic stress disorder (PTSD) in ex-service personnel is associated with high levels of co-morbidity and significant functional impairment. This paper reports on predictors of treatment outcomes in UK veterans with PTSD. The sample for the study consisted of 244 participants who had received a standardised six week residential treatment programme for PTSD. The programme consisted of individual trauma-focused CBT and group therapy sessions. In this paper evidence is presented that shows improvements in intrusive, avoidance and hyper-arousal PTSD symptoms six months after the end of treatment; with post-treatment avoidance PTSD symptoms showing the most improvements. The findings suggest that higher levels of baseline anxiety and dissociation are associated with worse post-treatment PTSD outcomes. This suggests the importance of treating these difficulties in UK veterans before intervening for symptoms of PTSD. Hazardous Drinking is not a predictor of poorer outcome.

Current Projects Research Challenges: Formal Link into Kings Centre for Military Health Research & International collaborations Referral patterns, access and engagement into clinical services 1994-2014 (in process of submission) Treatment outcome predictors study (in process of submission). Brain Injury (ongoing) Mental Health Needs of Partners and Carers studies collaboration with TRBL (ongoing) Telemedicine Study in collaboration with Blind Veterans UK (funding application made) Dementia and PTSD in collaboration with TRBL (planning phase) Psychometric cross validation studies collaboration with Australian Veterans Medication and PTSD Treatment in Veterans in collaboration with Canadian Veterans services (study in audit phase) Prison & Forensic Services in collaboration with NHS (planning phase)

Research and Audit Formal Link into Kings Centre for Military Health Research & International collaborations Research Challenges: Who are the help seeking veterans? What are their needs? What works in treatment? Research aimed at identifying needs of help-seeking veterans and service development Scoping Study: Klein, S., Alexander, D., & Busuttil, W. (2012) Scoping review: A Needs-Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland Robert Gordon University. Aberdeen December 2012 www.scotland.gov.uk/resource/0041/00417172.pdf Collaborative academic studies currently include 2 PhDs, 3 Clin Psych D, and 2 MSc projects conducted with KCMHR, University of Surrey, University of Essex, University of Bournemouth and University College London. Current University linked Academic Projects include: Trajectory studies Rehabilitation Pathway, Wellbeing and Break Centre Programme outcomes. Genetics and PTSD Family and PTSD; Domestic Violence Art Therapy collaboration with Walter Reed Hospital Washington DC Physical health of mentally ill veterans

The Future Consolidate all programmes & pathways Community Emphasis Migration More Joint Working & Collaboration Research Aimed at Service Development