Characteristics of MST Are Similar to Complex Trauma May be repeated Veteran experiences harm or neglect (ignoring, disbelief) by responsible adults Occurs at a vulnerable time in life Victim remains exposed to perpetrator and may even depend on that person for his/her life
Sequelae of MST Are Similar to Complex Trauma Co-morbid mental health diagnoses such as PTSD, depression, anxiety disorders, substance abuse, and personality disorders (Kimerling et al., 2007; Street et al., 2009) Co-morbid medical problems involving gynecological, neurological, gastrointestinal, pulmonary, and cardiovascular conditions (Frayne et al., 1999) Other problems such as self-harm behaviors, obesity, and dissociation (Kimerling et al., 2007)
MST and Post-Military Trauma Domestic violence and sexual revictimization (Cougle et al., 2009; Drause et al., 2007) Homelessness (Gamache et al, 2003)
Other Common Co-Morbid Problems in Veterans
Increasing Depression among OEF-OIF Veterans 2007 study measured Depression among OEF-OIF veterans post-deployment and 6 months later Rate of depression doubled in active duty personnel from 5% to 10% Rate of depression tripled in reserve personnel to 13% Milliken et al., 2007
Co-occurring PTSD and Depression among OEF-OIF Veterans 14% have PTSD 14% have Depression 18.5% have PTSD or Depression Therefore, 9.5% have both 68% of veterans with one have the other Rand, 2008
Common Co-Morbidities with PTSD in Veterans Substance abuse Depression Traumatic brain injuries (TBI) Chronic pain Insomnia DOD, 2012
Disorders That Co-occur with PTSD in Veterans Inpatient PTSD program study 70% had lifetime Major Depression 79% had lifetime Alcohol Dependence 39% had lifetime Panic Disorder Bremner et al., 1996
Family Stress and Deployment OEF/OIF Army wives experience more mental health problems when spouses are deployed compared to wives of nondeployed soldiers (Gibbs, 2011) Deployment is increasingly associated with declines in marital satisfaction and increases in intent to divorce (MHAT Advisory Team, 2003-09) Divorce rate among military personnel has risen from 2.6% in 2001 to 3.5% in 2012, an increase of 35% (Bushatz, 2013) Especially high among women and Marines
Family Stress and PTSD Vietnam veteran families with PTSD Problems in marital and family adjustment, parenting and violent behavior (Jordan et al., 1992) Greater severity of PTSD symptoms increased intimacy problems (Riggs et al., 1998) OEF/OIF veterans (Sayers et al., 2009) Three-fourths of married/cohabitating veterans reported family problems in the past week Veterans with PTSD or depression had increased problems
Child Abuse and Domestic Violence in Army Families DOD, 2012
Alcohol Involvement in Child Abuse and Domestic Violence DOD, 2012
Relationship Problems Associated with PTSD Domestic violence Angry outbursts Distrust of others Social isolation Divorce Vietnam Veterans with PTSD twice as likely to be divorced as those without PTSD (Kulka et al., 1988) Serial relationships Secondary traumatization of families Multigenerational damage
Problems of Children in Military Families Parental PTSD is associated with family relationship problems and secondary traumatization (Galovski & Lyons, 2004; Goff et al., 2007) Significantly more mental health diagnoses in children before, during, and after deployment (Mansfield et al., 2011) Conduct problems and aggression increase (Chandra et al., 2010; Morris & Age, 2009) Poorer academic functioning during deployment (Lyle, 2006; Mmari et al., 2009)
Functional Problems Associated with PTSD Avoidance of public places Job discrimination due to PTSD and mtbi Job loss/ unemployment Vietnam Veterans with PTSD 5X more likely to be unemployed than VV without PTSD (Kulka et al., 1988) Homelessness 2/3 of Iraq and Afghanistan homeless veterans have PTSD (Tsai et al., 2013) Violence Legal problems By 1988, nearly half of Vietnam Veterans had been arrested or jailed at least once (Kulka et al., 1988)
Tommy Rieman
PTSD and Pain There are few studies evaluating the relationship between PTSD and pain in Veterans Studies of Veterans indicate that 66-80% of Veterans with PTSD experience chronic pain (Beckham et al., 1997; Shipherd et al., 2007) In a study of Veterans screened for traumatic brain injuries at a VA Polytrauma Network site, 86% of those diagnosed with PTSD also had chronic pain (Lew et al., 2009) The prevalence of PTSD in populations presenting with pain ranges from 10-50% (Otis et al., 2003)
Outpatient Visit Rates by Illness Type in the Armed Services 2002-2012 MSMR 4/2013
Health Problems Associated with PTSD Heart disease Diabetes Multiple chronic health problems Vietnam Veterans with PTSD are 3X more likely to have four or more chronic health problems as those without (Kulka et al., 1988) Dementia VA study 2000-2007 found dementia in 10.6% of PTSD Veterans and 6.6% of non-ptsd Veterans (Yaffe et al., 2010)
Increased Death Rates Premature death 17% of Veterans with cardiovascular disease and PTSD died over a 3.5 year period, compared with 10% of those without PTSD (Ahmadi et al., 2011) Higher rates of suicidal ideation and behavior (Pompili et al., 2013) 1.8 X higher rates of suicide among Veterans compared to those without PTSD at VAMCs (Ilgen et al., 2010)
Treatment of PTSD and Co-Occurring Problems in Veterans
Why Should We Treat Co-Occurring Disorders Integratively? Mental health problems do not go away with abstinence Improved mental health does not bring about abstinence from substance use Separate treatment is at best uncoordinated and at worst countertherapeutic Integrated treatment leads to better outcomes
The Importance of Integrated Treatment for PTSD and SUDs Treating one disorder without treating the other is ineffective Sequential treatment (usually SUD first) is ineffective Fully integrated treatment is optimal Simultaneous treatment is next best
The Importance of Integrated Treatment for PTSD and SUDs Recent evidence on integrated and simultaneous treatment (Hien et al., 2010) suggests: - If PTSD symptoms decline, so do SUDs - If SUDs decline, PTSD symptoms do not Therefore, treating substance abuse without treating PTSD will fail This includes ASAP programs
Recent Research on Treatment for PTSD and SUDs Two recent studies of treatment of PTSD and SUDs using PE and simultaneous SUD treatment (Mills et al., 2012; Foa et al., 2013) show mixed results Exposure therapy does not increase substance use One study found that integrated exposure therapy plus SUD treatment improves trauma symptoms but not substance abuse, depression or anxiety compared to TAU (Mills et al., 2012) The other found that Prolonged Exposure plus Naltrexone does not improve trauma symptoms more than TAU (Foa et al., 2013)
Some Barriers to Integrated Treatment Most insurance does not pay for substance abuse treatment Separate payment streams Separate treatment systems Professional training biases Lack of dually trained clinicians
PTSD and Substance Abuse Treatment PTSD symptoms may worsen in the early stages of abstinence Earlier concern that PTSD exposure therapies may trigger substance abuse relapses seems not to be the case Some aspects of 12-Step groups are difficult for some trauma patients Powerlessness Higher Power Issues of forgiveness
Phases of Integrated Treatment I. Safety and Stabilization II. Remembrance and mourning III. Reconnection After Herman, 1992
Medication Treatment of Substance Use Disorders Alcohol: Antabuse (Disulfiram) Naltrexone Acamprosate Opiates: Methadone Buprenorphine
Psychological Treatment of Substance Use Disorders Evidence-Based Treatments: Motivational Interviewing Motivational Enhancement Therapy Cognitive-Behavioral Therapy (CBT) Contingency Management Twelve-step Facilitation Therapy Behavioral Couples Therapy
Medical Treatment of Depression Medication: Antidepressants Mood stabilizers Atypical antipsychotics Anticonvulsant Stimulation: ECT
Psychological Treatment of Depression Evidence-Based Psychotherapies: Cognitive-Behavioral Therapy (CBT) Acceptance and Commitment Therapy (ACT) Mindfulness-Based Cognitive Therapy (MBCT) Interpersonal Psychotherapy Problem-Solving Therapy
Treatment of Insomnia Medication: Trazodone Sleep aids Over the counter: Melatonin L-Tryptophan Cognitive-Behavioral Therapy for Insomnia
Medical Treatment of PTSD Medication for symptom management and co-morbid disorders Antidepressants Mood stabilizers Atypical antipsychotics not Risperdal Anticonvulsants Anxiolytics (Buspar) not benzodiazepines Sleep aids (Trazodone) There is no medication that specifically treats PTSD Only SSRIs (Prozac, Zoloft, & Paxil) have been approved by the FDA for treating PTSD