Working with veterans suffering from mental health problems


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Veterans with chronic mental health problems commonly isolate themselves from mainstream society, have poor relationships with others and suffer marital, family and economic difficulties. While the true scale of the mental health problem is unknown in Britain, as veteran population studies have not been performed, Combat Stress – the national charity that looks after veterans with mental health problems – has had increasing demands for help over the past few years. This session discussed rehabilitation strategies for veterans with mental health problems and highlighted the work of Combat Stress.

From the Remembering War Symposium at Wellcome Collection

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Working with veterans suffering from mental health problems

  1. 1. Working with veterans suffering from mental health problems The role of the Charity Combat Stress Dr Walter Busuttil Medical Director & Consultant Psychiatrist Combat Stress [email_address]
  2. 2. Veterans <ul><li>A veteran is someone who has served at least one day in the military </li></ul><ul><li>Veterans and combat veterans </li></ul><ul><li>Around 25,000 leave the military each year. </li></ul><ul><li>There are about 5 million Veterans in the UK and 7.5 million first degree dependents. </li></ul>
  3. 3. UK Veterans <ul><li>What are the issues? </li></ul><ul><li>What is the need? Numbers, Clinical need Welfare need? </li></ul><ul><li>What services are needed? </li></ul>
  4. 4. Why is working with veterans complicated? <ul><li>Mental health problems can arise from a variety of causes in Veterans: </li></ul><ul><li>Pre service vulnerabilities </li></ul><ul><li>Military life itself </li></ul><ul><li>Earlier onset of physical disorders </li></ul><ul><li>Leaving the service and adjusting to civilian life </li></ul><ul><li>Help seeking issues </li></ul><ul><li>Combination of the above </li></ul>
  5. 5. Incidence of mental health problems in Veterans <ul><li>No UK Population Studies </li></ul><ul><li>Need National Vietnam Veterans Readjustment Study (NVVRS) equivalent studies </li></ul><ul><li>KCL OP Telec (Iraq Invasion and occupation) Studies will help as long as population is followed up as veterans </li></ul><ul><li>Population Studies being set up in Scotland and Wales </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>PTSD </li></ul><ul><li>Alcohol </li></ul><ul><li>Drugs </li></ul><ul><li>Personality problems </li></ul>
  6. 6. Combat Stress: Ex-Servicemen’s Welfare Society established 1919 <ul><li>National Charity 85,000 helped so far. </li></ul><ul><li>Only mental health charity of any size for Veterans </li></ul><ul><li>Part funded via War Pensions system Part funded by Charity </li></ul><ul><li>Offers multidisciplinary community outreach service including welfare needs and multidisciplinary inpatient bespoke programmes. </li></ul><ul><li>Clinical Outreach services being expanded. </li></ul><ul><li>Helplines / websites </li></ul><ul><li>Most referrals self referral or through family (46%) or ex-service charities (31%) - NHS only 3%! </li></ul><ul><li>1200 new referrals last year </li></ul><ul><li>3500 active patients – receiving either welfare or clinical help or both </li></ul>
  7. 7. Typical new referral 2008 <ul><li>Average age 44 year old (youngest aged 20 oldest 93) </li></ul><ul><li>Ex Army </li></ul><ul><li>Childhood trauma, neglect, poor care giving </li></ul><ul><li>Multiple traumatic exposure. Service in many war theatres NI commonest. </li></ul><ul><li>Family Ultimatum – usually second marriage </li></ul><ul><li>History of Multiple house moves, employers, long spells of unemployment or homelessness </li></ul><ul><li>Many children mostly not in touch </li></ul><ul><li>History of domestic violence </li></ul><ul><li>Significant physical illness </li></ul><ul><li>Classically diagnosed with PTSD, Depression; Alcohol misuse </li></ul><ul><li>No prior intervention </li></ul><ul><li>NHS has not helped (for a variety of reasons) </li></ul>
  8. 8. The needs of Combat Stress Population: Clinical Audit Data Combat Stress 2007 % New Patients (n=162) % Review patients (n=169) Significant Physical illness 59 86 Physical injury during military service 45 62 Psychiatric illness as a measure of chronicity 75 95 Multiple exposure to psychological trauma 95 84 Present and past history of alcohol and drug dependence and abuse 69 74 Significant attachment difficulties in childhood / adolescence incl CSA and other abuse. 59 39
  9. 9. Complex Bio-Psychosocial presentations <ul><li>Psychiatric disorders </li></ul><ul><li>Chronic PTSD, Depression, Alcohol; attachment disorders </li></ul><ul><li>Behavioural Disorders </li></ul><ul><li>Anger, Aggression, domestic violence, </li></ul><ul><li>Physical Disorders </li></ul><ul><li>Orthopaedic, ENT, Diabetes, Cardiac </li></ul><ul><li>Social exclusion </li></ul><ul><li>Isolation, family breakdown, unemployment , Homelessness </li></ul><ul><li>Source </li></ul><ul><li>Combat Stress Clinical Audit data (n=331) & Psychometric Data Analyses (n=480) 2005-2008 </li></ul>
  10. 10. PTSD: CO-MORBIDITY: (incl NVVRS Study and other studies) BIO/PSYCHO/SOCIAL <ul><li>Depressive illness 50-75% </li></ul><ul><li>Anxiety disorder 20 -40% </li></ul><ul><li>Phobias 15 - 30% </li></ul><ul><li>Panic disorder 5 -37% </li></ul><ul><li>alcohol abuse / dependence 6 - 55% </li></ul><ul><li>drug / abuse / dependence 25% </li></ul><ul><li>Divorce </li></ul><ul><li>Unemployment </li></ul><ul><li>Accidents: </li></ul><ul><li>RTA rates 49% higher in Vietnam vets than non-vets </li></ul><ul><li>Suicide: 65% higher in combat veterans </li></ul>
  11. 11. Family issues <ul><li>Usually wife or Woman bring veteran into care </li></ul><ul><li>Direct and indirect traumatisation of the family </li></ul><ul><li>Direct exposure to service life, husband’s operation experiences </li></ul><ul><li>Emotional contamination – ripple effect on Family members if these are still around. </li></ul><ul><li>Usually multiple relationships and divorces , partners, children. </li></ul>
  12. 12. Most powerful predictors of ongoing PTSD in combat veterans are: <ul><li>Dose of exposure to trauma / combat / time in front line </li></ul><ul><li>Impaired family functioning – more powerful than personality and developmental issues. </li></ul><ul><li>Very strong correlation between PTSD severity and family dysfunction. </li></ul><ul><li>Veterans who do well in treatment: those in supportive relationship with a female – usually wife – marital support crucial to adjustment in veterans (Egendorlf 1980) </li></ul>
  13. 13. Combat Stress Treatment Strategy (Dec 2007) Chronic Disease management as per 2005 NICE Guidelines for treatment of Veterans for PTSD <ul><li>Initial preparation. </li></ul><ul><li>Stabilisation and safety. </li></ul><ul><li>Disclosure and working through of the traumatic material and psychotherapy on an individual basis. </li></ul><ul><li>Rehabilitation and reintegration within society; normalising activities of daily living. </li></ul>
  14. 14. Treatment of PTSD in Veterans: Basic Principles <ul><li>Multimodal Assessment: </li></ul><ul><li>Clinical History & Mental State Examination; Psychometric Tests: subjective and Objective </li></ul><ul><li>Stabilise: </li></ul><ul><li>Prepare for therapy: detox alcohol, drugs, </li></ul><ul><li>welfare needs – homelessness, isolation, job skills etc: </li></ul><ul><li>Prescribe appropriate medications SSRI and related antidepressants, Mood stabilisers, anti-impulse, major tranquillizers; medications for pain, </li></ul><ul><li>Therapy : </li></ul><ul><li>Outpatient </li></ul><ul><li>assessment plus TF-CBT; EMDR – single trauma much easier!! </li></ul><ul><li>Residential specialist services: </li></ul><ul><li>initial stabilisation then disclosure / psychotherapy/ then rehabilitation. </li></ul><ul><li>Group Programmes: psychoeducation; cognitive restructuring groups individual TF-CBT; EMDR; psychodynamic incl disclosure work; narrative therapy. </li></ul><ul><li>Repeat admissions? Integrated community and inpatient programmes: eg Australian Veterans; American Veterans Association </li></ul><ul><li>Appropriate treatment for co-morbid disorders </li></ul><ul><li>Family and spouse interventions – carer’s groups, family and couple therapy </li></ul><ul><li>Safety – supports </li></ul>
  15. 15. Current Clinical Intervention <ul><li>Initial Regional Welfare Officer assessment – ESSENTIAL PORTAL OF ENTRY INTO CARE </li></ul><ul><li>Community Psychiatric Nurse assessment / clinical outreach </li></ul><ul><li>Five day week admission for assessment - followed by: </li></ul><ul><li>Three two week treatment admissions over one year period as a maximum </li></ul><ul><li>Or Six one week admissions over one year </li></ul><ul><li>Whole person care plan </li></ul><ul><li>Try to plug into NHS care </li></ul>
  16. 16. Current Rolling Programme <ul><li>Establish trust and rapport </li></ul><ul><li>Unique therapeutic milieu </li></ul><ul><li>Group Psycho education: incl PTSD, depression groups; anxiety management; anger management, coping skills training / mindfulness etc. </li></ul><ul><li>Stabilisation on Medication </li></ul><ul><li>Individual therapy include arts therapies to engage; solution focussed therapy. </li></ul><ul><li>Trauma Focussed therapies (including TF-CBT and EMDR) </li></ul><ul><li>Rehabilitation – Occupational Therapy; Social Skills activities centre; retraining schemes </li></ul><ul><li>Families and carers groups </li></ul><ul><li>Liaison and plug in to local NHS </li></ul>
  17. 17. Combat Stress Clinical Strategy <ul><li>Upgrade existing services </li></ul><ul><li>Further develop residential Multidisciplinary Teams incl Training needs </li></ul><ul><li>Bespoke Programmes – intensive & old age. </li></ul><ul><li>Enhance Rolling Programme </li></ul><ul><li>Expansion of Services </li></ul><ul><li>Outreach and outpatient community services. </li></ul><ul><li>Work in partnership with other service charities and NHS / Other international rehabilitation programmes for Veterans </li></ul>
  18. 18. Government Initiatives <ul><li>MOD/NHS mental health pilots – six so far assessed / signposted 180 patients. </li></ul><ul><li>Advice to NHS about priority treatment </li></ul><ul><li>Command Paper – promise of help to veterans </li></ul><ul><li>Assessment services UK MAP, Chillwell. </li></ul><ul><li>Advice about IAPT (Improving access into Psychological Therapies) </li></ul>
  19. 19. Bespoke Programmes run on the same lines as Australian Veterans Programmes <ul><li>( Australian Veterans Service Heidelberg Melbourne) </li></ul><ul><li>Time Limited intensive residential ‘course’ of group treatment comprising: </li></ul><ul><li>Psychoeducation </li></ul><ul><li>Trauma focussed therapies </li></ul><ul><li>Cognitive restructuring </li></ul><ul><li>Rehabilitation </li></ul><ul><li>Referral for Work Re-training </li></ul><ul><li>Maintenance in community – follow-on therapies </li></ul><ul><li>Follow-up ‘top-up’ brief residential reunions </li></ul>
  20. 20. Major challenges for NHS and Combat Stress <ul><li>Complex Trauma Presentations (Complex PTSD) </li></ul><ul><li>Acute alcohol / drug Detox – seamless plug into trauma work </li></ul><ul><li>Schedule 1 Sex Offenders </li></ul><ul><li>Forensic cases – imminent violence, severe behavioural disturbance </li></ul><ul><li>Veterans with mental ill health in the prison population </li></ul><ul><li>Increasing population of Old Age Veterans in the general population – hidden psychiatric morbidity plus locked in chronic PTSD </li></ul><ul><li>Growing number of in service families with psychological and mental health problems </li></ul><ul><li>War Pensions – Benefits Trap: WPs should not be counterproductive to treatment and therapy </li></ul>
  21. 21. References <ul><li>Busuttil, W. (2004) Post Traumatic Stress Disorder and the Elderly: A need for investigation International Journal of Geriatric Psychiatry, 19, 429-439.   </li></ul><ul><li>Busuttil, W (2006) The development of a 90 day residential program for the treatment of Complex Posttraumatic Stress Disorder. (eds M B Williams & J Garrick). In Trauma Treatment Techniques Innovative Trends. pp29-55, Haworth Press, New York. </li></ul><ul><li>Busuttil, W. (2007) Psychological trauma and Post Traumatic Stress Disorder. In: When the Body Speaks its Mind. The Interface between the Female Body and Mental Health. Pp 41-56, (eds M Nasser, Kbaistow & J Treasure). Routledge: London. </li></ul><ul><li>Busuttil, W. & Busuttil, A. M. C. (2001) Psychological effects on families subjected to enforced and prolonged separations generated under life threatening situations. Sexual and Relationship Therapy, (Special Psychological Trauma Edition) 16: 3; pp 207-228. </li></ul><ul><li>Creamer, M., Morris, P., Biddle, D., & Elliott, P. (1999). Treatment outcome in Australian veterans with combat- related posttraumatic stress disorder: A cause for cautious optimism? Journal of Traumatic Stress, 12, 545–558. </li></ul><ul><li>Kearney GE, Creamer M, Marshall R, Goyne A (2003) Military Stress and Performance: The Australian Defence Force Experience. Paul & Co Pub Consortium: Defence Science </li></ul><ul><li>and Technology Organisation. Canberra. </li></ul><ul><li>Williams, T. (1987) Post Traumatic Stress Disorders, A handbook for Clinicians. Disabled American Veterans: Ohio. </li></ul>