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Ask the Expert


Military Families: Access to Care for Active Duty, National Guard, Reserve, Veterans, Their Families, and Those Close to Them

Dr. Bradley Karlin

05 Military Families

Ask the Expert:  Dr. Bradley Karlin is the National Mental Health Director for Psychotherapy and Psychogeriatrics for the U.S. Department of Veterans Affairs (VA).

1) Question: A Lieutenant I know detoxed, and his aftercare/recovery includes evidenced-based medication and counseling services. Are these services available to all military personnel? Can active service men and women receive addiction services, such as detox, while they are in active duty? How would this work?

Answer: Active duty Service members and TRICARE beneficiaries have access to a full range of mental health and addiction services through military medical facilities, network health care providers and facilities, and through other mechanisms.  The Department of Defense Centers for Excellence for Psychological Health and Traumatic Brain Injury Outreach Center can provide additional information about specific services for active duty Service members.  The Outreach Center can be contacted by phone at 1-866-966-1020, by e-mail at resources@dcoeoutreach.org or via online chat service at http://www.dcoe.health.mil/24-7help.aspx

2) Question: I am not seeing enough focus on using the Faith-Based Community as a support base for veterans.  As a Vietnam Veteran who was impacted by drugs, the war itself, and prior family problems, it was clear that prior to my two attempts to commit suicide would have been successful had it not been for the 'Prayer Power of my Grandmothers'.  Those of us who have survived are evidence enough, specifically for those that are not as strong to survive. In Houston, Texas we are promoting "Veteran Family Ministry" groups in Faith communities and need support in our efforts to do so. Can you tell me how faith-based communities can become more active with veterans, or with veterans groups or services?

Answer: Thank you for your service.  Spirituality is an important part of recovery for many individuals, and chaplains play a critical role in helping many Veterans and military Service members cope with mental health problems and address spiritual and existential issues.  Chaplains are members of patient care teams at VA medical centers and provide education, counseling, and consultation to Veterans in a variety of clinical settings.  VA chaplains also commonly make referrals to faith-based agencies and resources in the community.

I appreciate your interest in wanting to provide support to other Veterans.  I would recommend contacting the Chaplain Service at your local VA medical center.  You may do this by contacting the main number of the medical center and asking the operator to connect you with the Chaplain Service.  You can locate your local VA medical center by entering your zip code in the VA Facility Locator, which can be accessed at:  http://www2.va.gov/directory/guide/home.asp?isFlash=1. You can also access locate a local VA Chaplain using the “Locate a Chaplain” function on the website of the VA National Chaplain Center, which can be accessed at http://www.va.gov/chaplain/.

3) Question: What are the statistics on mild brain injury, depression, and suicide in veterans?

Answer: Traumatic Brain Injury
The VA conducts regular screening for traumatic brain injury (TBI) and provides a range of rehabilitation services to Veterans with TBI.  The VA also engages in cutting-edge research on TBI and, along with the Department of Defense, has developed a Clinical Practice Guideline on the Management of Concussion/mild Traumatic Brain Injury, which can be accessed at:  http://www.dvbic.org/images/pdfs/providers/VADoD-CPG---Concussion-mTBI.aspx.

Between April 2007 and January 2011, 500,562 Veterans have been screened by VA for possible traumatic brain injury (TBI).  93,477 screened positive and consented to follow-up; of those, 38,250 received a confirmed diagnosis of having incurred mild TBI (7.6% of all who are screened and complete comprehensive follow-up evaluations). Over 90 percent of all screened Veterans have been determined not to have incurred a TBI.  However, Veterans who are screened and report current symptoms are evaluated, referred, and treated as appropriate.  An individualized rehabilitation and community reintegration plan of care is developed for patients receiving on-going rehabilitation treatment for TBI, which can include:  cognitive rehabilitation; interventions that promote independence with activities of daily living; psychosocial support; counseling and education; vocational counseling; and provision of prosthetics and adaptive devices.

Analyses conducted by the Serious Mental Illness Treatment Research and Evaluation Center in the Veterans Health Administration have revealed that Veterans with a history of TBI recorded in their VA medical record were 1.5 times more likely to die from suicide than those without a history of TBI.  Further, TBI seems to have an independent influence on suicide risk separate from other mental health disorders. 

Suicide
With respect to rates of suicide, VA relies on multiple sources for this information.  This includes VA’s Beneficiary Identification and Records Locator Subsystem, records from the Social Security Administration, and data compiled by the National Center for Health Statistics in its National Death Index.  Veterans account for approximately 20 percent of the estimated 30,000 suicides annually in the United States.  Specific rates of suicide just recently became available for 2008 after the National Center for Health Statistics completed its most recent update of the National Death Index.  The overall rate of suicide for men in the Veterans Health Administration (VHA) patient population was 38.3 per 100,000 patient years in 2008.  The rate in 2007 was 37.1.  There was an apparent increase in calculated rates among men under age 25 from 38.3 in 2007 to 58.7 in 2008.  The overall rate of suicide for women in the VHA patient population was 10.6 in 2007 and 14.8 in 2008. 


Every Veteran suicide is a tragic outcome and, regardless of the numbers or rates, one Veteran suicide is too many. VA’s basic strategy for suicide prevention requires ready access to high quality mental health (and other health care) services supplemented by programs designed to help individuals and families engage in care and to address suicide prevention in high-risk patients.  A number of specific suicide prevention initiatives have been developed in VA, including:
• A 24/7 Veterans Crisis Line: Veterans can call the national crisis line number 1-800-273-TALK (8255) and then “push 1” to reach a trained VA professional who can deal with any immediate crisis.  More than 400,000 callers have called the Crisis Line and over 225,000 of these callers have identified themselves as Veterans or family members or friends of Veterans.  There have been over 14,000 rescues of actively suicidal Veterans to date.  An on-line Chat Service was initiated in July 2009 and to date, there have been over 16,000 chatters that have utilized the Service.  Several of them have been referred to the Crisis Line for immediate care. The Chat Service can be accessed at: http://www.veteranscrisisline.net/ 

• Each VA Medical Center has a Suicide Prevention Coordinator or team.  The coordinators and their teams ensure that the Veteran receives the appropriate services.  Calls from the Hotline are referred to the coordinators, who follow up with Veterans and coordinate care.

• Screening and assessment processes have been set up throughout the system to assist in the identification of patients at risk for suicide. 

• Patients who have been identified as being at high risk receive an enhanced level of care, including missed appointment follow-ups, safety planning, weekly follow-up visits and care plans that directly address their suicidal risk.

Depression
In Fiscal Year 2010 (October 1, 2009 – September 30, 2010), 5.1% of VHA patients had a diagnosis of Major Depression; 14.2% of VHA patients had a diagnosis of Dysthymia, a milder, more chronic form of depression; and 16.8% had a diagnosis of Major Depression or Dysthymia.

Recent analyses have shown that VHA patients that have served in the Iraq or Afghanistan wars who have Major Depression are at heightened risk of suicide compared to Veterans that have served in Iraq or Afghanistan without a diagnosis of Major Depression or Veterans of prior eras with such a diagnosis.  Therefore, routine screening and access to effective treatment for depression is essential.  VA has implemented regular screening of depression in primary care throughout the VHA system and has been working to nationally disseminate and implement two evidence-based psychotherapies for depression – Cognitive Behavioral Depression for Depression and Acceptance and Commitment Therapy for Depression – to ensure that Veterans have access to the most effective treatments currently available.

4) Question: In the Road to Recovery May program, ‘partnerships between agencies’ was mentioned several times. Can you explain a little more clearly what was meant by partnerships between agencies? How would this affect the average veteran? What is the real world impact of partnerships between agencies?

Answer: The Veterans Health Administration and the Department of Defense regularly enter into partnerships with community organizations and agencies to augment or expand the services that they deliver, to provide important quality control functions, and to support community agencies interested in helping Veterans and military Service members.  For example, the Veterans Health Administration has closely partnered with the National Alliance on Mental Illness (NAMI) to provide NAMI’s Family-to-Family Education Program at VA medical centers across the country. This valuable program helps family members of Veterans with mental health problems learn about their loved one’s mental illness and discover ways to help the Veteran with his or her recovery. This program has demonstrated effectiveness and provides an important service that would otherwise not be readily available to Veterans and their families. Another example of a partnership involves the Commission on the Accreditation of Rehabilitation Facilities (CARF). CARF provides accreditation for a variety of health care programs, including mental health programs. This accreditation process ensures that VA’s mental health programs provide high quality services to Veteran enrollees. Veterans and their family members clearly benefit from these partnerships, but the outside agencies also benefit from the partnerships.

In an effort to further expand the reach and availability of state-of-the-art treatments for Post-traumatic Stress Disorder (PTSD), VA and the Department of Defense have worked together to train a large number of mental health providers in the two agencies and in the private sector in the delivery of new, evidence-based psychotherapies for PTSD.  In addition, VA and the Department of Defense have recently developed and are implementing a comprehensive plan for promoting mental health care coordination and collaboration between the agencies.  The goal of this partnership is to ensure well coordinated and mutually supporting systems of mental health care for military Service members and Veterans.

Furthermore, VA has partnered closely with SAMHSA in developing the Veterans Crisis Line.  The number for the Crisis Line (1-800-273-8255) is the same number for the National Suicide Prevention Hotline administered by SAMSHA, though Veterans can press 1 to identify themselves as Veterans, which will immediately connect them with a VA mental health counselor at the Veterans Crisis Line.  Among many other partnerships the two agencies have been engaged in, VA and SAMHSA have worked together to develop public messaging and a media campaign related to suicide prevention among Veterans.


5) Question: Different symptoms of PTSD were mentioned in the webcast. Can you describe more fully what those symptoms would look like in someone else? How would they appear to an observer?

Answer: Symptoms of PTSD can be terrifying and may disrupt one’s life, making it hard to continue with daily aspects of life.  PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or years later. They also may come and go over many years. Not all individuals who experience a traumatic event, however, will develop PTSD.  If symptoms last longer than 4 weeks, cause great distress, or interfere with work, relationships, or home life, they may reflect PTSD. 

 
There are four types of PTSD symptoms:
1. Reliving the event (or “re-experiencing” symptoms): Individuals with PTSD often have memories or “flashbacks” that take them back to the traumatic event.  Often times, there is a trigger, such as a sight, sound, odor, or place, that sets off these memories or flashbacks.  These “re-experiencing” events may instill the same horror and fear that the individual felt at the time of actual traumatic event.  Re-experiencing events may also take the form of nightmares.


2. Avoidance of reminders of the traumatic event: Individuals with PTSD often avoid places or people that remind them of the traumatic event, as well avoid thoughts or feelings about the traumatic event.  For example, a person who was in a severe car accident and later developed PTSD may avoid driving or driving in certain locations. 

3. Emotional numbing: Individuals with PTSD typically may feel emotionally numb and detached from others.  They may lose interest in activities they used to enjoy.  They may also have difficulty remembering aspects of the traumatic event or may not be able to talk about the trauma.


4. Increased emotional arousal: Individuals with PTSD often feel on edge and are on the lookout for danger. This may cause the individual to suddenly become angry or irritable, be easily startled, have difficulty concentrating or sleeping, and fear for their safety.
Individuals with PTSD may also have feelings of hopelessness, guilt, shame, or despair and relationship and/or employment difficulties.  In addition, individuals with PTSD may have problems related to drinking or drug use, which may be an attempt to block the emotional pain.


An excellent source for additional information about PTSD, PTSD symptoms, and treatment is the VA National Center for PTSD Internet site, which can be accessed at http://www.ptsd.va.gov/. The website also includes a range of videos and other educational materials on PTSD for Veterans, friends and family members, providers, and researchers.



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