Psychological Health Center of Excellence (PHCoE)€¦ · prevention of psychological health...

Psychological Health Center of Excellence (PHCoE)

Dr. Jenelle AnthonyContractor, Salient CRGT, supporting PHCoE, D&I Section, Clinical Care Branch

Research and Development Directorate (J-9), Defense Health Agency (DHA)(301) 295-3714

[email protected]

“Medically Ready Force…Ready Medical Force” 1

mailto:[email protected]

Disclosure

The views expressed in this presentation are those of the presenter and do not reflect the official policy of DoD or the U.S. Government

We have no relevant financial relationships to disclose

We do not intend to discuss off-label/investigative use of commercial products or devices


Agenda

Psychological Health Center of Excellence (PHCoE) Overview Key signs and symptoms of the following: Anxiety disorders Posttraumatic stress disorder (PTSD) Depression Suicidal Ideation, homicidal ideation & violence risk Substance use & misuse

Where to Refer Best Practices PHCoE Resources


Psychological Health Center of Excellence Overview


PHCoE MISSIONImprove the lives of our nation’s Service members, veterans, and their families/

caregivers by advancing excellence

in psychological health care, readiness, and

prevention of psychological health

disorders.

Core Strategic Priorities:1. Support the services and combatant commands2. Improve care quality3. Increase access, reduce barriers, and encourage optimal use of psychological health resources4. Advance the science of psychological health5. Foster organizational development

These strategic priorities serve to improve the psychological health service delivery for Service members, veterans, and their families/caregiver and beneficiaries; translate our efforts to enhance health outcomes; maximize force readiness; and optimize value.

Anxiety Disorders1 of 2

Anxiety disorders have features of excessive fear or anxiety and related behavioral issues

Although anxiety is within the range of the human emotional experience, it is important to understand when anxiety has become elevated to a problematic level

Some examples of mild, normal, anxiety include: Feeling worried or concerned before an important event Occasional worries about finances or your financial future Infrequent fears about danger or safety Concerns about current medical issues


APA DSM-5® (2013)ADAA (2017)

Anxiety Disorderscont. 2 of 2

Warning signs of an anxiety disorder include: Impaired daily living (e.g., frequently late for work, missed

appointments, avoiding friends or family) Emotional response seems excessive or out of proportion to

the stressor Worry is irrational or seems uncontrollable Frequently feeling tense, on edge or jumpy Sudden periods of intense anxiety Physical health problems related to anxiety (e.g., stomach

aches, chest pain)


NIMH (2016)

PTSD in the Defense Department

In DoD, 5 to 20 percent of the more than 2.6 million Service members who deployed in support of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn have or may develop symptoms of PTSD according to 2009 estimates

According to the latest data available, 32,704 or 2.2 percent of patients in the Military Health System have a diagnosis of PTSD

PTSD is treatable and Service members recover with appropriate treatment


VA/DoD CPG for PTSD and ASD (2017)

Acute Stress Disorder

A common, normal and often adaptive response to experiencing or observing a traumatic or stressful event such as a car accident, natural disaster or military combat.

Symptoms typically subside within three days to one month after the event.


SymptomsRacing heart

Shaking hands

Sweating

Feeling nervous or afraid

Avoiding activity that caused the event

Bad dreams about the eventAPA DSM-5® (2013)

Combat Stress

Combat stress is an expected and predictable reaction to combat experiences. It's not unusual for a Service member participating in combat (or seeing its aftermath) to be filled with complicated and conflicting emotions, often including fear, sadness, helplessness and horror.

Combat and Operational Stress Reaction (COSR).

Stress reactions can last from a few hours to a few weeks.


Common SymptomsProblems sleeping

Uncharacteristic irritability or angry outbursts

Unusual anxiety or panic symptoms

Signs of depression (apathy, loss of interest in hobbies, poor

hygiene)

Other changes in behavior, personality or thinking

VA/DoD CPG for PTSD and ASD (2017)

Post-Traumatic Stress Disorder

A trauma and stressor-related disorder that can occurafter exposure to traumaticevents such as combat, naturaldisasters, or assault.

Symptoms usually begin within three months after trauma, but may be delayed by months or years.


PTSD SymptomsIntrusive (reoccurring distressing memories, dreams or flashbacks)

Avoidance (of people or places reminiscent of the trauma)

Persistent negative mood or thoughts (such as excessive blame, fear, guilt

or shame)

Arousal or reactivity (irritable, hyper-vigilance, difficulty concentrating

APA DSM-5® (2013)

Depression1 of 2

Depression characterized by sad, low or irritable mood that affects an individual’s capacity to function

7-14% of Service members returning from Operation Enduring Freedom (OEF) and 8-15% of Service members returning from Operation Iraqi Freedom (OIF) screened positive for major depressive disorder


APA DSM-5® (2013)ADAA (2017)

Depressioncont. 2 of 2

Depressive disorders are some of the most common mental health conditions. Depression may be a response to chronic stress or loss, or it may arise without a trigger. Other mood disorders may also include symptoms of depression (e.g., Bipolar Disorder).

Symptoms: Depressed mood, irritability or anger Loss of interest in daily activities Feeling helpless or hopeless Difficulty with focus or concentration, difficulty making small decisions Lack of energy, feeling very tired or physically exhausted Thoughts of death or dying Significant changes in sleep (insomnia or sleeping too much) Significant change in weight or appetite


Suicide in Military Populations

2016 military suicide rate was 21.1 per 100,000

While Department of Defense (DoD) rate of suicide was stable from 2013-2016, preventing suicide remains top priority for DoD and Department of Veterans Affairs (VA)


DoDSER, 2018

Suicide Risk Factors

Rates highest among ages 18-24 and 65+

More women attempt but more men complete suicide

Presence/absence of risk factors not predictive

Consider Protective Factors*Method used in 62.2% of military suicides DoDSER (2018), VA/DoD CPG for PTSD and ASD (2017), Center for the Study of Traumatic Stress, Suicide Facts (2018)


Risk FactorsPrior Suicide/Self-Harm Attempt

Alcohol or Substance Misuse

History of Trauma/Abuse/Loss

Family Mental Illness or Suicide

Age and Gender

Poor problem-solving, Impulsivity, and Access to Firearms *

Suicide Warning Signs*

“Everyone would be better off without me.”

“I just want to sleep and never wake up.”

“I feel better knowing I have a way out if things get too bad.”

“I cut myself a little but I couldn’t go through with it. I’m such a failure.”

“I can’t live with this pain.”“When I’m not here anymore, they’ll be

sorry.”

*List not exhaustive. Warning signs may not be obvious, even to those close to individual struggling with suicidality


Warning SignsSuicidal/Self-Harm Ideation, Intent, Plan,

Prep/Rehearsal, Behavior, Means

Feeling Hopeless, Helpless, Worthless, Trapped, or a Burden

Increased Substance Use, Agitation, Impulsivity, Sleep Problems

Guilt/Shame, Mood Changes

Anger, Irritability, Isolative and/or Withdrawn Behavior, Recklessness

DoDSER 2018; VA/DoD CPG for Suicide (2013)

Suicide Risk Assessment and Safety Planning

Columbia Suicide Severity Rating Scale (C-SSRS)

VA Safety Plan

Action Steps: If you think someone is suicidal, do not leave them unattended Encourage them to seek immediate medical attention (i.e., escort to nearest ED or call 911) If possible, eliminate access to weapons and other potential means

of self-harm/lethality


Suicide – Communication and Documentation

When suicidal thoughts are reported, it’s critical to communicate information immediately to care team, documenting:

Service member-reported thoughts and feelings

Observations of Service member’s behavior

Resources provided (e.g.,1-800-272-TALK, Military OneSource)

Referral and warm hand-off information with name of provider, clinic or hospital


Support: Where to Refer?

Non-emergency: Embedded Behavioral Health Team (EBH), MTF Behavioral Health Specialty Clinic

Non-emergency by Provider Referral: Intensive Outpatient Program (IOP)/Partial Hospitalization Program (PHP)

Emergency/Acute Services (no referral needed): Inpatient care/hospitalization


In the event of an emergency or if you are concerned about the Service member’s safety:

Call 911 Escort the member to an emergency department

Violence Risk Prevention

Violence = Inflicting or threatening to inflict physical harm Protective Factors: Social Support, Perceived Self-

determination, Resilience, Financial Stability, Basic needs met

Reduce Risk: Collaborative Safety Planning, Boost Protectives, Whole Person Approach (social, occupational, physical, psych)

If you think someone is a danger to others: Follow safety and emergency protocols at your facility (e.g., Color

Codes for Violent person or Active Shooter, call Base Security, call 911, etc.)

Non-Emergency: Report concerns to the appropriate clinical and/or security personnel, Treatment Referral


Norman, Elbogen, & Schnurr National Center for PTSD

Violence Risk Factors and Warning Signs


History of Violence

Alcohol or Substance Misuse

Anger Problems

Co-morbid Psychiatric Disorders

Younger Age, Gender Male Age and Gender

Housing/Financial Problems, Lower SES, Crime Exposure in Childhood, Combat Exposure

Impulsivity and Access to Firearms *

No Consistent Warning Signs(can be unpredictable, impulsive, or

planned)

Homicidal or Violent Ideation, Threats, Intent, Plan, Behavior, Rehearsal, Obtaining Means

Intense Anger/Hostility

Signs of anger(e.g., tensed muscles, agitation,

“seeing red”)

Risk Factors Warning Signs

Substance Use & Misuse

Substance Use Disorders describe a problematic pattern of using alcohol or other substances that result in impairment in daily life or noticeable distress. They can limit the Service member’s ability to fulfill roles in their professional or personal life and can have other legal, social or physical ramifications.

Commonly misused substances: Alcohol Prescription medications: Opioid painkillers, sedatives and stimulants Marijuana Over-the-counter medications Steroids Dietary supplements Inhalants Designer drugs: Synthetic marijuana (“spice”) and synthetic

stimulants (“bath salts”)“Medically Ready Force…Ready Medical Force” 21

Substance Use Disorders

Common signs of substance use disorders:

Failure to fulfill major duties at work or home (missing formations, falling asleep on the job, etc.)

Engagement in physically-risky behaviors while intoxicated (picking fights with others, driving while under the influence or underage drinking)

Repeated substance-related legal problems (DWIs/DUIs, arrests, domestic violence or fines)


Case Study

SGT Jason Smith is a 29-year-old male currently serving in the U.S. Army. While deployed, he witnessed a truck in his convoy hit a roadside bomb. After returning from the deployment, he began having panic attacks and nightmares related to the event. The medications prescribed for his anxiety and sleep problems didn’t seem to help. He didn’t want to leave the house and felt anxious performing his primary duties. He regularly feels guilty that he was one of the few surviving members of the incident.

Are there any signs or symptoms to be concerned about? What other information would you like to know? What is your next step?


Assisting Those Dealing With Behavioral Health Challenges

Know the signs and symptoms of mental illness, suicidality, and increased violence risk

Know how and where to refer Service members, their families or caregivers for help

Know the available resources


Image courtesy of PHCoE

Where to Refer?1 of 2

Service member’s Primary Care Manager (PCM)

Internal Behavior Health Consultant (IBHC) Psychologists and Social Workers are part of the primary care team IBHC may decide to refer to specialty behavioral health

Embedded Behavioral Health Team (EBH) Located with unit Team consists of a psychologist, social worker, case manager, nurse

and psychiatrist

Specialized clinic Located at MTF and sees more serious cases as well as

neuropsychological and forensic cases


Service member’s PCM/Primary Mental Health Provider (PMHP) may also refer to more specialized care Intensive Outpatient treatment (IOP) Inpatient care/hospitalization

Service member may also receive care through the Vet Centers, Military OneSource, Military Family Life Consultants (MFLC), chaplains, and off-post providers


In the event of an emergency or if you are concerned about the Service member’s safety: Call 911 Escort the member to an emergency department

Where to Refer?cont. 2 of 2

Encourage Engagement

Stress conditions, depression and anxiety are highly treatable conditions

There are many treatments that work

These treatments take time


Best Practices

Refer to early effective intervention for better outcomes Educate yourself on available resources Minimize negative stigma Utilize established programs and tools Maintain safety, including emergency care when

appropriate Validate that problems are challenging but not hopeless Sailor Assistance and Intercept for Life (SAIL), Military

OneSource, inTransition, Chaplains, Real Warriors, Veterans Crisis Hotline, mobile applications, etc.


Real Warriors Campaign

The Real Warriors Campaign is a Defense Department communications campaign to encourage help-seeking behavior among Service members, veterans and their families.


Psychological Health Resource Center


We Are•Professional health resource consultants with expertise in psychological health who understand military culture.•Available 24/7 by phone, online chat or email.We Provide•A trusted source of psychological health information and resources.•Customized responses to your specific questions and needs. If we can’t answer your question, we will connect you to someone who can.

[email protected]

LIVE CHATrealwarriors.net/livechat


https://www.realwarriors.net/livechat

inTransition


Provides support to Service members receiving mental health services as they transition between health care systems or providers

Provides voluntary one-on-one coaching to Service members

Designed as a bridge of support for Service members when:– Relocating to another assignment– Returning from deployment– Transitioning from active duty to reserve,

reserve to active duty or returning to civilian life

Visit http://www.pdhealth.mil/resource-center/intransition

http://www.pdhealth.mil/resource-center/intransition


PHCoE Website Resources

Products and resources are available on the PHCoE website: http://www.pdhealth.mil/clinical-guidance/resource-center About PHCoE Anti-stigma Co-occurring conditions Depression General training and eLearning Integrative health and wellness Military children and families Peer support Posttraumatic stress Resilience Stress management Substance use Suicide Traumatic brain injury Transition

http://www.pdhealth.mil/clinical-guidance/resource-center

References1 of 2

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:

American Psychiatric Association.

American Psychological Association. (2013). Gun violence: Prediction, prevention, and policy: APA panel of experts

report. American Psychological Association.

Anxiety Disorders Association of America. (n.d.). Retrieved April 13, 2017 from https://www.adaa.org/

Assessment and Management of Risk for Suicide Working Group. (2013). VA/DoD clinical practice guideline for

assessment and management of patients at risk for suicide. Washington, D.C.: Department of Veterans Affairs,

Department of Defense.

Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University. (2018). Suicide

facts: What military families should know to help loved ones who may be at risk. Retrieved February 8, 2019

from https://www.cstsonline.org/resources/resource-master-list/courage-to-care-suicide-facts-for-families

Management of Posttraumatic Stress Disorder Work Group, Department of Veterans Affairs & Department of Defense.

(2017). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress

disorder. Version 3.0. Washington, D.C.: Department of Veterans Affairs, Department of Defense.


https://www.adaa.org/

https://www.cstsonline.org/resources/resource-master-list/courage-to-care-suicide-facts-for-families

Referencescont. 2 of 2

Management of Substance Use Disorders Work Group, Department of Veterans Affairs & Department of Defense.

(2015). VA/DoD clinical practice guideline for the management of substance use disorders. Version 3.0.

Washington, D.C.: Department of Veterans Affairs, Department of Defense.

National Institute of Mental Health. (2016, March). Retrieved April 7, 2017 from

https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

Norman, S., Elbogen, E. B., & Schnurr, P. P.. Research Findings on PTSD and Violence. National Center for PTSD.

Retrieved March 5, 2019 from https://www.ptsd.va.gov/professional/treat/cooccurring/research_violence.asp

Pruitt, L. D., Smolenski, D. J., Bush, N. E., Skopp, N. A., Edwards-Stewart, A., & Hoyt, T. V. (2018). DoDSER: Department

of Defense Suicide Event Report: Calendar year 2016 annual report. Washington, DC: National Center for

Telehealth & Technology.

Psychological Health Center of Excellence (2017, December). Psychological Health by the Numbers: Mental Health

Disorder Prevalence among Active Duty Service Members, 2005-2016. Available at:

https://www.pdhealth.mil/research-analytics/psychological-health-numbers/mental-health-disorder-prevalence


https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

https://www.ptsd.va.gov/professional/treat/cooccurring/research_violence.asp

https://www.pdhealth.mil/research-analytics/psychological-health-numbers/mental-health-disorder-prevalence

Connect with PHCoE

Email: [email protected]: http://pdhealth.milFacebook: www.facebook.com/PHCoEinTransition: www.pdhealth.mil/resource-center/intransitionReal Warriors Campaign: www.realwarriors.net

Point of ContactDr. Jenelle Anthony

Contractor, Salient CRGT, supporting PHCoE, D&I Section, Clinical Care BranchResearch and Development Directorate (J-9), Defense Health Agency (DHA)

(301) [email protected]



http://pdhealth.mil/

http://www.facebook.com/PHCoE

http://www.pdhealth.mil/resource-center/intransition

http://www.realwarriors.net/


Psychological Health Center of Excellence (PHCoE)€¦ · prevention of psychological health...

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