Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions.

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness. Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist-Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge. Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge. Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

Individual augmentee deployment and newly reported mental health morbidity.

OBJECTIVE: To investigate the association between US Navy individual augmentee (IA) deployers, who may lack the protective effects of unit cohesion and social support, and newly reported mental health. METHODS: Responses from the Millennium Cohort Study questionnaires were examined for 2086 Navy deployers in this prospective exploratory study. Multivariable logistic regression was used to evaluate IA deployment and newly reported mental health symptoms. RESULTS: After adjusting for covariates, IA deployment was not significantly associated with newly reported posttraumatic stress disorder (odds ratio = 1.02; 95% confidence interval: 0.53-1.95) or mental health symptoms (odds ratio = 1.03; 95% confidence interval: 0.66-1.60) compared with non-IA deployment. CONCLUSION: IA deployment was not associated with increased risk for posttraumatic stress disorder or mental health symptoms following deployment. It is likely that social isolation was not highly influential among Navy IAs in this study.

Family-centered preventive intervention for military families: implications for implementation science.

In this paper, we report on the development and dissemination of a preventive intervention, Families OverComing Under Stress (FOCUS), an eight-session family-centered intervention for families facing the impact of wartime deployments. Specific attention is given to the challenges of rapidly deploying a prevention program across diverse sites, as well as to key elements of implementation success. FOCUS, developed by a UCLA-Harvard team, was disseminated through a large-scale demonstration project funded by the United States Bureau of Navy Medicine and Surgery (BUMED) beginning in 2008 at 7 installations and expanding to 14 installations by 2010. Data are presented to describe the range of services offered, as well as initial intervention outcomes. It proved possible to develop the intervention rapidly and to deploy it consistently and effectively.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Consensus recommendations for common data elements for operational stress research and surveillance: report of a federal interagency working group.

Empirical studies and surveillance projects increasingly assess and address potentially adverse psychological health outcomes from the stress of military operations, but no standards yet exist for common concept definitions, variable categories, and measures. This article reports the consensus recommendations of the federal interagency Operational Stress Working Group for common data elements to be used in future operational stress research and surveillance with the goal of improving comparability across studies. Operational stress encompasses more than just combat; it occurs everywhere service members and their families live and work. Posttraumatic stress is not the only adverse mental or behavioral health outcome of importance. The Operational Stress Working Group contends that a primary goal of operational stress research and surveillance is to promote prevention of adverse mental and behavioral outcomes, especially by recognizing the preclinical and subclinical states of distress and dysfunction that portend a risk for failure of role performance or future mental disorders. Recommendations for data elements are divided into 3 tiers: core, supplemental, and emerging, including variable domains and specific measures for assessing operational stressor exposures, stress outcomes, moderating factors, and mediating processes. Attention is drawn to the emerging construct of stress injury as a generic term for subclinical operational stress, and to emerging data elements addressing biological, psychological, and spiritual mediators of risk. Methodologies are needed for identifying preclinical and subclinical states of distress or dysfunction that are markers of risk for failure of role performance and future clinical mental disorders, so that targeted prevention interventions can be developed and evaluated.

Combat-related post-traumatic stress disorder: a case report using virtual reality graded exposure therapy with physiological monitoring with a female Seabee.

In this report we describe virtual reality graded exposure therapy (VRGET) for the treatment of combat-related post-traumatic stress disorder (PTSD). In addition, we summarize the outcomes of a case study, from an Office Of Naval Research (ONR)-funded project of VRGET with an active duty female Seabee who completed three combat tours to Iraq. Details of the collaborative program involving this ONR-funded project at Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) are also discussed.

Cost effectiveness of virtual reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder.

Virtual Reality Graded Exposure Therapy (VRGET) is an effective treatment for combat-related PTSD. We summarize the outcomes of a VRGET pilot study with 12 participants who completed one to multiple combat tours in support of the War on Terrorism and who were subsequently diagnosed with combat-related PTSD. Details of the collaborative program amongst the Virtual Reality Medical Center (VRMC), Office of Naval Research, the Naval Medical Center San Diego (NMCSD) and the Navy Hospital Camp Pendleton are discussed as is the VRGET outcomes of significant reductions in PTSD symptoms severity. We also described the estimated cost-effectiveness of VRGET for the treatment of combat-related PTSD, as contrasted to Treatment as Usual (TAU) for combat-related PTSD.

Combat duty in Iraq and Afghanistan, mental health problems and barriers to care.

BACKGROUND: The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS: We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. The recent military operations in Iraq and Afghanistan, which have involved the first sustained ground combat undertaken by the United States since the war in Vietnam, raise important questions about the effect of the experience on the mental health of members of the military services who have been deployed there. Research conducted after other military conflicts has shown that deployment stressors and exposure to combat result in considerable risks of mental health problems, including posttraumatic stress disorder, major depression, substance abuse, impairment in social functioning and in the ability to work, and the increased use of healthcare services. One study that was conducted just before the military operations in Iraq and Afghanistan began found that at least 6% of all US military service members on active duty receive treatment for a mental disorder each year. Given the ongoing military operations in Iraq and Afghanistan, mental disorders are likely to remain an important healthcare concern among those serving there. Many gaps exist in the understanding of the full psychosocial effect of combat. The all-volunteer force deployed to Iraq and Afghanistan and the type of warfare conducted in these regions are very different from those involved in past wars, differences that highlight the need for studies of members of the armed services who are involved in the current operations. Most studies that have examined the effects of combat on mental health were conducted among veterans years after their military service had ended. A problem in the methods of such studies is the long recall period after exposure to combat. Very few studies have examined a broad range of mental health outcomes near to the time of subjects' deployment. Little of the existing research is useful in guiding policy with regard to how best to promote access to and the delivery of mental health care to members of the armed services. Although screening for mental health problems is now routine both before and after deployment and is encouraged in primary care settings, we are not aware of any studies that have assessed the use of mental health care, the perceived need for such care, and the perceived barriers to treatment among members of the military services before or after combat deployment. We studied the prevalence of mental health problems among members of the US armed services who were recruited from comparable combat units before or after their deployment to Iraq or Afghanistan. We identified the proportion of service members with mental health concerns who were not receiving care and the barriers they perceived to accessing and receiving such care.

Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.

BACKGROUND: The current combat operations in Iraq and Afghanistan have involved U.S. military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS: We studied members of four U.S. combat infantry units (three Army units and one Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or three to four months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS: Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23 to 40 percent sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS: This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care.

Psychiatric medevacs during a 6-month aircraft carrier battle group deployment to the Persian Gulf: a Navy Force Health Protection preliminary report.

When a U.S. Navy Aircraft Carrier battle group deploys overseas, the aircraft carrier's medical department is responsible for the medical needs of over 12,000 personnel with their indigenous developmental, stress, family, alcohol, drug, and interpersonal and intrapersonal relationship difficulties. This article reviews the effectiveness of having a U.S. Navy clinical psychologist and a psychiatric technician onboard the USS Carl Vinson, the flag ship of Vinson's battle group, during this battle group's 1998/1999 Persian Gulf deployment (i.e., Western Pacific Deployment). Importantly, these two individuals reported to the USS Vinson as permanent members of the ship's company. The clinical psychologist logged 448 individual outpatient-care consults and 79 individual consults with sailors who had a history of overusing or abusing alcohol. Additionally, nine sailors with acute disabling psychiatric diagnoses were hospitalized on the ship's medical ward, and four sailors were medically evacuated (medevaced), by fixed wing aircraft, from USS Vinson to a Navy Hospital in the United States for definitive evaluation, treatment, and disposition. These four medevacs were less than the number of medevacs from two previous Aircraft Carrier Battle Group Persian Gulf deployments. Importantly, these two previous WESTPAC deployments were made without having a clinical psychologist as a full-time member of the respective aircraft carrier's medical department. Providing clinical psychology/mental health services at the "tip of the spear" is an effective, beneficial, and cost-saving landmark improvement in providing quality medical care to the fleet.