Experts About Progress in Noticing and Treating of TBI and PTSD

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Directors of military centers and programs that address post-traumatic stress disorder and traumatic brain injury in service members and their families yesterday announced progress in the timely identification and treatment of these and related disorders.

The Defense Department's assessment of clinical trials and programs for PTSD and TBI was presented to the House Armed Services Committee's Military Personnel Subcommittee by Navy Capt. Mike Colston, director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, and Air Force Deputy Director for Psychological Health Col. Steven Pflanz.

They were joined by Lt. Col. (Dr.) Chris Ivany, chief of mental health at the Army Surgeon General's Office, and Navy Capt. (Dr.) Thomas Johnson, director of the Navy's Intrepid Spirit Concussion Recovery Center at Camp Lejeune, N.C.

Focus on prevention

Colston began his testimony by noting that last year, about a quarter of service members were diagnosed with PTSD, TBI or a mental health issue. “We've made the management issues of PTSD and TBI focus on prevention,” he said, describing recent progress.

PTSD cases fell from 17,000 to 14,000 between 2012 and 2015, and TBI cases fell from 31,000 to 23,000 during the same period, he said. Colston told the group that the center has expanded access to care by tripling its mental health infrastructure since 2001, and that a recent Rand study found that the military outperforms civilian health systems in follow-up after psychiatric hospitalization for PTSD or depression.

“One of our biggest challenges is to better understand why PTSD and TBI are often associated with depression, chronic pain, substance use disorders and suicide risk,” she said, noting that longitudinal studies, such as the 15-year TBI study, will help understand and provide a framework for creating effective rehabilitation and support programs.

“We have evaluated more than 150 mental health, traumatic brain injury, substance abuse, and suicide prevention programs over the past five years, and this program evaluation has been invaluable,” Colston said.

“The release of this five-year study will occur at the end of this fiscal year and will help us ….. [Ensure our funding is tied to programs that work, such as the U.S. Army's Integrated Mental Health Program and its associated health information portal,” he added.

In 2015, more than 52,000 people died from drug overdoses in the United States. The rate of opioid overdose deaths increased to 10.4 deaths per 100,000 people in 2015. The Department of Defense figure was 2.7 per 100,000, or about a quarter. This was achieved because leaders focused on the well-being of service members and prioritized outcomes-based prevention efforts: primary prevention, targeted and referral-based prevention, drug screening, provider education, pharmacy protection and medication management, Colston told the panel.

“We hope to generalize to other areas, such as suicide prevention and alcohol use disorders, some of the successes we've seen in PTSD, TBI, and opioid overdose deaths,” he said.

In-depth review

Pflanz said in his speech that all Air Force mental health providers are trained in one or more evidence-based PTSD treatment methods, and that all Airmen can be assured of receiving a high level of care when they visit an Air Force mental health clinic.

Pflanz added that, fortunately, the rate of PTSD and TBI among pilots remains low.

“Nevertheless,” he added, “we are excited about the successful translation of research into clinical practice, including the use of evidence-based therapies for PTSD, event-based protocols for identifying TBI and the use of step-down therapy for concussions.”

Other advances that will help identify and manage these conditions include integrating behavioral health care into primary care clinics, integrating mental health professionals into operational units in high-stress careers, and conducting comprehensive screenings for PTSD and TBI after deployments and throughout airmen's careers, he said.

Pflanz added that the Invisible Wound Clinic, which will be established at Eglin Air Force Base, Florida, in 2018, will significantly improve PTSD and TBI treatment and serve as a referral and intermediary center for care and expertise throughout the Air Force.

“A multidisciplinary team is identifying and addressing system gaps in consistent care and integrated service assessment for invisibly injured Airmen,” he said, noting that 27 solutions are underway, ranging from education and training to culture and policy, that will lead directly to better services for Airmen.

Critical to readiness

Speaking on the panel, Ivany said health care is critical to readiness, which is a priority for the military. No area has faced more challenges, seen more changes and made more progress than military behavioral health, he told the panel.

“At the beginning of the war in Iraq and Afghanistan, the Army realized that the size and organization of our behavioral health unit was not sufficient to meet the needs of beneficiaries,” Ivany said. He added that they significantly increased resources and expanded the number of clinical programs.

Army medical leaders also made the critical decision to centralize oversight and management of all clinical programs, creating a small team of experts within the surgeon general's office, he added. The group analyzed the effectiveness of clinical programs, identified best practices and replicated them across the corps. From this process came an integrated behavioral health policy that reduced barriers to care for soldiers in combat units and improved access to care and readiness.

“Today, more than 450 providers in 62 integrated behavioral health teams support all operational units in the Army,” Ivany said, noting that Soldiers receive care faster and require fewer hospitalizations.

Other innovations, such as behavioral health in schools, come from the civilian sector. The Army has taken this approach and placed providers in schools at military posts around the world.

Ivany said that for TBI treatment, the Army has partnered with the Department of Defense and other services to establish clear clinical standards and offer them in multidisciplinary clinics throughout the force.

Multidisciplinary care

The director of the Navy's Intrepid Spirit Concussion Recovery Center said in his speech that about 80 percent of concussions are classified as mild. People with mild concussions may experience only subtle changes in mood, memory, sleep and balance. According to Johnson, they have no visible signs of injury, but often have difficulty functioning at work, at home and in the community.

“The reality is that there is currently no diagnostic tool that is sensitive and specific for mild TBI,” he said. “However, we have tried to address this problem by developing a comprehensive, integrated, multidisciplinary model of care that uses a standard assessment that includes physical, psychological and spiritual dimensions.”

He added that the center uses this information to diagnose and treat each patient using traditional therapies and complementary and integrative medicine.

“We use minimal medication, almost none, and more than 90 percent return to full employment at the end of the program,” Johnson said.

He said the military health system has a robust research portfolio in collaboration with civilian academic institutions to fill knowledge gaps and improve care for service members with TBI, including a progressive return-to-work protocol that provides guidance to service members on how to increase activity to maximize recovery.

Johnson said the Defense Department is conducting a long-term study of traumatic brain injury in the military to better understand the condition and ensure patients receive the care they need.

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