Provision of Mental Health Counseling Services Under TRICARE (2010) / Chapter Skim
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2 TRICARE Beneficiaries and Mental Health Issues in Military Families
2 TRICARE Beneficiaries and Mental Health Issues in Military Families
Pages 47-90
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From page 47... ...
The intent of the chapter is to provide background information on patients that might be seen by mental health professionals who deliver diagnostic and treatment services to TRICARE beneficiaries. DEMOgRAPHICS OF THE TRICARE POPuLATION TRICARE submits yearly reports of its operations to Congress that include details on the demographics of its beneficiary population.
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From page 48... ...
The data there are intended to provide more background on the similarities and differences between the TRICARE population and other managed–health-care populations. SPECIAL ExPOSuRES AND RISK FACTORS IN THE TRICARE POPuLATION Military life presents a number of exposures and risk factors that may influence the likelihood of experiencing a mental health problem.
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From page 49... ...
During their tours of duty in Iraq, 92% were attacked or ambushed; 95% received small arms fire; 94% saw dead bodies or human remains; 89% received artillery, rocket, or mortar fire; 86% knew someone who was killed or seriously injured; and 56% reported being responsible for the death of an enemy combatant. Research indicates that TRICARE may experience a relatively high volume of OIF and OEF veterans seeking treatment for posttraumatic stress disorder (PTSD)
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The noteworthy disparity in reported rates can be partially explained by victimized active-duty soldiers' fear of retaliation, especially if the offenders were superior officers or if allegations had been countered with censure. Issues for Military Families and Retirees Demographic data compiled by the Department of Defense (DOD, 2007a)
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Parental concerns expressed, in addition to facilitating typical childhood development, include parenting skills to manage frequent deployments, reintegration and reentry programs when the service member returns to the family, addressing anxiety and fears experienced by children with regard to the deployed parent, managing multiple moves, and bereavement support (National Military Family Association, 2006)
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The incidence of PTSD increases significantly with the number of injuries suffered. Rates of PTSD and major depression were highest among Army soldiers, Marines, and those who were no longer on active duty (people in the Reserves and those discharged or retired from the military)
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Such positive social supports serve as vital buffers against the emergence of mental health problems. "Signature" Mental Health and Psychosocial Issues Unlike Vietnam-era veterans, for whom PTSD was the prominent adverse mental health outcome, veterans of recent conflicts report high rates of various distinct yet interrelated syndromes, including PTSD, depression with suicidal ideation and behavior, substance misuse and abuse, and traumatic brain injury (TBI)
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More complete descriptions of the diagnostic criteria and etiology of these conditions are contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
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Such events stimulated an intense traumatic stress response that activated arousal that alternated with numbness and detachment; this was consistent with posttraumatic stress and/or PTSD.
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Major depressive disorder (also known as major depression) is diagnosed when a person experiences one or more major depressive episodes
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with no history of manic symptoms. It is often an episodic illness, but persons with major depression can also experience chronic depressive symptoms (Judd et al., 1998)
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Indecisiveness or diminished concentration NOTE: A diagnosis of major depression requires fulfillment of criteria beyond experiencing one or more major depressive episodes. SOURCE: Adapted and abbreviated from APA (2000)
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Exclusion of schizoaffective and mood disorders 5. Exclusion of substance abuse or general medical conditions There are further criteria for the different subtypes.
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. Posttraumatic Stress Disorder Many people who have experienced a catastrophic event involving possible or actual injury, destruction, or death can be distressed, be fearful, or feel helpless.
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VA/DOD's (2004) clinical practice guideline lists a number of potential differential diagnoses or comorbidities associated with PTSD including dementia, depression, substance abuse/withdrawal, bereavement, psychosis, bipolar disease, seizure disorder, thyroid disease, neoplasms, somatization disorder, anxiety disorder, toxicosis, rheumatoidcollagen vascular disease, hypoxia, sleep apnea, closed-head injury, congestive heart failure, and delirium.
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, but it is important to remember that bipolar disorder, although often episodic, is a chronic condition that requires continuing maintenance treatment. Mental Disorders Due to a general Medical Condition Some general medical conditions can cause psychiatric symptoms or conditions.
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. TABLE 2.7 Common Diagnostic Criteria for All Mental Disorders Due to a General Medical Condition 1.
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In another study of combat deployment, troops who had combat experience reported more severe somatic symptoms than troops who lacked combat experience; this TABLE 2.8 Major Diagnostic Criteria for Somatization Disorder (DSM-IV-TR code 300.81)
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Of those patients, 59 (69%) met the DSM-IV-TR criteria for delirium due to a general medical condition at the time of admission.
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Diagnoses of delirium corresponded with more severe brain injury as measured by the number of contusions on a computed-tomography image. The increased severity of the patients' injuries was borne out by their worse scores on the Galveston Orientation and Amnesia Test, which measures orientation and memory of events surrounding a TBI, and the Agitated Behavior Scale (ABS)
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From page 67... ...
There is no known cure for dementia of the Alzheimer type, and the symptoms worsen with time. However, a brain injury that results in dementia may leave symptoms that are relatively unchanging (Moore and Jefferson, 2004c)
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From page 68... ...
For example, an alcohol-induced blackout would produce transient amnesia, whereas damage to the temporal lobes would be more likely to produce TABLE 2.12 Major Diagnostic Criteria for Amnesia Due to a General Medical Condition (DSM-IV-TR 294.0)
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In contrast, substance dependence (Table 2.14) is characterized by an increasing preoccupation with getting, using, or recovering from use of a substance TABLE 2.13 Major Diagnostic Criteria for Substance Abuse 1.
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The VA/DOD (2009c) clinical practice guideline for management of SUDs recommends that the management of co-occurring medical and psychiatric conditions be prioritized and singles out cessation treatment for patients with nicotine dependence.
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Risk factors for increased alcohol consumption included depression after TBI and a pre-TBI history of substance abuse. TBI severity did not correlate with the quantity of alcohol consumed.
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VA/DOD (2009a) clinical practice guideline lists chronic pain, mood disorders, stress disorder, and personality disorder among the TABLE 2.15 Common Criteria for Judging the Severity of Traumatic Brain Injury Severity Ctiteria Mild Loss of consciousness for under 30 minutes without skull fracture Moderate Loss of consciousness for over 30 minutes and under 24 hours with or without skull fracture Severe Loss of consciousness for over 24 hours with contusion, hematoma, or skull fracture SOURCE: Lowenstein (2009)
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Epilepsy Following Traumatic Brain Injury Epileptic seizures are alterations in behavior caused by hyperactive neural discharges in the brain. They are time-limited and occur suddenly.
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of 188 patients admitted to the four VA polytrauma rehabilitation centers (PRCs) found that polytrauma patients injured by blast were more disabled than polytrauma patients
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. PSYCHOSOCIAL ISSuES IN uS MILITARY FAMILIES In addition to the disorders discussed above, TRICARE beneficiaries are at special risk for some psychosocial problems.
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. A 2008 IOM report contains a review of two primary and three secondary studies of Vietnam veterans who had combat-related PTSD; they showed a direct association between combat exposure and an increase in marital conflict that persisted for many years after the war (IOM, 2008)
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A meta-analysis of 64 published reports in 2005 revealed increased rates of IPV in military populations. For both military veterans and active-duty service members, IPV results in substantial victim injury (Marshall et al., 2005)
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This study, the largest of suicide and mental health among military personnel ever undertaken, is intended to identify risk and protective factors to help the Army develop effective strategies for mitigating suicide risk (NIMH, 2009a)
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(2007) conducted a time-series analysis of Texas child-maltreatment data for 2000–2003 to examine changes in the occurrence of child maltreatment in military and nonmilitary families.
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. Because social supports remain the major protective factors in mediating adverse mental health outcomes while also promoting healing, attention should be focused on the social contexts of service members and their families during any phase of clinical intervention.
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Major depressive disorder 204,078 10,480 5.1 Schizophrenia 4,335 182 4.2 Posttraumatic stress disorder 36,526 2,484 6.8 Bipolar disorder 40,970 2,573 6.3 Mental health disorder related to 9,681 144 1.5 a general medical condition Somatoform disorder 529 9 1.7 Delirium 586 1 0.2 Dementia 1,042 8 0.8 Amnestic disorder 188 3 1.6 Substance-use disorder 66,067 974 1.1 Traumatic brain injury 38,159 11 0.03 Data may include providers who have different levels of licensure, certification, a education, and experience.
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From page 82... ...
2005. Treatment of depression following traumatic brain injury.
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2004. Somatoform disorders in general practice: Prevalence, functional impairment and comorbidity with anxiety and depressive disorders.
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2005. Patterns of alcohol use 1 year after traumatic brain injury: A population-based, epidemiological study.
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In Systems engineering to improve traumatic brain injury care in the military health system: Workshop summary, edited by Butler D, Buono J, Erdtmann F, and Reid P Washington, DC: The National Academies Press.
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2004. Acute confusion following traumatic brain injury.
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2004. Posttraumatic stress disorder symptoms and parenting satisfaction among a national sample of male Vietnam veterans.
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2009a. VA/DoD clinical practice guideline for management of concussion/mild trau matic brain injury.
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2005. The effect of moderate to severe traumatic brain injury (TBI)
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