Evaluation of the Department of Veterans Affairs Mental Health Services (2018) / Chapter Skim
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4 Clinical Management of Mental Health Conditions at the Veterans Health Adminstration
4 Clinical Management of Mental Health Conditions at the Veterans Health Adminstration
Pages 45-78
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From page 45... ...
The conditions discussed include posttraumatic stress disorder (PTSD) , generalized anxiety disorder (GAD)
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From page 46... ...
Protective factors can include medication that controls symptoms, abstention from drugs and alcohol, personal coping skills, social support, and meaningful life structures, such as employment. 1 Cohorts consisted of veterans whose Veterans Health Administration (VHA)
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From page 47... ...
The section Prevalence, Risk Factors, and Protective Factors, below, discusses this and other sources of variation in published estimates of mental health disorders in the veteran population. Posttraumatic Stress Disorder PTSD is a psychiatric disorder that can develop after the direct personal experience of or the witnessing of an event that poses a perceived threat of death or serious injury (Criterion A, see Table 4-1)
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PTSD has become part of a new DSM chapter titled Trauma- and Stressor-Related Disorders and is no longer considered an anxiety disorder, as it was in DSM-IV-TR.
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. Major Depressive Disorder MDD is characterized by a depressed mood most of the day (nearly every day)
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. The standardized definitions enhanced data quality for public health surveillance, research, and clinical management purposes.
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More details about the prevalence rates in Table 4-3 and a discussion of risk factors and protective factors for each condition follow. Posttraumatic Stress Disorder Prevalence The prevalence of PTSD has been widely documented in U.S.
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GAD = generalized anxiety disorder; MDD = major depressive disorder; PTSD = posttraumatic stress disorder; SUD = substance use disorder.
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. The IOM notes that stressors such as longer deployments, multiple deployments with shorter rest and recovery times between deployments, and greater time away from base camp are also risk factors for PTSD (IOM, 2012)
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(2013a) examined the risk factors associated with sexual assault or harassment in a cohort of 13,262 active- and reserve-component women.
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or grouped anxiety with other mental health conditions. Robust information about GAD is also impeded by the non-existence of VA clinical practice guidelines for anxiety and the lack of a policy for standardized screening; by contrast, there is standardized screening in VA primary care settings for PTSD, MDD, and SUD.
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From page 56... ...
, unmarried, and having less than a college education increased the likelihood of depression. Other risk factors that have been reported in the literature include military sexual trauma and childhood physical abuse and other adverse childhood experiences (Cabrera et al., 2007; Fritch et al., 2010; Kimerling et al., 2010; Suris and Lind, 2008)
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. Protective Factors There has not been much research on protective factors for alcohol and substance use disorders, particularly in military and veteran populations.
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. Protective Factors The protective factors that decrease the likelihood of suicide are not as well studied as its risk factors, and most of the research has been carried out in civilian populations.
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VA/DoD joint guidelines exist for the four conditions addressed in this report, PTSD, MDD, SUD, and suicide risk. They are, respectively: VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress Disorder (VA and DoD, 2010)
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The VA/DoD guideline for the assessment and management of patients at risk for suicide, published in 2013, is the first VA/DoD CPG related to suicide risk. Mental Health Screening and Assessment in the Department of Veterans Affairs Within the Veterans Health Administration (VHA)
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NOTES: MDD = major depressive disorder; PTSD = posttraumatic stress disorder; VA = Department of Veterans Affairs; VHA = Veterans Health Administration. aAccording to the U.S.
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, "any person who is identified as being at possible suicide risk should be formally assessed for suicidal ideation, plans, intent and behavior, the availability of lethal means, and the presence of risk factors and warning signs" (p.
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According to VA policy, it is the responsibility of suicide prevention coordinators to submit suicide behavior reports for all known suicide events (deaths, attempts, and serious suicidal ideation)
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Posttraumatic Stress Disorder Determining the appropriate treatment for PTSD can be complicated because PTSD presents with varied psychosocial morbidity and functional impairment and is often comorbid with other psychiatric disorders, particularly SUD, major depression, and mild TBI. In general, the treatment for PTSD symptoms includes three broad intervention categories: psychotherapy (based on psychology techniques)
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. Major Depressive Disorder For initial treatment for mild or moderate MDD, the VA/DoD guideline advocates the use of monotherapy -- either psychotherapy or pharmacotherapy with a single antidepressant (Management of Major Depressive Disorder Working Group, 2016)
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. Of these treatments, a VA policy directive states that all veterans who have depression (or anxiety disorders)
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For cannabis, the guideline indicates that there is some evidence that CBT is effective. Suicidal Ideation and Behavior This section describes the recommendations for treating patients at risk for suicide as identified by the 2013 VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (VA and DoD, 2013)
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The guideline cites evidence for the benefits of lithium in reducing suicide risk and suicide attempt relapses in patients with major depressive disorder and bipolar disorder. In a review of 372 randomized, double-blind, placebo-controlled trials, the FDA found that although there is no indication that prescribing antidepressants to patients with mood disorders helps to lessen the risk of suicide, antidepressants were not shown to increase the risk of suicidal ideation or behavior in patients over age 25 either (Stone et al., 2009)
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. In 2009 the VA Office of Mental Health and Suicide Prevention and the VA Office of Rehabilitation Services sponsored two consensus panels to make practice recommendations related to the diagnosis and management of common comorbid conditions in veterans.
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. Assessment of Clinical Practices for Screening, Assessment, and Treatment in the Department of Veterans Affairs In 2013 the IOM released Returning Home from Iraq and Afghanistan, Assessment of the Readjustment Needs of Veterans, Service Members and Their Families (IOM, 2013a)
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2009. Assessment and diagnosis of mild traumatic brain injury, posttraumatic stress disorder, and other polytrauma conditions: Burden of adversity hypothesis.
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2011. Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: A systematic review of the evidence.
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2015. The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
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2014b. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment.
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2012. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.
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2015. Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan.
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2009. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008.
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2013. The evolving construct of posttraumatic stress disorder (PTSD)
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