Veterans’ Mental Illness in the UK

Post-Iraq and Afghanistan Wars:

The Role of Combat Stress

Combat Stress 24 Hour Helpline

0800 138 1619

Dr Walter Busuttil Consultant Psychiatrist & Medical Director

Veterans’ Mental Illness in the UK Post-Iraq and Afghanistan Wars

1. Epidemiology

2. Treatment services

3. Help Seekers – Needs Assessments

4. Treatment Programmes and Outcomes

Iraq and Afghanistan Cohort Study 2010

N=25,000 representative sample of 180,000

Most recent study (2010) 56% response rate

Reservists more vulnerable = 5% PTSD (vs 1% in non-deployed)

Overall 4% PTSD for all deployed (or 7200 of 180,000) – (4% non-deployed)

Direct Combat 6.9% PTSD

Alcohol related problems 13% (or 23,400 of 180,000)

19.7% common mental disorders,

Iraq and Afghanistan Cohort Study 2010-2018 (n=8093 representing 230,000)

[VALUE] [VALUE] [VALUE]

[VALUE]

1 2 3 4 5

PTSD Rates 2010-2016

Combat

2010 2018 2010 2018

Deployment

Iraq and Afghanistan Cohort Study 2010-2018

0

5

10

15

20

25

Alcohol Disorders & CMD 2007-9 & 2014-16

United Kingdom Veterans’ Mental Health Services

National Health Service

England Community services only

Transition and Intervention Liaison Service (TILS)

Complex Treatment Service (CTS)

Improving Access to Psychological Therapies (IAPT)

Norther Ireland – statutory NHS treatment for both sides

Wales – community services only:

All Wales Veteran Service

Scotland – Community and Residential

Combat Stress main Provider (NHS)

Military Charities across the UK

Combat Stress – largest provider bespoke services

Walking with the Wounded

Help For Heroes

Combat Stress the Charity est 1919

Combat Stress before 2007

Respite care

Residential Care

“Mental Health Welfare”

Veterans seeking help sooner

Referral Patterns and Trajectories: Northern Ireland, Iraq & Afghanistan Era Veterans in past 20 years (to 2014) Murphy, D., Weijers, B., Palmer, E., Busuttil, W. (2015) Exploring patterns in referrals to Combat Stress for UK veterans with mental health difficulties between 1994 and 2014. International Journal of Emergency Mental Health

Veteran Help Seekers

Currently around 2400 annually

If prediction of liner acceleration is correct then we can expect an increase by another half in the next five years from 2400 to 3200

Combat Stress Needs studies and clinical audits have shown consistently

Very high rates of co-morbidity with

• PTSD

• Depression

• Alcohol misuse disorders

Clinical Needs and Co-morbidity: Mental health profile of new referrals to Combat Stress

Health outcome % (N=425) (Murphy 2014)

PTSD 79%

Depression 88%

Anxiety 79%

Anger problems 46%

Alcohol problems 44%

Drug misuse 13%

Functional impairment

Significant 25%

Severe 64%

Childhood adversity (e.g. CSA,

neglect etc.)

52%

Significant Physical illness 71%

Needs Studies 2017-8: Very high rates of physical illness associated with Chronic Mental health Illness

Combat Stress Phasic Treatment Pathways (Herman, 1992)

Chronic Disease Management (2005 NICE Guidelines for treatment of Veterans with PTSD)

Interventions along a clinical pathway:

1. Initial preparation

2. Stabilisation and safety

3. Disclosure and working through of the traumatic material and psychotherapy on an individual basis

4. Rehabilitation and reintegration within society; normalising activities of daily living and maintenance within the chronic disease model

5. Relapse Prevention / Maintenance

Combat Stress Clinical Services (approx. 2400 new vets pa; 3500 in treatment)

Peer support – 600 veterans

National 24 Hour Help Line – 1600 calls per month

Separate Helpline for Serving personnel – 70 calls per month

Telephone Triage – 200 new patients per month

Community Services • Community and Outreach Service (CPN & OT assessment, interventions). • Hub and Spoke The Royal British Legion (TRBL) Pop In Centres (42 sites) • Substance Misuse Case Management • Outpatient Clinics (Consultant Psychiatrists and Psychologists) • Group Programmes

Residential Services

57 Residential beds across two treatment centres in Scotland (Ayr); and England (Leatherhead, Surrey)

• Preparation for Treatment program • Trans diagnostic program • Anger Management program • Intensive Treatment Program (ITP) • Individual Interventions • Wellbeing, Recovery and Social Reintegration Programme

Research Department linked to Kings Centre for Military Health

Research (KCMHR).

Easy Access & Engagement

1. National 24 Hour Help Line

2. Telephone Triage

3. Triage Outcome Meeting

……………..form the clinical pathway into Combat Stress services.

Medication: symptomatic/comorbidity:

Medication

Antidepressant

(SSRIs; Mirtazepine; *Trazodone )

Neuroleptics

(major tranquillizers)

Mood Stabilizers/ Antiepileptic

(Carbamazepine; valproate)

Anxiolytic

(Pregabalin)

Anti-impulse

(clonidine/ prazocin / propranolol)

Sedatives

Nabilone, melatonin, Trazodone

Indication PTSD & Depressive symptoms

(hyperarousal, re experiencing; *sleep)

Pseudo-psychotic presentations;

Dissociation; Tranquilization; co-morbid psychotic depression

PTSD Symptoms, dissociation & Mood stabilizing properties / anger

(nightmares, flbks, hyperarousal)

Severe anxiety/hyperarousal /anger

(Mood stabilizer, hyperarousal,

re –experiencing)

Impulse control - self- harm (clonidine)

(also nmares; prazocin, sleep

sleep

21

Preparation for Treatment ( PFT)

Psychoeducation & Distress Tolerance

OT Workshops Aim to prepare veterans to improve function: relationships, work

Anger management programme

Aims at reducing anger in the context of having been in Combat,

Modular Intensive treatment PTSD treatment (ITP) programme

Community based programme using group and individual trauma focussed therapy

Skype based therapies Moderately unwell, work and other commitments, live in remote areas. Pilot with Cognitive Processing Therapy works well (2018)

One to one & group interventions

Community Psychiatric Nurses anxiety management; Outpatient treatment psychology, psychiatry, OT. Substance misuse case management

Community Programmes Planned and in place (2018/9)

22

Preparation for Treatment ( PFT)

Emotional dysregulation counteracted through

anxiety management and Dialectic Behavioural

Therapy techniques,

Trans-diagnostic

and Recovery

programme

Skills Training and Resilience through structured

skill based interventions

Anger management

programme Aims at reducing anger in the context of having

been in Combat,

Intensive treatment

PTSD treatment

(ITP) programme

Six week programme veterans with complex

psychiatric needs: chronic, moderate to severe

PTSD significant psychiatric co-morbidity

(anxiety, depression and/or substance misuse);

severe family/social breakdown.

Individualised

Trauma focused

programmes

Complex and multiple traumas additional treatment on

completion of ITP

Recovery & Social

Re-integration

programme

Re-integration into the local community promoting

social inclusion; continues to build on the veteran’s

resilience and motivation to recover.

Residential programmes (as at 2018/9)

(Residential) Intensive Treatment (Six Week PTSD) Programme (ITP)

Salami Sandwich: Essential components:

1. Group Psycho-Education;

2. Individual TF-CBT;

3. Group Skills Training

Good uptake – close to 2000 have completed this programme

High Completion rate - Low drop out rate (mean 3-4%)

Audit data and Psychometric Subjective and Objective measures much improved clinically and functionally.

How outcomes compare internationally.

Veterans with chronic co morbid PTSD

Intervention Country Effect Size Time scale

Murphy et al 2015 British Medical

Journal

Treatment Programme

ITP

(Combat Stress) United Kingdom

1.04 6 months

Murphy et al 2016 British Medical

Journal

Treatment Programme

ITP

(Combat Stress) United Kingdom

1.03 12 months

Forbes/ Creamer 1999-current

Treatment Programme

Australia 0.9 2 years

Monson et al 2006 Cognitive Processing

Therapy

USA 0.7-0.9 1 month post treatment

Turek et al, 2011 Exposure Therapy USA 1.2-2.1 Immediately post treatment

Partners’ Mental health profile

Percentage meeting criteria

Depression 39%

Anxiety 37%

PTSD 17%

Alcohol Disorder 45%

Mental Health Profile of Veterans’ Partners (n=100)

Percentage meeting criteria

Common mental health

disorders

20%

PTSD 3%

Hazardous drinking 16%

Comparison with female population within the Adult Psychiatric

Morbidity Survey England

Significant/severe Functional Impairment 62% (Scale measures five areas: work, home

management, social leisure, private leisure and family & relationships).

Intervention Outcome Studies see website

https://www.combatstress.org.uk/about-us/research

• Intensive Treatment Programmes (seven papers published and other studies ongoing)

• Peer Support (Study in progress)

• Anger Management Programme (published)

• Breakaway Centre Rehabilitation (internal audit)

• Trans Diagnostic Programme (internal study completed)

• Preparation for Treatment programme (Study in progress)

• Telemedicine using Cognitive Processing Therapy (published and more in progress)

• Spouse Carer’s interventions (study in progress)

Likely advances in PTSD and Mental Health in the next five years

Promising interventions:

1. Combination of medication (MDMA) and psychotherapy - human trials.

2. Efficacy of Neuro-peptide Y medication – now human trials taking place.

3. Trans Magnetic Stimulation useful for depression. Some evidence for PTSD but might be useful for PTSD – so far unproven.

4. Concurrent pain management programme and PTSD programme – Boston and Florida VA – evidence base sparse but promising

5. Delphi – Medications? Must be international