US Dept. of State – RMOP Program - Cleveland Clinic...US Dept. of State – RMOP Program Kenneth B. Dekleva, MD Department of State Director of Mental Health Services, Office of
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US Dept. of State – RMOP Program Kenneth B. Dekleva, MD Department of State Director of Mental Health Services, Office of Medical Services Jan/Feb 2014 2014 CME/CNE Meeting, Atlanta 1
Director of Mental Health Services, Office of Medical Services
Jan/Feb 2014 2014 CME/CNE Meeting, Atlanta 1
Jan/Feb 2014 2014 CME/CNE Meeting, Atlanta 2
Jan/Feb 2014 2014 CME/CNE Meeting, Atlanta 3
Foreign Service Life
Terrorism Frequent moves Change of school Lack of spousal
employment Excessive travel Environmental Loss of control
Fishbowl Phenomenon Work Stress Inadequate resources Family issues Lack of support system Crime War Zones
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A Typical Embassy
State Dept. DAO AID FBI DEA DHS FAS FCS FAA
CDC NASA DoD Peace Corps DOE DOJ Treasury Other agencies
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Bombing
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Special populations
• ‘Trailing spouses’ • Multi-ethnic and multi-racial families • Minorities • Singles; Gays & Lesbians • Foreign Service Nationals • Third Culture Kids (TCKs) • Children with special needs/disabilities
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Control Groups & Comparison Groups in Travel Medicine
Medical Director Foreign Programs MED Clearances Mental Health Services ECS; ADAP; DSSP;
DSMP Occupational Health DASHO Travel Medicine
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Mental Health Program
Culture shock Stress management School consultation Management
consultation Travel medicine Occupational health Medical diplomacy ADAP DSSP
Disaster response General psychiatry Security/forensic issues Emergency Response Family advocacy Crime War Zone concerns ECS DSMP
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Our Panel of Experts
1st Psychiatrist
The Anti-Psychiatrist
HMO Psychiatrist Veteran RMOP
former MHS Director
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Presenter
Presentation Notes
Freud –1st Psychiatrist; Lucy – HMO psychiatrist; Tom Cruise – the anti-psychiatrist; Alfred E. Neumann – cured patient; Homer Simpson – opinion leader
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RMOP Positions
Amman London Pretoria Vienna Mexico City New Delhi Moscow Beijing Manama Athens
Frankfurt Cairo Jakarta Accra Lima Dakar Tokyo Nairobi Bangkok Singapore
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HU Population in 2 regions (unpublished data by RMOPs)
50% employees; 50% EFMs 6% med-evac for psych disorders; 3% curtailed ADHD: nearly 50% of all children seen by RMOP Psychotic disorders: < 1% Anxiety disorders: 7-9% Mood disorders: 20-30% Substance-abuse disorders: 2-4% Adjustment disorders: 6-10% No psychiatric diagnosis (30%) or V Code (52%)
High points: Do people come to see us? Yes, and it appears they do at slightly lower rates than found in the US. Worry they might not. Some express concern about effects of seeing a psychiatrist on their security and medical clearances. But US rate of 8.8% (2001-3) and overseas rate (2006) of 5.6% are in the same ballpark. Lower value for US, 2.3 visits was for those w/o a disorder; 3.6 visits was for those for a disorder. Higher overall number of visits for a 12-month disorder, 3.7 for non disorder and 7.4, for any disorder were observed when other MH providers, such as therapists and mental health nurses, were included. Basically double the rate when expand to all MH providers.� 50-60% of visits v codes and adjustment disorders; 17-20% for MDD. High percentage of v codes and adjustment disorders is notable was consistent among two studies. Data from 2006 from one region (Amman, Flynn) and from the late 1980s (Cairo, Valk) found v codes and adjustment disorders respectively composed 56% and 51% of outpatient visits while visits for depression were 19% vs. 17%. Thus, 68%-75% of outpatient visits for v codes, adjustment disorders or depressive disorders. � RMOP data, 2006, from a Middle East region averaged 2-3 visits per patient and suggests one for the challenges of our work when cover 8-10 countries and have typically no more than 4 visits per year to an embassy. Important collaboration with RMOs/FSHP. Local resources for referral may be available in some countries, but not all, and lack of local language ability often limits the ability of our diplomats and their family to make use of MH providers. Flynn’s V codes. Interesting that by 2001-3 US psychiatrists appeared to have similar average frequency of contact with their patient. � National Co-Morbidity Replication study, which uses data from a household sample of individuals 18 and older from 2001-2003 and is based on face-to-face interviews using the Composite International Diagnostic Interview (CIDI). Overall response rate was 70%� In 1990-92, US outpatient for the initial Nat Co-morbidity survey showed average of 13-15 outpatient visits for depressive, anxiety and substance abuse disorders over a 12-month period. reflects annual average of 6 visits for low distress mental health conditions to 12 visits for high distress ones. References Wang PS et al. Twelve-Month Use of Mental Health Services in the United States. Results from the National Comorbidity Survey Replication. Arch Gen Psych 2005; 62:629-640� Valk TH, Foreign Service Medical bulletin, 1990, 280; 6-11.� Amman RMOP data, 2006, Unpublished. Pop size with 161 cases Jan-Dec 31, 2006, from the Middle East. 5.6% of population seen by RMOP for out patient care in this one region in 2006. RMOP data 2,845 pop size and 161 cases Jan-Dec 31, 2006. � Pirraglia PA et al. Psychological distress and Trends in Health care expenditures and outpatient health care. Am J Managed Care. 2011; May; 17 (5): 319-328 Med evac rate 2008-10 was 0.2 % For every 25 contacts we had roughly medical evacuation (4%). What were the cases that required evacuation? Partner relationship problems about 15 percent of outpatient and 15 percent of med evacs.
0%
1%
2%
3%
4%
5%
6%
State Outpt Med evac
Mental health evacuations needed by perhaps 5%
Rate of Outpatient Visits and Mental Health Evacuations at State
56 per 1,000*
2 per 1,000
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Presenter
Presentation Notes
Talking points: 5.6% of population was seen by RMOP for out patient care in a Middle Eastern region in 2006. Med evac for mental health conditions in 2008-10 was 0.2 %. Assuming for a moment that this data is representative, that amounts to about one mental health evacuation for every 25 contacts (4-5%). Data collected from 1982-86 found a remarkable similar rate of mental health evacuations—1.63 per thousand covered individuals. Partner relationship problems about 15 percent of outpatient and 15 percent of med evacs. Domestic violence, severe conflict that threatens ability to function and work, not just marital problems. References: Valk TH. Psychiatric Medical Evacuations within the Foreign Service. Foreign Service Medical Bulletin, 1987;268, 9-11.
Conditions Leading to a Mental Health Evacuation, 2008-10
22%
17%
16%
8% 8% 6% 4%
0%
20%
40%
60%
80%
100%
Suicide AParent-ChildPTSDAdjPartnerAlcoholMood
Mood disorders, alcohol and partner problems together
5-6x as common as PTSD
55%
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Presenter
Presentation Notes
Talking Points. � What disorders were severe enough to lead to a medical evacuation? � Mood disorders were most common, as in the US. Interesting that while mood disorders (prevalence US, 9.5%) are three times more common than alcohol abuse (prevalence US, 3.1%) they composed just a slightly smaller percentage of our med evac cases. Two disorder alone--mood disorders and alcohol abuse/dependence--together accounted for 60% of the days spent on a medical evacuation. Rate of medical evacuations for alcohol for were 3 times greater for Africa than the DOS average—3 per thousand vs. 1 per thousand. But what we don’t know is if medical evacuations were more likely because services were not available or if the prevalence was greater. AF can be a hard place to live. 3 conditions pop out in med evac data that we didn’t see in our outpatient contact: alcohol abuse/dependence (17%), PTSD (8%) and suicide attempts (4%). Risk of med evac was highest for Africa and war zones—about 2.5 times about the State Dept average. �� 8% of all med evacs for PTSD. Where do they come from? One presumes AIP. Lets now shift our focus now to medical evacuations from war zones. References: Kessler et al. Past-year Use of Outpatient Services for Psychiatric Problems in the National Co-Morbidity Survey. AJP 156;1, Jan 1999: 115-123.
Mental Health Evacuations in Afghanistan, Iraq and Pakistan, 2008-10
47% 36%
18%
9% 9%
27%
0%
20%
40%
60%
80%
100%
PTSD Cause
War Exp, New
Assault
Natual Disaster
Mil Combatant
Prior Tour
Prior Trauma, 73%
(8/11)
Prior trauma plays a role in a majority of PTSD mental health evacuations
N=23
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Presenter
Presentation Notes
Key Points: Eleven of 23 (47%) med evacs in AIP were for PTSD, but only 3 of 11 cases of PTSD due to new-onset PTSD due to war zone exposure. 8 of 11 (73%) officers reported prior exposure to trauma, related to political violence in prior tours (eg, sectarian violence in Lebanon), natural disasters or service as a MIL combatant prior to joining State. Individuals with prior trauma appear to have been more vulnerable to sx exacerbation. In many cases diagnostic data was accompanied by PCL-C scores, which were typically > 50. PCL-C scores > 50 and DSM diagnosis of PTSD are considered a basis for moderately severe PTSD with functional impairment. Rate of medical evacuation for PTSD for AIP was 2.3 per 1,000 per year vs 0.32 per 1,000 per year for DOS as a whole, a 7 fold difference. Low incidence, higher prevalence. Based on these 3 new cases, the incidence rate for new cases of PTSD is about 0.6 per thousand (3/1,620), much lower than that of the military of 10-12 per thousand reported in the Millennium cohort study. However, its important to remember that as diplomats spend most of their lives deployed overseas the prevalence is likely to be higher as officers may face ongoing risks of war or sectarian violence in subsequent tours as well as threats posed by accidents, and crime. Military combatants exposed to high risks when deployed as combatants, but presumably lower ones when they are serving back in the US or at bases overseas which work hard to recreate life in a US community. Recall, incidence is the number of new cases occurring in a period of time, while prevalence is the total number of cases. Prevalence = incidence x duration. DOS faces ongoing risks, but ones that continue. Like G Diamonds concern about ongoing, low level risks of getting in and out of the shower. � That brings us down to just under 2% of all of our med evacs. Note that all PTSD treated cases in 2009-10 (N=8) via Exposure Therapy at DOS had PCL-C scores higher than 50 at start of tx and DSM-4 diagnosis of PTSD.
US Diplomats Serving in AIP: Population Prevalence vs. Treated Prevalence of PTSD
12%
5%*
0%
2%
4%
6%
8%
10%
12%
ConsultedMHS
PTSD* Med EvacPTSD
Gap between distress and dysfunction suggests resilience
0.2%
*PCLC > 50 Jan/Feb 2014 2014 CME/CNE Meeting, Atlanta 22
Presenter
Presentation Notes
Talking point: About 12% of our officers reported problems in functioning during AIP or UT tours and sought out MHS services. And while 5% of officers may well have had PTSD, only 0.2% of officers received mental health evacuations for PTSD (4%). Gap between distress and dysfunction suggests a high degree of resilience and begs the question, what factors contribute to resilience? Relative roles of leadership, sense of mission and underlying demographics of our population. References Survey of FS employees Who Served in Iraq, Afghanistan or Other Unaccompanied Posts, 2007. This report states that 2% “probably” had PTSD, while 15% “possibly” had PTSD”. Analysis of PCL-C scores in May, 2013, found that 5% (29/546) of respondents had PCL-C scores > 50; another 4% (20/549) had scores between 44-50. Survey 2,600 respondents Sent out between June1-July 15, 2007 that asked about PTSD symptoms during after and currently among those who had served UT tours between 2002-7. There were 877 replies (33% response rate); 70% of respondents from AIP; Saudi, 13%; Sudan, 4%; Algiers, 3%, Beirut 3%, Monrovia 3%. 67% male, 80% < 55 yrs, 93% State. Only 19% had departed post w/in past 6 months. � Significant Findings:� 2% “likely” PTSD rate based on 2007 survey of PCL-C scores of 877 respondents who served in Iraq, Afghanistan and other unaccompanied tours between 2002-7. Another 15% reported with were affected quite a bit (5%) or moderately affected (10%) 36% UT tour adversely affected emotional health; 12% percent reported that tour affected ability to function; 12% said they consulted MH. 78% said professionally rewarding and 66% said they would volunteer again. Insomnia (47%), irritability (30%) and social withdrawal (30%) most common. Insomnia at time of interview was as common as during AIP tour. Problems relating to spouse spiked from 28-55% after tour. Excessive alcohol declined from 9 to 3%.
Why are DoS med-evac and suicide rates so low?
Role of self-selection (‘salutogenesis’) and medical clearances? Epidemiologically --- a healthier population? Role of social contract and high levels (e.g. 5X) of
medical/behavioral health support? What is the optimal ratio of clinicians to covered lives? Confounding variables (e.g. moving, flying, tourist travel)? Are med-evac, suicide rates the best metrics w/r to overall
behavioral health outcomes in a diplomatic population? There are very few comparison data overall, and no long-term,
prospective studies have been done. What are the best control groups?
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Conclusion & Questions?
Need for more studies, proper control groups Are we asking the right questions? Excessive focus on mental health/pathology, rather than resilience Need for prospective, longitudinal studies Confounding biases w/r to organizing concepts? Wrong outcome measures? Ratio of MHS providers to covered lives --- impact of a resource-
rich model upon outcome data? DOS = approx. 5X rate of HMOs Need for family studies (ex: Steinglass P and Edwards M. Risk
and Resiliency Factors in State Dept. Families. Ackerman Inst. For Family Therapy, 1993)
