>> GOOD AFTERNOON, EVERYBODY. WE'LL GET STARTED. MY NAME IS DR. MIGUEL ROBERTS, I WAS LATE EDITION TO THE AGENDA WHICH PROBABLY EXPLAINS OUR LOW ATTENDANCE, I GUESS THE WORD GOT OUT THAT I WAS GOING TO BE SPEAKING. SO WE'RE -- THIS IS A PSYCHOLOGICAL HEALTH SECTION, IN THE LAST SESSION WE HER ABOUT EVIDENCE BASED PRACTICE AND THOSE METHODOLOGIES OF TREATMENT THAT WERE -- THAT ARE SUPPORTED BY THE EVIDENCE FOR OUR POPULATION. THIS SESSION WE'RE GOING TO TALK ABOUT TRANSLATION. SO HOW DO WE TRANSLATE THAT INTO ACTUAL PRACTICE? MY TALK WE'RE GO TO FOCUS ON CLINICAL SUPPORT TOOLS AT DICO. COLONEL ROBINSON WILL GO NEXT AND TALK ABOUT IN THEATER CARE AND FINALLY WRAPPING UP COMMANDER VYTHILINGAM WILL BE PRESENTING ABOUT PREVENTION ON BOTH PSYCHOLOGICAL TREATMENT, PSYCHOLOGICAL PREVENTION AND MEDICATION FOR PREVENGS. LET'S GET STARTED. SO THAT'S WHAT WE'RE TALKING ABOUT. SO WHY SHOULD WE FOCUS ON THIS? I THINK WITH THIS AUDIENCE WE HAVE HEARD OVER THE LAST COUPLE OF DAYS WITH THE SCOPE OF THE PROBLEM AND NUMBER OF DIFFERENT WAYS ALSO HEARD ABOUT WHY THIS IS A IMPORTANT VENTURE TO BE FOCUSING ON PSYCHOLOGICAL HEALTH. THE CHAIRMAN OF JOINT CHIEFS SUMMARIZING IT WELL THERE WITH THAT QUOTE, THAT HOW WE TAKE CARE OF THOSE WHO ARE WOUNDED AND FAIR FAMILIES AND FAMILY THATION HAVE FALLEN IS AT THE ENTER OF MY LIFE. I THINK THAT PUTS A FOCUS WELL ON WHAT WE ARE DOING AND WHY WE SHOULD DO IT. IT'S IMPORTANT TO REMEMBER THIS IS A LONG TERM COMMITMENT, A STORY THAT I LIKE TO TELL FOLKS IS WHEN IN 2002, I WAS LIVING IN MISSISSIPPI AND LOCAL PAPER HAD HEADLINED LAST CIVIL WAR WIDOW DIES. THINK ABOUT THAT, 160 YEARS AFTER THE CONFLICT ENDS THE LAST CIVIL WAR WIDOW DIED. SHE WAS LIKE 17 AND MARRIED AN ELDERLY VETERAN OF THE CIVIL WAR BUT THE POINT IF WE'RE TALKING ABOUT EXPANDING CARE TO FAMILIES , WIDOW, 160 YEARS IS QUITE A TALE. THIS IS A SHIFT IN OUR THINKING. HOW WE AS MILITARY HEALTH SYSTEM, HOW WE FOCUS ON THESE ISSUES THE CHANGE IN THE LAST 30 YEARS. THAT ORIENTATION OF OUR LEADERSHIP THAT SHIFTS IN THE THINKING CAN BE SEEN THERE SO WE HAVE A NUMBER OF INITIATIVES THAT ARE CHANGING -- FOCUSED ON MAKING LEADERSHIP AWARE OF HOW PSYCHOLOGICAL HEALTH IMPACT THEIR SERVICE MEMBERS, WHY THAT'S IMPORTANT. SO THERE ARE CORE MESSAGES YOU HEARD THESE A BUNCH OF TIMES OVER THE COWFERS A COUPLE OF DAYS. SO LET'S'S TALK ABOUT PTSD. SO I'M GOING TO GO THROUGH QUICKLY, THIS AUDIENCE KNOWS AND HAVE HEARD THIS A MILLION TIMES BUT PTSD INVOLVES A TRAUMATIC EVENT AS WELL AS SYMPTOMS OF EXPERIENCING AVOIDANCE AN HYPERRER AROUSAL. THAT'S THE DSM DEFINITION, I THINK WALT WHITMAN SAID IT EQUALLY WELL, LONG TRENCHES AN FIELDS THROUGH THE CARNAGE I MOVED WITH A CALLOUS COME POE SURE OR AWAY FROM THE FOLLOWING. ONWARD I SPEN AT TIME BUT NOR FORMS I DREAM I DREAM I DREAM. UNCLE WALT WAS GETTING AT IS I THINK BEAUTIFULLY PUT THE REGRET, THE REEXPERIENCING, THE PAIN OF THOSE EVENTS. SO HOW BIG A PROBLEM IS IT? HERE IS A SUMMARY OF A BUNCH OF DIFFERENT STUDIES, BIG POINT, DON'T GET CONFUSED AND FREAKED OUT ABOUT THE NUMBER OF DATA POINTS THERE, THE BIG PICTURE IS MOST STUDIES FIND THAT PTSD PREVALENCE FALLS IN -- SHOULD BE IN THE 10 TO 15% RANGE. WE HAVE HAD OVER 2.2 MILLION SERVICE MEMBERS DEPLOYED, ELECTRONIC MEDICAL RECORD, 2.4% OF OUR SERVICE MEMBERS THAT WERE DEPLOYED IN SUPPORT OF OIF ARC OEF CARRY A DIAGNOSIS, THAT'S A MEDICAL RECORD DIAGNOSES, THE STUDIES AGAIN FALL BETWEEN -- WHEN WE ASK PEOPLE TO SELF-REPORT THE STUDIES FIND BETWEEN 10 AND 17%. BUT IT'S IMPORTANT TO KEEP IN MINE THAT WE DONE KNOW. WE HAVEN'T DONE A GREAT STUDY THAT INVOLVES ACTUAL CLINICIAN DIAGNOSES. SO THAT'S WHY I SAY TRUE PREVALENCE IS UNKNOWN SO WE KNOW SOME INDICATORS. IS A COMPLEX PICTURE THAT ALSO INVOLVES COMORBIDITY. WITH THINGS LIKE TRAUMATIC BRAIN INJURY AND WE TALKED SOME ABOUT THIS YESTERDAY, YESTERDAY'S SESSION THERE'S SOME DIFFERENCES IN COMBAT RELATED PTSD SOME OF THE STUDIES USING OUR BEST TREATMENTS HAVE FOUND THAT IT DOESN'T RESPOND AS WELL TO THOSE TREATMENTS. S THAT THE REMISSION RATE FOR PTSD IS LOWER THAN COMBAT PTSD. AND WE KNOW THE NATURE OF THE SITUATION IS SOMEWHAT DIFFERENT. IN COMBAT. SO DURATION OF THE STRESSOR ALSO THE REPEATED NATURE OF IT, AND HOW THAT IS CHANGED OR AFFECTED BY ACTUAL TRAINING FOR AN PREAP RATION FOR THOSE EVENTS. IF YOU'RE IN A MOTOR VEHICLE ACCIDENT IT'S NOT SOMETHING YOU TRAIN AND PREPARE FOR BEING IN A TRAUMATIC MOTOR VEHICLE ACCIDENT OR TRAIN OR PREPARE FOR BEING IN A NATIONAL DISASTER THAT'S DIFFERENCE FROM COMBAT. WE DON'T KNOW HOW THAT AFFECTS THINGS SO THERE'S SOME INDICATION THAT THE EMOTIONAL RESPONSE TO THAT EVENT IS DIFFERENT IN COMBAT. DEPRESSION. DEPRESSED MOOD REDUCTION, OR LOSS OF INTEREST AND PLEASURE IS -- CAN TAKE AWAY THE STUDIES HERE A BIT MORE SLAIRRIED. ALSO IMPORTANTLY MOST OF THE THESE STUDIES THE RANGE FALLS IN THE ONE AND 6, 1 IN 8 RANGE. ALSO IMPORTANT TO NOTE HERE LONGITUDINALLY WE SEE AN INCREASE IN DEPRESSION OVER TIME. SUBSTANCE USE DISORDER. THE DSM HAS TWO BROAD CATEGORIES OF SUBSTANCE ABUSE AN MOST SEVERE SUBSTANCE DEPENDENT. WE DON'T HAVE GREAT NUMBERS ON SUBSTANCE BUT THIS IS ONE OF THE DATA POINTS THAT WE DO HAVE IN OUR POPULATION THAT LOOKS AT TRENDS OVER THE LAST 30 DAYS OF HEAVY DRINKING WHAT WE FIND IS THAT THERE'S INCREASE TREND TOWARD HEAVY DRINKING. ALSO IN THAT AREA OF SUBSTANCES, ELICIT DRUG USE WITH PAIN RELIEVERS LIKE OPIOIDS BEING -- GETTING A LOT OF ATTENTION AT HIGH LEVELS OF THE GOVERNMENT AND HIGH LEVELS OF THE DOD BUT WE KNOW IT ALSO GOES BEYOND THE ACTUAL DIAGNOSTIC CATEGORIES. WE HAVE BEEN TALKING DEPRESSION, TALKING ABOUT A SUBSTANCE AND TALKING PTSD WHICH GETS A LOT OF ATTENTION, BUT IT'S IMPORTANT TO GET KEEP IN MIND IT'S -- WE SHOULDN'T LIMIT OUR THINKING TO THOSE THINGS. THERE'S ADJUSTMENT PROBLEMS AFTER YOU GET HOME T MARITAL STRESS. THEN THERE'S THE STRAIN ON THE CHILDREN AND FAMILIES. AND THE DIVORCE AND THEN THERE'S THAT HIGH RISK BEHAVIOR, WHAT DO I MEAN BY THAT, THINGS LIKE RISKY DRIVING, RISKY DRINKING, THOSE TYPES OF THINGS. SO THE HIGH RISK BEHAVIORS. THEN ALL IN THE CONTEXT OF INCREASED RATES OF SUICIDE, SINCE THE START OF THE? AGAIN CO-OCCUR, HOW MUCH DOES IT CO-OCCUR. WHEN THE VA DID A CONSENSUS CONFERENCE, THEY FOUND THE RATES OF CO-OCCURRENCE ARE BETWEEN 5 AND 7% HAVING SERVICE MEMBERS HAVING BOTH. THEN ALSO IF YOU LOOK AT JUST THOSE WITH SO BROADLY 5 TO 7% OF EVERYBODY, THOSE WITH TBI ABOUT A THIRD OF THOSE FOLKS HAVE PTSD ALSO. SO THAT'S IMPORTANT TO KEEP IN MIND THE SIGNATURE INJURY AS CALLED BY RAND. AND FURTHER, SOME OF THE SPECIFIC UNIQUE FEATURES OF OUR POPULATION LIKE NATIONAL GUARD AND RESERVISTS, THAT DEPLOY AND GO BACK TO THEIR HOME STATION THAT IS IN GEOGRAPHICALLY DISPERSED AREAS LIKE MONTANA OR WHATEVER SO IN THOSE FOLKS ALSO HAVING THE SAME PROBLEMS. THAT'S IMPORTANT TO KEEP IN MIND SOME OF THOSE DIFFERENCES GEOGRAPHIC DISPERSION BECAUSE 40% OF OUR DEEMPLOYERS ARE NATIONAL GUARD AN RESERVISTS. SO WHAT DO WE DO ABOUT IT? PTSD WE HAVE HEARD WHAT TREATMENTS ARE THAT ARE SUPPORTED BY THE EVIDENCE. THIS IS THE EVIDENCE TABLE FROM THE RETRACKED GUIDELINE RECENTLY REVISED. THE FINDING THAT THE BEST -- THE STRONGEST RECOMMENDATION IS TRAUMA-FOCUSED PSYCHOTHERAPIES, THIS ISN'T JUST PSYCHOTHERAPY, EEL GET THE MEDICATION IN A MINUTE. EMDR CPT PROLONGED EXPOSURE, INNOCULATION. HERE IS MEDICATION, THE STRONGEST EVIDENCE IN THE AREA THE STRONGEST EVIDENCE BEING IN THE AREA FOR SSRI WITH SPECIFIC SSRI LISTED THERE HAVING THE MOST STUDIES, AND FNRI ALSO. SO WHAT DOES THE CPG RECOMMEND TO DO? FOR MEDICATIONS THOSE THINGS FOR PSYCHOTHERAPY THOSE TRAUMA FOCUS BUT IT ALSO HAS RECOMMENDATIONS FOR OTHER ASPECTS OF CARE >> CLINICAL PRACTICE GUIDELINES ARE TARGETED FOR PRIMARY CARE PROVIDERS, WHY PRIMARY CARE PROVIDE ?ERS WHAT'S THE QUOTE ABOUT WHY DO YOU ROB BANKS? THAT'S WHERE THE MONEY IS. WHY DO YOU SEE -- WHY DO YOU TARGET IT FOR PRIMARY CARE. BECAUSE THAT'S WHERE THESE PATIENTS ARE GOING. SO TO PROVIDE THAT ASSISTANCE TO PROVIDERS, THAT MAY OR MAY NOT HAVE GREAT EXPERIENCE WITH HOW TO ASSESS AN TREAT AN MANAGE PTSD. THAT'S WHY OUR CLINICAL PRACTICE GUIDELINES ARE TARGETED AT THAT AUDIENCE. THERE ARE OTHER ASPECTS THAT ARE IMPORTANT IN THE CLINICAL PRACTICE GUIDELINES INCLUDING THINGS LIKE SCREENING. PC PTSD, PRIMARY CARE PTSD SCREEN IS A FOUR ITEM SCREENER FOR PTSD THAT WAS DEVELOPED SPECIFICALLY FOR USE IN THAT AUDIENCE. AND HAS GOOD EVIDENCE TO SHOW IT'S EFFECTIVE AT DETECTING SIGNIFICANT SYMPTOMS OF PTSD THAT REQUIRE FURTHER EVALUATION. SO WHAT DO YOU DO? SCREEN FOR PTSD, THE RECOMMENDATION IS ANNUALLY OR MORE FREQUENTLY IF THERE IS A SIGNIFICANT CHANGE. SCREEN FOR PTSD. IF WE CAN GET FOLKS SCRIENING FOR PTSD IN A RUE TUNE WAY I THINK WE'D BE CHANGING A LOT AS FAR DETECTION OF THESE SYMPTOMS. OR AT LEAST KNOWING A LOT MORE ABOUT THESE SYMPTOMS. SCREENING IS ONE THING THAT'S IMPORTANT. IT'S ALSO IMPORTANT INTO THEIR MENU OF OPTIONS ARE. THE CPC INCLUDES RECOMMENDATION. SO WITH THE POSITIVE SCREEN IT GIVES YOU INDICATION THE PERSON NEEDS TO BE FURTHER EVALUATED. THAT'S A GREAT OPPORTUNITY TO PROVIDE THAT EDUCATION TO THE SERVICE MEMBER. OR THE VETERAN ABOUT PTSD AND WHAT IT IS. SO THAT COMPONENT IS A REALLY IMPORTANT THING. ALSO KNOWING WHAT THE THINGS THAT WE COVERED BELIEVEIOUSLY -- PREVIOUSLY ABOUT THE OTHER TYPES OF TREATMENTS THAT ARE SUPPORTED BY THE EVIDENCE. I WENT THROUGH THIS ALSO AGAIN, THE SSRIs. THIS IS A GREAT TIME TO TALK ABOUT CHANGES IN EVIDENCE. SO WITH THE ATYPICAL ANTIPSYCHOTIC, THAT WAS SOMETHING THAT THE EVIDENCE WAS RECENTLY CHANGED. YOU MAY HAVE SEEN THAT STUDY WHERE THEY USED RESPERDOL FOR AUGMENTING TREATMENT FOR PTSD. ANYBODY? COUPLE OF NODS. ALL RIGHT. SO BASED ON THAT STUDY AND THE BROADER LITERATURE REGARDING ATYPICALS, THE EVIDENCE WAS DOWNGRADED FROM A MAY CONSIDER TO A RECOMMENDATION IS NOT RECOMMENDED ADJUNCT OR MONOTHERAPY THAT'S A SIGNIFICANT CHANGE ON THE RECOMMENDATION OF THE CPG BASED ON SCIENCE. THAT'S WHAT THE CPGs ARE INTENDED TO DO. WE TACK A PANEL ACROSS DEPARTMENTS AND GET THEM INTO A ROOM AND SAY WHAT APPLIES TO OUR POPULATION? BASED ON THE SCIENCE THEY CHANGED THAT RECOMMENDATION FOR ATYPICAL AND FOR RISPERDAL SPECIFICALLY. HOW DO WE TRANSLATE WHAT THAT CPG SAYS INTO EVERY DAY PRACTICE. ONE THING WE'RE DOING IS WORKING CLOSELY WITH THE ARMY MED EXECUTIVE AGENT FOR TOOL KIT DEVELOPMENT IN CLINICAL PRACTICE GUIDELINES WORKING CLOSELY TO DEVELOP THE CLINICAL SUPPORT TOOLS FOR USE IN OUR DEPARTMENTS. THIS IS A SCREEN SHOT OF -- SO YOU GUYS SEE IT FOR THE FIRST TIME. THE CLINICAL -- ONE OF THE CLINICAL SUPPORT TOOLS THAT WE'RE DWOLLING THAT INCLUDES THE ASPECTS OF CARE THAT WE HAVE JUST BEEN TALKING ABOUT, SCREEB, HOW TO SCREEN WITH THE FOUR ITEM SCREENER AS WELL AS HOW TO PROVIDE FEEDBACK FOR THE PATIENT IN THE MEANFUL WAY, SERVICE MEMBER VETERAN PATIENTS IN MEANINGFUL WAY WHAT THEIR RESPONSES MEAN. THE OPPORTUNITY FOR PSYCHOEDUCATION IS A GREAT TIME TO TOUCH THE PATIENTS, HOW TO NORMALLYZE THE SYMPTOMS. WE CONE KNOW, WHAT WALT WHITMAN EXPERIENCED WORK AS A NURSE, WAS PTSD OR NOT. OR IF IT WAS MORE A NORMATIVE REACTION TO A TRAUMATIC EVENT. WE ALSO DONE KNOW THAT WITH OUR SERVICE MEMBERS. UNTIL WE ASK. GREAT OPPORTUNITY TO TALK ABOUT PTSD AND PTSD RELATED SYMPTOM AND PROVIDE EDUCATION ABOUT WHAT WORKS. THIS IS ALL SELF-CONTAINED IN ONE HANDY DANDY TOOL KIT FOR OUR PROVIDERS AN PATIENTS. SOMETHING LIKE THIS. SO I THINK IT'S ALSO IMPORTANT TO KNOW WHAT PATIENTS ARE DOING. SOME OF THE SURVEYS OF USE OF COMPLIMENTARY AN ALTERNATIVE MEDICINE SHOWS IT'S VERY WIDELY USED IN SERVICE MEMBERS IN THE GENERAL POPULATION AND THE USE IS CENTERED AROUND PSYCHOLOGICAL HEALTH. THE CLINICAL PRACTICE GUIDELINE TOOK A HARD LOOK AT THE EVIDENCE FOR THOSE MODALITIES. AND CONCLUDED THAT IT CAN BE CONSIDERED AS AN ADJUNCT FOR CERTAIN MODALITIES, AND AS YOU KNOW THE EVIDENCE IS NOT WHOLLY UNIFORM OR ACROSS ALL MODALITIES OF TREATMENT. SO THERE'S SOME THAT HAVE BETTER EVIDENCE THAN OTHERS BUT IN GENERAL THOSE STUDIES, WE NEED THEM FOR THOSE MODALITIES T. DATA IS JUST NOT THAT GREAT. SOME PROMISING IDEAS, ACUPUNCTURE YOGA AND MINDFULNESS TRAINING THAT FOCUS ON RELAXATION COMPONENT. I SKIPPED THE OTHER IMPORTANT POINT. FOR A CO-MORBID CONDITION. THINGS LIKE PAIN COMMONLY CO-MORBID IN PTSD. ING UG THE OTHER THING SMAIKING THE REFERRAL TO BEHAVIORAL HEALTH. SO WHEN AND HOW TO MAKE THAT REFERRAL IN A STRONG WAY TO THE SERVICE MEMBERS. SO WE HAVE A TOOL FOR THAT. SO THIS IS A PATIENT BOOKLET. SO WE HAD PROVIDER TOOLS THAT LAST, PROVIDER TOOL, THIS IS A PATIENT BOOKLET THAT IS -- CONTAINS MUCH OF THAT INFORMATION ABOUT HOW TO EDUCATE WHAT IS PTSD, HOW COMMON IS IT, SO THE THINGS THAT WE WANT OUR PATIENTS TO KNOW, SO LET'S SHIFT GEARS HERE A LITTLE BIT NOW THAT WE HAVE TALKED ABOUT PTSD AND PTSD TOOLS AND TALK ABOUT DEPRESSION. ANOTHER ASPECT, IMPORTANT ASPECT OF CARE IS SCREENING. SO THE VA IS USING THE PHQ-2, TWO ITEMS SCREENER FOR DEPRESSION RECOMMENDED IN THE PRIMARY CARE SETTING AND CURRENTLY THE VA USES IT ANNUALLY. GREAT OPPORTUNITY TO UNDERSTAND WHAT'S HAPPENING WITH OUR SERVICE MEMBERS, VETERANS IF WE CAN SCREEN ANNUALLY. THE CLINICAL PRACTICE GUIDELINE PROVIDES GUIDANCE ON WHAT TO DO WITH THAT INFORMATION. HOW DO WE CONVERT THAT RECOMMENDATION TO SOMETHING USABLE, WE HAVE A TOOL FOR THAT. I -- THIS IS ONE OF MY FAVORITE TOOLS, I GOT EXCITED ABOUT THIS. OUR DEPRESSION 1, 2, 3. SO IT CONTAINS BASIC INFORMATION ABOUT WHAT THE CLINICAL PRACTICE GUIDELINE SAYS. SO THAT'S HERE, THE KEY ELEMENTS OF THE GUIDELINE. ALSO CONTAINS INFORMATION ABOUT SCREENING HERE, THE TWO ITEM AS WELL AS MORE COMPREHENSIVE ASSESSMENT. SO ONCE YOU SCREEN, HAVE A POSITIVE SCREEN WHAT DO YOU DO WITH THAT INFORMATION FOLLOW-UP TO GET FURTHER INFORMATION ABOUT THE DISORDER. THE PHQ-9 IS ONE WAY TO DO THAT, CONTAIN FOR PROVIDERS WITH ENTERPRETIVE INFORMATION, ALL THERE. THE BEST EVIDENCE IN DEPRESSION IS FOR COGNITIVE BEHAVIORAL INTERPERSONAL AND PROBLEM SOLVING THERAPIES. AS WELL AS PHARMACO THERAPY FOR SSRI, SNRI AND A FEW OTHERS. SO WE HAVE A CLEAR RECOMMENDATION OF FIRST LINE TREATMENT IN PRIMARY CARE. ONE IMPORTANT THING TO REMEMBER WITH THE SSRIs IS THAT IT'S NOT LIKE WE HAVE STUDIES THAT DO -- WE DON'T HAVE A COMPARATIVE EFFECTIVENESS OF EACH AND EVERY SSRI TO SAY THIS IS THE BEST FOR EVERY PATIENT. WE DONE HAVE THAT DATA. OVERALL WE HAVE STRONG EVIDENCE OF SSRI THAT'S WHY I HAVE THAT STATEMENT H THERE, ALSO TO CONSIDER THE TCA AS WELL AS TITRATION INFORMATION. SO HOW DO YOU RAMP UP THE DOSE? THAT'S ANOTHER REASON I THIRU TEEN AND REGULAR ASSESSMENT OF RESPONSE TO TREATMENT IS IMPORTANT WITH A SELF-REPORT OR VALID AND RELIABLE SELF-REPORT MEASURE LIKE THE PHQ-9. THAT WAY WE CAN ASSESS RESPONSIVE TREATMENT, ARE PATIENTS BETTER? SO THE CPG RECOMMENDS AFTER SIX WEEKS OF NON-RESPONSE TO TRAIN THE TREATMENT IN SIGNIFICANT SPECIFIC WAYS. WE HAVE A TOOL THAT TELLS YOU HOW TO DO THAT. HERE IS A TRIFOLD FOR PATIENTS SO PATIENTS CAN HAVE THE INFORMATION ABOUT WHAT WORKS, ABOUT WHAT IS DEPRESSION AND WHAT THEY CAN DO ABOUT IT. SO THIS IS A TWO-WAY STREET THAT PATIENTS NEED TO DO SOME THINGS ON THEIR OWN ALSO. THIS WE ATTENDED A WAITING ROOM TYPE PAMPHLET YOU CAN GO AND GET QUICKLY INFORMATION. THE MORE COMPREHENSIVE INFORMATION FOR PATIENTS IS CONTAINED IN THE BOOK THAT LOOKS LIKE THIS. THAT HAS THAT SELF-MANAGEMENT THEY FILL OUT WHAT THEY CAN DO TO MANAGE THEIR DEPRESSION ON THEIR OWN. FINALLY SUBSTANCE USE DISORDER. HOW AM I ON TIME? TEN MORE MINUTES. OKAY. AGAIN, YOU'RE SEEING THIS PROBABLY FOR THE FIRST TIME BECAUSE THIS IS NOT YET PUBLICLY AVAILABLE. THEY'RE CLEAR FOR RELEASE BUT NOT POSTED AND AVAILABLE YET BECAUSE THEY'RE DISTRIBUTED THROUGH THE ARMY MED COM SITE AND HAVEN'T QUITE GOTTEN THEM ON THE WEBSITE YET. SO AGAIN SUBSTANCE USE DISORDER WE HAVE TOOLS THAT PROVIDE FOR -- WE HAVE THE DRAFT STATEMENT SO WE HAVE TOOLS FOR HOW TO MANAGE HOW SUBSTANCE USE AFFECT IT IS FAMILIES, THIS PROVIDES INFORMATION FOR SERVICE MEMBERS AS WELL AS PRACTICAL STEPS THEY CAN TAKE TO MANAGE ON THEIR OWN. AND WE THOUGHT IT'S ALSO IMPORTANT TO RECOGNIZE THAT MEDICATION PLAYS AN IMPORTANT ROLE IN ALCOHOL TREATMENT. SO THERE'S SOME MEDICATIONS THAT ARE BENEFICIAL FOR THAT BUT THAT INFORMATION FOR PATIENTS IS NOT ACCESSIBLE. FOR EXAMPLE, IF YOU HAVE ERECTILE DYSFUNCTION YOU SEE THE PURPLE PILL COMMERCIAL, YOU CAN'T GET AWAY FROM THE PURPLE PILL COMMERCIAL LIKE IF YOU WATCH GNASHAL NEWS, BUT THAT INFORMATION ISN'T OUT THERE READILY AVAILABLE FOR PATIENTS WITH ALCOHOL DEPENDENCE. SO WE THOUGHT AFTER TALKING TO PROVIDERS HERE HEARING WHAT PROVIDERS WANT, HEARING WHAT PATIENTS WANT IN THEIR TOOLS, THEY SAID WE NEED A TOOL THAT PROVIDES PATIENTS WITH WHAT MEDICATIONS ARE SUPPORTED BY THE EVIDENCE. SO WE DID THAT. WE PUT TOGETHER A TOOL THAT HAS THOSE MEDICATIONS THAT ARE SUPPORTED FOR ALCOHOL DEPENDENCE AS WELL AS SOME OTHER TREATMENT MODALITIES. ACROSS ALL THESE TOOLS WE PUT RESOURCES. RESOURCES FOR PATIENTS. RESOURCES FOR PROVIDERS. SO THE PTSD TOOLS THAT I GAVE A LITTLE SPOILER ABOUT, THOSE ARE AVAILABLE SOON. WE'RE FINALIZING SOME OF THE CHANGES THAT MEDICATION STUFF IS ALWAYS A BIT TRICKY. SO GETTING IT THROUGH THE PHARMACY FOLKS GETTING THE INFORMATION CORRECT, AT THE RIGHT LEVEL AND SOMETHING USABLE IS A REAL CHALLENGE SO WE'RE PUTTING THE FINAL TOUCHES ON THAT A AND HOPING TO HAVE THOSE OUT IN -- BY THE END OF THE MONTH AND THEN AFTER THAT THEY'LL BE A PROCESS OF MED COM WEBSITE. ALL THESE TOOLS WE COLLABORATED WITH WHY I'M IN ARMY MED COM, ARMY IS EXPECT T AGENT FOR ALL THE TOOLS AN TOOL DEVELOPMENT, THEY DEVELOP THE TOOLS FOR THE SERVICES. AND POST-IT ON THE SHOPPING CART. IF YOU GOOGLE SEARCH VA DOD CLINICAL PRACTICE GUIDELINE, IT WILL BE ONE OF THE FIRST SITES THAT POP UP, GO TO A SHOPPING CART IF YOU'RE AT MCF AN REQUEST THOSE TOOLS, THEY'LL SHIP IT TO YOU AND BILL THE SERVICES. SO IT DOESN'T COST YOU NOTHING. BY THE WAY, I DONE GET PAID -- I HAVE A JOB BUT DON'T GET PAID EXTRA. I'M TALKING ABOUT THEM BECAUSE I LOVE THEM. WE'RE ALSO REALLY EXCITED ABOUT WHAT'S TO COME. WHAT'S THE NEXT THING. WE KNOW SOME PROVIDERS LIKE THEIR PAPER TOOLS. WE ALSO KNOW THAT A LOT OF PROVIDERS LIKE TO HAVE IT IN THEIR POCKET LIKE THEIR SMART PHONE. SO WE'RE WORKING WITH TELEHEALTH TO DEVELOP THE ELECTRONIC VERSIONS OF THE TOOLS. WE HAVE DONE IT A COUPLE OF TIMES WITH THE POCKET GUIDE W THE CO-OCCURRING DISORDERS, THAT SHOULD BE OUT SHORTLY. WE'RE WORKING ON IT WITH A COUPLE OF OTHERS LIKE THE SUBSTANCE USE SO THAT WILL BE FANTASTIC. WE'RE PLANNING TO DO IT ALSO PTSD TOOL. ALL THESE TOOLS ARE AVAILABLE IN BOTH PAPER AN ELECTRONIC VERSIONS. THERE MAYBE SOME LAG ON WHEN THEY'RE DEVELOPED BUT WE'LL GET THERE. THERE'S THE ORDER INFORMATION, IF YOU'RE VA PROVIDER YOU CAN GO THROUGH THE HEALTH HEALTHQUALITY.VA WEBSITE AND INFORMATION ON HOW TO ORDER THE TOOLS. SO WHAT'S NEXT? WE HAVE BEEN TALKING ABOUT SKIPPING THROUGH AND GIVE YOU THE BOTTOM LINE UP FRONT. WE HAVE BEEN TALKING WHAT TO DO WITH THESE PATIENTS. AND I RECOGNIZE THAT I HAVE BEEN TALKING ABOUT IT SOMEWHAT LIKE IT'S A KNOWLEDGE DEFICIT IF ONLY PROVIDERS DO WHAT THEY'RE SUPPOSED TO DO THEY'LL DO IT. I RECOGNIZE AT THE SAME TIME THERE ARE A NUMBER OF REASONS WHY PROVIDERS AROUND USING THESE TOOLS AND AREN'T FOLLOWING THE CPG TO THE LETTER. IT'S A COMPLEX SYSTEM. THERE ARE BARRIERS ON THE PATIENT AND THE PATIENTS HAVE SOME SAY ABOUT WHAT TREATMENTS THEY WANT. IF THE PATIENT SAYS NO WAY I DON'T WANT THAT PROLONGED EXPOSURE YOU GOT -- YOU HAVE TO WORK WITH THEM ON THAT. THERE'S ALSO SOME BARRIERS THAT ARE IMPORTANT TO KEEP IN MIND. IF YOU HAVE TO HAVE A 90 MINUTE SESSION FOR EVIDENCE BASED PRACTICES AND YOU CAN ONLY DO A 60 MINUTE SESSION IN YOUR CLINIC , THAT IS A SYSTEM BARRIER. THAT IS COMPLEX AND WE RECOGNIZE THAT, WE'RE HOPING TO CHANGE THAT ONE PIECE. I THINK WHAT WE DO ABOUT THESE ISSUES OF PSYCHOLOGICAL HEALTH IS IT CHALLENGE OF OUR HEALTHCARE SYSTEM, IN A TIME WE HAVE SEEN A FUNDING ALLOCATION OVER THE LAST FIVE YEARS DOUBLING WHAT WE AS A MILITARY SYSTEM DO. I SEE THESE FUTURE HOW WE MANAGE THESE PROBLEMS ALSO LIKE NOT TO BE GRANDIOSE BUT PUT A MAN ON THE MOON MOMENT. WHY DO WE DO THAT? EVERYBODY KNOWS A LINE, WHY DO WE PUT A MAN ON THE MOON, WE DO BECAUSE NOT BECAUSE IT'S EASY BUT BECAUSE IT'S HARD. NEXT LINE I THINK IS JUST AS IMPORTANT, THAT BECAUSE THAT GOAL WILL SERVE TO ORGANIZE AND MEASURE THE BEST OF OUR ENERGY AN SKILLS. WHAT WE DO WITH PSYCHOLOGICAL HEALTH, IT'S THE SAME THING HERE. THAT GOAL WILL ORGANIZE OUR SKILLS AS THE BEST IN THE HEALTHCARE SYSTEM. THANK YOU. [APPLAUSE] (OFF MIC) >> THE POINT ABOUT SYSTEM BARRIERS, THERE IT IS. IF YOU HAVE TEN MINUTES HOW AM I SUPPOSED TO INTEGRATE ALL SIX CLINICAL PRACTICE GUIDE LOONS FOR PSYCHOLOGICAL HEALTH IN MY TEN MINUTE SESSION? AND TO YOUR OTHER POINT ABOUT THEM BEING AT THE TABLE, YEAH. SO I THINK WE DIDN'T GO MUCH INTO THE PROCESS HOW WE DEVELOP THE TOOLS BUT WE DEVELOP TOOLS WORKING COLLABORATIVELY WITH THE VA AND DOD PROCESS AND BROUGHT TOGETHER A WORKING GROUP PROVIDERS FROM BOTH DEPARTMENTS THAT INCLUDED SPECIALTY CARE, NURSING, PAs, AND PRIMARY CARE. SO YOU HAVE THE RIGHT GROUP OF FOLKS THAT WORK ON THE CONTENT OF THESE TOOLS. WHAT I DIDN'T MENTION WAS I JUST GOT BACK THIS WEEK FROM A TWO AND A HALF DAY WORKING GROUP TO DEVELOP THE TOOLS FOR OPIOID THERAPY FOR CHRONIC PAIN. THERE'S A LARGE COMPONENT IF YOU LOOK AT THAT CPG FOCUSING ON THE ABERRANT BEHAVIOR, THE ADDICTION COMPONENT OF USING THESE MEDICATIONS AND PRIMARY CARE SETTING. THAT'S AN EXAMPLE HOW WE DO THAT AS A PROCESS. WE HAVE PAIN SPECIALISTS THERE, PRIMARY CARE DOCS, BEHAVIORAL FOLKS THERE LIKE MYSELF, AS WELL AS NURSING AND PAs ABSOLUTELY. HOW DO WE GET AROUND THE CHALLENGE? I DON'T HAVE THE SYSTEM LEVEL SOLUTION TO THAT. I REALLY DON'T. I WISH I DID. A LOT MORE POWERFUL, ONE OF THE TWO, THANK YOU. ANY OTHER QUESTIONS? (OFF MIC) >> THANKS. YEAH, YOU KNOW, I DON'T KNOW. I DON'T HAVE ALL THE ANSWERS, I JUST HAVE THIS ONE ANSWER. I KNOW IT'S ONLY A PARTIAL SOLUTION. IN THE MEANTIME WE'LL KEEP WORKING WITH THE VA AND WITH OUR OTHER AGENCIES LIKE THE DOD, EXECUTIVE AGENT. THE IMPLEMENTATION PIECE, I DIDN'T GET TO THAT ONE, THAT ONE IS TOUGH. WE'RE WORKING ON THAT TOO, WE'RE WORKING ON DEVELOPING TRAINING FOR THAT CAN BE USED READILY AN QUICKLY FOR HOW TO IMPLEMENT THOSE IN YOUR EVERY DAY PRACTICE. WE'RE DOING TALKS LIKE THIS ONE SO YOU GUYS HERE IN THIS AUDIENCE, I FEEL LIKE WE'RE REACHING THE RIGHT PEOPLE, WE'RE GOING TO KEEP BEATING THAT DRUM. THANK YOU. [APPLAUSE] >> GOOD AFTERNOON. I KNOW WE'RE DOWN TOWARDS THE LAST WANING MOMENTS OF THE CONFERENCE AND I SEEM THE MOST STEADFAST MEMBERS OF THE CONFERENCE RIGHT NOW AND APPRECIATE THAT. BUT MY NAME IS COLONEL CHRIS ROBINSON, I WORK AT THE DEFENSE CENTERS OF EXCELLENCE, DEPUTY DIRECTOR FOR PSYCH LOGICAL HEALTH SO WE HAVE DIVIDED DECO TO TWO LANES, TBI LANE AND THE PSYCHOLOGICAL HEALTH LANE SO MY AREA PSYCHOLOGICAL HEALTH FOLKS I WORK WITH CLINICAL STANDARDS OF CARE AND THESE TWO FOLKS HERE ARE WORKING IN THAT DIRECTORATE AND WITH THE PREVENTION FOLKS, THAT'S THE WHOLE CON WUM OF CARE FOR PSYCHOLOGICAL HEALTH. SO I'M GOING TO SHOW YOU SOME SLIDES ABOUT DEPLOYMENT, MENTAL HEALTH, YOU HEARD SOME OF THE MEETINGS, I HEARD PEOPLE REFER TO THIS AS A UNIQUE CHALLENGING VIERP. I WAS THERE AND ABLE TO WITNESS WHAT THAT WAS LIKE FIRSTHAND AND HAVE SOME I THINK PHOTOS THAT YOU MIGHT LIKE TO SHOW YOU, I WOULD LIKE TO SHOW YOU AND TALK AB SOME OF THE WAYS THAT WE'RE TRYING TO DO THIS WORK IN THAT PARTICULAR ENVIRONMENT. BECAUSE IT IS -- DR. RIGGS WAS UP HERE A WHILE AGO TALKED ABOUT SEEING PATIENTS IN A DITCH. I NEVER DID THAT. BUT I SEE SOME PEOPLE IN PRETTY AUSTERE CIRCUMSTANCES. JUST BEFORE WE GET STARTED, IN TERMS OF DICO I WANT TO SAY THAT DECO IS AN INTERESTING BODY. WE DONE SEE PATIENTS AT DECO, WE DONE DO RESEARCH, WE DON'T FUND RESEARCH. THE QUESTION IS WHAT DO YOU GUYS DO, WHAT GOOD ARE YOU GUYS. A LOT OF WHAT DR. ROBERTS WITH TALKING ABOUT, WE'RE THE FOLKS CREATING KNOWLEDGE BASE PRODUCTS TO TRY TO HELP SERVICE MEMBERS BY INTERVENING WITH THE PROVIDERS. TRYING TO GIVE THE PROVIDERS THE TOOLS THEY NEED AND THEN ALSO TRYING TO GIVE THEM THIS CHANGE WE TALK ABOUT IN TERMS OF HOW DO I NOT ONLY USE THESE OR GET THESE TOOLS BUT ALSO USE THEM. SO ISLE TALK ABOUT HOW TO DO THAT IN AN EMPLOYED ENVIRONMENT. SO NOW BACK TO THE TOPIC AT HAND, JUST THIS NOTION OF WHAT IS THE IMPACT OF COMBAT ON HUMAN BEINGS. THE JURY IS NO LONGER OUT ON THIS, WE ARE CERTAIN IT'S NOT ALWAYS A HEALTHY THING. THIS IS A PICTURE FROM VIETNAM, I LIKE THIS PICTURE AND THIS QUOTE, ABLE TO CAPTURE THE SUSTAINABLE EFFECT ON HUMAN BEINGS OR REALITY THAT EVERY WAR TRAVELS HOME WITH THE SOLDIERS WHO FIGHT IT. IT IS A -- YOU SEE IN THE MEDIA SOMETIMES THAT IF YOU DEPLOY YOU COME BACK WITH PTSD. THAT IS NOT TRUE. CATEGORICALLY NOT TRUE. HOWEVER, YOU WILL COME BACK A DIFFERENT PERSON NO MATTER WHAT BECAUSE OF WHAT YOU SEE AND WHAT YOU EXPERIENCE. THERE ARE AS DR. ROBERTS WAS TALKING ABOUT, THERE ARE A CERTAIN PERCENTAGE OF THOSE FOLK WHOSE DO COME BACK WITH DIAGNOSEABLE PTSD.U I THINK IT'S IMPORTANT TO LOOK AT THIS IN CONTEXT, STARTING FAR RIGHT, WHERE IT SAYS 2007 AND BEYOND, THAT'S WHEN DECO STARTED. THIS PROBLEM DIDN'T START IN 2007. THAT'S JUST WHEN A LOT OF PEOPLE STARTED PUTTING A LOT OF EMPHASIS AN RESOURCES TOWARDS THIS PARTICULAR PROBLEM. LET'S BACK IT UP A ALL THE WAY UP TO THE SIL WAR. WE CAN PROBABLY GO TO ANY AND FINE THESE SAME THINGS, IN 1871 THIS IS TWO DISORDERS YOU SEE RAILWAY IS FINE AND DECOSTOS SYNDROME, BOTH IF YOU WERE TO GOOGLE THOSE OR GO TO WIKIPEDIA TO GET MORE INFORMATION BUT BASICALLY WHAT THEY WERE DOING WERE FINDING THAT PEOPLE IN THE CIVIL WAR HAD THESE PROBLEMS AND WERE SUFFERING AND THEY WEREN'T ABLE TO IDENTIFY A MEDICAL REASON WHY. AT THAT TIME THEY THOUGHT THERE WAS SOME MEDICAL REASON. YOU HAD TO HAVE SOMETHING MEDICALLY WRONG WITH YOU. BOTH OF THESE WERE EXAMPLES OF SYNDROMES THAT PEOPLE WERE DIAGNOSED WITH THAT DIDN'T HAVE ANYTHING MEDICAL GOING ON BUT WHAT I PROBABLY WOULD ARGUE NOW, THIS IS -- THESE WERE PROBABLY EXAMPLES OF EITHER TRAUMATIC BRAIN INJURY OR PSYCHOLOGICAL HEALTH, PTSD PROBLEMS SO THEN YOU MOVE FROM THAT OVER FURTHER TOWARD WORLD WAR I AND TO WORLD WAR II YOU SEE DIFFERENCE NAMES, SHELL SHOCK, POST CONCUSSION SYNDROME, COMBAT FATIGUE, GROSS STRESS REACTION, POST VIETNAM SYNDROME. THE DIAGNOSIS OF PTSD WASN'T EVEN ESTABLISHED UNTIL 1982. THAT DOESN'T MEAN PTSD WAS DISCOVERED IN 1982, THAT'S WHEN WE STARRED IDENTIFYING IT AND SAYING HERE IS THE SYMPTOMS THAT YOU HAVE SEEN MULTIPLE TIMES IN THIS CONFERENCE. AND THEN SO NOW THEN IN 2007 WE HAVE ALL THE SERVICES AND HEALTH IN A LOT OF PEOPLE, REALLY RENEWED INTEREST ON THIS WHERE I THINK WE KNOW PTSD AND PSYCHOLOGICAL HEALTH PROBLEMS BETTER THAN WE EVER HAVE BEFORE. JUST TO EMPHASIZE THAT POINT ABOUT HOW OR DOES COMBAT OR BEING DEPLOYED HAVE AN IMPACT ON US, I JUST WANT TO SHOW YOU SOME DATA FROM THE ARMED FORCES HEALTH SURVEILLANCE CENTER, AND WHAT THESE ARE ARE PTSD CASES IN EACH COLUMN, THE MIDDLE -- THE MIDDLE COLUMN, INCIDENT CASES NOT DEPLOYED YOU SEE THOSE NUMBERS. AND THEN VERSUS THE INCIDENT CASES OF THOSE THAT WERE DEPLOYED. THE NUMBERS THEMSELVES AREN'T AS IMPORTANT AS JUST TO ME LOOKING AT THAT YELLOW BAR AT THE BOTTOM HOW DIFFERENT THOSE TWO ARE. I WANT TO EMPHASIZE THAT POINT, THERE'S A LEVEL OF PTSD IN OUR POPULATION LIKE THERE IS IN ANY POPULATION. WHO HAVE PTSD WITHOUT BEING DEPLOYED. SO WHEN YOU TALK TO OUR TRAUMATIC BRAIN INJURY FOLKS THEY'LL POINT THAT OUT A LOT, THERE'S A LEVEL OF T BIRKS WITHOUT PEOPLE GOING TO WORK, SAME THING WITH PTSD AND THESE OTHER PSYCHOLOGICAL HEALTH THINGS. ALSO AT IS BOTTOM WHEN YOU SEE TALKS IN 2011, THAT NUMBER DOESN'T MEAN IT'S GONE DOWN, WE JUST DID HAVE THE DATA YET FOR 2011 SO THAT'S WHY THAT NUMBER IS DOWN LALE BIT. THIS SLIDE YOU SAW THIS A MINUTE AGO SO I -- THE ONLY POINT I WANT TO MAKE ON THIS SLIDE IS THIS LOWER LEFT QUADRANT WHERE IT TALKS ABOUT STIGMA. I ALSO HAVE A -- I SEE PATIENTS ONE DAY A WEEK AT ANDREWS, THIS INCIDENT OF STIGMA, EVERY TIME I SEE SOMEBODY I'M AMAZED HOW HAR IT IS FOR SERVICE MEMBERS TO COME IN AND SEEK CARE AS MUCH AS WE TRY TO PUT THIS OUT THERE IT'S NOT GOING TO END YOUR CAREER. I SAW SOMEBODY A COUPLE OF WEEKS AGO A YOUNG LADY IN THE PENTAGON, WHEN THE PLANE HIT THE PENTAGON IN 2001 AND DESCRIBED CLASSIC SYMPTOMS OF PTSD SHE HAS BEEN HIDING AND SITTING ON FOR TEN YEARS JUST NOW STARTED TO JUST NOW CAME TO THE CLINIC. TEN YEARS, A LOT OF SUFFERING ON HER PART. LARGELY BECAUSE SHE WAS CONVINCED THAT IF I COME IN MY CAREER IS GOING TO BE OVER. SO THIS ISSUE OF STIGMA IS VERY REAL. AND SOMETHING THAT WE'RE REALLY WORKING HARD TO TRY TO ADDRESS ACROSS THE SYSTEM. THE POINT OF THIS SLIDE, DR. ROBERTS TALKED A LITTLE BIT BUT ACTUALLY IF YOU LOOK AT THAT TIME OVERALL PREVALENCE THERE'S HIGHER PREVALENCE OF DEPRESSION IN PTSD AND WE KNOW THEY OVERLAP. WE HAVE HEARD THAT MANY TIMES THOSE TWO, THOSE ARE THE TWO DIAGNOSES FOCUSING ON, PTSD AND DEPRESSION. SO PSYCHOLOGICAL HEALTH OVERVIEW. MILITARY PSYCHOLOGICAL HEALTH IS DIFFERENCE THAN MORE TRADITIONAL GO DOWNTOWN AND GET MENTAL HEALTHCARE. THAT'S BECAUSE THERE'S A LOT OF THINGS INVOLVED WITH MILITARY PSYCHOLOGICAL HEALTH. YOU HAVE -- YOU HAVE A PERSON SITTING THERE IN FRONT OF YOU WHO ALSO HAS A JOB SOMETIMES A DANGEROUS JOB, SOMETIMES A JOB THAT INVOLVES A NEED FOR A LOT OF FOCUS AND PAYING ATTENTION TO THINGS. SO YOU HAVE TO MAKE SURE YOU'RE TAKING CARE OF THAT PERSON IN FRONT OF YOU BUT ALSO THINKING HOW DOES THIS AFFECT THIS PERSON IN TERMS OF READINESS AND ABILITY TO DO THEIR WORK. LAST THING IS WE HAVE TO HAVE SOMEBODY GET HURT OR HURT SOMEBODY ELSE BECAUSE OF THESE THINGS GOING ON. SO IT'S A COMMAND ISSUE MEANING WE DO INTERACT WITH THE COMMAND AND LEADERSHIP. WE DO THAT VERY DISCREETLY MEANING I DONE GO TO THE COMMANDER AND SAY EVERY DETAIL THE PERSON MIGHT HAVE TALKED TO ME ABOUT BUT I WILL SHARE IF I HAVE A CONCERN MAYBE THIS PERSON SHOULDN'T BE FLYING A HELICOPTER IN AFGHANISTAN. MAYBE WE SHOULD PULL THEM BACK FOR A WHILE AND HAVE CARE AN TREATMENT. IT'S ALSO A READINESS ISSUE, A IMMUNITY ISSUE AND MEDICAL ISSUE. THERE WAS ONE EARLIER THEY TALKED ABOUT THE LEADERSHIP, THE LINE LEADER SHI. THAT IS VERY IMPORTANT, NOT JUST A MEDICAL PROBLEM IS THE POINT. IT INVOLVES ALL SORTS OF FOLKS. I MADE THE POINT ABOUT EXPOSURE TO COMBAT INCREASE IT IS RISK FOR MENTAL HEALTH CONDITIONS AN DR. ROBERT WAS TALKING ABOUT THAT TOO, THIS WHOLE IDEA OF BOY THIS POPULATION IS NOT RESPONDING TO THE THE TREATMENT WILL NOT WORK AS WELL AS WE THOUGHT THEY WOULD. TALKING ABOUT THE TRAINING, WE ACTUALLY PRACTICE OVERTRAINENING THE MILITARY. YOU LEARN TO CLONE YOUR WEAPON AT NIGHT. YOU DON'T LEARN TO DO EVERYTHING TO THE POINT WHERE IT'S WROTE. SO OFTENTIMES WHAT I FOUND IN THE DEPLOYED ENVIRONMENT IS I WOULD HAVE SOMEBODY WHO HAD -- WAS COMING TO SEE ME BUT YOU GO TO THE COMMANDER AND SAY THEY CAN'T BE HAVING STRESS, THEY'RE DOING FINE ON THEIR MISSIONS NO PROBLEMS. I HAVE TO SAY THAT'S DUE TO THE GOOD TRAINING YOU GUY VERSUS PROVIDED. THEY ARE STILL HAVING SYMPTOMS AND HERE IS WHAT THEY ARE. HERE IS WHAT I'M CONCERNED ABOUT. SO IT'S A DIFFERENT KIND OF POPULATION WE'RE JUST NOW TEASING OUT. THE LENGTH AND NUMBER OF DEPLOYMENTS HEAVILY INFLUENCE THE ONSET OF PSYCHOLOGICAL HEALTH CONDITIONS. WE RECENTLY DISCOVERED, RECENTLY SEEN THE DWELL TIMES BECOMING VERY,VERY IMPORTANT. THIS HE'S TIME IN BETWEEN DEPLOYMENTS. TALK TO ANYBODY DOING THIS WORK, THE LONG TEAR DWELL TIME, THE LONGER TIME BETWEEN DEPLOYMENTS, THE BETTER FOR EVERYONE, MEMBERS OF THE FAMILY, ET CETERA. HOWEVER SOME INFORMATION AND DATA RECENTLY CAME OUT FROM THE ARMED FORCES HEALTH SURVEILLANCE CENTER ABOUT THE -- INCREASE IN DIAGNOSING MENTAL HEALTH PROBLEMS FOR THE PEOPLE THAT WERE ON DURING THE LONGER DWELL TIME T. LONG TEAR DWELL TIME THE NOR MORE DIAGNOSES. THAT WAS COUNTER INTUITIVE BECAUSE PEOPLE THOUGHT THAT MEANT MAYBE THESE DWELL TIMES ARE WORSE FOR PEOPLE. ACTUALLY TO ME, MY UNDERSTANDING OF IT, MY BELIEF IS THESE -- THE LONGER THE TIME THEY COME BACK AND ABLE TO GET BACK IN THEIR ENVIRONMENT AND GET WITH THEIR FAMILY, THE MORE THEY'RE LIKELY TO THEN SAY I NEED TO GO GET HELP. SO I CAN SEE THIS AS A GOOD SIGN. MORE PEOPLE ARE SEEKING THE CARE THEY NEED. WHEREAS IF YOU COME BACK AND YOU KNOW YOU GOT TO TURN AROUND AND GO RIGHT BACK IN A FEW MONTHS YOU MAY SAY I GOT TO KEEP IT TOGETHER AND NOT TELL ANYBODY AND THEN I'LL BE OKAY. WE ALREADY TALKED ABOUT SOCIAL ISSUES AN DIVORCE RATES ALSO INCREASING SO WE KNOW THAT'S A CONCERN AS WELL. SO NOW I WANT TO TALK ABOUT COMBAT STRESS CONTROL IN A DEPLOYED ENVIRONMENT. THE 2005 MILITARY HEALTH ASSESSMENT TEAM THAT CAME BACK IN 2005 OR THEIR REPORT PUBLISHED IN 2005, ONE THING THEY STARTED EMPHASIZING IS WE NEED TO SEND PROVIDERS OUT TO THE DEPLOYED ENVIRONMENT. WE NEED TO SEND MORE PEOPLE OUT SO THAT'S WHEN THIS STARTED HAPPENING. I DIDN'T KNOW THIS AT THE TIME BUT THE MEDICAL PEOPLE THE MENTAL HEALTH PEOPLE ARE DEPLOYED FURTHEST FORWARD AND WE'RE TRAINED TO DO MISSION AND ALL SORTS OF THINGS BECAUSE WE'RE GOING OUT TO THE FURTHER OUTPOST. SO IT IS EXCITING TO SEE THIS HAPPEN. WHEN I SAY SOME OF THE NOT IN A SPIRITUAL WAY BUT THEIR MODEL AS YOU ATTACH CHAPLAINS TO THE UNITS, THAT'S WHAT WE'RE TRYING TO DO NOW TOO IS DEPLOY MENTAL HEALTH FOLKS WITH THE UNITS. THE FOCUS IS ON KEEPING SERVICE MEMBERS IN THE FIGHT. SOMETIMES I WORRY ABOUT THAT BULLET, OH JUST COVER IT UP AND GIVE MEDICATIONS AN SEN HIM BACK UP THERE. THAT'S NOT THE CASE. IF SOMEONE IS SO IMPAIRED THEY NEED TO COME BACK, WE WILL MAKE THAT ARRANGEMENT AND GET THEM OUT OF THE THEATER. AND WE DID THAT A LOOT. WE ALSO KNOW TREATMENTS AND THINGS WE CAN DO IN THEATER TO HELP THESE PEOPLE TO KEEP THEM THERE WITH THEIR BUDDIES AND DOING THE MISSION AND THING THEY WANT TO DO. WE LEARNED IN PREVIOUS WARS LIKE VIETNAM AND SENDING PEOPLE BACK OR LABELING THEM AS SICK AND SAY YOU NEED TO GO BACK TO THE STATES IS NOT HELPFUL PSYCHOLOGICALLY AND LONG TERM SO SOMETIMES KEEPING THOSE FOLKS THERE, EVEN THOUGH THEY'RE HAVING TO STRESS AND HAVING PROBLEMS. WE PROVIDE TO -- WE PROVIDE OUTREACH TO COMBAT PLATOONS AT HIGHEST LEVEL OF COMBAT. WE KNOW THAT THE MORE COMBAT YOU HAVE THE MORE LIKELY YOU TO HAVE THESE PROBLEMS OR AT LEAST MEMBERS OF YOUR PLATOON WILL. ALL PROVIDER WERE AND TECHNICIANS WERE QUALIFIED TO TRAVEL THROUGHOUT THE THEATER. SO THERE'S TWO DIAGNOSES, AND REASON THIS IS IMPORTANT IS BECAUSE ON THE BOTTOM WHERE IT SAY BEHAVIORAL HEALTH DIAGNOSES, THOSE ARE TRADITIONAL HEALTH DIAGNOSES THAT YOU THINK AB. WHEN WE STARTED DEPLOYING THESE PEOPLE OUT IN PLACES PEOPLE STARTED SAYING YOU'RE GOING TO GO AND SEE PEOPLE IN A VERY HIGH STRESS HIGH IMPACT ENVIRONMENT AND DIAGNOSING WITH THEM WHAT THESE DIAGNOSES AND HURT THEIR CAREERS. MAYBE NORMAL REACTIONS TO STRESS THAT YOU MIGHT SEE IF ANY OF US WERE INVOLVED WITH SUSTAINED BAD THINGS OR SUSTAINED STRESS, MAYBE THEY'RE JUST -- THESE REACTOR -- REACTIONS ARE NORMAL. THAT'S WHEN WE SAY YOU'RE RIGHT. WE NEED TO DEVELOP A SYSTEM WHERE WE HAVE DIAGNOSE KNOW SOAS THAT CAN CAPTURE THAT CONCEPT. THAT'S WHAT THE FIRST ONE IS, A COMBAT, OPERATIONAL STRESS REACTION IS CONSIDERED A NORMAL REACTION TO ADVERSE EVENT LIKE COMBAT SO YOU MAY HAVE THINGS LIKE PTSD OR SYMPTOMS OF PTSD OR ACUTE STRESS DISORDER BUT THEY'RE NOT DOCUMENTED THE SAME WAY. AND LAST THING WE WANT TO DO IS IN HELPING PEOPLE WE DON'T WANT TO HURT THEIR CAREER AS WELL. SO WE'RE TRYING TO THEN TEEDZ OUT THE DIFFERENCE BETWEEN THESE TWO AND THE WAY I USED TO DO IT IS BEHAVIORAL HEALTH DIAGNOSIS, SOMEONE SAYS I HAVE BEEN IN THEATER THREE MONTHS AND BEEN DEPRESSED TEN YEARS, I THINK THAT PERSON PROBABLY CAME HERE AND MAYBE THEY MADE IT THROUGH THE SCREENING SYSTEM BY MINIMIZING SOME OF THOSE SYMPTOMS SO I'M GOING TO GIVE THEM A BEHAVIORAL HEALTH DIAGNOSIS BECAUSE THEY HAVE HAD THIS, INSTEAD OF JUST RELATED, I MAY HAVE EXACERBATED IT BECAUSE OF WHAT'S GOING ON BUT IT WASN'T CAUSED BY VERSUS A PERSON THAT SAYS HEY, I WAS FINE, I CAME HERE, I SAW THIS AND THAT AND NOW I HAVE THESE SYMPTOMS. THAT'S MORE A COMBAT OPERATIONAL STRESS REACTION. SO THE MISSION THAT WE HAD COMBAT STRESS CONTROL FAR FORWARD PREVENTIVE SERVICES, COMBINE JOINT OPERATIONS AREA, HEIGHTENED THE RETURN TO DUTY RATES SO THAT'S WHAT WE ARE TRYING TO DO THROUGH EDUCATION AN COMMAND SUPPORT, EDUCATION WE GO TO THESE FAR OUTPOSTS AND HAVE CLASSES ON RELAXATION TRAINING OR SLEEP HYGIENE, COMMAND SUPPORT I WOULD INTERVENE WITH LEADERS. LEADERS IN THE ARMY ARE FAIRLY YOUNG FROM MY PERSPECTIVE NOW. SO THESE COMPANY GRADE OFFICER LEADING THESE YOUNG MEN AND WOMEN MAY NOT HAVE HAD EXPERIENCE DOING THIS. TRY TO BE MORE EFFECTIVE LEADERS AS WELL AS UNDERSTAND THINGS GOING ON WITH THEIR MEMBERS. WE HAVE CLINICAL CARE SO SOMETIMES I'LL CLOSE MY DOOR, DOING PROLONG EXPOSURE OR COGNITIVE PROCESSING THERAPY OR EMDR FOR SOME PEOPLE. SO WE DID THAT AS WELL AS WORKING WITH THE FOLKS WHO WERE HAVING SOME PROBLEMS RELATED TO THE ENVIRONMENT AND HOW THEY CAN BETTER COPE WITH THAT. SO I THINK SOME OF THESE, THE FIRST TWO I MENTIONED, SO WE ALSO INVOLVE OR I WAS INVOLVED WITH WORKING WITH TRAUMATIC BRAIN INJURY FOLKS. I WANT TO EMPHASIZE TRAUMATIC BRAIN INJURY IS NOT A PSYCHOLOGICAL HEALTH DISORDER. WE WERE OUT THERE AND THESE FAR FORWARD PLACES AND I WILL TAKE MACES WITH ME AND HELP -- MOST EVERYBODY THAT I SAW THE PROVIDERS NEW ABOUT IT AND WERE ALREADY DOING IT BUT SOME DIDN'T SO WE WOULD HELP THEM MAKE BETTER DIAGNOSES. WORK WITH COMMAND, TRAUMATIC EVENT MANAGEMENT IS THE IDEA OF WHAT DO YOU DO IF SOMETHING REALLY BAD HAPPENED? HOW DO YOU INTERVENE WITH THAT PARTICULAR UNIT? WAITING UNTIL THEY COME IN TO YOUR CLINIC AS INDIVIDUALS WHY NOT DO SOMETHING TO HELP WITH THEIR UNIT. SO WE WILL BE INVOLVED WITH THOSE INTERVENTIONS AFTER A BAD THING HAPPENED. OUTREACH AND PREVENTION. BRIEFING AN CLASSES AS WELL. SO HERE YOU CAN GET AN IDEA OF WHAT IT LOOKS LIKE. SO THAT IS A BLESSING WHICH SOMEWHERE I WAS ON THE NORTHEAST PART OF AFGHANISTAN THIS IS ALMOST CHRISTMAS TWO YEARS AGO. SO YOU WONDER BOY, EVERYBODY THINKS AFGHANISTAN IS COLD. THIS REALLY WASN'T. THIS PROBABLY WAS UP TO LIKE 65 OR 70. PRETTY COUNTRY ACTUALLY. THAT'S NOT ANY -- RIGHT OFF BASE ALL THE LOCALS LIVE -- THAT'S NOT BOMBING OR ANYTHING LIKE THAT. IF YOU CAN SEE ONE OUTPOST AROUND THIS FOB OR MOUNTAIN AND AROUND THE -- ON THE TOP OF THOSE RIDGES WERE OUTPOSTS WHERE SOME GUYS WERE TOO. SO TALK ABOUT A TREK, I WOULD GO WITH ALL THE ESCORTS I WOULD NEVER DO THIS ALONE. BUT THEY WOULD GO UP THERE FOR SOME OTHER MISSION AND I TAG ALONG AND WE GO AN CLIMB UP THESE MOUNTAINS WITH THESE GUYS. SOME WERE DOING GREAT, SOME HAVING DIFFERENT PROBLEMS SO REALLY THOSE ARE THE AUSTERE CONDITIONS I WAS TALKING ABOUT. THAT'S THE NEXT DAY, A LITTLE HIGHER LOOKING DOWN AND YOU CAN SEE I DON'T KNOW IF YOU CAN TELL WHERE THE GREEN IS ON THE FAR, WHERE THE LOCALS LIVED. WHERE YOU SEE THE MILITARY TYPE STUFF, THE FOB. SO WHERE DID YOU LIVE AND DO PATIENT CARE? THAT'S A GREAT QUESTION. I WAS IN THE TOP THAT WAS A MENTAL HEALTH CLINIC, COMBAT STRESS CLINIC. EXCUSE ME. SO THIS IS IS SECOND PLACE, THE FIRST PLACE I DON'T HAVE A PICTURE OF BUT THIS IS ACTUALLY BETTER I LIVED ON THE LEFT-HAND SIDE AT THE TOP AND THEN I SAW HAD A CLINIC DESK ON THE OTHER SIDE AND BUT IT WAS MUCH MORE PRIVATE THAN THE FIRST PLACE I HAD. I'LL TALK ABOUT THAT IN A LITTLE BIT. SO WHAT ARE SOME COMMON PROBLEMS THAT WE SAW? WE CERTAINLY SAW PTSD EMERGING PTSD WHICH WE WERE TRYING TO INTERVENE BEFORE IT BECAME CHRONIC PTSD. WE SAW THAT A LOT. YOUNG PEOPLE WHO WITNESSED VERY BAD THINGS COMING TO SEE ME AND TALKING ABOUT NIGHTMARES AND I CAN'T FOCUS AND I VERY JUDGE PI AND STARTLE YOU, AND WE GIVE THEM THE SCREENS AND TURNED OUTLOOKS LIKE THEY WERE DEVELOPING PTSD SO WE CERTAINLY WORK WITH THOSE FOLKS, SAW DEPRESSION AND ANXIETY DISORDERS AS WELL. SUICIDAL AND HOMICIDAL IDEATIONS. WE SAW THAT, WE PROBABLY SAW MORE PEOPLE REPORTING HOMICIDAL IDEATION THAN EVER BEFORE, BECAUSE YOU'RE OUT THERE, AWAY, THERE'S A LOT OF STRESS, FROM BEING INVOLVED WITH COMBAT AS WELL AS JUST BEING WITH THE GROUP OF PEOPLE THAT YOU SEE EVERY DAY SEVEN DAY AS WEEK, 24/7. THE OTHER WRINKLE IS EVERYBODY HAS A WEAPON. IF YOU DONE HAVE A WEAPON, -- DON'T HAVE A WEAPON YOU CAN GET ONE EASILY. IN FACT, YOU ARE AN OUTLIER IF YOU'RE NOT WALKING WITH YOUR WEAPON, PEOPLE WILL IMMEDIATELY SAY HEY, WHY AREN'T YOU WEARING -- CARRYING YOUR WEB? SO OFTEN THE INTERVENTION WAS SOME OF THESE FOLKS, IF WE FELL LIKE WE CAN MANAGE IN THEATER PULL THEIR FIRING PIN AND SOME OF THOSE FOLKS, THAT'S A NIFTY WAY TO DO IT, THEY STILL HAVE THEIR WEB THAT WAY, NO ONE IS ASKING, NOT A FUNCTIONAL WEAPON, LEADERSHIP KNOWS WE HAVE DONE THAT, BUT THEY DON'T WALK AROUND WITHOUT A WEAPON WHICH ISN'T A STIGMA THING ON A FOB SO THEY HAVE THEIR WEB. ONE YOUNG MAN HAVING A HARD TIME WITH HIS SUPERVISOR, SUPERVISOR WAS KIND OF A ROUGH GUY, PROBABLY 20 YEARS OLDER THAN THIS YOUNG MAN THIS YOUNG KID HAD IT ONE DAY AND HE TURNED AROUND WITH HIS WEAPON AND AIMED IT AT THE SUPERVISOR AND IMMEDIATELY PUT IT DOWN LIKE I CAN BELIEVE I DID THAT. ADS YOU CAN IMAGINE THAT'S A BIG DEAL TO THINK ABOUT DOING THAT. MUCH LESS TO LIFT UP YOUR WEAPON AND DO IT. THAT'S THE EXAMPLE OF SOME OF THE THINGS, THIS KID NEVER DID ANYTHING AIRKS SIEWM BY THE TIME I LEFT HE WAS FINE, AN IMPULSIVE THING. THAT'S SOME OF THE THINGS THAT MIGHT HAPPEN THERE. MARITAL AND FAMILY PROBLEMS, HOW CAN YOU HAVE MARITAL AND FAMILY PROBLEMS? YOU ARE IN A DEPLOYED ENVIRONMENT? EVERYBODY IS SO CONNECTED PEOPLE HAVE SATELLITE PHONES AND SKYPE AND SO YOU GO WHERE EVERYBODY CAN CALL HOME AND PEOPLE WOULD BE ARGUING WITH THEIR SPOUSES ON PHONE, SOME TO THE POINT WHERE YOU WOULD WANT TO PULL THEM OUTSIDE AND SAY DUDE, COME ON, YOU'RE YELLING ON THE PHONE. TOGETHER IN THE THEATER AT THE SAME TIME AND WERE HAVING SOME FAIRLY SIGNIFICANT MARITAL PROBLEMS SO I ACTUALLY DID MARITAL COUNSELING WITH A COUPLE WHICH YOU DON'T SEE THAT OFTEN IN A DEPLOYED ENVIRONMENT. SO YOU DEFINITELY SEE THOSE THINGS. SLEEP PROBLEMS ARE RAMPANT. IF WE CAN DO ANY ONE THING TO HELP OUR DEPLOYED MEMBER, TO HELP THEM GET BETTER SLEEP. THAT'S A VARIETY OF REASONS FOR THAT, SOME WHICH ARE RELATED TO THINGS LIKE CAFFEINE AND THE RIPPETTS THEY DRINK AND STIMULANTS, TOBACCO USE, YOU SEE PEOPLE SAY I NEVER SMOKE UNLESS I'M DEPLOYED. WELL THAT'S PROBABLY NOT A GOOD IDEA IN TERMS OF SLEEP. IT MAY HELP YOU COPE WITH SOME OF THE THINGS YOU'RE DEALING WITH, BUT SO SLEEP PROBLEMS, I THINK ALSO THE DEVICES EVERYONE HAS, THERE'S SUPPOSED TO BE -- IN THEIR RAC ASLEEP BUT THAW EAR ON SKYPE WITH THEIR SPOUSES BECAUSE OF THE 12 HOUR DIFFERENCE, IT'S DAYTIME AT HOME SO NOT GETTING A LOT OF GOOD SLEEP. ADJUSTMENT DISORDERS WHICH BASICALLY MEANS DIFFICULTIES COPING. AND I ALREADY MENTIONED THE LAST. SO WHAT KIND OF VOLUME ARE WE SEEING OVER THERE? THIS IS THE ONE FOB I SHOWED YOU A PICTURE OF WAS A FOB OF THE 11 THAT WE HAD. WE HAD 11 FOBS THAT'S JUST THE EASTERN PART OF AFGHANISTAN SO 11 TOTAL FOBS THAT HAD MENTAL HEALTH PROVIDERS AN TECHNICIANS THERE. SO THIS SHOWS YOU SOME OF THE VOLUME AND THOSE, AGAIN THOSE COMBAT OPERATIONAL STRESS REACTIONS ARE THE LIGHT BLUE, THE BEHAVIORAL HEALTH DIAGNOSES, DARK BLUE AND FEBRUARY 2010 DOESN'T MEAN IT WENT DOWN, JUST THAT I DIDN'T GET THE FULL MONTH COUNTING THAT MONTH. SO THAT SHOWS YOU THE VOLUME SO THESE -- THERE WAS PROBABLY 32 PROVIDERS, 11 FOBS, 32 PEOPLE SAYING THAT MANY PEOPLE SO WE WERE QUITE BUSY. WHAT KIND OF THINGS WERE YOU SEEING IS THE NEXT QUESTION? THE WAY TO LOOK AT THIS, THAT TOP LEFT -- RIGHT CORNER, 27% LIGHT BLUE, COMBAT EXPOSURE OUR BIGGEST BLOCK THERE SO THE BIGGEST STRESSOR WAS COMBAT THERE. NON-COMBAT PT STANDS FOR POTENTIAL TRAUMATIZING EVENT, THAT MEANS SOMETHING DIFFICULT FOR THAT PERSON TO DEAL WITH, IT WASN'T NECESSARILY RELATED TO COMBAT BUT DIFFICULT FOR EXAMPLE, WE -- YOU'D BE ON SYSTEM OF THESE FOBS AND THERE WOULD BE FIGHTS FOR EXAMPLE OR SOME OTHER BAD THING THAT WASN'T RELATED TO COMBAT. PEER AND UNIT PROBLEMIOUS HAD PEOPLE HAD TROUBLE GET AGO LONG WITH EACH OTHER, AS YOU CAN IMAGINE WITH ANY GROUP OF PEOPLE THAT ARE TOGETHER THAT MUCH. LEADERSHIP PROBLEMS, HOME FRONT ISSUES WAS THE NEXT BIGGEST BLOCK OF PEOPLE THAT WE SAW. ALL THE WAY DOWN THE MISSION AND ET CETERA. SO THESE -- THIS IS THE PIE BROKEN DOWN BEHAVIORAL HEALTH DIAGNOSES, THE BIGGEST ONE YOU SEE THERE, THE PRIOR ACCESS ONE AND FOR THE NON-MENTAL HEALTH FOLKS THAT MEANS CLINICAL DISORDERS LIKE DEPRESSION OR PTSD OR AING SHIETY DISORDER THAT MEANS THEY SHOWED UP WITH SOMETHING. HOW DID THAT HAPPEN? YOU DEPLOY YOUR BEST IS WHAT THEY SAY, RIGHT? SOMETIMES PEOPLE THAT GOT THROUGH YOU JUST SCRATCH YOUR HEAD WONDERING, CERTAINLY NOT ALL THE CASES BUT SOME REALLY WERE NOT BEING FORTHCOMING ON THOSE SCREENING INSTRUMENTS. ALL WE CAN TAKE AS FAR AS DEFENDING THE SCREENING PROCESS, ALL WE CAN DO IS GO WITH WHAT PEOPLE TELL US, YOU CAN TELL THEM ALL SORTS OF THINGS SO THEY GOT THROUGH AND UNFORTUNATELY DEPRESSION GOT WORSE OR WHATEVER IT WAS. THEN YOU SEE SOME OF THOSE OTHER THINGS THE NEXT BIGGEST CHUNK IS THE DEPRESSION AS I WAS MENTIONING, PTSD, THESE RATES ARE PRETTY CONSISTENT WITH SOME OF THE NUMBERS WE'RE SEEING NOW AS WELL. ON THE SYSTEM WIDE. ALL THOSE PEOPLE YOU SAW THOSE PIE CHARTS WHAT DID DWOA? LOOK AT 92% WERE RETURN TO DUTY WITHOUT LIMITATION. THAT MEANS THEY WERE SENT BACK, WE DIDN'T TAKE THE WEAPON AWAY, WE DIDN'T DO ANYTHING BESIDES PROVIDE THEM WITH SOME SORT OF INTERVENTION, MEDICATION, PSYCHOTHERAPY, SOMETHING. WE FELT LIKE THEY WERE GOOD ENOUGH TO GO SEND THEM RIGHT BECOME TO THEIR JOB, 92%. THE NEXT BLOCK HAD WITH LIMITATION, THAT MEANS WE TOOK THEIR FIRING PIN AWAY FOR A REASON OR WE SAID WE NEED YOU TO NOT GO OUT ON A MISSION FOR THE NEXT WEEK AND WE'RE GOING TO SPEND TIME WITH YOU OUT HERE AND WORKING ON SOME OF THESE THINGS. THE NEXT BLOCK, THE DARK BLUE IS REST WITH UNIT. THEN EVEN THOUGH IT SAYS 0%, 113 IS NOT ZERO SO 113 PEOPLE WERE REFERRED FOR HIGHER CARE WHICH MEANT -- MEANS THAT IF WE'RE AT A FOB WE MAY REFER THEM BACK TO BOTTOM WHICH IS WHERE THE BIGGER HOSPITAL WAS WHERE THEY HAD MORE RESOURCES. AND THEN ONLY 1% WERE EVACUATED OUT OF THEATER SO 246 PEOPLE WERE EVACUATED AND SENT BECOME FOR WHATEVER REASON. 292% OF PEOPLE WHO KNOWS WHAT HAPPENS IN PREVIOUS CONFLICTS BUT HOPEFULLY WE PROVIDED SOMETHING THAT THEY WESTERN GETTING BEFORE OUT THERE. HERE IS A GOOD EXAMPLE, SOMETHING BAD THAT CAN HAPPEN. THAT'S A BEE HUT, TWO PEOPLE LIVING IN THAT THING THAT'S A RESULT OF AN RPG AND WHAT THE BAD GUYS DO AT NIGHT IS THEY WOULD HIDE -- I DON'T HAVE A PICTURE BUT THERE WAS A CORN FIELD OFF THE OUTSIDE GATE AND THEY COULD HIDE THERE AND THEN THEY POP UP AT NIGHT AND JUST SHOOT AN RPG ON THE BASE AND HOPE IT HITS SOMETHING AND THIS PARTICULAR TIME IT DID. NO ONE WAS KILLED ON THIS ONE. LUCKILY AS YOU CAN TELL THERE WASN'T ANYONE IN THERE. THE OTHER SIDES IS WHERE MY PATIENT WAS AND HE WAS NOT -- HE WAS -- HE HAD A TRAUMATIC BRAIN INJURY AND HE WAS SHOOKEN UP SO I WON'T SAY HE WASN'T INJURED BUT HE WASN'T PHYSICALLY INJURED. CAN YOU IMAGINE WAKING UP TO THAT, A GRENADE GOING OFF WHILE YOU'RE ASLEEP. SO I SAW HIM THE NEXT DAY NOT AS A PATIENT I WAS JUST OUT WALKING AROUND AND I DIDN'T HEAR THIS, THIS IS UNBEKNOWNST TO ME UNTIL THE NEXT DAY, IT WAS THE TALK OF THE TOWN AS YOU CAN IMAGINE, AND HE -- BUT HE WAS JUST WALKING AROUND, THESE GUYS ARE SO IMPRESSIVE BECAUSE HE WAS ALREADY GEARED UP READY TO GO ON HIS NEXT MISSION BUT YOU CAN TELL HE WAS DAZED. SO I WENT AHEAD AND SAID LOOK, WE NEED TO DO A MACE AND TAKE CARE OF YOU. HE DIDN'T WANT TO DO THAT BUT YOU CAN TELL HE WAS MISERABLE. SO WE PULLED HIM BACK FOR THREE DAYS LIKE YOU'RE SUPPOSED TO AND HE ENDED UP DOING FINE. SO I WAS TALKING ABOUT WALK ABOUT CONTACTS. REASON THAT'S IMPORTANT, I DON'T WANT PEOPLE TO THINK THAT WE JUST DO WHAT WE DO BACK HERE, WHICH IS MAYBE STAY IN OUR CLINICS A LOT AND JUST KIND OF WAIT FOR PATIENTS TO COME TO US. WE DON'T DO THAT IN A DEPLOYED ENVIRONMENT. WE PROBABLY SHOULDN'T DO THAT IN GARY SON ENVIRONMENT. BUT WE ESPECIALLY IN DEPLOY ENVIRONMENT WE DO WALK ABOUTS. THAT JUST MEANS -- THAT'S -- A NICE WAY TO GET OUT AND MEET PEOPLE, WE'RE NOT SCARY FOLKS, WE'RE RELATIVELY NORMAL, I WATCH FOOTBALL WITH PEOPLE, I EXERCISE WITH THEM, WE HAD A PERSON WHO LIKED BASKETBALL, PLAYED BASKETBALL WITH THEM. JUST TO GET TO KNOW THEM SOY WE'RE NOT JUST HIDENING CLINICS. GUESS WHAT HAPPENS? YOU BE OUT WALKING AND SOMEBODY SAYS HEY QUICK QUESTION. TURNED OUT SOME SORT OF CLINICAL TYPE QUESTION OR SOMETHING ABOUT THEIR SPOUSE OR ONE OF THEIR KIDS. SO RATHER THAN US WAITING TO COME THROUGH AND GET SCREENED AND GO THROUGH THE PROCESS OF THE CLINIC WE GO OUT THERE AND WALK AROUND AND MAKE OURSELVES MORE ACCESSIBLE. IF WE WEREN'T IN A CLINIC DO THE CLINICAL CARE WE DO WALK AROUNDS. SO AS YOU SEE THAT DARK BLUE OR THE BLUE IS THE TOTAL NUMBER WE SAW THAT MONTH AND IN THE RED ARE THE ONES YOU KNOW WHAT, I'M GOING TO HAVE YOU COME SEE ME BECAUSE SOUNDS LIKE FOR WHATEVER REASON THERE IS MORE I CAN DO THE HELP YOU. SO A LION'S SHARE WERE THINGS WE WERE ANSWERING QUESTIONS ABOUT. BUT SOME WE ACTUALLY WERE ABLE TO CAPTURE THIS PEOPLE IN THE -- PEOPLE IN NEED. HERE IS ANOTHER PICTURE GOING OUT. THE GUY SAW ME TAKING A PICTURE AN UD R WAS MAKING MUSCLES ON THE TOP. SUN IS GOING DOWN BUT THAW EAR GETTING READY TO GO ON A MISSION LIKE THEY DID EVERY SINGLE DAY THESE GUYS. THE GUY TALKING IN THE MIDDLE THERE IS THE -- ONE OF THE AFGHAN ARMY GENERALS, GENERAL OFFICER TALKING TO HIS FOLKS. YOU SEE HIS FOLKS IN THE OLDER STYLE BDUs IN FRONT OF HIM, SAME YOON FORM. OUR GUYS ARE ON THE RIGHT AND THAT'S AN INTERPRETER THERE MIND THEM AND THAT'S SOME OF OUR LEADERSHIP BEHIND THEM BUT I THOUGHT THIS WAS A NICE WAY TO SHOW WE ACTUALLY WORK -- OUR GUYS NOT ME BUT THESE -- THE WAR FIGHTERS WERE WORKING CLOSELY WITH THE AFGHANEES TO HELP TO TRAIN THEM, TEACH THEM SOME OF THESE THINGS. THIS GENERAL'S SPEECH, HE WAS REALLY TRYING TO FIRE THEM UP AND SAYING GOOD THINGS ABOUT THE AMERICANS, AND AFTERWARD HE SAID DOES ANYBODY HAVE ANY QUESTIONS? AND ONE OF THE AFGHANEE RAISE HIDZ HAND AND SAID SIR, WHEN ARE WE GOING TO GET PAID? I HAVEN'T BEEN PAID IN TWO MONTHS. THE GENERAL SAID WE HAVE A GUY OVER HERE WITH THE MONEY AND WE'LL GIVE TO IT YOU GUYS, WHICH -- IN THE DOD, UNITED STATES WE WOULD NEVER JUST HAND OUT CAB LIKE -- CASH LIKE THAT. THAT WAS HIS ONLY QUESTION, CAN WE GET SOME MONEY TO SUPPORT MY FAMILY. THAT'S JUST ANOTHER DAY ON A FOB SOMEWHERE. SO SOME SPECIFIC CHALLENGES WE SAW, I HAVE HEARD THIS SAID A COUPLE OF TIMES. PRIVACY AND CONFIDENTIALITY, BECAUSE WE DO THOSE WALK AROUNDS LIKE I WAS TALKING ABOUT, VERY QUICKLY EVERYBODY KNOWS WHO I AM AND WHO THE PROVIDERS ARE AND IF YOU'RE TALKING TO ONE OF THE PROVIDERS BOY, YOU MUST HAVE A PROBLEM. SOME PEOPLE DIDN'T CARE THEY COME UP ANYWAY BUT SOME WOULDN'T WANT TO BE SEEN BECAUSE THEY THINK PEOPLE INTERPRET THAT AS MEANING YOU HAVE A MENTAL HEALTH PROBLEM. I SHOWED YOU THE PICTURE WHERE I WAS SEEING PATIENTS. I COMPLAIN SOD MUCH BECAUSE FIRST PLACE I HAD WAS NOT PRIVATE AND CONFIDENTIAL, IT WAS ONE IN ONE OF THOSE TYPE OF BEE SHUTS THAT GOT BLOWN UP. IT WAS SOMETHING LIKE THAT BECAUSE BIGGER AREA WHERE OTHER PEOPLE ARE DOING THEIR BUSINESS TEAR MISSION. THESE ARE COMMUNICATION GUYS. I WAS RIGHT NEXT TO THEM, THERE WAS NO CONFIDENTIALITY, PEOPLE COULD HEAR WHAT WAS SAID IN MY OFFICE, IT WAS TERRIBLE. SO WE HAD TO FIGHT TRY TO GET A BETTER PLACE BUT THAT'S A SPECIFIC CHALLENGE THE SECOND ITEM LEADERSHIP OVERSENSITIVITY. THIS WAS MIND BLOWING TO ME, I HAVE BEEN DOING THIS A LONG TIME. USED TO BE THAT IT WOULD TAKE YOU PREFER TO CONVINCE A LINE LEADER THAT YOU -- BOY, THIS PERSON I'M WORRIED ABOUT, WE NEED TO DO SOMETHING, THE LINE LEADER THEY'RE GOOD. NOW DEPENDING ON -- THIS IS LARGELY BECAUSE WE HAVE CHANGED THE WAY WE LOOK AT SUICIDE NOW IN THE MILITARY. USED TO BE SUICIDE WAS THE INDIVIDUAL PROBLEM, SO YOU'RE NOT -- YOU HAVE A PROBLEM, YOU HAVE A MENTAL HEALTH DISORDER OR SOMETHING SO IT WAS THE INDIVIDUAL'S PROBLEM. THE PENDULUM SWUNG, IF YOU KILL YOURSELF IT'S YOUR LEADER OR YOUR BUDDY'S FALL. WE NEED TO BRING THAT IN MORE. ME AS A MILITARY MEMBER I NEED TO TAKE CARE OF MYSELF TOO. I HAVE THAT BURDEN, NOT JUST MY LEADERS BUT AS A RESULT THE LEADERSHIPS ARE SENSITIVE, FIRST TIME I LEARNED THIS I WAS GOING IN AND HAD A PERSON YOUNG PRIVATE I WAS SEEING JUST SAY HEY, SIR I WANT TO LET YOU KNOW THIS IS GOING ON, I GOT IT COVERED. THE BATTALION COMMANDER WANTED TO SEND HIM BACK. I SAID WAIT A SECOND. I DON'T THINK HE NEEDS TO GO BACK, HE CAN FINE TO TO STAY HERE BUT I QUICKLY LEARNED THAT -- ABOUT THIS OVERSENSITIVITY SO IT KIND OF GOES BACK AND FORTH, MAYBE THAT MIGHT HAVE BEEN MY PARTICULAR BATTALION COMMAND WAS VERY KEY OR VERY FOCUSED ON MAKING SURE TAKING CARE OF HIS FOLKS BUT I HAD TO TEMPER WHAT I SAID TO HIM A LITTLE BIT OR HE WOULD HAVE SENT EVERYBODY BACK. THE THIRD THING BEING AN OUTSIDER, THAT'S ESPECIALLY TRUE, SO I'M AN AIR FORCE GUY, HERE I WAS WITH A ARMY BATTALION, EVEN MORE AN OUTSIDER AN NOW I'M ALSO A MENTAL HEALTH GUY, EVEN MORE AN OUTSIDER. I HAVE HOPE IT IS AIR FORCE MOVES TO WHERE IT DEPLOYS LIKE THE ARMY DOES. THAT'S AN ADVANTAGE BECAUSE WHEN THEY DO THEY KNOW EACH OTHER AND YOU'RE MORE CONNECTED. THAT WAS A CHALLENGE I HAD AS AN OUTSIDER. THE FOURTH BOOK CONTINUE EXPOSURE TO TRAUMATIC STIMULI. YOU SEE A GUY WITH PTSD, GUESS WHAT THE NEXT DAY THEY GO OUT AN EXPOSED TO THE SAME THING AGAIN. AND THERE'S CONSTANT LOUD NOISES, BOMBS GOING OFF. ESPECIALLY WHERE I WAS DOWN RANGE CONSTANTLY EVERY DAY. FOR PEOPLE, ONE OF THOSE SYMPTOMS EXAGGERATED STARTLE REFLEX AN SENSITIVE TO LOUD NOISES, THEY HAVE AN ESPECIALLY LARGE TIME. EVERYONE IS ARMED, MENTIONED THAT ALREADY, OVERUSE OF CAFFEINE, NICOTINE, PERFORMANCE ENHANCEMENT STIMULANTS, I DON'T KNOW WHAT THEY WERE TAKING BUT THEY WERE REALLY GETTING -- BIGGER MUSCLES THAN THEY SHOULD HAVE GOTTEN. SO A LOT OF THING PROBABLY NOT HELPING OTHER THINGS THEN THIS BACK AND FORTH BETWEEN HAVING ALL THIS DOWN TIME AND NOT KNOWING WHAT TO DO WITH YOURSELF AND THEN ALL OF A SUDDEN SOMETHING TERRIBLE HAPPENS. SO THIS IS MY LAST SLIDE, THEN THE -- WHAT IS THE WAY FORWARD? WHAT ARE THINGS WE CAN DO TO PARTICULARLY HELP THIS OUR PROVIDE NERS THIS DEPLOYED ENVIRONMENT? THE FIRST THING, DECREASE VARIATIONS IN BEHAVIORAL HEALTHCARE, REALLY TRYING TO MAKE SURE WE HAVE OUR PROVIDERS LIKE YOU HEARD US SAY, KNOW AB THE CPG, KNOW THE THINGS THAT YOU CAN USE, THESE TOOLS. AND HAVE THEM IMPLEMENT THEM, STANDARDIZE, NOT COMPLETELY STANDARD ACROSS EVERYBODY BECAUSE WE'RE HUMAN BEINGS THAT DO THINGS DIFFERENTLY BUT THIS SHOULD BE THINGS THAT ARE THE SAME NO MATTER IF I GO HERE OR SOMEWHERE ELSE. IMPROVED SLEEP HYGIENE, IF WE CAN ADDRESS SLEEP AFFECTIVELY WE WOULD BE 90% OF THE WAY THERE. EXPAND PROBES AN BETTER BEHAVIORAL HEALTH PROVIDERS, THAT'S DOESN'T NECESSARILY MEAN SEND MORE BEHAVIORAL HEALTH PROVIDERS, IT MAY BUT IT ALSO IS TELEBEHAVIORAL MEDICINE. USING THESE PROPROVIDER EXTENDERS. THE NEXT BULLET TALKING ABOUT HOW CAN WE USE TECHNICIANS BETTER, MENTAL HEALTH TECHNICIANS WHERE I WAS WERE UNDERUTILIZED. WE SHOULD HAVE THEM OUT THERE STAND ALONES AND THEN CALL THEIR PROVIDERS WITH QUESTIONS THEY HAD OR SOLICIT THE NEED FOR GUIDANCE, THOSE ARE TWO THINGS WE CAN DO TO EXTEND THIS PROGRAM FURTHER. THE NEXT BULLET TALKING PSYCHOLOGICAL FIRST AID WHICH IS ONE OF THE INTERVENTIONS WITH KNOW THAT DOES OR CAN WORK. AND LET'S STANDARDIZE THAT AND MAKE SURE THAT WE KNOW EVERYBODY IS DOING THAT THE SAME. COMPLIMENTARY AN ALTERNATIVE MEDICINE. I WAS LUCKY BECAUSE I HAD ONE FOLK NOW WORKING AT NICO DR. KAUFFMAN WITH ME DOING ACUPUNCTURE. SO WE WORK TOGETHER ON SOME PATIENTS AND HE DID A GREAT JOB, HE WAS GOING ALL OVER THE THEATER DOING ACUPUNCTURE. BUT WE NEED MORE THAT KIND OF THING. DOESN'T NECESSARILY HAVE TO BE TRADITIONAL TYPE PSYCHOTHERAPY AND MEDICATIONS, ONCE WE KNOW THESE KIND OF THINGS WORK. BETTER AND TIGHTER PREDE EMPLOYMENT STANDARDS. YOU HER ME TALK ABOUT THAT A LITTLE BIT. LEADERSHIP SUPPORT, WE'RE GETTING BETTER AT THAT. THEN THE FINAL BULLET PRODUCE AND PUBLISH GUIDANCE FOR COMBAT OPERATIONAL STRESS CONTROL. WE HAVE A COUPLE OF POLICIES NOW BUT WE NEED TO REALLY WORK ON MAKING SURE THAT WE PUT IN WRITING WITH SOME OF THE THINGS WE THINK WE NEED TO DO. THERE IS MY LAST SLIDE. THAT'S AN ACTUAL COMPANY GUYS PERFORMING A CEREMONY RECOGNIZING ONE OF THE GUYS THE GUY IN THE FRONT TO THE LEFT OF THE FLAG IS PROBABLY 24 YEARS OLD LEADING ALL THOSE MEN, I DON'T THINK THERE'S ANY WOMEN THERE, ALL NOSE MEN. SO I WAS PROUD TO BE OUT THERE WORKING WITH THOSE GUYS. SO I'LL TAKE QUESTIONS BEFORE WE LET THE LAST SPEAKER GO. ANYBODY HAVE ANY QUESTIONS? (OFF MIC) >> TECH ANYTHING? THOSE WE HAVE ENLISTED TECH NEXT ANYTHINGS WITH A LOT OF TRAINENING BEHAVIORAL HEALTH. THEY'RE NOT PROVIDERS, THEY CAN'T FUNCTION INDEPENDENTLY BECAUSE THINK NOT CREDENTIALED BECAUSE CERTAINLY CAN AND DO WORK WITH US, THE CHALLENGE IS IN AN IN-GARY SON ENVIRONMENT THEY'RE OFTEN'oF USED, UNDERUTILIZED BECAUSE THEY HAVE ALL THE PROVIDERS THERE. I JUST NEED YOU TO ANSWER THE PHONE OR DO THE ADMINISTRATIVE WORK, THAT'S NOT HELPFUL BECAUSE WHEN THEY'RE DEPLOYED WE PUT THEM IN A DIFFERENT ROLL, SO WE'RE WORKING TO TRY THE ADDRESS THAT. ANY OTHER QUESTIONS BEFORE I TURN IT OVER TO DR. VYTHILINGAM? OKAY. GOOD. PLUS PLAWS >> WHILE I'M PUTTING ON MY MIC FELL FREE TO GET UP, STAN UP, TAKE A LITTLE BREAK. TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST >> GOOD AFTERNOON. MY NAME IS MEENA VYTHILINGAM FROM THE U.S. PUBLIC HEALTH SERVICE. I'M A PSYCHIATRIST, I WORK IN THE DEPARTMENT OF DEFENSE IN THE DEFENSE SENORS OF EXCELLENCE. I'M DIRECTOR FOR THE PSYCH LOGICAL HEALTH CLINICAL STANDARDS OF CARE. SO WHAT I'M GOING THE TALK ABOUT TODAY IS TALK ABOUT PREVENTION OF PTSD. YOU HEARD A LOT ABOUT FROM COLONEL ROBINSON WHAT DEPLOYED PSYCH HEALTH LOOKS LIKE AND WHAT ARE THE -- ONE OF THE KEY QUESTIONS IS WE'RE SENNING MEN AND WOMEN INTO THE FRONT LINE AND WHAT ARE WE DOING TO ACTUALLY ENSURE THAT THEY DO NOT GET PTSD OR DO NOT GET ACUTE STRESS DISORDER? SO THAT IS THE KEY QUESTION I'M GOING THE ADDRESS. TALKING ABOUT THE NIH, USED TO WORK THERE AND ONE OF THE BIG THRUSTS WITH NIH RESEARCH, HOW DO YOU TRANSLATE ALL THE RESEARCH BEING DONE IN THE LAB FROM THE BENCH TO THE BEDSIDE? HOW AM I GOING TO TRANSLATE ALL THE NEURONAL RESEARCH AND AMYGDALA AND HIPPOCAMPUS RESEARCH INTO SOMETHING USEFUL TO HUMAN BEINGS? SO MY -- THAT'S CALLED TRANSLATION FROM BENCH TO BEDSIDE. MY TALK SAYS THAT SOMEWHERE IN THIS TRANSLATION, THE MEANING IS LOST. THE METHOD IS GETTING LOST IN TRANSLATION. LET ME BALK THREW MY REASONS FOR WHY I THINK THE MESSAGE IS LOST IN TRANSLATING DATA FROM BENCH TO BEDSIDE. MY TALK IS GOING TO BE THREE SECTIONS. I'M TALKING ABOUT BENCH RESEARCH T ACUTE RESPONSE TO TRAUMA. AND I'M GOING TO BE TAUGHTING ABOUT WHAT'S DONE -- TALKING ABOUT WHAT'S DONE BEDSIDE, TALKING ABOUT DRUGS AN PSYCHOTHERAPY AND I'M GOING TO END WITH TAKE HOME POINTS. I'M NOT SURE IF FOLKS ARE FAMILIAR WITH THIS. ANYONE FAMILIAR WITH THIS IOM RETRACTOR? HOW MANY PHYSICIANS ARE HERE IN THE AUDIENCE? ONE PHYSICIAN. OKAY. SO I JUST WANTED TO MAKE SURE THAT I ADDRESS THE TAWX TALK SO EVERYONE CAN TRACK WHAT I'M SAYING. THIS IS THE IOM PROTRACTOR IN TERMS OF PREVENTION. SO ESSENTIALLY YOU HAVE HEARD PRIMARY SECONDARY AN TERTIARY PREVENTION. WHAT THE IOM GROUP HAS DONE IS -- DOES THIS WORK? CAN FOLKS SEE THIS? ALL RIGHT. SO WHAT THE IOM HAS DONE IS BROKEN UP THE PRIMARY PREVENTION, WHICH THE RAISE ?ER THIS ONE? OKAY. GOT IT. SO WHAT THEY HAVE DONE IS BROKEN DOWN THE PRIMARY PREVENTION INTO MORE SUBTLE CATEGORIES. SO LET ME TELL YOU WHAT IT MEANS IN TERMS OF THINKING ABOUT MEN AND WOMEN WHO ARE GOING INTO WAR. SO THE FIRST STEP IS YOU INTERVENE BEFORE YOU DEPLOY SERVICE MEMBERS. SO THIS IS BEFORE THEY GO OUT TO THEATER. THAT'S UNIVERSAL PREVENTION. AN EXAMPLE IS A COMPREHENSIVE SOLDIER FITNESS ROLLED OUT BY THE ARMY. THE NEXT LEVELj$[ IS CALLED SELECTIVE PREVENTION. WHAT SELECTIVE PREVENTION IS, THE KINDS OF SITUATIONS THAT COLONEL ROBINSON SPOKE ABOUT, A UNIT WITH HIGH LOSS, HIGH CASUALTY AND HOW DO YOU TAKE CARE OF THEM WHEN THEY'RE BACK TO THE FOB. THIS IS A HIGH RISK GROUP SORKS THEY HAVE BEEN EBS POSED TO TRAUMA BUT NOT YET DEVELOPED SYMPTOMS. THAT'S CALLED SELECTIVE PREVENTION. THIRD CATEGORY, THEY'RE EXPOSED TO TRAUMA, THEY HAVE HIGH RISK GROUP, THEY HAVE SOME SYMPTOMS LIKE THE COMBAT OPERATION STRESS REACTION, BUT NOT DEVELOPED THE FULL BLOWN DISORDER. SUB HOLD CLINICAL SYMPTOMS. THEN OF COURSE IS THE NEXT PART OF THE PROPRAKTOR -- PROTRACTOR WHICH IS TREATMENT. PREVENTION SO YOU DON'T HAVE THE DISORDER YET THEN YOU HAVE THE TREATMENT. YOU HAVE THE CLEAR CUT DISORDER. SO AS CLINICS WE SPENT TIME IN TREATMENT PART. SO I'M MAINLY FOCUSING ON THIS BLUE PART OF THE PROTRACTOR, VEERING A LITTLE TO THE YELLOW PART. NEXT SLIDE, WON'T GO INTO TOO MANY DETAILS ABOUT THE AMAT MY AND PHYSIOLOGY OF THE STRESS RESPONSE, BUT MAIN POINTS HERE, WE HAVE LEARNED A LOT FROM THE BENCH SO THERE'S WHAT IS TRABS LATEED FROM BENCH TO BEDSIDE, WE KNOW HOW THE BRAIN WORKS AND HOW THE BRAIN LOOKS BECAUSE WE KNOW THAT WHEN IT COMES TO FEAR RESPONSE THERE IS A VERY IMPORTANT STRUCTURE CALLED THE AMYGDALA ASSESSING THREAT, THE HEALTH SERVICE MEMBER DIFFERENTIATE A FRIEND FROM FOE AND THEN YOU HAVE THE PRE-FRONTAL CORTEX WHICH BASICALLY HELPS DISCRIMINATE AND HIGHER LEVEL PROCESSING. THE HIPPOCAMPUS HEPS FIGURE OUT THE CONTEXTUAL MEMORY, YOU HOLE IN YOUR MIND WHERE IT HAPPENED AND ABLE TO RECALL WITH PRECISION STUFF YOU LEARNED SO ESSENTIALLY THAT'S THEdN– STRUCTURE. IN TERMS OF FUNCTION THE AMYGDALA ARE RESPONSIBLE FOR FEAR CONDITIONING AND MEDIAL PRE-PROBLEM TALL CORTEX OR INHIBITION AN EXTINCTION, I TELL YOU WHY IT'S VERY IMPORTANT IN PTSD. AND THE HIPPOCAMPUS IS FROM CONTEXT MEMORY. ONE WAY TO THINK FROM A MECHANICAL STANDPOINT OF VIEW IS IF THE MY AMIG THAT IS THE ACCELERATOR, THE PRE-FRONTAL CORTEX IS THE BREAK. THE REASON THIS IS IMPORTANT TO UNDERSTAND, WHAT HAPPENS IN PTSD, THIS AGAIN WE LEARNED LESSONS FROM THE BENCH TO BEDSIDE, LOTS OF PATIENTS WITH PTSD HAVE BEEN IMAGED, THEIR ANATOMY HAS BEEN MEASURED AND FUNCTIONAL -- FUNCTIONALITY IS MEASURED WITH FMRI AND PET STUDIES. WHAT LITERATURE TELLS US IS THAT IN PATIENTS WITH PTSD, THE FEAR CENTER IS ON OVERDRIVE. WHILE ABILITY TO INHIBIT IS DECREASED. FOOT IS ON THE ACCELERATOR BUT BREAK CANNOT BE APPLIED SO THE FEAR SYSTEM IS ON OVERDRIVE AFTER RETURN TO A SAFE ENVIRONMENT. SO MAKES IT DIFFICULT TO DAMAGE THE STRESS RESPONSE. THAT WE LEARNED A LOT FROM THE BENCH FROM THAT STANDPOINT OF VIEW. WE HAVE ALSO LEARNED ABOUT THE BATH WATER AROUND THE BRAIN. THE BRAIN EXISTS SURROUNDED BY CSF WHICH IS BY ALL THE NEUROTRANSMITTERS THAT CIRCULATE THROUGH THE BODY AND WE HAVE ALSO LEARNED THAT WHEN THERE IS AN ACUTE STRESS REACTION THERE IS FLIGHT FIGHT OR FREEZE RESPONSE. AS COLONEL ROBINSON WAS SAYING SERVICE MEMBERS ARE TRAINED TO FIGHT. NOT TRAINED TO FREEZE OR FLEE. THERE ARE TWO ARMS OF THE STRESS RESPONSE TRGERRED IN ACUTE SETTING. TWO ARM IT IS HYPERTHALAMIC ADRENAL ACCESS AND THE SYMPATHETIC NERVOUS SYSTEM. SO WE LEARNED ALL THIS GOOD STUFF FROM THE BENCH. IN ACUTE STRESS WHAT HAPPENS IS THE CORTICAL RELEASING HORMONE GOES UP, CORTISOL GOES UP, A ACTH GOES UP AND NOREPINEPHRINE GOES UP. WHAT HAPPENS IN STUDIES THAT HAVE LOOKED AT ACUTE PATIENTS HAVE SHOWN UP IN THE EMERGENCY ROOM, HARD TO DO THIS IN A COMBAT ENVIRONMENT FOR OBVIOUS REASONS SO THE THE EASIEST WAY TO DO IS EVALUATE PATIENTS IN THE EMERGENCY ROOM AND MEASURE BLOOD HORMONES AN NEUROTRANSMITTERS AN LEVELS IN THE URINE AND SEE WHAT PARTICULAR BIOMARKER PREDICTS PTSD. THE PREDICTION IS IF YOU HAVE TOO HIGH A STRESS HORMONE DURING ACUTE AROUSAL, MORE LIKELY YOU'LL DEVELOP PTSD. THAT WAS THE HYPOTHESIS. AND WHAT WAS SHOWN IS THAT IF THERE IS ELEVATION OF NOREPINEPHRINE THAT'S SUSTAINED DURING THE EMERGENCY ROOM VISIT LIKELY -- THE PERSON IS LIKELY TO DEVELOP PTSD IN THE FUTURE. SAME WITH ELEVATED LEVEL OF IL-6 A PROINFLAMMATORY CYTOKINE. THIS IS JUST ONE STUDY, THOUGH THERE WAS EXPECTATION THAT CORTISOL WOULD BE HIGHER WHEN THEY COME TO THE EMERGENCY ROOM, THAT'S A PREDICTOR OF PTSD, THERE WAS ONE STUDY WITH PATTY REZNIK THAT SHOWED CORTISOL LEVELS ARE LOWER IN WOMEN ARRAYED TO PTSD. SO A LITTLE PARADOX. BUT THE REASON I SAY THIS IS NOW THINK OF THE CLUES THE WE KNOW WHAT NEUROTRANSMITTERS ARE THAT PREDICT IT, MAYBE WE CAN WORK TO DAMPEN THOSE SPECIFIC NEUROTRANSMITTERS THAT. HE'S WHY TRANSLATION FROM THE BENCH IS SUPPOSED TO HELP DEVISE BEAR TREATMENTS. BUT WHAT HAPPENS? SO THE KEY IS, LET'S THINK OF THE DRUGS THAT CAN DAMPEN THE NOR EPINEPHRINE RESPONSE AND SOME EXAMPLES ARE MORPHINE AND PROPRANALOL, CHOSEN BECAUSE OF LITERATURE CONFIRMING THEY REDUCE LEVELS IN THE AMYGDALA, THE FEAR SENOR. NOW, BECAUSE OF THE STUDY I MENTIONED THAT LOW CORTISOL IS A RISK FACTOR, ONE POSSIBILITY, THOSE ACUTELY TRAUMATIZED YOU CAN GIVE CORTISOL. FOLKS TAKE PRED ANY SEWN ALL THE TIME. IT'S OAT PRED PREDNISONE ALL THE TIME. REDUCE EPINEPHRINE, GIVE CORTISOL AND THE KEY THING IS THAT THE GREATER THE AROUSAL DURING THE TRAUMATIC EVENT THE GREATER THE CHANCES OF DEVELOPING PTSD. WHAT CAN WE DO TOn ALTER TRAUMA PERCEPTION. THE CHEAPEST SOCIALLY ACCEPTABLE AND DRUG THAT DOES NOT REQUIRE PRESCRIPTION IS ALCOHOL. THAT DOES EXACTLY THAT, SO BECAUSE SEVERAL STUDIES HAVE SHOWN THESE ARE NATURALISTIC STUDIES THE DRIVER IS INTOXICATE AND THEY COME IN. WHAT'S INTERESTED IS INTOXICATION DURING THE TRAUMA DECREASES LIKELIHOOD OF PTSD. SO WOULDN'T IT BE GREAT TO GIVE ALCOHOL AND MAKE SURE PTSD IS REDUCED? THE WAY ALCOHOL PREVENTS PTSD IS IT DISRUPTS COGNITIVE APPRAISAL AND PROCESSING OF THREAT INFORMATION AND DAMPEN IT IS STRESS RESPONSE. SO IF YOU DONE THINK IT'S SUCH A HORRIBLE ACCIDENT THEN THE WAY YOU PROCESS THE EVENT CHANGES. SO WHY NOT GIVE EVERYBODY ALCOHOL? THE PROBLEM WITH GIVING ALCOHOL AS PREVENTION METHOD FOR PTSD, ONE IS IT NEEDS TO BE CONSUMED BEFORE THE STRESSFUL EVENT SO FROM SERVICE MEMBERS YOU CAN IMAGINE IF YOU'RE GIVING THEM PRE-DOSING THEM WITH ALCOHOL AND THEN SENDING THEM OUT IN THE HUMVEE, IT'S NOT GOING TO WORK. AND THE SECOND THING YOU NEED MODERATE TO HIGH LEVELS FOR PREVENTIVE EFFECT. CASE CLOSED. I MADE A CASE FOR WHY ALCOHOL IS NOT A GREAT TREATMENT. SO -- LET'S GO TO BENZODIAZEPINE. I'M THINKING, I PRESENTED THAT BRAIN MODEL AND THE NEUROTRANSMITTER MODEL TO SAY OKAY WHAT HAVE WE LEARNED FROM THE BENCH THAT CAN BE TRANSLATED BUT HAVING TROUBLE MAKING THE TRANSLATING MAKING THE LINK SO THE SECOND -- WE HAVE DONE THE ALCOHOL PIECE, LET'S GO TO BENEFIT DOE DIAZ PEEN, THEY ACT ON -- BENZODIAZEPINE, IT REDUCES ANXIETY, AND THE PREDICTION, LESS CHILL THE PERSONALITY IMMEDIATELY AFTER TRAUMA, THAT WILL TAKE CARE OF PROBLEM. LET THEM SLEEP, GIVE THEM BENZODIAZEPINE, TWO STUDIES, AGAIN, NOW, REMEMBER, WHAT I TOLD YOU, THERE WERE THREE LEVELS OF PRIMARY PREVENTION T UNIVERSAL SELECTIVE AND INDICATED. THESE PATIENTS ARE EVERYBODY WHO CAME TO A LEVEL ONE TRAUMA CENTER. THIS FALLS UNDER SELECTIVE PREVENTION. m]z THESE ARE HIGH RISK PE OPLE WHO HAVE TRAUMA EXPOSURE HAVE COME IN. SO BENZODIAZEPINE, NO EFFECT. IN THIS GROUP, CLINAZAPAM MADE PATIENTS WORK AT 6 MONTHS SO BENZODIAZEPINE IS NOT THAT GREAT. IT DOESN'T SEEM TO BE PREVENTING PTSD IF GIVEN IN ACUTE AFTER MATH OF TRAUMA. ROGER PITMAN CAME UP WITH AN IMPORTANT STUDY SHOWING THAT THOSE HAVE ELEVATED HEART RATE IN THE EMERGENCY ROOM LIKELY DEVELOP PTSD. LIT'S BRING DOWN THE SYMPATHETIC NERVOUS SYSTEM DRIVE AND PREVENT PTSD EASY, FOR CHEAP DRUG, WELL USED FOR SOCIAL PHOBIA, HYPERTENSION PIECE OF CAKE. IT WAS FULL OF EXPECTATIONS, IT WAS STUDY, 41 PATIENTS MULTIPLE TRAUMA, EMERGENCY ROOM PATIENTS, ONE MONTHS, THREE MONTHS NO DIFFERENCE IN PREVENTING PTSD COMPARED TO PLACEBO. THERE WAS SOME DIFFERENCE FROM A PSYCH FIZZ YOL POINT OF VIEW TO SHOW THEY MAYBE LESS REACTIVE IN A LAB SETTING BUT DID NOT ACTUALLY TRANSLATE INTO DIFFERENCE IN DIAGNOSIS. SAME WITH GA PA PEN TIN GABBA PEN TIN. NO DIFFERENCE. SIMILAR TO DIAZ PEEN. SO THE FIELD HAS TRIED HARD TO TRANSLATE THIS WORK ON REDUCING THE SYMPATHETIC NERVOUS SYSTEM ACTIVATION IN THE AFTER MATH OF THE TRAUMA, IT JUST HAS NOT PANNED OUT. THIS IS A INTERESTING STUDY. LET'S GO THE POSITIVE. I HAVE BEEN NEGATIVE ON THE RESEARCH AND BENCH SO FAR. THIS IS ACTUALLY VERY INTERESTING STUDY THAT LOOKED AT VERY SICK MEDICALLY ILL PATIENTS IN THE ICU. SO PATIENTS WERE ADMITTED WITH SEPTIC SHOCK AND THOSE WHO HAD CARDIAC SURGERY. REMEMBER I MENTIONED THAT THE STUDIES SHOWED LOW CORTISOL IN THE EMERGENCY ROOM, IN THE WOMEN WHO ARE RAPED, IS A RISK FACTOR FOR DEVELOPING PTSD. SO WHAT THIS GROUP DID IS THEY WENT AHEAD AN GAVE PATIENTS WITH SEPTIC SHOCK AND CARDIAC SURGERY IN THE ICU THE RANDOMIZED THEM TO HYDRO CORTISONE OR PLACEBO. WHAT'S INTERESTING IS THEY FOUND THAT THOSE WHO RECEIVED HYDRO CORTISONE HAD LOWER RATE OF DEVELOPING PTSD AT FOLLOW-UP. AND AGAIN, HERE THEY HAD LESS LIKELIHOOD OF RECALLING TRAUMATIC MEMORY. SO HYDRO CORTISOL HAS PROMISE AND MRMC DOD IS FUNDING A STUDY E -- GIVING HYDRO CORTISONE, NOT SURE IF ACUTE TRAUMA OR PTSD. PTSD. OKAY. INTERESTING INTERVENTION TO SEE WHETHER IT COULD PREVENT PTSD BECAUSE IT COULD INTERFERE WITH CONSOLIDATION OF MEMORY. THIS IS AN EXTREMELY INTERESTING STUDY. NMDA ANTAGONIST,S THAT THIS IS A BURN CENTER. CET MEAN IS A GREAT ANESTHETIC SO THEY GIVE CET MEAN FOR BURN SURGERIES AN THIS GROUP LOOKED AT SOLDIERS RECEIVED CET MEAN DURING BURN SURGERY, VERSUS THOSE WHO DIDN'T GET CETAMENE THEY FOUND THOSE THAT DID HAD A LESS SIGNIFICANT LESS LIKELY TO DEVELOP PTSD COMPARED TO THOSE WHO DID NOT GET IT. BUT YOU CAN IMAGINE GIVING KETAMINE TO SOMEONE PSYCHOLOGICALLY TRAUMATIZED. IT WON'T HAPPEN. IT'S A MEDIC DRUG AND NOT EASY TO GIVE. THOUGH AT NIH THEY DO STUDIES ON IT AND REFRACTORY DEPRESSION. BUT IN TERMS OF PREVENTION VERY UNLIKELY YOU'RE GOING TO GIVE SOMEONE WITHOUT SYMPTOMS KETAMINE. THIS IS ANOTHER LAND MARK STUDY. SO WE'RE GOING TOWARD SOME HAS POTENTIAL. MORPHINE, THIS IS A VERY INTERESTING STUDY, RETROSPECTIVE STUDY, NAVY, MARINE CORE TRAUMA COMBAT REGISTRY. THESE ARE SERVICE MEMBERS WHO RECEIVED SERIOUS PHYSICAL INJURY WHO RECEIVED MORPHINE WITHIN ONE HOUR OF THE GREVIOUS INJURY. THERE WERE 696 SERVICE MEMBERS RECEIVED MORPHINE AND THEY WERE -- THE CHARTS ARE REVIEWED. ALL THE SERVICE MEMBERS RECEIVE MORPHINE, WHAT IS OUTCOME? MORPHINE VZ NO MORPHINE. AND WHAT'S INTERESTING IS OF THE SERVICE MEMBERS WHO RECEIVED MORPHINE, SIGNIFICANT REDUCTION IN PTSD. RED IS PTSD AND GREEN IS NO PTSD. SIGNIFICANT REDUCTION IN PTSD THAN THOAN WHO RECEIVE MORPHINE, THOSE WHO RECEIVE MORPHINE IT WAS COMPARABLE IN TERMS OF WHO RECEIVED PTSD AND WHO DIDN'T. SO MORPHINE PROBABLY HAS A TERRIFIC ROLE BUT THE STUDY IS PHYSICAL TRAUMA. WE DONE KNOW THE ANSWER. IF A WOMAN IS RAPED BUT NOT PHYSICALLY INJURED IN THE ER OR A SOLDIER MEMBER WATCHES A SERVICE MEMBER DIE BUT HE'S NOT INJURED IS MORPHINE THE ANSWER FOR THE PSYCHOLOGICAL TRAUMA? THOSE STUDIES KNEE TO BE DONE. THERE IS A SCUTY PUBLISHED BY THE ISRAEL GROUP WHICH IS A FAN STUDY. THE TAKE HOME POINT HERE THERE ARE TWO FDA APPROVED DRUGS FOR PTSD AND BOTH ARE SSRIs SO ONE IS PEROX AHRQTINE AND THE OTHER IS SITOLINE. IF IT'S EWE TOED FOR TREATING PTSD IS IT PREVENTED FOR PTSD? THAT QUESTION WAS NOT ANSWERED UP UNTIL LAST MONTH. AND WHAT (INAUDIBLE) SHOWEDDED IS THAT THIS LINE HERE WHEN THIS TRIANGLE IS THE SSRI GROUP AND THE SQUARE PLACEBO GROUP. AS YOU CAN SEE IT'S PRETTY FLAT AND OVERLYING ON EACH OTHER. SO ESSENTIALLY SSRI'S DON'T DO A GREAT JOB PREVENTING PTSD. SO THE CONSIDERATION FOR MED PROPHYLAXIS, IDEALLY THE BENCH HAS DONE A GREAT JOB WORKING OUT THE DETAIL TOFS STRESS RESPONSE AND THEY HAVE ANIMAL MODEL STRESS, ET CETERA, ET CETERA, CAN WE GET A GREAT DRUG PREVENTING PTSD BASED ON WHAT WE KNOW FROM THE BENCH? WE WANT A DRUG WITH LOW OR NO IMPACT ON COG ANYTHING, JUDGMENT, MORAL DECISION MAKING, AMBIGUOUS SITUATIONS LIKE THEATER. AND TARGET MINORITY WHO DONE RECOVER, THE MAJORITY DO RECOVER, 85 TO 90% RECOVER FROM TRAUMATIC EXPERIENCES. WE WANT A DRUG FORESIVILLEIAN TRAUMA, COMBAT -- FOR THE CIVILIAN TRAUMA, COMBAT TRAUMA, AND THERE SHOULD BE NO LEGAL RAMIFICATIONS. THERE WAS LOTS OF LEGAL AND ETHICAL DEBATES ABOUT CAN YOU ALTER MEMORIES OF HUMAN BEINGS. THIS IS THE DRUG WE WANT. ARE WE THERE YET? NO. YES NOT THERE. SO SOMETHING IS LOST IN TRANSLATION FROM WHAT WE KNOW FROM THE BASIC SCIENCE TO WHAT WE OFFER PATIENTS TO PTSD. IS ANYBODY LOOKING AT NIH RESEARCH? NO. IDEALLY WE SHOULD HAVE A CONVERSATION WITH NIH TO SEE WHAT WE CAN DO TO BRIDGE THE GAP. WHY IS -- ARE WE NOT ABLE TO TALK TO EACH OTHER? SO I WANT TO END THIS SECTION BY SAYING THE CLINICAL PRACTICE GUIDELINES THAT DR. ROBERTS SPOKE ABOUT SAY THERE'S NO EVIDENCE TO SUPPORT A RECOMMENDATION FOR THE USE OF A PHARMACOLOGICAL AGENT TO PREVENT THE DEVELOPMENT OF ACUTE STRESS DISORDER OR POST TRAUMATIC STRETS DISORDER. THIS IS THE OTHER IMPORTANT PIECE, IF YOU SEE YOUR PSYCHIATRIST OR DOCTOR PRESCRIBING BENZODIAZEPINE FOR ACUTE TRAUMA OR PTSD, FEEL FREE TO POINT OUT THE CLINICAL PRACTICE GUIDELINES BECAUSE THEY STRONGLY DISCOURAGE THE USE OF BENZODIAZEPINES IN THIS POPULATION. THAT'S A DISMAL NOTE, WE DONE HAVE A MEDICATION. LET ME SWITCH GEARS AND SAY YOU HEARD DR. GEEN MENTION THIS MORNING PROLONGED EXPOSURE FOR TREATMENT FOR PTSD, THOSE TREATMENTS AND BEHAVIOR THERAPY HAS BEEN GOING ON WAY BEFORE 1980s, WHEN DID IT START, THE CBT MOVEMENT FOR PHOBIA? '60s? MRI, FMRI, ALL Tœ s STUFF, EXCUSE ME. IS A RECENT PHENOMENON. WHAT I WANT TO SAY IS THE BENCH LEARNED A LOT FROM THE BEDSIDE. BECAUSE THEY KNOW CBT COGNITIVE BEHAVIORAL THERAPY WORKS FOR DEPRESSION, IT WORKS FOR PTSD. SO WHAT THE BENCH OR THE PRE-CLINICAL RESEARCHERS HAVE DONE IS TRIED TO FIGURE OUT HOW IT WORKS. WHAT HAPPENS TO THE BRAIN? WHAT CHANGES IN THE BRAIN WHEN YOU EVALUATE BEFORE AND AFTER TREATMENT? THAT'S REALLY INTERESTING. QUESTION IS HOW DO YOU FIGURE OUT WHY DID IT WORK? WHAT THEY FOUND IS SIMPLE. COGNITIVE BEHAVIORAL THERAPY AND REAPPRAISAL ACTUALLY DAMPENS THE REACTIVITY OF THE FEAR SENOR. SO ALL THE EXPOSURE TREATMENT NARRATING THE STORY, FACING YOUR FEARS EXTINGUISHES AND LOWERS -- AND BRINGS BACK -- TAKING LEG OFF ACCELERATOR. YOU BRING YOUR FRONTAL CORTEX BACK ONLINE. YOU'RE ABLE TO INHIBIT, YOU'RE ABLE TO INHIBIT AMYGDALA RESPONSE AND REMIND YOURSELVES I DONE ARE TO DUCK WHEN I HEAR A CAR BACKFIRE, THIS IS A CAR BACK FIER, I'M NOT BACK IN THEATER. THERE'S SEVERAL MODALITIES THAT BRING THE PRE-FRONTAL CORTEX ON LINE. THE MEDITATION, REAPPRAISAL, COGNITIVE BEHAVIORAL THERAPY. I WOULD SAY ACTUALLY THE BENCH HAS LEARNED A LOT FROM WHAT THE BEDSIDE HAS LEARNED AND ACTUALLY HELPED US FIGURE OUT HOW THESE THERAPIES WORK. SO WHAT SHOULD BE DONE? ROBINSON WAS TELLING US EXPERIENCES IN THEATER, AND WHAT SHOULD BE DONE IN THAT ENVIRONMENT? WHAT IS EVIDENCE BASED? AS YOU HEARD, THERE IS NOT ONE THING THAT HAPPENS IN THEATER. THERE'S MANY KINDS OF EXPERIENCES AND MANY DIFFERENT LEVELS OF CARE THAT HAVE TO BE PROVIDED. SO LET'S TALK ABOUT INTERVENTIONS OFFERED 40 DAYS AFTER TRAUMA EXPOSURE. THIS IS FOR ACUTE STRESS DISORDER. SO THE VADOD PRACTICE GUIDELINES SAY FROM 4 TO 30 DAYS AFTER TRAUMA EXPOSURE THEY RECOMMEND BRIEF COG INEFFECTIVE BEHAVIORAL THERAPY SESSIONS. DO NOT RECOMMEND, MENTION THE WORD PSYCHOLOGICAL DEBRIEFING, IT'S NOT SHOWN TO BE EFFECTIVE, I' SHOWN TO BE DETRIMENTAL. BENZODIAZEPINE FOR ASYMPTOMATIC SURVIVORS. THAT'S THE KEY WORD. THE MILITARY STRUGGLING WITH THE PSYCHOLOGICAL FIRST AID, WE ARE DOING IT AND THAT'S WHAT'S DONE. ESPECIALLY FOR COMBAT OPERATION STRESS REACTION BUT WE HAVE NO IDEA IF IT WORKS, THE EVIDENCE IS INCONCLUSIVE. AT DECO WE'RE EVALUATING WHETHER THE MARINE CORE MODEL, THE OSCAR OPERATIONAL STRESS AND MARINE CORPS MODEL, IT'S FIRST AID. WE'RE TRYING TO EVALUATE IF THAT INDEED REDUCE IT IS RATE OF -- REDUCES THE RATE OF ADVERSE CONSEQUENCES TO COMBAT EXPOSURE. IT'S INCONCLUSIVE, WE DON'T KNOW IF IT'S EFFECTIVE OR NOT BUT THE DATA IS GATHERED AS WE SPEAK. THIS IS TO WAKE YOU UP. AND THE BOTTOM LINE HERE IS THE VA DOD CLINICAL PRACTICE GUIDELINES OUTLINES EVERY STUDY THAT WAS TAKEN INTO ACCOUNT IN EXCRUCIATING DETAIL TO EVALUATE THE EVIDENCE TO SAY WHAT SHOULD BE DONE IN ACUTE STRESS DISORDER. I WANT TO TALK ABOUT THE SHELETTE STUDY, ONE OF THE MOST ELEGANTLY DONE STUDY IN A WHILE WITH ACUTE TRAUMA. ALL THE RESEARCH I MENTIONED IS IN CIVILIAN TRAUMA. THOUGH DONE IN ISRAEL, IF THESE ARE EMERGENCY ROOM PATIENTS WITH MOTOR VEHICLE ACCIDENTS AN COMBAT EXPOSURE PROBABLY A SMALL MINORITY OF THEM, THE BEAUTY OF THIS DESIGN IS HE HAS PROLONGED EXPOSURE GROUP, 63 PATIENTS IN PROLONGED EXPOSURE, THAT'S THE DIAMONDS, AND FOLLOW ALONG WITH ME, YOU CAN SEE THE LINE GOING DOWN. THIS IS THE PTSD SELF-ROR SCORE. THE HIGHER THE NUMBER, THE GREATER THE PTSD SYMPTOMS. AND THEN THE PROLONGED EXPOSURE WHICH IS THE EXPOSURE BASED COGNITIVE BEHAVIORAL THERAPY IS THE DIAMOND. THE COGNITIVE THERAPY WITHOUT THE EXPOSURE COMPONENT IS THE SQUARE. AS YOU CAN SEE, BOTH THESE INTERVENTIONS SIGNIFICANTLY REDUCE THE PTSD SYMPTOM ALL THE WAY FROM 30 TO ABOUT 15. ANYTHING BELOW 13 IS CONSIDERED NO PTSD. SO CLEARLY THE NUMBERS ARE COMING DOWN OVER THE COURSE OF A 12 WEEK TRIAL. NOW, NOTE IN CONTRAST TO PROLONGED EXPOSURE COGNITIVE THERAPY, THIS IS ALL BEING TREATMENT WAS STARTED ONE MONTH AFTER TRAUMA EXPOSURE. THEY CAME TO THE EMERGENCY ROOM AND WITHIN A MONTH THEY WERE SCREENED, ASSESSED AN TREATMENT WAS STARTED. AND NOTE ON TOP THAT YOU HAVE THE PLACEBO GROUP WHICH IS THE SQUARES AN RIGHT SUPER IMPOSED ON PLACEBO GROUP IS THE SSRI SUBGROUP. IN FACT THE SSRI IS SYMPTOMS ARE HIGH WHEREAS PLACEBO IS ON THE SAME LINE AS THE WEIGH LIST GROUP. SO DOESN'T MATTER THAT'S AMAZING. I HAVE NEVER SEEN SUCH RESULTS DUB IN ACUTE TRAUMA SETTING. 'S DIFFICULT IN ACUTE RESEARCH. THE POINT I WANT THE MAKE HERE, THIS IS THE FIRST -- THE SLIDE I SHOWED BEFORE WAS 12 WEEKS. WHAT HAPPENS IF YOU FOLLOW THE SAME PATIENTS OUT FIVE MONTHS AND NINE MONTHS AND WHAT'S INTERESTING IS THEY SHOWED COGNITIVE THERAPY, THE SYMPTOMS REDUCED AT 12 MONTHS, 12 WEEKS, FIVE MONTHS AND STAYED THE BENEFITS OF PE AN CBT STAYED FOR NINE MONTHS. AND THE WAIT LIST, THEY GOT BETTER TOO. THE WAIT LIST GOT BETTER BUT WHAT HAPPENS IS AFTER 12 WEEKS, THIS IS A LITTLE BIT TRICKY, THE REASON THIS SAYS WAIT LIST DELAYED, AFTER 12 WEEKS THEY STARTED PROLONGED EXPOSURE. SO THE DELAYED INSTEAD OF GIVING THEM PROLONGED EXPOSURE THEY STARRED THEM ON PROLONGED EXPOSURE. SO AS YOU CAN SEE IF YOU WAIT 12 WEEKS AN TREAT SOMEONE, THE SYMPTOMS COME DOWN AT THE END OF NINE MONTHS. SO IT DOESN'T MATTER IF YOU TREAT RIGHT AWAY OR WAIT FOR 12 WEEKS. AND THE SSRIs, CLEARLY NOT DOING SO WELL. LOOK HOW THIS COMPARES, THIS RED BAR COMPARES TO THIS RED BAR. LOOK HOW THE GREEN BAR COMPARES TO THIS GREEN BAR. AN PLACEBO IS SIMILAR TO THE SSRI. SO THE MORAL OF THIS STORY IS SSRI ARE ARE NOT DOING SO WELL IN ACUTE SETTING. CPT AND PE, ARE PROBABLY THE BEST BANG FOR YOUR BUCK. NOW, WHAT DO YOU DO IF SOMEONE SHOWS UP WITHIN FOUR DAYS OF A TRAUMA? COLONEL ROBINSON DESCRIBED SCENARIOS HAVING UNITS WITH HIGH COMBAT, HIGH LOSSES, THE BOTTOM LINE AS MENTAL HEALTH PROFESSIONALS IS GET OUT OF THE WAY. BECAUSE INCONCLUSIVE EVIDENCE AT THIS POINT IN TIME FOR CPT AND TE, LESS THAN FOUR DAYS IS TOO EARLY, YOU SHOULD THINK ABOUT SAFETY, CALM, SUPPORT RECONNECTING WITH THE YIEWN, MAKING SURE LEADERS UNDERSTAND WHAT'S GOING ON WITH TEAM MEMBERS BECAUSE THAT'S THE FAMILY DEPLOYED ENVIRONMENT. NOW, THE PSYCHOLOGICAL FIRST AID THAT I MENTIONED, SOCIAL SPORE, BEING PRACTICED RIGHT NOW AND IS BEING STUDIED BUT WE DONE HAVE THE EVIDENCE IS INCONCLUSIVE AT THIS TIME AND DO NOT DO PSYCHOLOGICAL DEBRIEFING. THIS IS A VERY CONFUSION SLIDE BUT LE ME TELL YOU WHAT I MEAN. THE BOTTOM LINE IS META ANALYSIS WHERE THEY LOOKED AT PATIENTS WITH EXPOSED TO TRAUMA WHO HAVE PTSD SYMPTOMS. WHO HAVE ACUTE STRESS DISORDER SYMPTOMS, SOME SYMPTOMS, THEN LOOKED AT THOSE WITH ACUTE STRESS DISORDER WITH FULL CRITERIA, ONE IS SUB THRESHOLD, ANOTHER IS FULL CRITERIA AND THE THIRD GROUP IS EXCLUDED ANYBODY ELSE WHO DID NOT MEET FULL CRITERIA. THE BOTTOM LINE IS COGNITIVE TRAUMA FOCUSED CBT WORK BEST ONLY IF AN INDIVIDUAL MET FULL CRITERIA FOR ACUTE STRESS DISORRER. WHAT DOES THAT MEAN? IF YOU INTERVENE WHEN THEY DO NOT HAVE SYMPTOMS OR WHEN THEY HAVE A FEW SYMPTOMS, IT MAY NOT BE THAT GOOD. IT MAY NOT WORK. CPT AND PE MAY NOT WORK. IN OTHER WORDS, THIS IS WHERE YOU HAVE TO INTERVENE. SO THEY HAVE CROSSED THE REALM OF HAVING SUB THRESHOLD SYMPTOMS BUT THEY HAVE ACTUALLY GONE OVER INTO MEETING FULL CRITERIA FOR ACUTE STRESS DISORDER OR ACUTE PTSD. ACUTE STRESS DISORDER IS LESS THAN A MONOAND ACUTE PTSD IS ONE TO THREE MONTHS. SO YOU HAVE TO WAIT UNTIL THEY HAVE FULLY MANIFESTED SYMPTOMS BEFORE YOU INTERVENE WITH THE CPT OR PE. SO WHAT ARE THE CONCLUSIONS? THE CONCLUSIONS ARE FROM THE MEDICATION STAND POINT OF VIEW, WE HAVE NOT THE MESSAGE IS LOST IN TRANSLATION. WE HAVE TO GO BACK TO OUR COLLEAGUES AN FIND OUT HOW BEST WE CAN BRIDGE THE GAP AND I KNOW THAT MRMC IS DOING JUST THAT, TO FIGURE OUT WHAT ARE THE OTHER DRUGS WE CAN WORK ON THAT WE CAN USE TO PREVENT PTSD. TRAUMA FOCUSED CBT, COGNITIVE BEHAVIORAL THERAPY AND PROLONGED EXPOSURE IS CLEARLY THE FRONT RUNNER IN PREVENTION OF PTSD THAT WE HAVE RIGHT NOW. THE NEXT BULLET IS TREAT ONLY THOSE WHO MEET FULL CRITERIA FOR PTSD. THE SERVICE MEMBER WHOSE HAD COMBAT FRAITIONAL STRESS REACTION, THEY ARE -- THEY COULD BE TRANSYEN, COULD BE -- THEY COULD SUBSIDE WITH SLEEP AND REST AND SUPPORT. RATHER THAN MEDICATING THEM OR TALKING, DOING CPT AND PE. AND IT'S NEVER TOO LATE TO TREAT. SO AS YOU SAW WITH THE DELAYED PE GROUP, EVEN AFTER 12 WEEKS AFTER THE WAIT LIST, THEY GOT BACK AND STARTED ON PTE AND THEY ACTUALLY GOT BETTER. AND THEY GOT BETTER. SO THANK YOU FOR YOUR TIME. AND I'M OPEN FOR QUESTIONS. [APPLAUSE] YES. (OFF MIC) >> I THINK THAT'S COLONEL CASTRO'S FAVORITE BEEF THAT HE SAYS THAT RESILIENCE TRAINING SHOULD START IN SCHOOL. AND THEN THAT WAY WE BILL THE BEST SERVICE MEMBERS IF YOU CAN GIVE THEM THE SKILLS THAT THEY NEED WHILE THEY ARE IN ELEMENTARY AN MIDDLE SCHOOL, THERE'S PROBABLY THE BEST WAY. DOD WE DON'T HAVE A PROGRAM FOR THAT. NOT YET. YES, MA'AM. (OFF MIC) >> THANK YOU ALL FOR YOUR ATTENTION AND HAVE A GREAT WEEKEND. [APPLAUSE]