Behavioral/Mental Behavioral/Mental Health IssuesHealth Issues

Dr. Jodi R. Owen, Psy.D.Dr. Jodi R. Owen, Psy.D.Licensed Psychologist/Clinical Director Licensed Psychologist/Clinical Director

Capital Area Counseling, PierreCapital Area Counseling, Pierre

Behavioral Health Officer (CPT), 730Behavioral Health Officer (CPT), 730thth ASMC ASMC

August 14 2012

Briefly…Briefly…

……who I am and what I dowho I am and what I do ……how I wind up seeing a Soldierhow I wind up seeing a Soldier ……what happens from there?what happens from there?

Some ???s a Provider might ask Some ???s a Provider might ask (from general to specific)(from general to specific)

Have you served in the military? (“Thank Have you served in the military? (“Thank you for your service”)you for your service”)

What branch/unit?What branch/unit? Are you currently serving?... full-time or?Are you currently serving?... full-time or? What’s your job in the ________?What’s your job in the ________? Have you ever been deployed? Have you ever been deployed? What was that like for you?What was that like for you? Any ongoing issues about that? Any ongoing issues about that? What sorts of things do you struggle with? What sorts of things do you struggle with?

(Ask about sleep, mood, relationships, (Ask about sleep, mood, relationships, anger, alcohol use, etc.) anger, alcohol use, etc.)

Behavioral Health issuesBehavioral Health issues…in no particular order……in no particular order…

Post-traumatic Stress (symptoms/disorder)Post-traumatic Stress (symptoms/disorder) DepressionDepression Suicidal Thoughts/BehaviorSuicidal Thoughts/Behavior Traumatic Brain InjuryTraumatic Brain Injury Military Sexual TraumaMilitary Sexual Trauma Alcohol Use/AbuseAlcohol Use/Abuse Adjustment/Readjustment IssuesAdjustment/Readjustment Issues AngerAnger Relationship IssuesRelationship Issues Sleep DifficultiesSleep Difficulties Etc…Etc…

Post-Traumatic Stress (Disorder)Post-Traumatic Stress (Disorder)

Audience assessment…Audience assessment…

Post-traumatic Stress (Disorder?)Post-traumatic Stress (Disorder?)(paraphrased from DSM-IV-TR)(paraphrased from DSM-IV-TR)

A) Traumatic eventA) Traumatic event B) ReexperiencingB) Reexperiencing C) AvoidanceC) Avoidance D) ArousalD) Arousal E) DurationE) Duration F) Causes distress/impairmentF) Causes distress/impairment

A. Traumatic EventA. Traumatic Event

1) person experienced, witnessed, or 1) person experienced, witnessed, or was confronted with an event/events was confronted with an event/events that involved actual or threatened that involved actual or threatened death or serious injury, or a threat to death or serious injury, or a threat to the physical integrity of self or others the physical integrity of self or others AND…AND…

2) person’s response involved 2) person’s response involved intense fear, helplessness, or horrorintense fear, helplessness, or horror

B. Traumatic event is persistently B. Traumatic event is persistently reexperienced (one or more)…reexperienced (one or more)…

1) recurrent and intrusive distressing recollections of the 1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptionsevent, including images, thoughts, or perceptions

2) recurrent distressing dreams of the event2) recurrent distressing dreams of the event

3) acting or feeling as if event were recurring (reliving, 3) acting or feeling as if event were recurring (reliving, illusions, hallucinations, dissociative flashback episodes)illusions, hallucinations, dissociative flashback episodes)

4) intense psychological distress at exposure to internal or 4) intense psychological distress at exposure to internal or external cues that remind of the eventexternal cues that remind of the event

5) physiological reactivity on exposure to cues5) physiological reactivity on exposure to cues

C. Persistent avoidance of stimuli C. Persistent avoidance of stimuli associated with associated with

the trauma and numbing of general responsivenessthe trauma and numbing of general responsiveness (3 or more)… (3 or more)…

1) efforts to avoid thoughts, feelings, or conversations associated 1) efforts to avoid thoughts, feelings, or conversations associated with the traumawith the trauma

2) efforts to avoid activities, places, or people that arouse 2) efforts to avoid activities, places, or people that arouse recollections of the traumarecollections of the trauma

3) inability to recall important aspect of the trauma3) inability to recall important aspect of the trauma

4) diminished interest or participation in activities4) diminished interest or participation in activities

5) feeling of detachment/estrangement from others5) feeling of detachment/estrangement from others

6) restricted range of affect (e.g., unable to have loving feelings)6) restricted range of affect (e.g., unable to have loving feelings)

7) sense of foreshortened future (e.g., does not expect to have 7) sense of foreshortened future (e.g., does not expect to have career, marriage, children, normal lifespan)career, marriage, children, normal lifespan)

D. Persistent symptoms of D. Persistent symptoms of increased arousal (2 or more…)increased arousal (2 or more…)

1) difficulty falling or staying asleep1) difficulty falling or staying asleep

2) irritability or outbursts of anger2) irritability or outbursts of anger

3) difficulty concentrating3) difficulty concentrating

4) hypervigilance4) hypervigilance

5) exaggerated startle response5) exaggerated startle response

E. DurationE. Duration

Duration of the symptoms = greater Duration of the symptoms = greater than…than…

1 month1 month

F. Causes F. Causes clinically significant distress clinically significant distress or impairmentor impairment in social, occupational, or in social, occupational, or

other important areas of functioningother important areas of functioning

?? What does this mean ???? What does this mean ??

Some questions to ask…Some questions to ask…

(If deployed) Any events during (If deployed) Any events during deployment that were very upsetting deployment that were very upsetting or that you still struggle with?or that you still struggle with?

(If not deployed) Any events in your (If not deployed) Any events in your history that were very upsetting and history that were very upsetting and that you still struggle with?that you still struggle with?

More questions…More questions…

How’s your sleep?How’s your sleep? How’s your mood (anger, sadness, How’s your mood (anger, sadness,

etc?) etc?) Any issues with thinking about or Any issues with thinking about or

talking about ________(the traumatic talking about ________(the traumatic event(s)?event(s)?

How’s your social/recreational life? How’s your social/recreational life? (Are they engaged/participating in (Are they engaged/participating in life?) What do you do for fun?life?) What do you do for fun?

DepressionDepression Whether deployed or not, some of our soldiers Whether deployed or not, some of our soldiers

struggle with depressionstruggle with depression

Younger soldiers deal with transitioning from Younger soldiers deal with transitioning from adolescence to adulthood, relationship issues, adolescence to adulthood, relationship issues, schooling, career, financial, whether to stay in schooling, career, financial, whether to stay in military, etc.military, etc.

Older soldiers deal with medical, financial, “when Older soldiers deal with medical, financial, “when to retire”, etc.to retire”, etc.

Readjustment after deploymentReadjustment after deployment

Suicidal Thoughts/BehaviorSuicidal Thoughts/Behavior

Suicide rate in the military is Suicide rate in the military is approaching general populationapproaching general population

Not necessarily related to Not necessarily related to deployment; many have notdeployment; many have not

Some say deploying is a protective Some say deploying is a protective factor, builds resilience, etcfactor, builds resilience, etc

Some ???sSome ???s How would you describe your mood most of the time?How would you describe your mood most of the time?

Do you find yourself feeling sad or down? Do you Do you find yourself feeling sad or down? Do you cry?cry?

How’s your sleep/concentration/energy level?How’s your sleep/concentration/energy level?

Ever feel hopeless?Ever feel hopeless?

When it gets bad, how bad does it get? When it gets bad, how bad does it get?

Do you think about hurting yourself or taking your Do you think about hurting yourself or taking your own life?own life?

If they say “no”…If they say “no”… Ask “NEVER—EVER thought about it?” Ask “NEVER—EVER thought about it?”

(it’s not unusual for people to have at least (it’s not unusual for people to have at least thought thought about suicide at some point in life)about suicide at some point in life)

They may admit thoughts in the past, but nothing They may admit thoughts in the past, but nothing current or beyond “thought”….normalize this…current or beyond “thought”….normalize this…offer support.offer support.

““A lot of people think about it at some point in A lot of people think about it at some point in their lives…I’m glad you’re finding better coping their lives…I’m glad you’re finding better coping now”.now”.

But do not be surprised…But do not be surprised…

……if your patient grudgingly says if your patient grudgingly says “yeah, sometimes—I’ve thought “yeah, sometimes—I’ve thought about it sometimes…” OR “I think about it sometimes…” OR “I think about it sometimes…”about it sometimes…”

(this is not time, nor cause for panic(this is not time, nor cause for panic—stay calm and supportive--this is an —stay calm and supportive--this is an opportunity to ask more questions…opportunity to ask more questions…and help your patient)and help your patient)

If they say “yes”, then ask…If they say “yes”, then ask… You said “yeah, sometimes”…When was that? You said “yeah, sometimes”…When was that?

Are you having those thoughts lately? Are you having those thoughts lately?

What kinds of things were you/are you thinking What kinds of things were you/are you thinking about?about?

Have you talked to anyone about it, gotten some Have you talked to anyone about it, gotten some help with it?help with it?

How seriously have you been considering it?How seriously have you been considering it?

Have you thought about how you would do it?Have you thought about how you would do it?

Decision time…Decision time…

If they are seriously considering If they are seriously considering suicide and have a plan…suicide and have a plan…

……and do not seem willing for and do not seem willing for immediate intervention…immediate intervention…

Implement emergency proceduresImplement emergency procedures

However…However…

……If they are seriously considering If they are seriously considering suicide and have a plan…suicide and have a plan…

……but say they want and will accept but say they want and will accept help…help…

You must decide…You must decide…

1) …to refer for immediate follow-up 1) …to refer for immediate follow-up care with a MH professional (if care with a MH professional (if available, depending on risk/risk-available, depending on risk/risk-tolerance)tolerance)

2) …to implement emergency 2) …to implement emergency proceduresprocedures

3)…??3)…??

Traumatic Brain InjuryTraumatic Brain Injury

Injury to the brain by sudden force, Injury to the brain by sudden force, concussive blast, or explosion.concussive blast, or explosion.

Can be mild, moderate, or severeCan be mild, moderate, or severe

Mild TBI (mTBI) is the most common, Mild TBI (mTBI) is the most common, and may or may not be diagnosed.and may or may not be diagnosed.

TBI PrevalenceTBI Prevalence

Veteran’s advocates believe that Veteran’s advocates believe that between 10 and 20% of Iraq between 10 and 20% of Iraq veterans, or 150,000 and 300,000 veterans, or 150,000 and 300,000 service members have some level of service members have some level of TBI.TBI.

30% of soldiers admitted to Walter 30% of soldiers admitted to Walter Reed Army Medical Center have Reed Army Medical Center have been diagnosed as having had a TBIbeen diagnosed as having had a TBI

TBI symptomsTBI symptoms

Persistent headache or neck pain Persistent headache or neck pain Sensitivity to light and noise Sensitivity to light and noise Loss of balance Loss of balance Changes in sleep patterns Changes in sleep patterns Feeling tired all the time, lacking energy Feeling tired all the time, lacking energy Ringing in the ears Ringing in the ears Loss of sense of smell and taste Loss of sense of smell and taste Slowness in thinking, acting, speaking or Slowness in thinking, acting, speaking or

reading reading

TBI symptoms, cont’dTBI symptoms, cont’d Symptoms that may appear to be mental health Symptoms that may appear to be mental health

conditions conditions – Sudden mood changes for little or no reason Sudden mood changes for little or no reason – Difficulty managing relationships Difficulty managing relationships – Chronic anxiety, depression, apathyChronic anxiety, depression, apathy– Sleep difficultySleep difficulty

Short term memory loss, disorganization, losing Short term memory loss, disorganization, losing things things

Getting lost or easily confused Getting lost or easily confused Having more trouble than usual with Having more trouble than usual with

– Paying attention or concentrating Paying attention or concentrating – Organizing daily tasks Organizing daily tasks – Making decisionsMaking decisions

AskAsk Have you ever had a head injury (in sports, car Have you ever had a head injury (in sports, car

accident, combat)??accident, combat)??

Were you “knocked out”?Were you “knocked out”?

How long?How long?

Treatment?Treatment?

Symptoms? What changes do you or others Symptoms? What changes do you or others notice?notice?

Military Sexual TraumaMilitary Sexual Trauma

"Military sexual trauma" or MST is the term used "Military sexual trauma" or MST is the term used by the Department of Veterans Affairs to refer to by the Department of Veterans Affairs to refer to experiences of sexual assault or repeated, experiences of sexual assault or repeated,

threatening acts of sexual harassment.threatening acts of sexual harassment.

VA screenings show reports by 1 in 5 females, 1 VA screenings show reports by 1 in 5 females, 1 in 100 malesin 100 males

(see brochure)(see brochure)

MST continued…MST continued…

……to be defined and treated as MST, to be defined and treated as MST, must have occurred while on active must have occurred while on active duty, or active duty for trainingduty, or active duty for training

Treated for free at VA, regardless of Treated for free at VA, regardless of service-connection or other VA service-connection or other VA eligibilityeligibility

2 MST Coordinators in SD2 MST Coordinators in SD

Christi Kitzelman, VA Black Hills, 605-718-Christi Kitzelman, VA Black Hills, 605-718-1095, ext. 30181095, ext. 3018

Robin Carter-Visscher, Ph.D., Sioux Falls Robin Carter-Visscher, Ph.D., Sioux Falls VA HCS, 605-336-3230, ext. 6923, VA HCS, 605-336-3230, ext. 6923, robin.carter-visscher@va.govrobin.carter-visscher@va.gov

These next 8 slides came directly These next 8 slides came directly from Dr. Carter-Visscher, MST from Dr. Carter-Visscher, MST CoordinatorCoordinator

Responses to DisclosureResponses to DisclosureOften, you may be the first person the survivor has ever told Often, you may be the first person the survivor has ever told

about his or her experiences. An empathic, supportive about his or her experiences. An empathic, supportive response has the power to be tremendously healing.response has the power to be tremendously healing.

Provide validation and empathy: Provide validation and empathy: “I’m sorry this “I’m sorry this happened to you while you were serving your country”happened to you while you were serving your country”

Provide education and normalization: Provide education and normalization: “Many Veterans “Many Veterans have had experiences like yours and for some, it can have had experiences like yours and for some, it can continue to affect them even many years later. continue to affect them even many years later. People can recover, however.”People can recover, however.”

Assess current difficulties: Assess current difficulties: “How much does this “How much does this continue to affect your daily life today? In what continue to affect your daily life today? In what ways?”ways?”

Assess social support: Assess social support: “Have you ever been able to “Have you ever been able to talk to anyone about this before?”talk to anyone about this before?”

Responses to Disclosure Responses to Disclosure (cont.)(cont.)

Assess implications for care: Assess implications for care: “How do you think this “How do you think this will affect our work together?”will affect our work together?”

Offer other VA services: Offer other VA services: “Some of the Veterans I’ve “Some of the Veterans I’ve met with have found it helpful to talk with someone met with have found it helpful to talk with someone about their experiences. The VA offers free about their experiences. The VA offers free counseling related to MST. Would it be okay if I asked counseling related to MST. Would it be okay if I asked this facility’s MST Coordinator to be in touch with you this facility’s MST Coordinator to be in touch with you to tell you about the services available? After talking to tell you about the services available? After talking with him/her about your options, you could decide if with him/her about your options, you could decide if you wanted to take it any further.”you wanted to take it any further.”– Not everyone needs counseling: Not everyone needs counseling: “If you ever “If you ever

change your mind and want to speak to someone, change your mind and want to speak to someone, just let me know.”just let me know.”

Offer a way to learn more: Offer a way to learn more: – MST brochureMST brochure– www.mentalhealth.va.govwww.mentalhealth.va.gov

Adapt care when necessaryAdapt care when necessary

Patient-provider relationship can resemble some Patient-provider relationship can resemble some aspects of the victim-perpetrator relationshipaspects of the victim-perpetrator relationship– Power differentialPower differential– Being in physical painBeing in physical pain– Physical exposure and touching of intimate Physical exposure and touching of intimate

body partsbody parts– Feeling a lack of control over the situationFeeling a lack of control over the situation– Perpetrator may have been a healthcare Perpetrator may have been a healthcare

providerprovider

Signs That a Veteran May Be Having an Signs That a Veteran May Be Having an MST-Related ReactionMST-Related Reaction

Veteran is highly anxious, agitated, or “jumpy”Veteran is highly anxious, agitated, or “jumpy” Appears tearful during exams, with no obvious causeAppears tearful during exams, with no obvious cause Physically withdraws, or becomes very quiet or “frozen”Physically withdraws, or becomes very quiet or “frozen” Has difficulty concentrating, is very distractible, or seems Has difficulty concentrating, is very distractible, or seems

disorienteddisoriented Minimizes symptoms that might require an intrusive examMinimizes symptoms that might require an intrusive exam Cancels appointments or refuses needed care Cancels appointments or refuses needed care Exhibits strong emotional reactions to relatively benign Exhibits strong emotional reactions to relatively benign

interactions (e.g., crying, panic, irritability, anger)interactions (e.g., crying, panic, irritability, anger) Experiences flashbacks or dissociates during appointmentsExperiences flashbacks or dissociates during appointments

Strategies for Managing Reactions to Exams Strategies for Managing Reactions to Exams and Proceduresand Procedures

Anticipate and prepareAnticipate and prepare– Explain that it is very common for MST survivors to have Explain that it is very common for MST survivors to have

strong reactions to certain proceduresstrong reactions to certain procedures– Describe the procedure and ask the patient what he or Describe the procedure and ask the patient what he or

she anticipates will be the most difficult partshe anticipates will be the most difficult part– Brainstorm coping strategies with patientBrainstorm coping strategies with patient

Seeing procedure suite in advanceSeeing procedure suite in advance Having a chaperone or family member present Having a chaperone or family member present SedationSedation Distraction (e.g., headphones, music, focused Distraction (e.g., headphones, music, focused

breathing, discussion of pleasant event)breathing, discussion of pleasant event) Things that have worked in the pastThings that have worked in the past

Ensure the Veteran feels in controlEnsure the Veteran feels in control– Ask permission before touchingAsk permission before touching– Let the patient know you will stop if he/she Let the patient know you will stop if he/she

asks you toasks you to– Keep a running commentary of exactly what Keep a running commentary of exactly what

you are doing and about to doyou are doing and about to do– Check in with him/her periodically, to ask Check in with him/her periodically, to ask

how he/she is doinghow he/she is doing Respect reactionsRespect reactions

– Never ignore or dismiss a patient’s request or Never ignore or dismiss a patient’s request or expression of distressexpression of distress

Strategies for Managing Reactions to Exams Strategies for Managing Reactions to Exams and Procedures (cont.)and Procedures (cont.)

Simple changes can reduce your patient’s distress and strengthen the patient-provider relationship. Simple changes can reduce your patient’s distress and strengthen the patient-provider relationship.

Whenever possible, have conversations while the patient is fully dressedWhenever possible, have conversations while the patient is fully dressed Sit at the same level as the patient, preferably without a desk between you. Make eye contact.Sit at the same level as the patient, preferably without a desk between you. Make eye contact. Give the patient options and choices whenever possible.Give the patient options and choices whenever possible. Be transparent; explain your reasoning for choosing certain courses of action.Be transparent; explain your reasoning for choosing certain courses of action. View the patient as an expert on his or her own body and functioning. Take complaints of pain or vague View the patient as an expert on his or her own body and functioning. Take complaints of pain or vague

symptoms seriously. symptoms seriously. Privacy (exam rooms, bathrooms)Privacy (exam rooms, bathrooms)

Handling Strong ReactionsHandling Strong Reactions It can be helpful to:It can be helpful to:

– Listen empathically, acknowledging their Listen empathically, acknowledging their distress.distress.

– Apologize, if appropriate.Apologize, if appropriate.– Explain the reasoning behind your behavior.Explain the reasoning behind your behavior.– Think about the reaction as likely due to Think about the reaction as likely due to

feelings of helplessness, of vulnerability, or of feelings of helplessness, of vulnerability, or of being unsafe. being unsafe.

Avoid:Avoid:– Touching the patient without his/her consentTouching the patient without his/her consent– Moving closer or “invading their space”Moving closer or “invading their space”– Making loud noises (e.g., hand clap, finger snapping)Making loud noises (e.g., hand clap, finger snapping)

Alcohol AbuseAlcohol Abuse(from DSM-IV-TR)(from DSM-IV-TR)

A. A maladaptive pattern of alcohol use leading to A. A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as clinically significant impairment or distress, as manifested by one (or more) of the following, manifested by one (or more) of the following, occurring within a 12-month period:occurring within a 12-month period:

(1) recurrent alcohol use resulting in a failure to (1) recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-performance related to alcohol use; alcohol-related absences, suspensions, or expulsions related absences, suspensions, or expulsions from school; neglect of children or household)from school; neglect of children or household)

(2) recurrent alcohol use in situations in which it (2) recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an is physically hazardous (e.g., driving an automobile or operating a machine when automobile or operating a machine when impaired by alcohol use) impaired by alcohol use)

Alcohol Abuse, cont’d…Alcohol Abuse, cont’d… (3) recurrent alcohol-related legal problems (e.g., (3) recurrent alcohol-related legal problems (e.g.,

arrests for alcohol-related disorderly conduct) arrests for alcohol-related disorderly conduct)

(4) continued alcohol use despite having (4) continued alcohol use despite having persistent or recurrent social or interpersonal persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about the alcohol (e.g., arguments with spouse about consequences of Intoxication, physical fights)consequences of Intoxication, physical fights)

B. The symptoms have never met the criteria for B. The symptoms have never met the criteria for Alcohol DependenceAlcohol Dependence..

Alcohol DependenceAlcohol Dependence(DSM-IV-TR)(DSM-IV-TR)

A maladaptive pattern of alcohol use, leading to clinically A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-more) of the following, occurring at any time in the same 12-month period:month period:

(1) tolerance, as defined by either of the following: (1) tolerance, as defined by either of the following: (a) a need for markedly increased amounts of alcohol to achieve (a) a need for markedly increased amounts of alcohol to achieve

Intoxication or desired effect Intoxication or desired effect (b) markedly diminished effect with continued use of the same (b) markedly diminished effect with continued use of the same

amount of alcoholamount of alcohol (2) Withdrawal, as manifested by either of the following: (2) Withdrawal, as manifested by either of the following: (a) autonomic hyperactivity (e.g., sweating or pulse rate greater (a) autonomic hyperactivity (e.g., sweating or pulse rate greater

than 100), increased hand tremor, insomnia, nausea/vomiting, than 100), increased hand tremor, insomnia, nausea/vomiting, transient visual, tactile, or auditory hallucinations or illusions, transient visual, tactile, or auditory hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizures psychomotor agitation, anxiety, grand mal seizures

(b) alcohol (or a closely related drug such as valium) is used to (b) alcohol (or a closely related drug such as valium) is used to relieve or avoid withdrawal symptoms relieve or avoid withdrawal symptoms

Alcohol Dependence cont’d…Alcohol Dependence cont’d… (3) alcohol is often used in larger amounts or over a longer period (3) alcohol is often used in larger amounts or over a longer period

than was intendedthan was intended (4) there is a persistent desire or unsuccessful efforts to cut down (4) there is a persistent desire or unsuccessful efforts to cut down

or control alcohol useor control alcohol use (5) a great deal of time is spent in activities necessary to obtain (5) a great deal of time is spent in activities necessary to obtain

alcohol, use alcohol, or recover from its effectsalcohol, use alcohol, or recover from its effects (6) important social, occupational, or recreational activities are (6) important social, occupational, or recreational activities are

given up or reduced because of alcohol usegiven up or reduced because of alcohol use (7) alcohol use is continued despite knowledge of having a (7) alcohol use is continued despite knowledge of having a

persistent or recurrent physical or psychological problem that is persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g. likely to have been caused or exacerbated by alcohol (e.g. continued drinking despite recognition that an ulcer was made continued drinking despite recognition that an ulcer was made worse by alcohol consumption) worse by alcohol consumption)

Alcohol use and educationAlcohol use and education Some soldiers meet criteria for Abuse, smaller number for Some soldiers meet criteria for Abuse, smaller number for

Dependence—referred for treatment (will discuss in referral Dependence—referred for treatment (will discuss in referral segment)segment)

More often, binge-drinking (often on drill weekends), that may More often, binge-drinking (often on drill weekends), that may meet one of the criteria for “abuse”, but does not cause “distress”meet one of the criteria for “abuse”, but does not cause “distress”

Self-medicating emotional or physical painSelf-medicating emotional or physical pain

Help with sleepHelp with sleep

Educate about “safe use” versus “harmful use”.Educate about “safe use” versus “harmful use”.

Fewer than 2/day, 14 per week, 2% of Americans consume 98% of Fewer than 2/day, 14 per week, 2% of Americans consume 98% of the alcoholthe alcohol

Discuss “normal” in their circles versus other circlesDiscuss “normal” in their circles versus other circles

AskAsk How much do you drink?How much do you drink?

Any trouble at work, school, etc?Any trouble at work, school, etc?

Do you drink and drive or do other things where you or Do you drink and drive or do other things where you or others could get hurt?others could get hurt?

Any legal issues related to drinking? (DUI, assault, etc)Any legal issues related to drinking? (DUI, assault, etc)

Anyone saying they’re concerned about your drinking?Anyone saying they’re concerned about your drinking?

Does it take more now to get the same buzz than it used Does it take more now to get the same buzz than it used to? (tolerance)to? (tolerance)

Discuss “hang-overs” (withdrawal?)Discuss “hang-overs” (withdrawal?)

AskAsk Do you drink more than you meant to? Do you drink more than you meant to?

Ever tried to “cut down”?Ever tried to “cut down”?

Are you spending more time drinking than you Are you spending more time drinking than you meant to? (or recovering?)meant to? (or recovering?)

Are you “not doing” things with friends or family Are you “not doing” things with friends or family and drinking instead?and drinking instead?

Any physical or health problems related to Any physical or health problems related to drinking?drinking?

Additional BH issuesAdditional BH issues

Adjustment/readjustment-family obligations, Adjustment/readjustment-family obligations, absence from work, renegotiating relationshipsabsence from work, renegotiating relationships

Anger, low frustration tolerance, short fuseAnger, low frustration tolerance, short fuse

Relationship Issues—young families, domestic Relationship Issues—young families, domestic violenceviolence

Sleep (50+ to 90+% of Veterans who have Sleep (50+ to 90+% of Veterans who have deployed report sleep problems)deployed report sleep problems)

When Symptoms OverlapWhen Symptoms Overlap Having TBI increases risk for Sleep Apnea, which Having TBI increases risk for Sleep Apnea, which

puts one at risk for heart attackputs one at risk for heart attack

Sleep difficulties are common with Depression, Sleep difficulties are common with Depression, PTSD, TBI, alcohol abuse/dependence, and in PTSD, TBI, alcohol abuse/dependence, and in Veterans who have none of the above, but have Veterans who have none of the above, but have been deployedbeen deployed

Anger is common in PTSD, Depression, Anger is common in PTSD, Depression, Alcoholism, or can stand aloneAlcoholism, or can stand alone

Lack of energy/interest happens in Depression, Lack of energy/interest happens in Depression, TBI, PTSD, or simple lack of sleepTBI, PTSD, or simple lack of sleep

Take-home MessageTake-home Message Rural providers are TREMENDOUSLY important as Rural providers are TREMENDOUSLY important as

first-line screeners for Behavioral Health/Mental first-line screeners for Behavioral Health/Mental Health and Addiction Issues.Health and Addiction Issues.

These issues can be complicated, complex, and These issues can be complicated, complex, and confusing.confusing.

You are not expected to know everything!!You are not expected to know everything!!

Utilize continuum of care and refer to specialists Utilize continuum of care and refer to specialists when need be when need be

Thanks for all you do!!Thanks for all you do!!

Thanks for your attention!!!Thanks for your attention!!!

Any questions?Any questions?

jowen@cacsnet.orgjowen@cacsnet.org