Veteran Psychiatry in the US Elspeth Cameron Ritchie • Maria D

Veteran Psychiatry in the US Elspeth Cameron Ritchie • Maria D. Llorente Editors

Veteran Psychiatry in the US Optimizing Clinical Outcomes Editors Elspeth Cameron Ritchie Maria D. Llorente Mental Health Community Georgetown University School of Medicine Based Outpatient Washington DC VA Medical Center Georgetown University Department of Psychiatry Mental Health Community Washington, DC Based Outpatient USA Silver Spring, MD USA

ISBN 978-3-030-05383-3 ISBN 978-3-030-05384-0 (eBook) https://doi.org/10.1007/978-3-030-05384-0

Library of Congress Control Number: 2019934812

© Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland This volume is dedicated to US service members, veterans, and their families with acknowledgment to many new contributions to science and practice in the areas of PTSD, TBI, and other psychological responses to the stress of deployment and combat. Knowledge gained through clinical trials in diverse areas, including schizophrenia, bipolar disorder, depression, sexual trauma, substance abuse, and population health, is shared here in hopes of enriching the awareness and education of present and future generations of medical students, residents, psychiatrists, primary care physicians, psychologists, and other clinical disciplines. Preface

Introduction

War and politics are always intertwined, and both impact the health care of the active duty service member. The health of veterans may be still more sensitive to this interconnection because politicians often rally to their cause in order to further their own careers. The current President fires up his base by stressing veterans’ health issues, although it is unclear whether his efforts are helpful or harmful. His VA Secretaries and Senior Executives seem to come and go as if through a revolving door. At the time of the writing of this preface, a former Navy aviator, prisoner of war, and Senator, John McCain, has just been laid to rest in the cemetery at the Naval Academy. Most agree that this veteran epitomized the principles of service to coun- try and leadership in government, but it’s difficult for one person, even a remarkable one, to prevail when national perspectives and aims are so much in conflict. Unquestionably, military service and the health of those who serve are a top priority of the nations’ leaders whether in war or peace. This volume seeks to go beyond the politics to lay out what is known and not known about the best way to care for veterans facing the psychological challenges of war.

Background

There is a rich literature on the psychological issues affecting the active duty military. The Textbooks of Military Medicine from the Borden Institute summarize lessons learned from numerous aspects of combat surgery, medicine, and psychiatry. For psychiatry, there are two volumes which focus on lessons from the first two World Wars and from the military psychiatry in peacetime [1, 2]. Two more recent psychiatric texts concentrate on lessons learned from the Vietnam War, the Gulf War, and the wars on Afghanistan and Iraq [3, 4]. On the veteran side, the Vietnam War spawned a rich literature focusing on PTSD. Military sexual trauma has also been an area of considerable research and publication.

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More recently, the Long War, i.e., the wars in Iraq and Afghanistan since 9/11, has led to numerous publications on behavioral health issues in active duty service members. Groundbreaking research on behavioral health issues in the recent the- aters of war has mounted rapidly [5–8]. Much of it has been published in high- profile civilian journals, such as the NEJM and JAMA, rather than the traditional venues of military medicine. On the other hand, and surprisingly, despite all the research published on psychiatric health and illness in veterans, this will be the first volume that presents a com- prehensive array of topics on psychiatric issues for veterans between one set of book covers.

Discussion of the Volume

There is often confusion about what is a veteran, compared to the active duty military. Further, it is safe to assume that many readers will not even be sure what terms such as “veterans” and “combat veterans” really mean. These are further defined herein. Some chapters focus only on veterans, while others include service members and the transitions between military and civilian life. Another question is “what is the VA?” Many think the Military Health System (MHS) and the Veterans Health Administration (VHA) system are the same, but they are actually distinct health-care systems. In turn, the VHA is part of the broader Veterans Administration (VA). So this volume opens with some definitions and context about these health-care systems [9]. The importance of the VHA is highlighted in the chapter by Dr. Kudler, who worked in it for almost 40 years and ended his career leading the mental health system. Another chapter by Dr. Cheryl Lowman outlines some of the best practices present in the VA. Veterans generally accumulate trauma during their military and/or wartime service, which may lead to diagnoses of PTSD, military sexual trauma (MST), or traumatic brain injury (TBI). Much has been published in the psychiatric and psychological literature on these topics, as mentioned above. There are clearly defined clinical practice guidelines and evidence-based practices for each. However, while important, these topics alone do not define the broad range of combat and deployment stress and the veteran experiences. Of relevance, the veterans usually enter the military in their late teens or early 20s. Their past lives include, in some cases, histories of depression, bipolar illness, psychotic illnesses, substance use, and physical and/or sexual trauma. Potential recruits may or may not disclose these conditions. Although there are some screen- ing protocols in place, there is no easy way to detect this prior history. Thus treatment of veterans must include common psychiatric illnesses that occur in the civilian world as well. Professionals and the public at large are increasingly aware of the significance of past history of head trauma and its possible consequences for military members at war. PTSD and TBI often co-occur as a result of combat, as a result to exposure to Preface ix bombs and other weapons. Of course other injuries do as well, leading to short- or long-term pain and disability. Suicide and opioid safety are critically important issues for civilians and the military alike. Both may reflect a combination of issues stemming from premilitary experience, service in war, and readjustment to civilian life. The chapters in this volume cover these topics in more detail. Other veteran topics have received less attention in civilian clinical journals. These include psychosis, bipolar illness, depression, and homelessness among recent veterans. This volume contains chapters on these issues. It also expands the literature on smaller subsets of veterans including female, gay, lesbian, and trans- gendered veterans.

Conclusion

Wars, even this long one, are relatively brief, compared with the long tail of their impact on the health of combat veterans. We anticipate that the psychological sequelae of the wars since 9/11 will last for decades. This volume seeks to deepen the understanding of the health-care systems designed for service members and veterans as well as the specific psychiatric disorders and problem behaviors which they are prone to. It builds upon the work of numerous distinguished psychiatrists whose work has focused on American military and VA health systems. They include Thomas Salmon, Albert Glass, Kenneth Artiss, Frank Jones, Harry Holloway, Norman (Mike) Camp, Paul Errera, Art Blank, Robert Ursano, Charles Engel, and Charles Hoge. Many of these authors have been instrumental in the publications mentioned above. The authors in this current volume have also either been major contributors or hopefully will be in their future professional careers. Finally, this volume also seeks to honor the blood, sweat, and sacrifice of America’s sons and daughters: our nation’s military and veterans.

Silver Spring, MD, USA Elspeth Cameron Ritchie Washington, DC, USA Maria D. Llorente x Preface

References

1. Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, editors. War psychiatry, textbook of military medicine, Borden Pavilion. Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute; 1995. 2. Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, editors. Military psychiatry preparing in peace for war, textbook of military medicine, Borden Pavilion. Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute; 1993. 3. Ritchie EC. Senior Editor, Combat and operational behavioral health, textbook of military medicine, Borden Pavilion. Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute; 2011. 4. Ritchie EC, Senior Editor. Forensic and ethical issues in military behavioral health. Textbook of military medicine, Borden Pavilion. Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute; 2014. 5. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat Duty in Iraq and Afghanistan, mental health problems, and barriers to care, N Engl J Med 2004;351:13–22. 6. Ursano RJ, Kessler KC, Naifeh JA, et al. Associations of time-related deployment variables with risk of suicide attempt among soldiers: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry 2018;75(6):596–604. 7. Nock MK, Stein MB, Heerings SG et al. Prevalence and correlates of suicidal behavior among soldiers: results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS). JAMA Psychiatry. 2014;71(5):514–22. 8. Galloway MS, Millikan A, Bell M, Ritchie EC. Epidemiological consultation teams. In: Ritchie EC, editor. Forensic and ethical issues in military behavioral health. Textbook of military medicine, Borden Institute; 2014. 9. Ritchie EC. The DoD and VA health care system overview. In: Cozza S, Goldenberg M, editors. Clinical manual for the care of military service members, veterans and their families, APPI; 2014. Contents

Part I Overview of the VA and Military 1 Introduction �� 3 Elspeth Cameron Ritchie, Harold Stephen Kudler, and Robert L. Koffman 2 Outline of Military Culture and Military and VA Health Systems �� 9 Elspeth Cameron Ritchie 3 Psychiatry in the United States Department of Veterans Affairs: A History and a Future �� 17 Harold Stephen Kudler 4 Optimizing Clinical Outcomes in VA Mental Health Care �� 29 Cheryl A. Lowman

Part II Clinical Issues—General 5 Military and Veteran Suicide Prevention �� 51 David A. Jobes, Leslie A. Haddock, and Michael R. Olivares 6 Treatment for Trauma-Related Disorders: The “Three Buckets” Model �� 73 Elspeth Cameron Ritchie, Rachel M. Sullivan, and Kyle J. Gray 7 Treatment-Resistant Depression Among US Military Veterans �� 93 R. Gregory Lande 8 Psychotic Disorders and Best Models of Care �� 113 Philip M. Yam, Dinesh Mittal, and Ayman H. Fanous 9 Alcohol and Alcohol Use Disorder �� 135 Thomas W. Meeks, Nicole M. Bekman, Nicole M. Lanouette, Kathryn A. Yung, and Ryan P. Vienna 10 Alcohol Pharmacotherapy �� 157 Jasmine Carpenter and Shannon Tulk

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11 Opiate Use in the Military Context �� 169 Mike Colston 12 Use of Stimulants for ADHD and TBI in Veterans �� 177 Donna L. Ticknor and Antoinette M. Valenti 13 Use of Complementary and Integrative Health for Chronic Pain Management �� 191 Marina A. Khusid, Elissa L. Stern, and Kathleen Reed 14 Traumatic Brain Injury �� 211 Blessen C. Eapen and Bruno Subbarao 15 Homeless Veterans and Mental Health �� 233 Kaitlin Slaven and Maria D. Llorente 16 Contextual Frameworks for Addressing Risk and Fostering Resilience Among Sexual and Gender Minority Veterans �� 241 Rebecca Gitlin and Michael R. Kauth 17 Older Veterans �� 265 John T. Little, Bryan A. Llorente, and Maria D. Llorente 18 Women Veterans �� 281 Kasey M. Llorente, Keelan K. O’Connell, Margaret Valverde, and Elspeth Cameron Ritchie 19 Military Environmental Exposures and Mental Health �� 299 Matthew J. Reinhard, Michelle Kennedy Prisco, Nicholas G. Lezama, and Elspeth Cameron Ritchie 20 Neuropsychiatric Quinism: Chronic Encephalopathy Caused by Poisoning by Mefloquine and Related Quinoline Drugs �� 315 Remington L. Nevin 21 Listening to Trauma, and Caring for the Caregiver: A Psychodynamic Reflection in the Age of Burnout �� 333 Joseph E. Wise

Index �� 343 Contributors

Nicole M. Bekman, PhD Naval Medical Center San Diego, Substance Abuse Rehabilitation Program, San Diego, CA, USA Jasmine Carpenter, PharmD, BCPS, BCPP Veterans Affairs Medical Center, Washington DC, Pharmacy Service/Mental Health Service, Washington, DC, USA Mike Colston, MD Fort Belvoir Community Hospital, Mental Health Department, Fort Belvoir, VA, USA Blessen C. Eapen, MD Chief, Physical Medicine and Rehabilitation,VA Greater Los Angeles Health Care System, Associate Professor, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA Ayman H. Fanous, MD SUNY Downstate Medical Center, Psychiatry and Behavioral Sciences, Brooklyn, NY, USA Rebecca Gitlin, PhD Los Angeles County Department of Mental Health, Los Angeles, CA, USA Kyle J. Gray, MD, MA Walter Reed National Military Medical Center, Behavioral Health, Bethesda, MD, USA Leslie A. Haddock, BS Department of Psychology, The Catholic University of America, Washington, DC, USA David A. Jobes, PhD Department of Psychology, The Catholic University of America, Washington, DC, USA Michael R. Kauth, PhD VHA LGBT Health Program, Washington, DC, USA VA South Central Mental Illness Research, Education, and Clinical Center, Houston, TX, USA Department of Psychiatry, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA Marina A. Khusid, MD, ND, MSA Jesse Brown Veterans Affairs Medical Center, University of Illinois at Chicago, Department of Family Medicine, Chicago, IL, USA

xiii xiv Contributors

Robert L. Koffman, MD, MPH Walter Reed National Military Medical Center, NICoE, Bethesda, MD, USA Harold Stephen Kudler, MD United States Department of Veterans Affairs Medical Center, Durham, NC, USA Duke University School of Medicine, Psychiatry and Behavioral Sciences, Durham, NC, USA R. Gregory Lande, DO Psychiatry Continuity Service, Walter Reed National Military Medical Center, Behavioral Health, Bethesda, MD, USA Nicole M. Lanouette, MD Uniformed Services University of the Health Sciences, Naval Medical Center San Diego, Substance Abuse Rehabilitation Program, Point Loma, San Diego, CA, USA Nicholas G. Lezama, MD, MPH War Related Illness and Injury Study Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA John T. Little, MD Departments of Psychiatry and Neurology, Georgetown University School of Medicine, Washington, DC, USA Geriatric Mental Health Services, Department of Veterans Affairs Medical Center, Department of Psychiatry, Washington, DC, USA Bryan A. Llorente, BA Social Work College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA Kasey M. Llorente, BS Creighton University, Omaha, NE, USA Maria D. Llorente, MD Georgetown University School of Medicine, Washington DC VA Medical Center, Department of Psychiatry, Washington, DC, USA Cheryl A. Lowman, PhD VA Capitol Health Care Network, VISN 5, Linthicum, MD, USA Thomas W. Meeks, MD University of California, Davis, Davis, CA, USA Sacramento VA Medical Center, Department of Psychiatry, Mather, CA, USA Dinesh Mittal, MD G. V. (Sonny) Montgomery VA Medical Center, Department of Mental Health, Jackson, MS, USA Remington L. Nevin, MD, MPH, DrPH The Quinism Foundation, White River Junction, VT, USA Keelan K. O’Connell, MD, BS, LT, MC, USN Walter Reed National Military Medical Center, Department of Behavioral Health, Bethesda, MD, USA Michael R. Olivares, BA Department of Psychology, The Catholic University of America, Washington, DC, USA Contributors xv

Michelle Kennedy Prisco, MSN War Related Illness and Injury Study Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA Kathleen Reed, MS in Nursing Jesse Brown Veterans Affairs Medical Center, Women Veteran Health Center, Chicago, IL, USA Matthew J. Reinhard, PsyD War Related Illness and Injury Study Center, Washington DC Veterans Affairs Medical Center, Washington, DC, USA Department of Psychiatry, Georgetown University Medical School, Washington DC Veterans Affairs Medical Center, Washington, DC, USA Uniformed Services University of the Health Sciences, Silver Spring, MD, USA Elspeth Cameron Ritchie, MD, MPH Department of Psychiatry, Georgetown University Medical School, Washington DC Veterans Affairs Medical Center, Washington, DC, USA Department of Psychiatry, MedStar Washington Hospital Center, Washington, DC, USA George Washington University School of Medicine, Washington, DC, USA Uniformed Services University of the Health Sciences, Silver Spring, MD, USA Mental Health Community Based Outpatient, Washington, DC, USA Kaitlin Slaven, MD George Washington University, Department of Psychiatry, Washington, DC, USA Elissa L. Stern, MD Jesse Brown Veterans Affairs Medical Center, Northwestern University Feinberg School of Medicine, Department of Medicine, Chicago, IL, USA Bruno Subbarao, DO Medical Director, Polytrauma/Transition and Care Management Programs, Phoenix Veterans Healthcare System, Physical Medicine and Rehabilitation, Phoenix, AZ, USA Rachel M. Sullivan, MD Psychiatry Residency Program, Tripler Army Medical Center, Behavioral Health, Honolulu, HI, USA Donna L. Ticknor, MD Washington DC Veterans Affairs Medical Center, Department of Psychiatry, Camp Springs, MD, USA Shannon Tulk, Pharm D, BCPS Minneapolis VA Health Care System, Pharmacy Service, Minneapolis, MN, USA Antoinette M. Valenti, MD Washington DC VA Medical Center, Department of Mental Health, Washington, DC, USA Margaret Valverde, MD George Washington University Hospital, Psychiatry and Behavioral Sciences, Washington, DC, USA xvi Contributors

Ryan P. Vienna, MD Naval Medical Center San Diego, Substance Abuse Rehabilitation Program, San Diego, CA, USA Joseph E. Wise, MD US Army, Walter Reed National Military Medical Center, Brooklyn, NY, USA Private Practice, Brooklyn, NY, USA Philip M. Yam, MD Naval Branch Health Clinic Belle Chasse, Department of Behavioral Health, Belle Chasse, LA, USA Kathryn A. Yung, MD Uniformed Services University of the Health Sciences, Naval Medical Center San Diego, Substance Abuse Rehabilitation Program, Point Loma, San Diego, CA, USA