Too many soldiers home from deployment bear the emotional scars of combat silently, leaving it to their doctors to uncover and treat hard-to-identify wounds that can tear lives apart long after a tour of duty ends. Fortunately, family physicians are uniquely qualified to ensure these returning veterans get the medical care they deserve.
According to a 2008 study from the RAND Corp.(www.rand.org), more than 300,000 U.S. veterans returning from combat in Iraq and Afghanistan -- nearly 20 percent of the total number of troops deployed at that time -- reported symptoms of post-traumatic stress disorder (PTSD) or major depression. Moreover, about one in three returning veterans experiences signs or symptoms of combat stress, depression, PTSD or traumatic brain injury (TBI).
In addition, the most recent data from the Armed Forces Health Surveillance Center(www.dvbic.org) (AFHSC), show that more than 30,000 soldiers were treated in 2010 for TBI. The AFHSC also reported in the October 2011 issue of Medical Surveillance Monthly Report(afhsc.mil) that alcohol abuse in soldiers is increasing sharply.
It is these discouraging numbers, in part, that have prompted the AAFP to unite with first lady Michelle Obama and Jill Biden, M.D., in the Joining Forces campaign(www.whitehouse.gov), which launched in April 2011. The initiative is intended to call attention to the critical issues facing veterans and military families and to expand access to wellness programs and other resources for this population.
- The AAFP is partnering with the White House to better serve combat veterans who are suffering from post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and similar health issues.
- Roughly half of these service members will receive their care outside of the U.S. Department of Veterans Affairs system.
- FPs are encouraged to look for symptoms of these disorders in returning service members and to ask questions of both patients and their family members to uncover any health issues.
- Educational resources on diagnosing and treating PTSD, TBI and depression are available online.
"According to the White House and the Department of Defense (DoD), about half of returning veterans from these two wars will soon get their care via the private sector -- not VA (U.S. Department of Veterans Affairs) hospitals or the DoD," said AAFP EVP Douglas Henley, M.D. "It is very likely that our members will be caring for these patients in their communities.
"It is important that members be aware of and comfortable with diagnosing these (combat-related) conditions or serve the important surveillance function of referring these patients, when needed, to other specialists for confirming such diagnoses and making recommendations for treatment."
Family physician and Capt. Mark Stephens, M.D., of Bethesda, said that although active-duty service members remain in the military health system when they return stateside, most reservists and those released from active duty typically access care through community-based resources.
"For the reserve component, they will remain on active duty for a little while after coming home, so we do try to keep folks around to look for medical issues that might arise after deployment," said Stephens. "But once reservists demobilize, they go back to their previous civilian life and that includes seeking medical care in the community."
Stephens, who is chair of the Department of Family Medicine at the Uniformed Services University of the Health Sciences, told AAFP News Now that the military is doing its best to ensure returning service members receive the care they need, but no system is perfect.
As part of the Joining Forces campaign(www.whitehouse.gov) initiated by first lady Michelle Obama and Jill Biden, M.D., the AAFP has gathered together a number of resources on treating returning veterans that can help FPs deal with these patients and their families.
The AAFP's Joining Forces webpage includes screening tools, articles from American Family Physician, patient information and free CME that family physicians can use to identify and treat their military patients.
"We have post-deployment health screenings … and the system does what it can to set up this safety net, but the reality is that some people, in wanting to just get home, may slip through the cracks in terms of underreporting symptoms," he noted. "For PTSD, somebody might be feeling fine when they come home and truly may not have symptoms at that time, but once they reintegrate into their 'normal' routine, then the intrusive thoughts can creep in."
According to FP Jeffrey Sonis, M.D., M.P.H., of Chapel Hill, N.C., family physicians are in a perfect position to plug the holes in the safety net. "There is a significant gap between treatment and need, as many of these soldiers go home to places where there is no VA hospital within hundreds of miles," Sonis said. "At least 50 percent of the veterans that have a problem when they get back don't receive care in the VA, even when they are eligible.
"Civilian FPs have a huge potential role here to serve as the de-facto mental health system for vets," Sonis said. "We are everywhere. If physicians can identify the problem and do a good job of treating it, we have an enormous opportunity to help."
Capt. Sara Kass, M.D., a family physician in Bethesda, Md., said she thinks that because FPs are positioned in communities across the United States, they are uniquely qualified to identify patients and their families who may be struggling with TBI and PTSD, as well as those facing depression and substance abuse issues. Kass is the deputy commander of the DoD's National Intrepid Center of Excellence -- an institute dedicated to providing cutting-edge evaluation, treatment planning, research, and education for active-duty service members and their families who are dealing with mild TBI and other psychological health conditions.
The future of treating post-traumatic stress disorder (PTSD) and mild traumatic brain injury (MTBI) is quite possibly being built at the National Intrepid Center of Excellence (NICoE) in Bethesda, Md.
Run by the United States Department of Defense, NICoE was established to provide cutting-edge evaluation, treatment planning, research and education for service members and their families dealing with the complex interactions of MTBI and psychological health conditions.
AAFP member Capt. Sara Kass, M.D., deputy commander of the NICoE, said the institute has a three-pronged mission focused on research, patient and clinician education, and clinical care.
"When we think of the wounds of this almost 10-year war we've been engaged in, people are aware of the issues with improvised explosive devices and the resulting amputations that have occurred … but there's also what we call the 'invisible wounds of war,'" Kass said. "While there are many efforts under way to address these conditions, they are complex entities by themselves … but oftentimes, they happen in a comorbid situation where both occur in the same individual.
"When that happens, it is a very complex disease entity, and we don't know all that we need to know about it and how to treat it. Therefore, the NICoE was established to advance the science in regards to PTSD and MTBI."
Kass said that the NICoE uses an interdisciplinary model involving the patient, the family and a primary care health care professional both during an inpatient period, as well as an intensive, four-week outpatient program.
"We do see improvements in clinical indicators, both in symptoms of post-traumatic stress, as well as other neural behavioral indicators," she said. "While it is early in our discovery, we're starting to see some things that indicate that the care patients are receiving here at the NICoE is really making a difference."
"By having that relationship with the whole family -- sometimes it is not the veterans themselves, but a family member who is struggling -- and by asking questions in the context of the whole family, it gives us that window into the situation to identify the problem and engage them in therapy," Kass said. "I think with a situation like this, you want as many portals to care as you can get … both in the military and civilian sectors, we (FPs) provide the biggest access portal to care."
Stephens agreed that FPs can make a significant impact, but to do so, he said, it's important that they pay attention to what their patients may be telling them nonverbally.
"This should be right up the alley of most family docs, there's no question about it," he said. "However, no one is realistically going to come in off the street and say, 'Hey, Doc, I have PTSD.' It is our job to know what questions to ask … to recognize those nonverbal cues that, in hindsight, are not that hard to spot when someone is depressed or has an alcohol problem.
"And it's our job to ask the follow-up questions. So when the medical complaints just aren't making sense -- the chronic headache, the hard-to-define abdominal pain, the red flags associated with either depression or alcohol use -- we have to connect those dots."
Stephens said that it is key for physicians who provide care for individuals with potential medical issues relating to a military deployment to ask open-ended questions, such as
- "Please tell me about your deployment."
- "Please describe any unusual situations or circumstances you were in that might relate to your current symptoms."
- "Are there any other issues potentially relating to your deployment that you would like to discuss?"
He also pointed to one particular issue -- changes in sleep patterns -- as a common clue to underlying deployment-related issues.
"Insomnia is a huge red flag," Stephens said. "Most FPs are pretty comfortable handling issues relating to sleep -- for instance, simple cognitive therapies to help patient with insomnia. Most family physicians will also be comfortable handling depression. In addition, most family docs are going to know what to do when someone talks about suicide.
"It is this versatility that makes family physicians so critical in recognizing and treating post-deployment medical issues -- in the military and also in the civilian community."
Sonis said that although many family physicians currently receive "a fair amount of training in treating depression," in his experience, few feel comfortable with PTSD or TBI. But training in recognizing and managing these health conditions is available. In fact, Sonis himself has designed a free, one-hour online AAFP-approved CME(www.aheconnect.com) course on treating PTSD.
"The course is obviously not comprehensive," he said. "But it does focus on practical steps one can take during the course of an office visit. It aims to give specific skills to help FPs treat PTSD and TBI appropriately and also helps civilians understand military culture a little better."
Sonis said family physicians and other health care professionals who want to serve returning military service members also can sign up to do so at the Citizen Soldier Support Program website WarWithin.org(www.warwithin.org).
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury: Co-occurring Conditions Toolkit: "Mild Traumatic Brain Injury and Psychological Health"(www.dcoe.health.mil)
(Rev. September 2011)