Tag: Military Veteran

What is the Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans?

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Research Paper Title

The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis.

Background

Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death

PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep.

Thus, increased symptoms may lead to increased end-of-life healthcare utilisation.

Therefore, the purpose of this study was to determine if veterans with PTSD have increased end-of-life healthcare utilisation or medication use and to examine predictors of medication administration.

Methods

Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center.

Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011.

Emergency room (ER) visits, hospitalisations, and medication administration in the last 7 days of life.

Results

Of 5341 veterans, 468 (8.76%) had PTSD.

Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalisations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001).

PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943).

Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138).

Conclusions

PTSD’s association with increased end-of-life healthcare utilisation and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD.

Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients.

Reference

Bickel, K.E., Kennedy, R., Levy, C., Burgio, K.L. & Bailey, F.A. (2019) The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. Journal of General Internal Medicine. doi: 10.1007/s11606-019-05538-x. [Epub ahead of print].

Timely Referrals from Primary Care to Specialty Mental Health, and Back

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Research Paper Title

Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care.

Background

Research to improve access to mental healthcare often focuses on increasing timely referrals from primary care (PC) to specialty mental health (SMH).

However, timely and appropriate transitions back to PC are indispensable for increasing access to SMH for new patients.

Methods

The researchers developed and implemented a formalised process to identify patients eligible for transition from SMH to PC.

The FLOW intervention was piloted at a Veterans Health Administration community-based outpatient clinic. Qualitatively examine provider perspectives regarding patient transitions at initiation and termination of the FLOW project.

Sixteen mental health providers and three PC staff completed qualitative interviews about the benefits and drawbacks of FLOW at initiation. Ten mental health providers and one PC staff completed interviews at 12-month follow-up. Primary benefits anticipated at initiation were that FLOW would increase access to SMH, provide acknowledgement of veterans’ recovery, and differentiate between higher and lower intensity mental health services.

Results

SMH providers reported additional perceived benefits at 12-month follow-up, including:

  • Decreased stress over their caseloads; and
  • Increased ability to deliver efficient, effective treatment.

Anticipated drawbacks at initiation were that veterans would get inconsistent care, PC could not offer the same level of care as SMH, and veterans might view transition as a rejection by their SMH provider.

Perceived drawbacks were similar at 12-month follow-up, but there was less frequent endorsement.

Conclusions

Findings highlight need for sustained and frequent provider education regarding:

  1. The appropriate characteristics of individuals eligible for transition; and
  2. Established procedures to ensure care coordination during and after transition.

Reference

Fletcher, T.L., Johnson, A.L., Kim, B., Yusuf, Z., Benzer, J. & Smith, T. (2019) Provider perspectives on a clinical demonstration project to transition patients with stable mental health conditions to primary care. Translational Behavioral Medicine. pii: ibz172. doi: 10.1093/tbm/ibz172. [Epub ahead of print].

A Technique to Help Military Veterans with Nightmares

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Introduction

Justin Havens, a former British Army officer and an Eye Movement Desensitisation and Reprocessing (EMDR) trained psychotherapist has been testing a novel approach to helping veterans resolve traumatic nightmares.

Background

Insomnia, anxiety, and the sheer misery associated with night terrors is a huge problem for many of the people with post-traumatic stress disorder (PTSD).

Consequently, Justin has been testing, since approximately 2014, an approach with veteran groups across the UK as part of a PhD at the Veterans and Families Institute of Anglia Ruskin University.

Early results, in 2016, demonstrated that it had been successful for 16 out of 24 veterans who had completed the programme. They had not only seen dramatic improvements to sleep, but also seen an average 50% reduction in PTSD symptoms, according to Justin’s findings.

What is the Technique?

  • The technique works by helping people imagine a different outcome to their bad dreams.
  • While awake, the individual asks themselves ‘what would I like to happen next in my nightmare that feels good and puts me in control?’
  • For example, a burns victim might have nightmares about being burned.
  • They might imagine a new ending to their dream: standing under a waterfall laughing as all the scabs get washed away.

The idea is that the individual does not wake up, the dream continues and they are able to experience the rapid eye movement (REM) sleep vital for feeling fully rested.

Although not a ‘cure’ for PTSD, the approach – known as Planned Dream Intervention (PDI) – can make life more bearable for people with PTSD, and help stabilise them ahead of further therapy.

The concept was originally developed by a former US Navy psychologist called Beverley Dexter, who has taught this skill to several hundred US service personnel and veterans, though no formal research has been undertaken.

Further Information

Useful Publications

Battling Bad Dreams – How a New Technique helps Veterans Confront their Nightmares (2017) xDownload
No More Nightmares – Testing a Novel Intervention for UK Veterans (Havens, 2018)Download
Planned Dream Interventions – A Pragmatic RCT to Evaluate a Psychological Treatment for Traumatic Nightmares in UK Military Veterans (Havens et al., 2018)Download

Useful Links

Dexter, B.A. (2018) No more nightmares: how to use planned dream intervention to end nightmares? International Conference on Psychiatric & Geriatrics Nursing and Stroke. 19-20 November, 2018. Available from World Wide Web: https://www.longdom.org/proceedings/no-more-nightmares-how-to-use-planned-dream-intervention-to-end-nightmares-45944.html. [Accessed: 20 November, 2019].

Havens, J. (2015) No More Nightmares – A Revolution for Sleep/PTSD. Available from World Wide Web: https://www.crowdfunder.co.uk/no-more-nightmares. [Accessed: 20 November, 2019].

King, H. (2016) The New Treatment Hoping To End PTSD Nightmares. Available from World Wide Web: https://www.forces.net/services/tri-service/new-treatment-hoping-end-ptsd-nightmares. [Accessed: 20 November, 2019].