Salem VAMC–U.S. Army Fort Bragg Warrior Transition Clinic Telepsychiatry Collaboration: 12-Month Operation Clinical Perspective

Abstract

Objective: To describe the clinical experience in the first Veterans Affairs (VA)–U.S. Army Warrior Transition Clinic (WTC) telepsychiatry operation (September 2008–August 2009). Materials: Joint VA and U.S. Army records. Methods: Analysis of intake, follow-up, and last visit records. Results: One hundred twenty active-duty U.S. Army soldiers were seen (394 clinic visits). Ninety-eight soldiers had one or more combat tours, principally in Iraq and Afghanistan. Posttraumatic stress disorder was diagnosed in 50.0% of the cases by the WTC telepsychiatrists. The majority of the soldiers had medical comorbidities, especially chronic pain (75.0%), in addition to mental health problems. Several of the soldiers were recovering from trauma (20.8%) and/or surgery (23.3%), 11.7% exhibited traumatic brain injuries, and 17.5% had headaches. Disrupted relationships (74.2%) were notable for non-family members, especially military cohorts such as other persons in the same WTC squad or platoon. Conclusion: The observations in this report come from a cross-section of soldiers who were triaged to meet WTC admission criteria. As this is the prototype VA–U.S. Army telepsychiatry collaboration, there are no comparative data at this time. The nature of the medical and psychiatric problems treated in the military WTC represents an index of the more severe combat trauma treated on military bases from ongoing combat operations and may predict future VA–U.S. Army collaborative telepsychiatry clinic experiences.

Introduction

The ongoing military conflicts in Iraq and Afghanistan have created a subgroup of combat veterans with severe medical and mental health problems who would benefit from early intervention. As the pool of volunteer soldiers is limited, soldiers often are required to serve multiple combat tours. The number of combat deployments appears to increase the risk of posttraumatic stress disorder (PTSD).¹ Of the more than 206,000 veterans entering the Veterans Affairs (VA) healthcare system between 2002 and 2007, 33% had one or more mental health diagnoses, and 41% were diagnosed with a mental health or adjustment disorder.² Potentially traumatic combat experiences have been estimated to include about 67% of U.S. soldiers deployed to Iraq.³

Combat soldiers also have interpersonal and family relationship disruptions that begin with predeployment preparations. Stresses continue with combat tour time away from families and then with reintegration into society and family life.^4

–9 Family interpersonal and relationship problems are exacerbated when PTSD and traumatic brain injury (TBI) are involved.^10
–12 Nondeployed military spouses do not escape the consequences of the combat tours, as it is estimated that 33% have sought mental health treatment.^8,9 Studies indicate that the caregiver burden for a partner living with a veteran suffering from PTSD can include depression¹³ and secondary traumatization.^14,15 In secondary traumatization, the partners themselves begin to experience symptoms of trauma.

Rates of PTSD and depression, which often coexist,¹⁶ vary according to combat theater and study methods. A study of hospitalized soldiers in 2003–2004 reported an incidence of 6.3% for both PTSD and depression up to 7 months following injury.¹⁷ Hoge et al.¹⁸ reported that 18% of U.S. Army soldiers returning from Iraq met PTSD criteria and 15% met criteria for depression. Inadequately treated depression with or without PTSD can contribute to substance abuse, marital problems, employment problems, and suicide, all of which may have a devastating impact on individuals, families, and society.¹⁹ These studies suggest a difficult treatment and recovery course for the Fort Bragg (NC) Warrior Transition Clinic (WTC) soldiers due to the concurrent presence of chronic pain, TBI, headaches, and seizures in addition to their mood and anxiety disorders.^{20

–28} An additional obstacle for rapid recovery is the frequent concurrent use of alcohol and illicit drugs after returning from combat.^{19,20,29

–36}

In total, 38 WTCs have been developed on U.S. military bases nationally and internationally to treat soldiers with the most severe health problems; as the number of U.S. Army mental health professionals is limited [J. Candelario, LTC(Ret) former Battalion Surgeon, WTC, Fort Bragg, pers. comm., March 5, 2010], the rising influx of wounded U.S. Army soldiers¹⁹ has required innovative answers for meeting their growing mental health needs. Consequently, in early 2008 the U.S. Army Medical Command at the Fort Bragg, North Carolina Womack Army Medical Center and the WTC approached the Department of Psychiatry at the Salem, Virginia VA Medical Center (VAMC), suggesting a collaborative telepsychiatry clinic. Subsequently, in September 2008 an interdisciplinary telepsychiatry clinic between the Salem VAMC and the WTC was initiated.³⁷ In this report, we describe some of the clinical observations during the initial 12 months of operation of the VA–U.S. Army telepsychiatry WTC.

Methods

Data for this retrospective analysis were collated from the VA records of the VA–U.S. Army telepsychiatry encounters at the Womack WTC from September 2008 to August 2009. The Salem VAMC Institutional Review Board approved the study. Each clinic note of all the soldiers was examined for relevant data and entered onto a Microsoft Office Excel 2007 spreadsheet for statistical analysis. Demographic data included age, gender, and number of combat tours. From the psychosocial sections of the interviews, data were collected about family and relationship status, including marital discord, recent and past divorces, the soldiers' relationships with their children, legal issues regarding the children, and relationships with non-family members.

The number and category of psychiatric diagnoses at telepsychiatry intake and at the last visit in the 12-month period are recorded. The two most highly weighted diagnoses on the grounds of level of disability for each clinic visit were selected from any one or combination of Axis I, Axis II, or Axis IV diagnoses after a review of the clinic note for the specific visit. Some cases had only one psychiatric diagnosis, whereas other cases had one or more diagnoses on the three axes.

The two most significant medical or surgical diagnoses were recorded at telepsychiatry intake and at the last visit in the 12-month period. These diverse medical and surgical diagnoses were taken from the U.S. Army medical records that accompanied the consult for each soldier to the VA telepsychiatry clinic, from Axis III at telepsychiatry intake, and from Axis III at the last visit in the 12-month period.

Descriptive statistics and measures of central tendency were calculated for variables describing treatment such as number of visits and global assessment of function (GAF) at intake and at the last visit. Higher GAF scores suggest a higher functional level. Differences between each soldier's first and last GAF scores were used to assess treatment results. A Pearson correlation between the number of visits and the GAF difference scores was performed to assess treatment effectiveness.

Results

During the first 12 months of the Telepsychiatry Womack WTC, 120 active-duty U.S. Army soldiers (15 women, 105 men; mean age, 31.7 years; range, 21–57 years) were seen for a total number of 394 clinic visits. Ninety-eight soldiers (81.6%) had one or more combat tours in Iraq, Afghanistan, or the Persian Gulf Wars with an average of 1.5 tours per soldier. The mean number of clinic visits for each soldier during the first 12 months was three, with 31.6% of soldiers having more than four visits. The majority of soldiers were married (63.3%), and 60.0% reported having children.

Of the 76 married soldiers, 33 (43.4%) communicated having marital discord; 16 soldiers reported recent or past divorces. Difficulties with child custody and legal issues secondary to separations and divorce were noted by seven soldiers. Fourteen (19.4%) of the 72 soldiers with children reported having troubled relationships with their children. Eighty-nine of the 120 WTC soldiers (74.2%) reported disrupted relationships with non-family members, especially with military cohorts such as other persons in the same WTC squad or platoon.

The two most frequent diagnoses at psychiatry intake and at the last psychiatry visit during the first 12 months of the Telepsychiatry Womack WTC were anxiety and mood disorders. There was an increase in the incidence of anxiety and mood disorders from the VA psychiatric intake (anxiety 59.2%, mood disorders 45.8%) to the final 12-month VA psychiatry visit (anxiety 65.0%, mood disorders 46.7%). Among the anxiety disorders, PTSD was initially diagnosed in 45.0% of the 120 soldiers and identified in 50.0% at 12 months. Adjustment disorders were the third most frequently noted diagnosis at intake (17.5%) and ranked fourth (18.3%) at the last visit, whereas cognitive disorders placed third (20.0%) at the final visit of this 12-month period. By the last 12-month visit, the incidence of substance problems had decreased from 13.3% to 10.0%. Other results are found in Table 1.

Table 1.

Summary of Intake and 12-Month Diagnoses for the Soldiers in the Warrior Transition Telepsychiatry Clinic

PSYCHIATRY INTAKE PROVISIONAL DIAGNOSES		LAST CLINIC VISIT DIAGNOSES
DIAGNOSIS	NUMBER (PERCENT)	DIAGNOSIS	NUMBER (PERCENT)
Anxiety disorders	71 (59.2%)	Anxiety disorders	78 (65.0%)
PTSD	54 (45.0%)	PTSD	60 (50.0%)
Mood disorders	55 (45.8%)	Mood disorders	56 (46.7%)
Adjustment disorders	21 (17.5%)	Cognitive disorders	24 (20.0%)
Cognitive disorders	26 (21.7%)	Adjustment disorders	22 (18.3%)
Substance-related disorders	16 (13.3%)	Substance-related disorders	12 (10.0%)
Sleep disorders	7 (5.8%)	Sleep disorders	9 (7.5%)
Attention deficit and disruptive behavior disorders	5 (4.2%)	Attention deficit and disruptive behavior disorders	6 (5.0%)

PTSD, posttraumatic stress disorder.

Based on analysis of the GAF data, the majority (55.0%) of soldiers improved, 35.0% had no change, and 11.7% worsened. The mean GAF at intake was 58.0, increasing to 62.3 at the last visit. The range from GAF intake to the last visit in the first 12 months of the WTC telepsychiatry clinic was from 28 GAF points above intake to 16 GAF points below intake. The mean difference in GAF scores was 4.3 points with a standard deviation of 7 points. The mean number of visits was 3.4 with a standard deviation of 2.24. The correlation between the number of telepsychiatry visits and GAF difference scores was positive but not statistically significant (r=0.1466, p=0.1115).³⁸

The majority of WTC soldiers had combat-related injuries and other medical comorbidities in addition to mental health problems (Table 2). Chronic pain (75.0%) was the most frequently reported medical- and surgical-related problem. The second and third most frequent medical comorbidities were recovery from surgery (23.3%) and from trauma (20.8%). Headaches (17.5%) and TBI (11.7%), respectively, were the fourth and fifth most recorded medical comorbidities. Hypertension was identified in 10.8% of cases. The three most frequently prescribed medications for the WTC telepsychiatry soldiers were antidepressants (87 cases), hypnotics (68 cases), and narcotic analgesics (32 cases).

Table 2.

Comorbid Medical Problems in the U.S. Army Warrior Transition Psychiatry Clinic: 120 Soldiers with 394 Visits During the First 12 Months

MEDICAL PROBLEMS	NUMBER	PERCENTAGE
Chronic pain	90	75.0
Status postsurgery	28	23.3
Status posttrauma	25	20.8
Headaches	21	17.5
Traumatic brain injury	14	11.7
Hypertension	13	10.8
Seizures	7	5.8
Coronary artery disease	5	4.2
Cancer	5	4.2
Gastroesophageal reflux disease	5	4.2
Sleep disorder	4	3.3
Hearing loss	4	3.3
Postconcussive syndrome	4	3.3
Sexual disorders	2	1.6
Paralysis	2	1.6
Other	24	20.0

Discussion

The psychosocial stresses on deployed soldiers and their families contribute to disrupted relationships, marital discord, divorce, and parent–child problems.^8,9 When soldiers suffer from PTSD, TBI, and other psychiatric and medical problems, the transition to military noncombat or civilian life is complicated.^10,11 Consistent with these findings, our results showed that 43.4% of the married soldiers were experiencing marital discord. One of the most unexpected findings of the returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) soldiers was their difficult interpersonal relationships with their immediate military unit members. Many of the WTC combat soldiers reported feeling that they were perceived as second-class soldiers because they had agreed to being treated for mental health problems. It is well documented that soldiers with psychiatric diagnoses are often identified by their cohorts as not having the “warrior mentality” and are thus considered potential liabilities to their units.³⁸

Other studies of returning combat soldiers have reported PTSD incidences of 6.3–18%.^17,18 In the WTC telepsychiatry clinic the PTSD incidence was 50.0% at the 12-month mark, higher than that found in the other research studies. This high incidence reflects the mental health needs of the soldiers triaged into the Fort Bragg WTC. The WTC has limited facilities, and soldiers must meet specific medical criteria to be admitted. The levels of physical and medical problems of the soldiers sent to the WTC are assessed to be more urgent or severe than for the other soldiers with medical and psychiatric problems in the general pool of U.S. Army soldiers at Fort Bragg.

In the WTC telepsychiatry clinic, anxiety disorders in general were the most frequently diagnosed problems (65.0%) at the last telepsychiatry 12-month visit. The diagnosis of mood disorders was assessed to be the second most frequent problem in the WTC soldiers. In the combat military population, depression often coexists with PTSD,^15,39 TBI,^14,18 marital conflicts,^5,40 domestic violence,⁴¹ interpersonal violence,^42,43 and divorce.⁴ Thus the high rate of mood disorders was not unexpected as it has been estimated that 18.5% (about 300,000) of U.S. troops who have been exposed to combat in Iraq and Afghanistan can be diagnosed with depression and/or PTSD.¹⁹

As the fifth most common diagnosis, substance-related disorders were a disruptive factor in the reintegration of the combat soldiers into society. Alcohol, even in small amounts, may negatively impact mood and treatment outcome, with increased morbidity, disability, and mortality.^19,29
–31 When substance abuse is comorbid with TBI, the risk of military discharge for drug and alcohol problems is increased.³² Moreover, this comorbidity reduces post-military employment possibilities and the veterans' quality of life.³⁶ Consequently, substance abuse treatment is extremely important for the well-being of the WTC soldiers. It is notable that the diagnosis of substance-related disorders by the VA psychiatrists decreased from 13.3% of cases at intake to 10.0% at 12 months. Four soldiers successfully underwent substance abuse treatment during the 12 months of clinic operation. Part of the increase in anxiety diagnosis may be secondary to the withdrawal of drugs and alcohol in this small subpopulation of WTC soldiers. Vietnam combat veterans have reported that their PTSD symptoms were improved with the use of cannabis, alcohol, heroin, and benzodiazepines, whereas cocaine exacerbated symptoms of hyperarousal.⁴⁴

The majority of WTC soldiers had combat-related injuries and other medical comorbidities in addition to mental health problems. Narcotic analgesics were the third most frequently prescribed medication following antidepressants and hypnotics. The high percentage of chronic pain (75.0%) in the WTC soldiers was more than can be accounted for by recovery from surgery and/or trauma (23.3% and 20.8%, respectively). One of the variables for this elevated incidence may be the interconnection of pain with many of the problems observed in the WTC telepsychiatry soldiers. The comorbidities of anxiety disorders, mood disorders, TBI, and headaches are often interrelated to chronic pain and may be exacerbated by the incidence of chronic pain.²²

TBI, headaches, and seizures combined were observed in several cases seen by the VA telepsychiatry team. These symptoms are found as frequent comorbidities in the medical presentation of combat soldiers. In this WTC population with a high incidence of PTSD, depression, and substance use, the comorbidities of TBI, seizures, and headaches may compound the complexity of clinical presentation. Headaches, reported in 17.5% of the WTC telepsychiatry clinic soldiers, are a common symptom of TBI,²⁵ PTSD,²⁷ and depression.²⁶ Headaches, including migraines, are also associated with chronic pain,²⁸ as are increased rates of depressive, anxiety, and alcohol abuse disorders when compared with controls.²⁰

TBI, seen in 11.7% of this study group, has been shown to have other medical associations. Seizures, seen in 5.8% of the WTC telepsychiatry soldiers, are often associated with TBI.²⁴ In a study of patients undergoing rehabilitation for TBI, 58% with mild TBI and 52% with moderate to severe TBI had chronic pain.²¹ Moreover, to further compound the clinical presentation, persons with TBI, PTSD, and depression in the general population have a higher prevalence of drug and alcohol use than individuals without these three diagnoses.

Some of the medical entities reported for the WTC soldiers could be associated with combat exposure, including seizures,⁴⁵ sleep disorders,⁴⁶ hearing loss,⁴⁷ and paralysis.⁴⁸ In this study of the VA–U.S. Army telepsychiatry patients, hypertension was the most frequent (10.8%) medical diagnosis that could have a stress-related component.⁴⁹ However, this frequency was less than expected, as the incidence in adults under 55 years of age in the United States has been estimated to be approximately 20%.⁵⁰ Thus, despite the stressors of combat for the majority of the soldiers seen by the telepsychiatrists, there was less hypertension than expected. Kibler et al.⁵¹ reported that cardiovascular risk factors such as hypertension and cardiovascular disease in general are more frequent in persons with PTSD. In the WTC telepsychiatry study, the lower incidence of hypertension could possibly be related to the young age of the soldiers (mean of 31.7 years) and the presumed fitness of recent combat troops.

Conclusions

The clinical observations included in this report represent a survey of the biopsychosocial problems diagnosed and treated in the VA–U.S. Army telepsychiatry clinic during the 12-month period of September 2008–August 2009. A WTC sees the highest level of traumatized soldiers. Therefore, the mental health profile of the soldiers who were seen in this prototype VA–U.S. Army WTC telepsychiatry clinic during its first 12 months is probably not representative of a broad cross-section of OEF/OIF soldiers with medical and mental health problems. This clinical cross-section provides an index of the more severe medical morbidities for the OEF/OIF campaigns between 2005 and 2009. The Fort Bragg WTC telepsychiatry soldier mental health morbidity is complicated, as most soldiers had more than one combat tour. Moreover, chronic pain and ongoing surgery and/or trauma sequelae exacerbated the mental health diagnoses. There are no similar data from other WTCs at this time that would allow comparative clinical observations in the effort to understand the medical and mental health profile of OEF/OIF soldiers. This prototype VA–U.S. Army project suggests that similar collaborations can bring VA mental healthcare clinicians into other WTCs in the effort to have a larger number of soldiers returning from combat tours in Iraq and Afghanistan evaluated and treated in a timely manner.

Footnotes

Disclosure Statement

No competing financial interests exist.

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