US Dept. of State RMOP Program Kenneth B. Dekleva, MD Department of State Director of Mental Health Services, Office of Medical Services

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1 US Dept. of State RMOP Program Kenneth B. Dekleva, MD Department of State Director of Mental Health Services, Office of Medical Services Jan/Feb CME/CNE Meeting, Atlanta 1

2 Jan/Feb CME/CNE Meeting, Atlanta 2

3 Jan/Feb CME/CNE Meeting, Atlanta 3

4 Foreign Service Life Terrorism Frequent moves Change of school Lack of spousal employment Excessive travel Environmental Loss of control Fishbowl Phenomenon Work Stress Inadequate resources Family issues Lack of support system Crime War Zones Jan/Feb CME/CNE Meeting, Atlanta 4

5 A Typical Embassy State Dept. DAO AID FBI DEA DHS FAS FCS FAA CDC NASA DoD Peace Corps DOE DOJ Treasury Other agencies Jan/Feb CME/CNE Meeting, Atlanta 5

6 Bombing Jan/Feb CME/CNE Meeting, Atlanta 6

7 Jan/Feb CME/CNE Meeting, Atlanta 7

8 Special populations Trailing spouses Multi-ethnic and multi-racial families Minorities Singles; Gays & Lesbians Foreign Service Nationals Third Culture Kids (TCKs) Children with special needs/disabilities Jan/Feb CME/CNE Meeting, Atlanta 8

9 Control Groups & Comparison Groups in Travel Medicine Tourists; expeditions; adventure travelers Diplomats; MSG; law enforcement; families NASA; military; scientists Third culture kids (TCKs) Missionaries; teachers Corporate NGOs, Peace Corps; journalists Students Jan/Feb CME/CNE Meeting, Atlanta 9

10 Office of Medical Services RMOs FSHPs RMOPs RMTs RMMs Local medical resources Nurses Operational Medicine Medical Director Foreign Programs MED Clearances Mental Health Services ECS; ADAP; DSSP; DSMP Occupational Health DASHO Travel Medicine Jan/Feb CME/CNE Meeting, Atlanta 10

11 Mental Health Program Culture shock Stress management School consultation Management consultation Travel medicine Occupational health Medical diplomacy ADAP DSSP Disaster response General psychiatry Security/forensic issues Emergency Response Family advocacy Crime War Zone concerns ECS DSMP Jan/Feb CME/CNE Meeting, Atlanta 11

12 Our Panel of Experts HMO Psychiatrist Veteran RMOP 1 st Psychiatrist Jan/Feb CME/CNE Meeting, Atlanta 12 The Anti-Psychiatrist former MHS Director

13 Jan/Feb CME/CNE Meeting, Atlanta 13

14 Jan/Feb CME/CNE Meeting, Atlanta 14

15 RMOP Positions Amman London Pretoria Vienna Mexico City New Delhi Moscow Beijing Manama Athens Frankfurt Cairo Jakarta Accra Lima Dakar Tokyo Nairobi Bangkok Singapore Jan/Feb CME/CNE Meeting, Atlanta 15

16 HU Population in 2 regions (unpublished data by RMOPs) 50% employees; 50% EFMs 6% med-evac for psych disorders; 3% curtailed ADHD: nearly 50% of all children seen by RMOP Psychotic disorders: < 1% Anxiety disorders: 7-9% Mood disorders: 20-30% Substance-abuse disorders: 2-4% Adjustment disorders: 6-10% No psychiatric diagnosis (30%) or V Code (52%) Jan/Feb CME/CNE Meeting, Atlanta 16

17 Trauma vs. Stress Disasters Terrorism Criminal violence Family Violence; child abuse/neglect Accidents (e.g. MVAs) Culture shock Pre-existing conditions, stressors, daily hassles Flying: adverse medical events Cumulative effects of trauma/stress Jan/Feb CME/CNE Meeting, Atlanta 17

18 12-Month Psychiatric Service Use: US vs. Diplomatic Community Overseas* 10% 8% 8.8% 6% 4% 2% 5.6%** Anxiety Child Depression Adj V Codes 50% 0% US Outpt State Outpt Use of psychiatrists in the same ballpark Jan/Feb CME/CNE Meeting, Atlanta 18 *Wang, AGP, 2005; **Flynn, DOS, 2006; Valk FSMB, 1990

19 Rate of Outpatient Visits and Mental Health Evacuations at State 6% 56 per 1,000* 5% 4% 3% 2% 1% 0% State Outpt 2 per 1,000 Med evac Mental health evacuations needed by perhaps 5% Jan/Feb CME/CNE Meeting, Atlanta 19

20 Conditions Leading to a Mental Health Evacuation, % 80% 60% 4% 6% 8% 8% Suicide A Parent-Child PTSD 40% 20% 16% 17% 22% Adj Partner Alcohol Mood 55 % 0% Mood disorders, alcohol and partner problems together 5-6x as common as PTSD Jan/Feb CME/CNE Meeting, Atlanta 20

21 100% Mental Health Evacuations in Afghanistan, Iraq and Pakistan, N=23 80% 27% War Exp, New 60% 40% 20% 47% 9% 9% 18% 36% Assault Natual Disaster Mil Combatant Prior Tour Prior Trauma, 73% (8/11) 0% PTSD Cause Prior trauma plays a role in a majority of PTSD mental health evacuations Jan/Feb CME/CNE Meeting, Atlanta 21

22 US Diplomats Serving in AIP: Population Prevalence vs. Treated Prevalence of PTSD 12% 10% 12% 8% 6% 4% 2% 5%* 0.2% 0% Consulted MHS PTSD* Med Evac PTSD *PCLC > 50 Gap between distress and dysfunction suggests resilience Jan/Feb CME/CNE Meeting, Atlanta 22

23 Why are DoS med-evac and suicide rates so low? Role of self-selection ( salutogenesis ) and medical clearances? Epidemiologically --- a healthier population? Role of social contract and high levels (e.g. 5X) of medical/behavioral health support? What is the optimal ratio of clinicians to covered lives? Confounding variables (e.g. moving, flying, tourist travel)? Are med-evac, suicide rates the best metrics w/r to overall behavioral health outcomes in a diplomatic population? There are very few comparison data overall, and no long-term, prospective studies have been done. What are the best control groups? Jan/Feb CME/CNE Meeting, Atlanta 23

24 Conclusion & Questions? Need for more studies, proper control groups Are we asking the right questions? Excessive focus on mental health/pathology, rather than resilience Need for prospective, longitudinal studies Confounding biases w/r to organizing concepts? Wrong outcome measures? Ratio of MHS providers to covered lives --- impact of a resourcerich model upon outcome data? DOS = approx. 5X rate of HMOs Need for family studies (ex: Steinglass P and Edwards M. Risk and Resiliency Factors in State Dept. Families. Ackerman Inst. For Family Therapy, 1993) Jan/Feb CME/CNE Meeting, Atlanta 24

25 Contacts Penner, Gary D. (MED - Director) pennergd@state.gov 1 (202) Rosenfarb, Charles H. (MED Deputy Director) rosenfarbch@state.gov 1 (202) Dekleva, Kenneth B. (MED/MHS Director MHS) deklevak@state.gov 1 (202) Rennick, John H. (MED/MHS Deputy Director MHS) rennickjh@state.gov 1 (202) Piotroski, Stan (MED/MHS Director ECS) piotroskiss@state.gov 1 (703) Jan/Feb CME/CNE Meeting, Atlanta 25

26 Jan/Feb CME/CNE Meeting, Atlanta 26

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