Dr Jamie Hacker Hughes CPsychol CSci FBPsS Military Mental Healthcare Services: Organisation and Treatment
Background Generally fit, young healthy population c. 80% below cut-offs using GHQ-12 King s Centre for Military Health Research Broadly in accordance with civilian population 20% above cut-off on self-rated scales Below many comparable occupations exposed to similar stressors 29 November 2010 Health of Military Personnel 2
Non-Deployed Population Single Service (ss) Stress Management Policies Routine role of Commanders, Welfare and Families Officers, Generic Social Workers and Chain of Command Overarching Review of Operational Stress Management (OROSM) 2005 Migration from inpatient and outpatient model to focus on role of Chain of Command supported by community-based mental health care 29 November 2010 Health of Military Personnel 3
PTSD KCMHR Cohort study 4% PTSD rates (7% in Combat Arms) Based on self-report Using 4-item PC-PTSD Number of diagnosed cases much lower 140 in 2009 (0.7 per 1000 strength DASA) 29 November 2010 Health of Military Personnel 4
Primary Care Single Service (ss) General Medical Practitioners (GMPs) Additional support from Welfare (Navy Personnel and Family Service, Army Welfare Service, RAF Welfare Service), Padres and TRiM (peer-support) practitioners First level MH support with DCMH liaison In NHS approx 0.3 of presentations are MH related Similar in British Armed Forces 29 November 2010 Health of Military Personnel 5
Trauma Risk Incident Management TRiM Peer-delivered risk assessment system Developed to fill void left after withdrawal of CISD in 2000 (Cochrane review etc) Developed by 2 Army Mental Health Nurses; Pioneered by Royal Marines (RM); Researched in an RCT within RN by ACDMH and KCMHR Now used in all three Services TRiM practitioners undertake immediate support and signpost on to formal MH care 29 November 2010 Health of Military Personnel 6
Defence Mental Health Services What can a Referred Soldier / Sailor / Aviator expect? Speed of Access both Inpatient and Community services Nurse-led assessment MDT functioning filter to psychiatrist / psychologist / nurse for: medication / diagnostic complexities / specific treatments / prognostic and occupational advice / direct liaison with unit etc) Fitness Return Fit or Partially Fit or Discharge (Those personnel discharged on MH grounds are supported throughout by Defence Mental Health Social Workers)
Primary/Intermediate Care - DCMH Departments of Community Mental Health UK 15, Germany 4, Cyprus 1, Gibraltar 1 Multiprofessional Psychiatrists, Clinical Psychologists, Community Mental Health Nurses (CMHN) Mental Health Social Workers Localised services to tri-service catchment areas 29 November 2010 Health of Military Personnel 8
UK Departments of Community Mental Health Kinloss Faslane Northern Ireland Brize Norton Donnington Leuchars Catterick Cranwell Marham Colchester Woolwich Plymouth Aldershot Tidworth Portsmouth
DCMH Aim is to provide local service enabling clients to stay in Service environment Normal social support networks maintained MES restricted if necessary Effective DCMH Treatments based on NICE guidelines: CBT, EMDR, Medication All DCMH nurses trained in psychotherapeutic interventions above 29 November 2010 Health of Military Personnel 10
DCMH DCMH aim 'to provide timely assessment and treatment to maximise operational and occupational capability within HM Forces, and, for those personnel who cannot be rehabilitated, to ensure they receive a smooth as possible transition to civilian life
DCMH DASA (Defence Analysis Statistics and Advice) DASA Annual Summary 2009 4482 new attendances (c. 2.26% of AF) Of these 3103 (1.55% of AF) diagnosed Very low threshold of referral to DCMH in comparison with National Health Service i.e. an Occupational Mental Health Service 29 November 2010 Health of Military Personnel 12
General Findings Army > Royal Navy and RAF Royal Marines < Army and RAF Females 2 x Males Other Ranks > Officers Most common Dx is Adjustment Disorder 140 personnel diagnosed with PTSD in 2009 (<0.01%) Rates of adjustment disorder, neurotic disorder and PTSD higher in those who have deployed (but lower rates of mood disorder) Use of alcohol is a problem within AF (Fear et al 2010) AF personnel drink more than their civilian counterparts 29 November 2010 Health of Military Personnel 13
Inpatient Care Last MoD inpatient unit closed in 2003 Priory Group from 2003 to 2008 Now consortium of 6 English and 2 Scottish NHS Trusts since Dec 2008 218 admissions to In-Patient Service Provider (ISP) in 2009 (c. O.01% of AF strength) Only 5% of DCMH referrals referred on for inpatient care Assured admission within 4 hours normally as near as possible to normal location 29 November 2010 Health of Military Personnel 14
Inpatient Care Following admission, visit by Service Liaison Officer (SLO) within 72 hours Daily telephone contact Weekly visits throughout remainder of admission including attendances at ward rounds, case conferences and reviews Average length of admission 10 days Length of stay decreasing with new ISP 29 November 2010 Health of Military Personnel 15
Reservists Operationally and Mobilised Same access to MH Care as Regulars Slightly higher risk of developing PTSD (5% vs. 4%) (KCMHR, 2006) Reservist Mental Health Programme (RMHP) established in November 2006 at RTMC Chilwell Eligible to all with operationally attributable injuries who have deployed since 2003 70 of 103 patients treated by DCMHs under RMHP have returned to deployable fitness 29 November 2010 Health of Military Personnel 16
OMHNE Operational Population Operational Mental Health Needs Evaluation Op Telic OMNHE (I) Feb 09 Rates of mental health problems similar to non-deployed population Op Herrick OMNHE (A) Jan 2010 29 November 2010 Health of Military Personnel 17
FMHTs Field Mental Health Teams Consist of Community Mental Health Nurses (CMHNs) Visiting Psychiatrist Operationally focused mental health service Major role in psycho-education (pre-, intra-, post-deployment) Those unfit returned to UK by Aeromedical Evacuation (AE) for ISP admission or review in Primary Care or at DCMH 29 November 2010 Health of Military Personnel 18
Decompression Formed units return to UK via Cyprus 36-hour decompression is executive responsibility Decompression aims to facilitate adjustment process CMHNs provide MH support and deliver psychoeducational briefs Additional support provided by Padre Decompression evaluated by ACDMH for PJHQ only 50% wished to go through process initially but over 90% found it to have been useful 29 November 2010 Health of Military Personnel 19
DMRC and RCDM Defence Medical Services Rehabilitation Centre Headley Court CMHNs and Psychologists, Psychiatric Support from DMHS Royal Centre for Defence Medicine Birmingham CMHNs, Psychiatric and Psychological Support from DMHS 29 November 2010 Health of Military Personnel 20
Training and Research OROSM recommended that all 3 Services should include psycho-educational material throughout initial training and promotion courses and on discharge currently being audited and implemented throughout Academic Centre for Defence Mental Health (ACDMH) run Diploma in Military Mental Health and MSc Courses RCDM run Enhanced Operational Mental Health Course CMHNs all attend CBT Basics, EMDR Level 1, and Motivational Interviewing Training Commitment to funding and conducting research 29 November 2010 Health of Military Personnel 21
In Conclusion - 1 MoD takes psychological disorders very seriously There is a high priority attached to increasing awareness, combating stigma and providing effective diagnosis and treatment DMS wishes to increase number of MH personnel 29 November 2010 Health of Military Personnel 22
In Conclusion - 2 It is hoped that efforts to increase awareness of mental health issues and support available will reduce incidence of mental health problems in future veterans It is believed that the themes and recommendations of Dr Andrew Murrison MP s recent report Fighting Fit will make a vital contribution towards rebuilding the Military Covenant and providing additional support to members of the Armed Forces and ex-service personnel with MH issues 29 November 2010 Health of Military Personnel 23
Thank you Dr Jamie Hacker Hughes DCA Psychology and Head of Defence Clinical Psychology Ministry of Defence Joint Medical Command HQ Surgeon General Coltman House DMS Whittington Lichfield WS14 9PY SGJMCHCare-ClinPsych@mod.uk