Shannon McCaslin-Rodrigo, Ph.D.Health Science Specialist

National Center for PTSD, VA Palo Alto Health Care SystemAssistant Professor (Vol)

University of California, San FranciscoShannon.McCaslin@va.gov

Tools for Working with PTSD and Associated Conditions

Resources and Challenges

In the Group Detecting/Assessing for PTSD Treatments for PTSD Tools and Resources for Providers

Overview

http://www.ptsd.va.gov/public/about_face/veterans/timm-lovitt/how-i-knew-i-had-ptsd.html

AboutFace

Experiences treating Veterans and needs?

VA experiences?

Knowledge of VA and online resources?

Questions for Providers

Detecting PTSD

PTSD is the most under-recognized and untreated anxiety disorder in primary care (Schonfeld et al., 1997)

Why?◦ No one asks◦ PTSD is a disorder of avoidance◦ Stigma and lack of problem recognition◦ Individuals with PTSD present to care for other reasons:

Major Depressive Disorder Other Anxiety Disorders Alcohol and Substance Use Disorders Relationship Problems Chronic pain Medical Conditions

Detecting PTSD

Primary Care PTSD Screen (PC-PTSD; Prins et al., 2004)In your life, have you ever had any experience that was so

frightening, horrible, or upsetting that, in the past month, you…

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?4. Felt numb or detached from others, activities, or your

surroundings?

Positive screen if 3 or more answered “yes”

Detecting PTSDhttp://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp

Posttraumatic Checklist (PCL; Weather et al., 1993) Description

◦ 17-item self-report measure ◦ Rate how much they were “bothered by that problem in the past month”

on a 5-point scale ranging from 1 (“not at all”) to 5 (“extremely”). Scoring

◦ Total score (range 17-85) Cutoff scores for a probable PTSD diagnosis (44 civilians, 50 military) Use DSM-IV criteria Combined scoring

Sample Item“In the past month, how much have you been bothered by: Repeated,disturbing memories, thoughts or images of a stressful experience from the past?”

1 = Not at all 2 = A little bit 3 = Moderately 4 = Quite a bit 5 = Extremely

Detecting and Tracking PTSD

Unstructured Clinical Interview Follow DSM-IV-TR criteriaStructured Clinical Interview Clinician Administered PTSD Scale (CAPS for

DSM-IV)Additional Information Self-report measures (e.g., PTSD Checklist) Collateral report Chart review

How do we Diagnosis PTSD?

Effectively Treating PTSD

Expert Consensus Guidelines (Journal of Clinical Psychiatry)◦ Foa, E.B., Davidson, J.R.T., & Frances, A.J.

(1999). Treatment of posttraumatic stress disorder (Expert consensus guideline series). Journal of Clinical Psychiatry, 60, Supplement 10.

ISTSS◦ Foa, E.B., Keane, T.M., & Friedman, M.J. (2000).

Effective Treatments for PTSD. New York: Guilford Press.

American Psychiatric Association Practice Guidelines

VA/DOD Joint PTSD Practice Guidelines www.healthquality.va.gov

Tx Guidelines and Recommendations

Significant benefit (good evidence): A strong recommendation that the inter-vention is always indicated and acceptable ◦ Cognitive Therapy◦ Exposure Therapy◦ Stress Inoculation Training◦ Eye Movement Desensitization Reprocessing

(EMDR)

VA/DoD Clinical Practice Guideline

Released October 2007 Sponsored by VA Identified a total of 2771 studies Included only randomized controlled trials

(RCTs) ◦ 37 pharmaceutical (14 RCTs of SSRIs)◦ 53 psychotherapy http://www.iom.edu/Reports/2007/Treatment-of-PTSD-An-

Assessment-of-The-Evidence.aspx

Institute of Medicine: Tx of PTSD: Assessment of the Evidence

Exposure-based therapy is the only therapy found evidence sufficient to conclude it is efficacious in PTSD

Overall evidence inadequate to confidently determine efficacy of SSRIs◦ Minority opinion stated evidence suggestive

although not sufficient for efficacy in the general population (not male, chronic, VA)

IOM’s Conclusions

Tools for Providers

88% of U.S. households currently have at least one mobile phone.

44% own a smartphone, as compared with 18 percent two years ago.

By 2013, mobile phones will overtake PCs as the most common Web access device worldwide.

62% of smartphone users downloaded an app within the last 30 days.◦ Discover apps through searching the public

marketplaces (63%) or relying on recommendations of trusted others (61%).

◦ Those who download apps have avg 33 apps on their mobile phones.

This marks the beginning of a wireless era in which smartphones will be the primary mechanism through which consumers will connect with friends, media, and the internet.

Mobile Phone Usage and Trends

Acknowledgement to Julia Hoffman and Eric Kuhn

PTSD Coach

• High ratings: IOS 5/5 stars; Android 4.5/5 stars • Awards: 2011 FAA Chairman’s Award for Advancement in Accessibility &

2012 ATA President’s Innovation Award• Named: Best Federal App (Nextgov.net) and Top 10 Health Apps (Yahoo)

54K downloads in 62 countries

PE Coach and CPT Coach (in development)

Using Apps to Support the Provision EBTs for PTSD

Coming soon…

Linkage to electronic health record and self-entered database

Ability to share directly with clinicians to optimize care. Bidirectional communication including personalization of apps by clinicians

System-wide surveillance to enhance program evaluation and mitigate crisis

Future Directions

Education Assessments Training

Online resources

Provider Pro Section◦ Assessments (29 measures)

Symptoms (e.g., alcohol, anger, PTSD) & wellness PCL –under the military sexual trauma section

◦ Educational Handouts Symptoms (e.g., depression, PTSD, mTBI) Work adjustment Sleep Resilience

◦ Have a chat feature for Service Members

http://www.afterdeployment.org/providers/home

Veteran Videos◦ Can filter by operation, gender◦ Can filter by signs, symptoms, conditions

Educational Client Handouts◦ Signs and symptoms◦ Conditions◦ Life events and experiences

Resources and Support

Make the Connectionwww.maketheconnection.net

Public and Provider Sections Video Trainings

◦ PTSD 101 (CEUs) Military Culture – handouts & training Educational Handouts Assessment and Treatment Information

National Center for PTSDhttp://www.ptsd.va.gov/

Trainings in CPT and PE Handouts on Conditions Resources Offer Workshops

Center for Deployment Psychologyhttp://deploymentpsych.org/

24 hour crisis line Can download materials Chat online

http://www.veteranscrisisline.net/24 hour crisis line

Free Web-based CPT Training

http://cpt.musc.edu/index9-hour courseContact hours maybe available for continuing

education creditIncludes video demonstrations of expert CPT clinicians

VA◦ www.va.gov◦ http://www.oefoif.va.gov ◦ www.PTSD.va.gov

PTSD 101 (free CEUs) Clinician’s Trauma Update

VA/DoD Clinical Practice Guidelines◦ www.oqp.med.va.gov/cpg/cpg.htm

International Society for Traumatic Stress Studies◦ www.ISTSS.org

Cognitive Processing Therapy◦ http://cpt.musc.edu/index (free 9-hour web training)

Seeking Safety◦ www.seekingsafety.org

Department of Defense ◦ www.Battlemind.army.mil◦ www.Afterdeployment.org

Helpful Clinical Resources

Enrollment Online: Visit the enrollment and benefits webpage

https://www.1010ez.med.va.gov/sec/vha/1010ez/

Telephone: 1-877-222-VETS (8387), Monday through Friday, between the hours of 8:00 AM and 8:00 PM (Eastern Time). A VA representative will have your completed form sent to you for verification and signature.

Mail: Print the 10-10EZ form or 10-10EZR form or call to have the form mailed to you. Complete and sign the application, then mail it to your local VA Medical Center or clinic.

In Person: Your client can visit the VA Medical Center or clinic nearest you to apply for enrollment or to update information

Program locator:http://www2.va.gov/directory/guide/home.asp?isflash=1

Partnering with VA

Family resources

http://www.caregiver.va.gov/◦ Caregiver toolkit◦ Services◦ Caregiver support line

National Center for PTSD

Partnering with VA (cont)

Military ResourcesDODmilitaryhomefront.dod.milVAwww.seamlesstransition.va.govNational Guardwww.guardfamily.orgoperationmilitarykids.orgOR National Guardwww.orng-vet.orgwww.mil.state.or.us/ORFP/fam_supp.html

Veteran Family ResourcesMilitary Wives: www.militarywives.com

Military Husbands: www.militaryhusbands.comMilitary Children: www.militarychild.orgNG & R Military Kids: www.ourmilitarykids.org

Mothers of Service members: www.bluestarmothers.org

Family Support: www.operationhomefront.net www.militaryhomefront.dod.mil

www.militaryfamily.org

THANK YOU & Questions

Shannon.mccaslin@va.gov

Acknowledgements:

NC-PTSD staffJulia Hoffman PsyD; Eric Kuhn, PhD

Suzanne Best, PhD