‘At Ease’ – promoting mental fitness

Mental health problems are common. Almost half of the Australian population aged 16-85 years has experienced a mental health problem at some stage in their lives and one in five has experienced a mental health problem during a twelve month period. Anxiety, depression and harmful use of alcohol are the most common problems.²

The prevalence of mental health disorders in the Australian Defence Force (ADF) and veteran communities is similar to that of the general population. However, the profile of disorders associated with the ADF and veteran communities differs, reflecting the unique demands of military service (Box 1).^{3, 4} Today’s ADF and veteran communities have a greater diversity in their experiences and demographics, including an increasing number of women. Younger or ‘contemporary’ veterans may have engaged in a range of confrontational, peacekeeping and humanitarian operations in areas such as Cambodia, Somalia, Rwanda, East Timor, Afghanistan and Iraq.^{5, 6}

Many veterans successfully adjust to civilian life after military service. However, for some, their experiences have a profound and lasting impact on their lives. For all military personnel, whether or not deployed overseas, adjusting to civilian life can be challenging and stressful due to the military culture of strict conformity and high standards of behaviour, and the nature of traumatic events often experienced.⁶ Early recognition of symptoms and appropriate treatment is recommended to prevent long term problems.⁷

This therapeutic brief provides information to help identify those veterans who may benefit from additional professional support or treatment, self-help strategies and general information about mental health and wellbeing.

Box 1: Common mental health problems in the veteran community⁶

Mood disorders including major depressive disorder

Dysthymia

Generalised anxiety disorder

Panic disorder with/without agoraphobia

Social anxiety

Post-traumatic stress disorder (PTSD)

Complicated grief

Alcohol misuse and dependence

Misuse of prescribed medicines

Misuse of other substances

When support might be needed

Many people are hesitant to seek treatment for mental health issues even though symptoms may impact on their everyday life. Some people feel they do not need treatment or that their symptoms will improve with time.⁶Others are unaware of the treatments that could benefit them.⁸ Many veterans are able to recognise the impact of their service-related experiences on their feelings and behaviours and the need for treatment; others may not readily acknowledge or accept the connection.⁶

For many veterans there is a stigma associated with mental health issues.^{3, 7} Currently serving ADF personnel may have concerns that identifying a mental health issue will limit their career progression and opportunities for re-deployment or that people will treat them differently. They may believe they should be able to cope without help and that seeking help is a sign of weakness.^{3, 6, 7}

Hence, veterans with mental health problems, may present with vague psychological or physical complaints.⁶ There may be no explained medical cause for their symptoms.¹ Because mental health disorders often overlap, veterans diagnosed with one disorder have a high likelihood of a co-morbid disorder.³ The veteran may not acknowledge their problem is multifactorial. For example, PTSD is commonly associated with alcohol and other substance misuse, problem gambling, depression and conflict or disengagement in the family.^{6, 7, 9}

Behaviours often associated with poor mental health, such as smoking, substance misuse, in particular cannabis and alcohol, over-eating and a sedentary lifestyle, may increase the incidence of physical illness.^{6, 10} A physical injury that has resulted in chronic pain is a significant risk factor for depression and anxiety-related disorders, which may lead to an inability to work and function in society.¹¹ Patients with depression and anxiety report a significantly higher somatic symptom burden, increased daily functional impairment and poor quality of life.^{10, 12} Given the bidirectional effects between psychological and physical illness, early recognition of symptoms and appropriate treatment is critical to avoid serious long term problems.⁷

If you are aware that your patient has a history of military service, be alert to potential mental health issues.⁶ Allow for a longer initial consultation time or suggest supsequent consultations to engage your patient and discuss potential support mechanisms and treatment options.^{1, 6} The Australian Centre for Posttraumatic Mental Health Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder (2013) provide a valuable resource for general practitioners.

ADF Post-discharge GP Health Assessment

All former serving personnel can access a comprehensive health assessment from their GP, funded under Medicare.

One of the key objectives of this assessment is to help GPs in identifying and diagnosing the early signs of physical and/or mental health problems among former serving ADF members. In supporting this, DVA has funded the development of a specifically designed screening tool.

The assessment tool is available on the DVA At Ease Professional portal (https://at-ease.dva.gov.au/professionals/clinical-resources/general-resources/)

Former ADF members are eligible for this resource

The tool includes specific screening tools and questions to assess factors such as: physical activity; chronic pain; sleep; any alcohol and substance use; psychological health; and sexual health.

Medicare Item numbers (701,703,705,707) – a new eligible ADF target group has been added to the existing health assessment items

Referral notes for GPs, providing some guidance on how to access DVA services and a number of veteran specific referral options.

When treatment is required

A personally tailored approach that integrates physical, psychological and social factors, along with cultural attitudes and beliefs of the patient delivers the best outcomes.¹⁴ Successful results are more likely when the family is involved and there is a sense of connection and belonging which is essential for recovery from mental health problems.⁶ A supportive family may also help reduce the risk of suicide as family conflict, relationship breakdown and social isolation are strong predictors of suicidal behaviour.¹⁵ When treating your veteran patient, consider the impact of mental health issues on all family members. The impact on partners and children can be significant and long lasting.⁶

Encourage self-help strategies such as reconnecting with social supports, including veterans’ support groups, physical exercise and maintaining daily routines in conjunction with more specific psychological and pharmacological treatments.⁶ Careful assessment and accurate diagnosis with clear definition of the type of mental health disorder is important for the patient to receive appropriate treatment.

Consider cognitive behaviour therapy (CBT) and interpersonal therapy for patients with mild to moderate anxiety and depressive disorders as first line therapies. Trauma-focused therapy and eye movement desensitisation and reprocessing (EMDR) for appropriate patients with PTSD has been shown to be effective.^{6, 16}

Medicines are an important component of the treatment plan for some patients. Consider pharmacological therapies for those patients:

• not sufficiently stable to commence with psychological therapies
• with moderate to severe mental health disorders
• unwilling or unable to engage in psychological therapies
• when psychological therapies have failed to produce a sufficient response.

If medicines are required, selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors (SNRIs) are considered first line therapies for most disorders. Best results are achieved when used in conjunction with self-management strategies and psychological therapies.^{6, 7, 13}

• Refer to the Therapeutic Guidelines: Psychotropic and the Australian Medicines Handbook for detailed medicines information.
• Refer to the Mental Health Advice Book for treating veterans with common mental health problems for general management strategies, available at: http://at-ease.dva.gov.au/professionals/files/2014/09/P01621-Mental-Health-Advice-Book.pdf
• Find a psychologist to suit your patient’s needs at: http://www.psychology.org.au/FindaPsychologist Psychologists can also be sourced through the Veterans and Veterans Families Counselling Service. For more information see www.vvcs.gov.au/Services/providers.htm

Some patients will benefit from both psychological therapies and medicines. In some cases medicines may be urgently indicated because of a need to address co-morbid disorders or associated symptoms. For example, patients with severe depression, psychotic features or very disabling anxiety or agitation may require prompt pharmacological intervention in conjunction with psychological therapies.⁷

If alcohol misuse is evident, CBT and motivational interviewing, in conjunction with pharmacological intervention to help manage cravings and withdrawal symptoms provides the best outcomes.⁶ Because key components of CBTs are specific to individual disorders, consider referral to a psychologist with expertise in CBT and addiction disorders.

Improving outcomes with therapy

Patients are more likely to follow a treatment regimen when they feel they have an alliance with their doctor, are empowered and have choices with joint responsibility and ownership in the decision-making process.^{6, 13, 19}

Not taking or forgetting to take medicines as prescribed, or not persisting with psychological therapies is common among patients with mental health disorders. Not taking medicines as prescribed may have serious consequences in the long term and may:

• increase the likelihood of illness relapse
• risk greater disability
• result in poor quality of life
• have a devastating impact on family and friends.¹³

There are many reasons why patients do not take their medicines. Explore your patient’s attitudes and beliefs towards taking medicines and allay any fears and misconceptions they might have. A key component of improving concordance is to educate your patient about their illness and treatment (Box 2).¹⁹ Give them information about the time over which medicines may be required, a review date, and the expected outcomes. Develop the treatment plan with your patient, clearly identifying goals and how they might be achieved through negotiation and agreement. Non-adherence during the planned treatment period is more likely if the patient feels well and hasn’t been told of the need to complete the treatment.^{6, 13, 19}

Box 2: Developing a treatment plan with medicines^{13, 19}

Develop an agreed treatment plan with your patient and provide information on:

rationale for choosing the medicine:

advantages of taking the medicine and disadvantages of reducing or ceasing the medicine

frequency of dosing

likely length of time required to take the medicine and expected outcomes

likely length of time before the patient will feel the benefits of the medicine

potential adverse effects and what to do if they occur

a review date

medicines prescribed: consumer medicine information any personalised instructions

encourage your patient to use a medicines list available from NPS MedicineWise at: www.nps.org.au/medical-info/consumer-info/keeping-a-medicines-list

Mental health resources for health professionals

• The Mental Health Advice Book for treating veterans with common mental health problems provides general management strategies to assist health professionals. It is available at: http://at-ease.dva.gov.au/professionals/mental-health-advice-book/
• The Veteran Mental Health Consultation Companion (VMHC²) is an electronic supplement to the Mental Health Advice Book. The VMHC² is a free mobile application (app) that contains clinical assessment tools, patient handouts and summaries of information in the book. It is available from both the iOS App Store and android Google Play. Further information can be found at http://at-ease.dva.gov.au/professionals/clinical-resources/vhmc2_app/
• Evidence based assessment and outcome tools, treatment options and the latest military mental health research are available at the At Ease Professional portal: www.at-ease.dva.gov.au/professionals
• A comprehensive summary of DVA mental health related resources and services can be accessed from the clinical resources page of the At Ease Professional website at http://at-ease.dva.gov.au/professionals/clinical-resources/general-resources/
• Understanding the Military Experience is a free online training program that helps providers understand how military service can impact upon the mental health and wellbeing of current and ex-serving personnel. Training is eligible for Continuing Professional Development (CPD) points. Go to http://dva.interactiontraining.net/registerexternal and enter the registration code ‘ext’.
• Some veterans present with co-morbid disorders and complex needs. Case Formulation is a free online training program that helps health providers to focus on the presenting problems that are likely to have the most impact on recovery and to set priorities for treatment. Training is eligible for Continuing Professional Development points. Go to http://dva.interactiontraining.net/registerexternal and enter the registration code ‘ext’.
• vetAWARE is a free online training program designed to assist community nurses, aged care providers and other health providers to better understand the common mental health challenges faced by veterans and war widows. Nurses who complete the training are eligible for Continuing Professional Development points. Go to http://dva.interactiontraining.net/registerexternal and enter the registration code ‘ext’.
• Working with Veterans with Mental Health Problems is a free online training program that helps GPs better understand common veteran mental health conditions, how military service can affect the mental health of serving and ex-serving personnel and where to refer DVA clients for mental health treatment. All GPs with access to RACGP’s gplearning can undertake the program and the training is eligible for Continuing Professional Development points. See http://at-ease.dva.gov.au/professionals/professional-development/

Referral services available to veterans

• In the case of a mental health emergency, such as risk of self-harm, suicide or homicide, the most appropriate course of action is to first call 000 or, if appropriate, refer your patient to a hospital or acute psychiatric intervention team.¹³
• The Veterans’ and Veterans’ Families Counselling Services (VVCS, www.vvcs.gov.au) offers counselling and group programs for veterans and their families Australia-wide, 24 hours a day on 1800 011 046.
• A range of community and veteran-specific services and resources are available at: www.at-ease.dva.gov.au/professionals/referrals/
• DVA provides funding for a comprehensive suite of mental health services including GP services, psychologist and social work services, specialist psychiatric services, pharmaceuticals, in-patient and out-patient hospital treatment and services through the Veterans and Veterans Families Counselling Service (VVCS).
• DVA purchases trauma recovery programs for PTSD in a range of private and public hospitals across Australia. These programs treat both current and former serving members of the Australian Defence Force, including veterans. To find out more information about these programs you can contact the hospitals directly and speak to the program coordinators. A list of programs and relevant contact details are available at http://phoenixaustralia.org/recovery/veterans-ptsd-programs/
• NOTE: DVA can pay for treatment of any mental health condition without the condition being related to service and without a diagnosis. This is for those with at least one day of permanent full-time service or Reservists with Continuous Full-time Service (CFTS) in the Australian Defence Force. In addition, Reservists with Disaster Relief Service, Border Protection Service or been involved in a serious service-related training accident are eligible. These arrangements, known as non-liability health care (NLHC), can help with early intervention and better health outcomes.
  See more information at www.dva.gov.au/nlhc
• In complex clinical situations where symptoms are severe and unrelenting or if you are uncertain about diagnosis or management, refer your patient to a psychiatrist.^6,13 Find a psychiatrist at: www.ranzcp.org/Resources/find-a-psychiatrist.aspx
• The Australian Centre for Posttraumatic Mental Health offers information and services for veterans at: http://www.acpmh.unimelb.edu.au/help.html

Mental health resources for veterans

The DVA At Ease portal, www.at-ease.dva.gov.au has up‑to‑date and comprehensive information, resources and self‑help strategies and tools that promote mental fitness for ADF personnel and the veteran community and their families. ‘High Res’ is an example of an online interactive tool that helps veterans to develop skills in problem solving, building support, helpful thinking, getting active, keeping calm, and sleeping better.

Encourage all your veterans to visit the DVA At Ease portal at: www.at-ease.dva.gov.au

Other useful resources:

• High Res – A Self-Management and Resilience Training (SMART) toolbox: https://at-ease.dva.gov.au/highres/#!/home

• The PTSD Coach Australia app can help patients learn about and manage symptoms that commonly occur after trauma*

• The Right Mix, – DVA’s alcohol management site that provides practical information and strategies to raise awareness about alcohol-related harm and achieve the ‘right balance’ with alcohol, diet and exercise, www.therightmix.gov.au
• Veterans and Veterans Families Counselling Service (VVCS), www.vvcs.gov.au: 24 hour confidential support. Phone 1800 011 046
• Operation Life Online – a website to raise awareness about, and help prevent suicide in the veteran community, www.at-ease.dva.gov.au/suicideprevention
• YouTube videos - There are a number of online videos about the impact of mental ill health on current and former serving personnel and their families at: http://atease.dva.gov.au/veterans/resources/videos/
• beyond blue: www.beyondblue.org.au
• Lifeline: phone 13 11 14
• National domestic violence hotline: a 24 hour confidential hotline. Phone 1800 737 732
• NPS MedicineWise provides options for using a medicines list to help keep track of medicines. www.nps.org.au/medical-info/consumer-info/keeping-a-medicines-list

*Mobile apps available free for Android and Apple devices

References

1. Tiller J. Depression and anxiety. The Medical Journal of Australia. 2012;1 Suppl 4:28-32.
2. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing: Summary of Results. 2007. Canberra available at: http://www.abs.gov.au/ausstats/abs@.nsf/latestproducts/4326.0main%20features32007?open [Accessed January 2014].
3. Hodson S. et al. Mental Health in the Australian Defence Force - 2010 ADF Mental Health Prevalence and Wellbeing Study: Executive Report. Department of Defence, Canberra.
4. Ikin J. et al. War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. The British Journal of Psychiatry. 2004;185:116-126.
5. Australian Government. Repatriation Commission. Military Rehabilitation and Compensation Commission. Department of Veterans' Affairs: Annual Reports 2010-2011. Available at: http://www.dva.gov.au/aboutDVA/publications/corporate/annualreport/2010-2011/Financial/Documents/annrepfull.pdf [Accessed February 2014].
6. Australian Centre for Posttraumatic Mental Health. 2012. Mental Health Advice Book for treating veterans with common mental health problems. Department of Veterans' Affairs, Canberra. Available at: http://at-ease.dva.gov.au/professionals/files/2014/09/P01621-Mental-Health-Advice-Book.pdf [Accessed January 2014].
7. Australian Centre for Posttraumatic Mental Health. 2013. Australian Guidelines for the Treatment of Acute Stress Disorder & Posttraumatic Stress Disorder. ACPMH, Melbourne, Victoria.
8. Andrews G. et al. Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment. Bulletin of the World Health Organization. 2000;78(4):446-454.
9. Biddle D. et al. Problem gambling in Australian PTSD treatment-seeking veterans. Journal of Traumatic Stress. 2005;18(6):759-767.
10. Katon W. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Society of Biological Psychiatry. 2003;54:216-226.
11. Gauntlett-Gilbert J & Wilson S. Veterans and chronic pain. British Journal of Pain. 2013;7(2):79-84.
12. Katon W, Lin E & Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. General Hospital Psychiatry. 2007;29:147-155.
13. Therapeutic Guidelines: Psychotropic. Version 7. 2013. Melbourne: Therapeutic Guidelines Ltd.
14. Commonwealth of Australia. 2013. Australian Government. Department of Veterans' Affairs. Veteran Mental Health Strategy. A ten year framework 2013-2023. Available at: http://at-ease.dva.gov.au/veterans/files/2013/06/Veteran-Mental-Health-Strategy.pdf-V050613.pdf [Accessed January 2014].
15. Van Orden K. et al. The interpersonal theory of suicide. Psychological Review. 2010;117(2):575-600.
16. Cuijpers P. et al. Interpersonal psychotherapy for depression: a meta-analysis. Am J Psychiatry. 2011;168(6):581-592.
17. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd. 2014.
18. Rapoport M. et al. Benzodiazepine use and driving: a meta-analysis. Journal of Clinical Psychiatry. 2009;70(5):663-673.
19. Brown M & Bussell J. Medication adherence: WHO cares? Mayo Clinic Proceedings. 2011;86(4):304-314.
20. Monasterio E & McKean A. Prescribing atypical antipsychotics in general practice. Best Practice Journal. 2011:40:14-23.
21. DUSC Review on the Utilisation of Antipsychotics. 2013. Available at: http://www.pbs.gov.au/industry/listing/elements/pbac-meetings/psd/2013-08/antipsychotics-psd-08-2013.pdf [Accessed April 2014].

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