Epidemiology of Pain, PTSD, and Post-concussive Syndrome among OEF/OIF Veterans

Michael E. Clark, Ph.D.Clinical Director, Chronic Pain Rehabilitation Program

Chair, VA National Polytrauma Pain Workgroup

Departments of Neurology and Psychology, University of South Florida

Headache Pain is Characteristic

• Kalra, Clark, & Scholten, 2008Kalra, Clark, & Scholten, 2008• 52%52% of 99 OEF/OIF former

service members registered for endorsed the presence of headaches when askedwhen asked

• 42%42% reported headache related interference and averaged 4 headaches per week

• Ruff, Ruff, & Wang, 2008Ruff, Ruff, & Wang, 2008• 63%63% of a sample of 126

outpatients with mild TBI symptoms reported headaches

• Among those with cognitive deficits, prevalence of headaches was 92%92%

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Comorbid Mental Health Conditions are Pervasive

65%65% of PRC inpatients received a mental Health Diagnosis: (Walker & Clark, 2006)

• Adjustment Disorder: Adjustment Disorder: 47% 47% • PTSD: PTSD: 29%29%• Depressive Disorder: Depressive Disorder: 24%24%• Substance Abuse: Substance Abuse: 7% 7%• Acute Stress Disorder:Acute Stress Disorder: 5% 5%

In a sample of 99 VA medical care registrants 67%67% reported emotional problems: (Kalra, Clark, Scholten, Murphy, & Clements, 2008)

36%36% Depression 16% 16% PTSD symptoms23%23% Adjustment problems 15%15% anger control issues20%20% Anxiety 12%12% alcohol abuse19%19% Marital or family problems

3CLARK- 2009

Pain, PTSD, mTBI, and substance use disorders often co-occur and interact

CLARK- 2009 4

Author Subjects Pain Sx PTSD Sx TBI Sx Subs Sx

Clark et al., 2007 PRC inpatients (Tampa) 96% 44% 80% 4%

Hoge et al., 2008 Soldiers with LOC 50%-100%* 44% 100% N/A

Kalra et al., 2008 Outpts with pain (Tampa) 100% 16% N/A 12%

Kang & Hyams, 2007 OEF/OIF VA disability evals N/A 15% N/A 3%

Lew et al., 2007 Outpts with H/O mild TBI 97% 42% 100% N/A

Ruff et al., 2008 OEF/OIF outpts with mild TBI 93%** 90% 100% N/A

Sayer et al., 2008 PRC inpatients (all PRCs) 82% 42% 88% N/A

Shipherd et al., 2007 Outpts seeking PTSD Tx 66% 100% N/A 28%

Villano et al., 2007295 OEF/OIF Mental Health patients

40% 46%*** N/A 49%

*Headaches only. Total pain % not reported but data for separate pain conditions suggests it approaches 100% in these war-injured. * *Headaches only. Total pain % not reported

PCS Symptoms* Mild TBI PTSD Chronic Pain SUD

Memory impairment1,2 √ √ √ √

Concentration problems1,2 √ √ √ √

Irritability1,2 √ √ √ √

Insomnia/Sleep Problems1,2 √ √ √ √

Fatigue1,2 √ √ √ √

Headache1,2 √ √ √ √

Dizziness1,2 √ √ √ ?

Intolerance of stress, emotion, or alcohol1 √ √ √ √

Affective disturbance2 √ √ √ √

Personality change2 √ √ √ √

Apathy2 √ √ √ √

There is substantial overlap in symptoms in mTBI, pain, PTSD and SUD

OEF/OIF pain may be more difficult to treat

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0

1

2

3

4

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Pre Post

Non-Combat

Combat/Blast

Combat/Non-Blast

Pain Change Following Interdisciplinary Treatment

Post-Deployment Multi-symptom Post-Deployment Multi-symptom DisorderDisorder

PTSD

TB

IPA

IN

TBI/Pain

TBI/PTSD Pain

/PTS

D

Post-deploymentMulti-symptom

Disorder

8CLARK- 2009

PMD Example

Overall prevalence:Pain 81.5%TBI 68.2%PTSD 66.8%

PTSD

TB

IPA

IN

Post-deploymentMulti-symptom

Disorder

TBI/Pain

TBI/PTSD Pain

/PTS

D

Lew, Otis, Tun, Kerns, Clark, & Cifu, 2009Sample = 340 OEF/OIF outpatients at Boston VA

42.1%

5.3%

2.9%

16.5%

10.3%

12.6%

6.8%

9CLARK- 2009

Latest Data

• HSR&D funded study examining OEF/OIF pain and emotional issues at 2 of the 4 PRC sites

• Participants recruited either from the polytrauma network of care (convenience) or local OEF/OIF registries (random)

• Follow all participants for 12 months• Approximately 600 data points• Utilize validated and accepted structured diagnostic

interview for DSM IV diagnoses• Following data represent a “first look” at some results

for 127 participants

Biases

PRC/PNS Sample(n= 69)

OEF/OIF Sample(n= 52)

Polytrauma already

selected for Tx

Agreed to participate

(40%)

Random sample from OEF/OIF VA

registry

Agreed to participate

(21%)

Regional effects?

(Minneapolis)

Regional effects? (Tampa)

Demographics

RecruitmentRecruitment Duty StatusDuty Status

OEF/OIF Registry 41.50% Active DutyActive Duty 17.2%17.2%

PRC/PNS 55.10% Inactive Reserve 8.2% Other 3.40% Active ReserveActive Reserve 23.8%23.8%AgeAge 34.9 TDRL 3.3%EducationEducation 14.29 Completed obligations 47.5%SexSex EmploymentEmployment Male 91.0% Full-time 52.0% Female 9.0% Part-time 8.0%RaceRace Unemp/not lookingUnemp/not looking 1.6%1.6% Caucasian 77.9% Unemp/lookingUnemp/looking 15.2%15.2% Hispanic 11.5% Disabled 7.2% Black 10.7% Retired 3.2%MaritalMarital Student 10.4%

Single 25.4% Service ConnectionService Connection

Married 45.9% NSC 19.2%

Living together 3.3% NSC-PN 1.4%

Divorced/Sep 25.4% SC 63.2% SC Claim Pending 20.9%

Deployment

Deployed fromDeployed from Blast TypeBlast Type

Active duty 57.4% IED 42.4%

Inactive reserve 28.7% Mortar 27.2%

Active reserve 13.9% RPG 5.6%

Deployed toDeployed to All other 24.4%

OEF only 9.6% Mean # of blastsMean # of blasts 111.2*111.2*

OIF only 69.6% Adjusted mean # of Adjusted mean # of blastsblasts 13.713.7

Both OEF/OIF 20.2% LOCLOC 20.8%20.8%Total deployment Total deployment timetime 15.3 months Injuries from blastInjuries from blast 50.0%50.0%

Mean time since Mean time since returnreturn 38.6 months Avg distance from Avg distance from

blastblast 271 feet

Exposed to blast(s)Exposed to blast(s) 90.2%90.2% Polytrauma %Polytrauma % 70.70%

Pain

• Persistent pain present in 86.4%, average pain 3.7 • Significant pain (4 or >) 50.4%

• Headache prevalence 72.5%• Days/week with headaches 3.6

• Most common pain locations Primary Pain Any Pain  Back 29.9% 75.9%   Head 29.0% 66.7%   Shoulder 11.2% 49.1%   Knee 7.5% 56.5%   Neck 5.6% 48.1%   Hand/wrist 4.7% 25.9%   Ankle/foot 3.8% 25.0%   Leg/Hip 2.8% 24.1%   Arm/elbow 1.9% 24.1%  

Mental Health Problems

Ever had a MH problemEver had a MH problem 83.60% Reported impairmentsReported impairments

Onset of MH problem Activity 73.60%

Pre-service 5.00% Sleep 65.30%

Pre-deployment 5.00% Recreational 60.30% Combat non-blast related 4.00% Occupational 59.50%

Combat blast-related 20.80% Emotional 58.70% Non-combat/during deployment 10.90% Social 51.20%

Post-deployment 48.50% Familial 43.00%

Post-service 5.90% Sexual 35.50%

Resolution of MH problemResolution of MH problem

Before deployment 9.80% After deployment 6.86%

During deployment 4.90% Ongoing- not resolved 87.25%

Treatment Experience

Pain Tx (Prior 3 months)Pain Tx (Prior 3 months) Treated in PRC/PNSTreated in PRC/PNS 56.40%

VA treatment for pain 45.50% Using VA for all medical and MH care 51.70%

Tx Satisfaction (0-10) 7.1 Overall satisfaction with VA (0-10) 8.2

Effectiveness (0-10) 5.7 Overall effectiveness of VA (0-10) 7.5

Community treatment for pain 16.40% Most common barriers to VA careMost common barriers to VA care

Tx Satisfaction (0-10) 6.9 Fear/embarrassment/stigma 16.00%

Effectiveness (0-10) 5.9 Distance/location 15.20%

MH Tx (Prior 3 months)MH Tx (Prior 3 months) Staff concerns/reputation for care 12.80%

VA MH Tx 45.70% Waiting time/access/delays 12.80%

Tx Satisfaction (0-10) 7.8 Paperwork/hassle 11.20%

Effectiveness (0-10) 7.1 Lack of info about services 11.20%

Community MH Tx 15.60% Limited hours for services 4.80%

Tx Satisfaction (0-10) 6.1 Fear of military accessing records 4.00%

Effectiveness (0-10) 5.6 No barriers 29.60%

DSM-IV Mental Health DiagnosesAt least 1 M.I.N.I. DxAt least 1 M.I.N.I. Dx 66.4% PTSDPTSD 35.9%

DepressionDepression Mood disorder with psychotic Mood disorder with psychotic featuresfeatures 2.6%

Major Depression 39.3% Antisocial Personality DisorderAntisocial Personality Disorder 4.3%

Dysthymia 3.4% Substance Use DisordersSubstance Use Disorders

1 or more depressive disorders 41.0% ETOH dependnece 16.2%

HypomaniaHypomania 29.1% ETOH Abuse 10.3%

AnxietyAnxiety Opioid Dependence 1.7%

Panic disorder 24.8% Opioid Abuse 1.7%

Agoraphobia 25.6% Other Substance Dependence 2.6%

Social Phobia 10.3% Other Substance Abuse 1.7%

Obsessive-compulsive disorder 17.1% Polysubstance Abuse 0.9%

Generalized Anxiety Disorder 17.2% 1 or more substance use disorders 26.5%

1 or more anxiety disorders (except PTSD) 44.0%

Diagnostic Overlap

Pain prevalencePain prevalence 86.4% ComorbiditiesComorbiditiesPTSD PrevalencePTSD Prevalence 35.9% Pain and PTSD only 20.5%mTBI prevalence mTBI prevalence (based on LOC) 25.9% Pain and mTBI only 8.2%

Pain only Pain only (no mTBI or PTSD) 47.2% PTSD and mTBI only 0.0%

mTBI only mTBI only (no pain or PTSD) 2.4% Pain, PTSD, and mTBI 13.1%

PTSD only PTSD only (no pain or mTBI) 0.8% Pain and Substance

Abuse 22.4%

Symptom Burden 1

Symptom Burden 2

Symptom Burden 3

PMD Treatment

Postconcussion

Pai

nPTSD

P3+

Post-Deployment Behavioral Health Program

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P3+Team Staff with specialties in

Behavioral Medicine Pain PTSD TBI Substance Abuse Case Management PM&RS therapies

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P3+ Integrated CarePost Deployment ClinicsPost Deployment Clinics Polytrauma TeamsPolytrauma Teams

Optional Core Treatments:Optional Core Treatments:Anger ManagementAnger Management

Negative AffectNegative AffectCognitive AdaptationCognitive Adaptation

Relationship EnhancementRelationship EnhancementWork SkillsWork Skills

Physical ConditioningPhysical Conditioning

TBI Tx TBI Tx

Pain Tx Pain Tx

PTSD Tx PTSD Tx

Substance Substance Abuse TxAbuse Tx

Focused Focused Treatments Treatments

(existing & (existing & expand)expand)

Evaluation/Tx PlanningEvaluation/Tx Planning

Required Core Treatment: Required Core Treatment: Life NeedsLife Needs (Sleep Hygiene, (Sleep Hygiene,

Relaxation Skills; Relaxation Skills; Substance Use)Substance Use)

New

Pro

gra

mN

ew

Pro

gra

m

VR Tx VR Tx

Exis

ting

Exis

ting

P

rog

ram

sP

rog

ram

sDoD FacilitiesDoD Facilities

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Where do we go from here?.

• Data, data, data!• How do these overlapping comorbidities interact, and

does it impact outcomes?• What are the most effective and efficient treatments

for PMD?• What increased health and adjustment risks are

associated with blast exposure?• Until data become available, develop innovative but

rational programs based on existing knowledge and conceptual models

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