GWI Veterans: Exposures, Symptoms and Clinical Care
Stephen C Hunt MD MPH Director, VA Post-Deployment Integrated Care Initiative
Institute of Medicine Washington DCJune 26, 2013
Rate the degree to which you believe “Persian Gulf Illness” is:
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Mostly a PhysicalDisorder
Mostly a Mental Disorder
Internal Medicine(n = 77)
Mental Health (n = 176)
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Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician Attributions for Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161: 1289-1294.
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Mostly BiologicalInterventions
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Rate the degree to which you believe “Persian Gulf Illness,” in general,
is most effectively treated by:
Richardson RD, Engel CC, McFall, M, McKnight K, Hunt SC. Clinician Attributions for Symptoms and Treatment of Gulf War-Related Health Concerns. Archives of Internal Medicine 2001; 161: 1289-1294.
VETERANS HEALTH ADMINISTRATION
Non-combat injury
Mentalhealth
Non-combatillness Post-Deployment
SymptomsCMI
Spiritual /existentialstruggles
Combat injury
TBIMarital/family
financialdifficulties
Environmentalexposure
illness
Hearing losstinnitus
C&P needs
Post-Deployment Health Care Needs
VETERANS HEALTH ADMINISTRATION
Non-combat injury
Mentalhealth
Non-combatillness Post-Deployment
SymptomsCMI
Spiritual /existentialstruggles
Combat injury
TBIMarital/family
financialdifficulties
Environmentalexposure
illness
Hearing losstinnitus
C&P needs
Post-Deployment Integrated Care
VETERANS HEALTH ADMINISTRATION
Integrated Post-Combat CarePDICI (Post-Deployment Integrated Care Initiative 2008)
Primary Care Provider Mental Health
Provider Veteran
Social Worker
Core Team members•Clinical Pharmacy Specialist: ± 3 panels
•Clinical Pharmacy anticoagulation: ± 5 panels
• Social Work: ± 2 panels• Nutrition: ± 5 panels• Case Manager• Integrated Behavioral
Health• Psychologist ± 3 panels• Social Worker ± 5 panels• Care Manager ± 5 panels• Psychiatrist ± 10 panels
PCPClinical Associate (LPN, MA, or Health Tech)Clerk
RN Care Manager
OEF/OIF/ONDProgram
staff
Combat
Veteran
PACT can care for special populationswith support and training. The PACT expands as needed to meet the Veteran’sneeds
04/20/2023 7
Substance Abuse
Polytrauma
PainSpecialty Mental
Health
Ortho
PT
Neurology
Vet Centers
EnvironmentalClinician
PIDICI Champ
Teamlet
VBA
C+P
Chaplain
VETERANS HEALTH ADMINISTRATION
What we don’t know about GW veterans health…
• The specific effects of many of the numerous combat related exposures on post-war health
• The specific cause(s) of the chronic multi-symptom illnesses so commonly seen in GW veterans
• The relative contributions of the many combat related exposures and experiences to specific post-war health symptoms and concerns
• The long term health risks of many of the numerous combat related exposures and experiences
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VETERANS HEALTH ADMINISTRATION
What we do know about GW veterans health…
• GW veterans have more medically unexplained symptoms than veterans of other conflicts
• GW veterans have a particular constellation of symptoms (fatigue, muscle/joint pain and memory/concentration problems) more often than combat veterans from other conflicts
• GW veterans combat experience involved more concerns about a wider variety of chemical and environmental agents than combat veterans of other conflicts
• GW veterans have poorer general health and functioning than expected• GW veterans had less exposure to traditional combat stressors but
more exposure to chemical/biological weapons threats than combat veterans from other conflicts
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VETERANS HEALTH ADMINISTRATION
What we do know about individuals with unexplained symptoms…
• Unexplained symptoms are not unique to GWI Veterans but are much more common in GWI Veterans
• Many individuals coming in to see their primary care doctors have symptoms for which a specific cause will not be found
• We do not have to know the specific cause of a symptom to effectively treat or manage the symptom
• Attributing symptoms to an incorrect cause may result in incorrect or ineffective management of the symptoms
• Living with medically unexplained symptoms or chronic multi-symptom illness can be more challenging than living with a diagnosed disease
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VETERANS HEALTH ADMINISTRATION
To say that we cannot identify the cause of a Veteran’s symptoms is not to say…
• The Veteran’s symptoms are “in their head” or reflect a psychological etiology
• The Veteran’s health concerns are not real or are not physical• The Veteran’s health concerns are not serious• There is nothing we can do
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VETERANS HEALTH ADMINISTRATION
To say that we do not know is to say…
• This is complex• To be simplistic is to dishonor the complexity of this reality• There are no “magic bullets” • Treatment will take time and a team effort• It is important not to guess at what is going on or to act upon
assumptions• It matters a great deal that we are honest and straightforward• It is more important than ever to pay attention, take care of one’s self,
stay involved in care, support ongoing research• Our goal is not to eradicate all symptoms; our goal is to mitigate
symptoms, improve functioning and optimize quality of life for you and your family
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VETERANS HEALTH ADMINISTRATION
What we do know about treating individuals with unexplained symptoms…
To effectively manage CMI in GWI Veterans: • Acknowledgement and appreciation of the Veteran’s service and
sacrifice• Validation of the Veteran’s symptom experience and health
concerns• Comprehensive initial assessment • Effective communication and education of team/Veteran/family• Ongoing care including evidence based treatments, symptom
management and vigilance to emergence of diagnosable conditions
• A willingness to acknowledge complexity and “not knowing”
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VETERANS HEALTH ADMINISTRATION
What we do know about treating individuals with unexplained symptoms…
To effectively manage CMI in GWI Veterans:
Patient centered: health maintenance, preventive medicine, health recovery
Ongoing monitoring of care and functional status; life long commitment
Ongoing research into the specific syndromes/conditions involved
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Gulf War Presumptive Conditions Included are medically unexplained chronic multi-symptom illnesses defined by a cluster
of signs or symptoms that have existed for six months or more, such as: Chronic fatigue syndrome Fibromyalgia Irritable bowel syndrome Any diagnosed or undiagnosed illness that the Secretary of Veterans Affairs determines warrants a
presumption of service connection.
• Signs or symptoms of an undiagnosed illness include: – Fatigue – sleep disturbance– skin symptoms – Headaches– neurological symptoms– muscle and joint pain – respiratory symptoms – GI symptoms– cardiovascular symptoms – weight loss– menstrual disorders
Disease and Illness in Health Care
AsymptomaticDisease
SymptomaticDisease
SymptomaticHealth Impairmentw/o Diagnosable
Disease
IllnessDisease
Disease and Illness in Health Care
AsymptomaticDisease
SymptomaticDisease
SymptomaticHealth Impairmentw/o Diagnosable
Disease
IllnessDisease
GWVeteran
CMI
Disease and Illness in Health Care
AsymptomaticDisease
SymptomaticDisease
SymptomaticHealth Impairmentw/o Diagnosable
Disease
IllnessDisease
GWVeteran
Disease and Illness in Health Care
AsymptomaticDisease
SymptomaticDisease
SymptomaticHealth Impairmentw/o Diagnosable
Disease
IllnessDiseaseGW
Veteran
Post-Deployment Integrated Care
AsymptomaticDisease
SymptomaticDisease
SymptomaticHealth Impairmentw/o Diagnosable
Disease
IllnessDisease
VETERANS HEALTH ADMINISTRATION
Case Definition (CDC)
A case definition is set of uniform criteria used to define a disease for public health surveillance. Case definitions enable public health to classify and count cases consistently across reporting jurisdictions, and should not be used by healthcare providers to determine how to meet an individual patient’s health needs.
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VETERANS HEALTH ADMINISTRATION
Chronic Multi-Symptom Illness
in Gulf War I Veterans
04/20/2023
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Centers for Disease Control (CDC) defined "chronic multi-symptom illness" and applied the definition to study the relationship of the Gulf War to subsequent illness. The chronic multi-symptom illness definition has the advantage of encompassing several common syndromes that are comprised of unexplained symptoms (Fukuda & Nisenbaum, 1998).
VETERANS HEALTH ADMINISTRATION
For a Veteran Centered Case Definition
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1. A GWI indicator and post-deployment indicator such as: A. CMI:GWI type, or B. CMI Subsequent to GWI Service
C. GWI related CMI
2.Nomenclature that has provisions for CMI predictors such as predisposing, precipitating and perpetuating factors including environmental exposures of an unquantifiable nature
VETERANS HEALTH ADMINISTRATION
For a Veteran Centered Case Definition
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3.Veteran (patient)centered orientation A. While our focus as clinicians certainly includes approaching CMI as a definable entity with evidence based approaches to treatment, in our new model of care, as was noted in the recent IOM report, our primary orientation involves thinking in terms of "the Veteran with CMI" or "the GWI Veteran with CMI" and how we might best optimize his/her health and functioning. B. a case definition that will not be entirely exclusive of those who are sub-syndrome or sub-threshold C. nomenclature and language that leverages the potential
therapeutic benefits of the disease model without undermining the centrality of the health and functional recovery orientation that is recommended for this complex and problematic health concern
VETERANS HEALTH ADMINISTRATION
Chronic Multi-Symptom Illness
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We know the complex ways in which war impacts the lives and health of those who are touched by it. We know how to effectively respond to these health impacts, even in situations where we do not fully understand the causal factors or pathophysiology of the symptoms or illness process.
Our ultimate goal is to assist the Veteran and his/her family in any ways possible to optimize their health and quality of life.