Medically Ready ForceReady Medical Force 1 AMSUS Psychological Health Research Current and Future Directions CAPT Michael Colston, Director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury 1-4 December 2015 Medically Ready ForceReady Medical Force 2 Agenda How the research mission is operationalized Operational Research-recent developments in Suicide, PTSD, resilience, and SUDs Gaps Future Directions Research: Delivering Solutions Across the Lifecycle Lifecycle SolutionsBiomedical Products Policy Regulations, Doctrine, Procedures Leadership Guidelines, Standards, Methodologies Training & Education Decision Support Tools, Best Clinical Practices, Training Existing COTS, COTS Modified, MIL-STDs, Materiel Safety Standards & Methodologies New Materiel Detectors, Sensors, Predictors, Pharmaceuticals 3 Medically Ready ForceReady Medical Force 4 DEVELOPING AND MAINTAINING A FIT AND READY FORCE Deployment Post-Deployment Employment Mobilization Reconstitution Treat Casualties Separation Post-Military Surveillance Reset Readiness Basic Training Accession Re-Deployment Research: Delivering Solutions Across the Deployment Cycle Medically Ready ForceReady Medical Force 5 5 Psychological Health Research Continuum Understand Intervene Implement Foundational Science Epidemiology Etiology Prevention and Screening Treatment Services Research Basic discovery science Population-level (to include at-risk) descriptive and characterization in nature; the study of the distribution of associations between health related states Neurobio- logical mechanisms of the disease to include possible causes of disorder Population, indicated prevention intervention at different stages of illness; screening measures; assessment tools and measurement; training Aimed at symptom amelioration (includes psychotherapies, drugs) at different stages of illness including refractory, chronic, relapse, relapse prevention; address co- morbidities; follow- up Focused on system of care improvements and provider and non- healthcare provider Medically Ready ForceReady Medical Force 6 Suicide Prevention Evidence for Cognitive-Behavioral approaches is accumulating Common Data Elements have been formulated for suicide research A DoD/VA Suicide Data Repository is established. A large VA medication trial is underway (Lithium) The Military Suicide Research Consortium (MSRC) has 22 studies aimed at delivering evidence-based prevention and treatment interventions STARRS longitudinal study, a follow-on to Army STARRS, is underway Medically Ready ForceReady Medical Force 7 7 Public Health Model for Suicide Preventiondomains in light of ASCVD advancements DomainASCVD AnalogueSuicide Analogue Lifesaving Intervention Angioplasty/Thrombolysis, Stents/Clot Retrieval Inpatient Admission Actuarial Understanding / Predictive Tool Framingham Model Army STARRS ($40M USA Funding, $15M NIH U-01 Grant) Best Prevention Strategy in Evidence Base Identification and Aggressive Management of Hypertension (SBP/DBP >120/80) Identification and Aggressive Management of Depression- remission/Outcome Measures Low Hanging Risk Reduction Smoking Weapons Access Prophylactic Medications Statins (good evidence base) Aspirin (evidence base in men) Lithium (some positive studies meta-analyses equivocal) Atypical Antipsychotics (same) Medically Ready ForceReady Medical Force 8 Weapons and Suicide Firearms are the most frequent means of suicide among Service members according to DoDSER Non-Military Firearm Military Firearm Hanging/ Asphyxiation Drugs/ ETOH %14%25%6% %11%21%4% %11%26%4% %7%29%3% %5%15%2% Lubin, G., Werbeloff, N., Halperin, D., Shmushkevitch, M., Weiser, M., & Knobler, H. (2010). Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: A naturalistic epidemiological study. Suicide and Life-threatening Behavior, 40(5), vb Medically Ready ForceReady Medical Force 9 Contrarian Findings in Recent Literature Deployment does not appear to have an overall association with suicide (defining cohorts is well underway) Combat exposure does not appear to have an overall association with suicide (again, cohort work is underway) Depression, bipolar disorder, and psychosis have greater odds ratios for correlations to suicide than PTSD. Among individuals with MH diagnoses, a PTSD diagnosis is a protective factor for suicide (in VA and DoD populations) 9 Medically Ready ForceReady Medical Force 10 PTSD Portfolio Common Data Elements (CDEs) for PTSD were promulgated PTSD Brain and specimen banks are established Promising DoD work is identifying diagnostic biomarkers Disease subtyping is underway VA/DoD/HHS are co-developing tools for clinicians Medically Ready ForceReady Medical Force 11 PTSD Diagnostics and Treatments Tele-behavioral health (TBH) Use of TBH treatments can reduce many of the barriers that might prevent individuals from pursuing or accessing care Ongoing projects determining the equivalency between in-office and tele-health methods of delivering therapy Data are demonstrating equivalency between methods of delivery Negative studies: avatars, virtual reality Therapies: CPT, Exposure Therapy, CBT, and Behavioral Activation for Depression/MST, PET Medically Ready ForceReady Medical Force 12 PTSD Diagnostics and Treatments Compressed Treatment Currently, therapy is provided over a longer period of time (i.e. 1x/wk for 12 weeks) Limits applicability for active duty troops that may not be able to otherwise complete treatment A longer period of time could mean a decremented force Compressed treatment regimens compare traditional provision as compared to providing therapy 1x/day for 2 weeks Data collection is ongoing, but demonstrating equality between traditional and compressed delivery Medically Ready ForceReady Medical Force 13 Resilience Research Evidence-based resilience building interventions Mindfulness Cognitive-bias modification Neurofeedback Strengths-based skills training Leadership and other external factors Medically Ready ForceReady Medical Force 14 Other PH Issues and Comorbidities Substance Abuse Prescription Opioids Alcohol and MAT Sexual Assault and Violence Prevention Prevention Interventions Behavioral Indicators/ Predictors DES and VASRD changes may affect diagnostic trends Medically Ready ForceReady Medical Force 15 Challenges Front end Systematic approach to needs gathering and priority setting Lessons from IOM 2012learning healthcare system Doing Research Regulatory challenges (IRBs approvals, safety reviews) Recruitment challenges, regulations around incentives not evenly interpreted Implementation and translation Move too fast and risk harm Move too slow and risk harm Evidence standards, need systems for training, accountability, and implementation Medically Ready ForceReady Medical Force 16 Research Gaps-Treatment MHS-wide approaches: Systems-level interventions for PH Increase uptake and practice of evidence-based clinical practice guidelines Factors affecting PH care adherence and engagement Existing evidence-based interventions adapted for telehealth delivery or self-care (technology-mediated) Medically Ready ForceReady Medical Force 17 Research Gaps-Treatment (Cont.) Optimal management of PH (e.g., PTSD, MDD, SUD) with co-morbidities (e.g. pain, TBI, sleep disturbances) Impact of non-clinical intervention factors that may be related to outcomes, including: when providers engage in consultation to patients supervisors and line leaders, fitness for duty and disability determinations, and impact of incentives for positive recovery and health 17 Medically Ready ForceReady Medical Force 18 Future Directions Predictive analytics, machine learning, health state transition modeling based on greater access to big data Precision medicine initiative Faster/better knowledge translation processes Applying the Learning Healthcare System to research Collaborative cross-disciplinary synergies Military-relevant functional resilience metrics Medically Ready ForceReady Medical Force 19 Psychological Health: Major Collaborations VA DoD NIH/HHS CAP MSRC MilCo VA DoD Suicide Data Repository Army STARRS FY13 SA Prevention Funding Opportunity Joint Substance Abuse Program Announcement Marine Resilience Study Joint Funding Opportunities Advisory Boards National Action Alliance for Suicide Prevention CDEs for PTSD/Suicide Medically Ready ForceReady Medical Force 20 Questions