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ADF Health April 2004 - Volume 5 Number 1

Mental Health

The Australian Centre for Posttraumatic Mental Health

An integrated approach to veteran and military mental health

• Professor Mark Creamer, PhD, FAPS, and Professor Bruce Singh, MB BS, PhD, FRACP, FRANZCP

AUSTRALIA HAS A PROUD TRADITION of caring for its veterans and their dependents since the Repatriation Commission was established in 1917. Although the potential psychiatric sequelae to war have long been recognised, 1 it was not until 1980 that the diagnosis of posttraumatic stress disorder (PTSD) was introduced. Despite some criticism, the diagnosis provided a degree of legitimacy for sufferers of postwar mental health problems and reduced the need for pejorative terms such as "inadequate personality" or non-specific descriptors such as "anxiety neurosis" that were used widely until then. The following decade saw considerable growth in awareness of veteran mental health issues, coinciding with major changes in psychiatric practice more generally. More recently, defence forces around the world have begun to address the challenge of mental health among serving personnel.

In response to a growing awareness of military mental health issues in Australia, the National Centre for War-Related PTSD was established in 1995. Funded by the Department of Veterans’ Affairs (DVA) and established in collaboration with the University of Melbourne, the Centre’s mission was to improve the recognition and treatment of PTSD within the veteran population. In July 2000, this role was extended to include the full range of mental health problems in veterans and serving personnel, while at the same time retaining a specialist focus on the psychiatric sequelae of trauma within both the civilian community and military populations. The name was changed to the Australian Centre for Posttraumatic Mental Health (ACPMH). Links with the Australian Defence Force (ADF) were strengthened, with the aim of improving the recognition, prevention and treatment of psychiatric problems among serving personnel.

Organisational structure

ACPMH functions as an independent legal entity, operating in the context of formal agreements with several other organisations. These include DVA (which provides most of the recurrent funding), ADF (which provides specialist personnel), and the University of Melbourne (which provides academic supervision and infrastructure support). A Board of Management, including representatives of DVA, ADF and the University, oversees the Centre’s work.

A national responsibility for veteran and military mental health has necessitated the evolution of structures that ensure responsiveness to differing local needs across the country. To this end, a "hub and spoke" model is often adopted, with the Centre providing a coordinating and leadership role to regional groups with specific areas of responsibility. A crucial development took place in mid-2002 with the formation of a Directorate of Mental Health within the Defence Health Services Branch. ACPMH has established a close collaborative relationship with the Directorate of Mental Health, providing clinical policy and program advice, training initiatives, and research support.

Key responsibilities

ACPMH functions within the context of the National Mental Health Plan, the DVA Mental Health Policy, and the ADF Mental Health Policy. The Centre’s three core activities are clinical policy and program development, training, and research. As far as possible, these activities are integrated so that research findings inform the clinical policy and program advice provided to key stakeholders, while policy and program developments dictate training needs. This work program is reflected in the ACPMH Terms of Reference as follows:

• To act as a Centre of Excellence and source of advice in the field of traumatic stress, as well as veteran and military mental health.

ACPMH provides advice to DVA and the ADF, as well as to service providers, policy makers, community organisations, researchers, consumers, and other interested parties, on issues associated with traumatic stress and veteran or military mental health. While some of this advice is provided through formal documents, much is provided through more informal mechanisms, such as telephone and email. Indeed, it is a dilemma shared by many such organisations that the volume of requests for advice and information - especially through email - is constantly increasing, placing considerable demands on the available resources.

ACPMH provides advice to the Directorate of Mental Health and Defence Health Service Branch on key clinical, policy, and program matters associated with military mental health. Very complex issues are raised as defence forces around the world adapt to changing attitudes to mental health and increased awareness of PTSD and related conditions. Occupational health and safety expectations, and legal proceedings such as the recent class action against the Ministry of Defence in Britain, have potentially serious implications for departments of defence and veterans affairs internationally.

• To provide consultancy and advice in the area of clinical program development.

ACPMH provides clinical consultancy to providers managing traumatic stress disorders, with particular reference to veterans and serving personnel. The Centre also has an accreditation and quality improvement role for DVA-funded PTSD treatment programs across Australia, helping to ensure consistency and establishing basic conditions for evaluating outcomes of treatment. A variety of inpatient, outpatient and community-based programs are offered, with an emphasis on coordinated care for those with complex psychiatric conditions. The broader mandate of ACPMH brings with it expanded challenges and responsibilities in this area and additional expertise has been recruited in order to provide advice in areas beyond PTSD. The development of effective intervention models for substance abuse disorders, for example, is a current priority for the Centre’s work with both the DVA and the ADF.

ACPMH is working closely with the Directorate of Mental Health on a low-key intervention program for personnel experiencing adjustment problems after deployment. It is hoped that early intervention at this point, with an emphasis on education and skills development, will improve outcomes, reduce the prevalence of more serious chronic conditions, and minimise the subsequent need for intensive mental health interventions.

• To evaluate the outcome of mental health treatment provided to veterans and serving personnel.

ACPMH monitors treatment outcomes by collecting data from accredited programs around Australia at intake and follow-up. Data from the PTSD treatment programs for veterans demonstrate significant reductions in core symptoms, as well as improvements in broader psychosocial functioning. 2 Although these results are impressive, optimism should be tempered with caution. Around a third of veterans did not respond to treatment, and a program of research is under way to investigate early predictors of treatment response. 3 ACPMH’s role in evaluating treatment outcomes is currently undergoing a phased expansion to include disorders other than PTSD.

• To provide and facilitate education and training in the field of traumatic stress, as well as veteran and military mental health.

ACPMH provides a range of education and training initiatives, with strategies including annual conferences, workshops and seminars held around Australia, development of written materials, training videos, internet-based services, and sponsored visits by one or two overseas experts each year. Training is targeted towards mental health and primary health care providers, defence force personnel, and consumers within both the veteran and general communities. To devolve responsibility for training to a local level, ACPMH works closely with state-based committees. These committees work with regional branches of professional organisations, providers, and consumer groups to develop a training agenda that is responsive to local needs. ACPMH takes a leadership and coordination role, providing administrative and technical support and overseeing the evaluation process. The active involvement of Divisions of General Practice around the country has been critical to the success of this initiative.

ACPMH provides regular training courses to defence force personnel, the highlight being the Traumatic Stress Syndromes (TSS) course. An intensive 2-week program for psychologists, medical officers, and related personnel, the course has a strong clinical component and features presentations by some of Australia’s leading experts. ACPMH collaborated closely with the Defence Health Service Branch in 2002 to conduct the successful Defence Health Symposium in Sydney. ACPMH organised the symposium’s mental health stream and arranged for the Director of Mental Health Policy in the US Armed Forces to provide a keynote address. A similar event is planned for 2005.

• To develop strategies designed to prevent the development of long-term mental health problems following trauma, with particular reference to veterans and serving personnel.

ACPMH has a strong collaborative relationship with the ADF, with several military mental health staff positions based at the Centre. These positions aim to enhance primary, secondary, and tertiary prevention of mental health problems among serving personnel by providing policy and program advice, training, and research support. The Centre contributes to the development and implementation of ADF mental health policy, providing advice on mental health issues to the Director General Defence Health Services. To facilitate a consistent approach, while also being responsive to the diverse needs of serving personnel around Australia, a network of regional teams has been established. Although initially set up by ACPMH, these Regional Mental Health Teams now come under the direct control of the Directorate of Mental Health. These multidisciplinary teams are responsible for coordinating military mental health activities within their individual health regions, with a focus on identifying existing services, developing professional networks, establishing multidisciplinary working environments, and providing feedback to the Directorate of Mental Health (and thereby to ACPMH) on gaps in policy and service provision.

In 2002, ACPMH worked closely with the ADF on policy and procedures to be adopted immediately following exposure to traumatic or "critical" incidents. Rather than relying almost exclusively on a psychological debriefing model (the efficacy of which has been questioned in recent times), the ADF now takes a more flexible approach that is at the forefront of world’s best practice. The Critical Incident Mental Health Support (CMS) model includes a standardised training package for providers, built-in screening instruments to detect those at high risk, and a low-key, four-phase response option.

• To conduct and facilitate research in the area of traumatic stress, as well as veteran and military mental health.

Research has always been a core mandate of ACPMH, but resource limitations in its early years curtailed research output. More recently, however, a research infrastructure has been developed and competitive grant funding and publications have begun to emerge. Key research areas include epidemiological studies (with particular reference to veteran and military populations), predictors and mechanisms of treatment outcomes, and development of effective measurement strategies. ACPMH is now home to the World Health Organization Quality of Life Australian Field Study Centre. In collaboration with the ADF, ACPMH is developing an integrated research agenda in the area of military mental health. ACPMH also has a strong program of research in civilian trauma, with a particular focus on seriously injured trauma survivors.

ACPMH works closely with the Directorate of Mental Health on a variety of projects and participates in the Directorate’s Research and Surveillance Advisory Committee.

• To liaise and collaborate with other relevant agencies in Australia and overseas.

ACPMH has strong working links with similar organisations in the US, Canada, the UK, and Israel. These links are fundamental to ensuring that Australia remains prominent in the fields of veteran and military mental health. ACPMH also has strong relationships with other organisations around Australia, ensuring that the Centre remains relevant to the research and clinical needs of the populations it has been established to serve.

An integrated approach

ACPMH, in collaboration with the DVA and ADF, clinicians, researchers and consumers, provides a focus for an integrated approach to veteran and military mental health. Involvement with both veterans and currently serving personnel provides a level of integration across the life course of psychiatric conditions in this population. It is important to optimise opportunities for mental health screening at key points in military service (such as recruitment, deployment and discharge), ensuring that problems are recognised and treated promptly with minimal impact on the person’s career. If we are to minimise the prevalence and severity of mental health problems during and following military service, it is crucial that we move more towards a longitudinal view of military mental health, with a shared responsibility for recognition, early intervention and, where appropriate, psychosocial rehabilitation. This will require considerable cultural and attitudinal change from all parties involved.

A unique, integrated network of specialist treatment programs for veterans with chronic mental health problems has been established across Australia, all complying with guidelines based on world’s best practice, participating in a standardised treatment outcome evaluation process, and sharing knowledge and experience at annual meetings. The challenge for ACPMH and those programs now is to develop a more holistic and integrated approach to care, designed to address the full spectrum of psychosocial needs, without losing the clinical benefits of specialist PTSD programs.

ACPMH is developing an integrated training strategy, driven by the needs of clinicians and consumers. The world’s best practice prevention and intervention models are being identified and used to highlight skill deficits that can be addressed by appropriately designed training models. Research at the Centre has always been integrated with treatment through the program’s evaluation database. In future, expansion of this research database will improve the Centre’s ability to provide evidence-based advice on the psychiatric aftermath of traumatic exposure.

Conclusions and future directions

Since its inception in mid-1995, ACPMH has achieved international recognition in the fields of traumatic stress and veteran and military mental health. Collaboration with the ADF will help to ensure that veterans of the future are better protected from the psychological sequelae of military service and that they receive prompt, effective treatment when required.

There are many challenges ahead in the field of military mental health. ACPMH believes that the first step is a genuinely integrated approach to the problem, starting at the point of recruitment, continuing through the member’s service career, through discharge from the ADF (and, potentially, into the care of DVA), and throughout life as a veteran. All parties - the serving member and his/her colleagues, the ADF and DVA - must accept shared responsibility for the mental health and well-being of current and former military personnel. It is also essential that all parties are genuinely committed to the concept of psychosocial rehabilitation. It seems highly likely that the current adversarial systems of determining entitlement for treatment and compensation serve to exacerbate problems and to impede effective recovery. The new Military Rehabilitation and Compensation Act, currently before Parliament, will set the scene for cultural change in these areas over the next decade. Importantly, however, all parties need to be convinced that such changes are genuinely in the best long-term interests of serving members. There is no doubt that the next decade will be a fascinating and important period in military mental health.

References

1. Gersons BP, Carlier IV. Post-traumatic stress disorder. The history of a recent concept. Br J Psychiatry 1992; 161: 742-748.
2. Creamer M, Morris P, Biddle D, Elliott P. Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: A cause for cautious optimism? J Trauma Stress 1999; 12: 545-558.
3. Forbes D, Creamer M, Hawthorne G, et al. J Nerv Ment Dis 2003; 191: 93-99.

(Received 15 Dec 2003, accepted 15 Jan 2004)

This article is adapted from an article first published in Australasian Psychiatry 2003; 11: 225-227.

Professor Mark Creamer is Director of the Australian Centre for Posttraumatic Mental Health and Professor of Psychology in the Department of Psychiatry at the University of Melbourne. He is a clinical psychologist with many years of research and clinical experience in the field of posttraumatic stress. He has provided advice to government and nongovernment agencies on psychological recovery from disaster and trauma. He has published widely on the subject and is on the Editorial Board of the Journal of Traumatic Stress.

Professor Bruce Singh is Cato Professor and Head of the Department of Psychiatry at the University of Melbourne. He has had a longstanding commitment to psychiatric services, particularly their move into the general health system. He is active in promoting psychiatry in the Asia-Pacific region. He has published 5 books and over 100 papers on psychiatry. He was awarded the Centenary of Federation Medal in 2003 for his services to medicine.

University of Melbourne, Melbourne, VIC.

Mark Creamer, PhD, FAPS, Director, Australian Centre for Posttraumatic Mental Health; Bruce Singh, MB BS, PhD, FRACP, FRANZCP, Head, Department of Psychiatry.

Correspondence: Professor Mark Creamer, ACPMH, ARMC Repatriation Campus, PO Box 544, West Heidelberg, VIC 3081. markcc@unimelb.edu.au