GWI Veterans: Exposures, Symptoms and Clinical Care

Stephen C Hunt MD MPH Director, VA Post-Deployment Integrated Care Initiative Institute of Medicine Washington DC

June 26, 2013

Rate the degree to which you believe Persian Gulf Illness is:
40
Internal Medicine (n = 77) Mental Health (n = 176)

P e r c e n t

35 30 25 20 15 10 5 0
Mostly a Physical Disorder Mostly a Mental Disorder

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.

Rate the degree to which you believe Persian Gulf Illness, in general, is most effectively treated by:

30

P e r c e n t

Internal Medicine (n = 77) Mental Health (n = 176)

25 20 15 10 5 0
Mostly Biological Interventions Mostly Psychological Interventions

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.

Post-Deployment Health Care Needs

Combat injury
TBI Marital/family financial difficulties
Post-Deployment Symptoms CMI

Noncombat injury

Environmental exposure illness

Non-combat illness Spiritual / existential struggles

Hearing loss tinnitus

C&P needs Mental health

VETERANS HEALTH ADMINISTRATION

Post-Deployment Integrated Care

Combat injury
TBI Marital/family financial difficulties
Post-Deployment Symptoms CMI

Noncombat injury

Environmental exposure illness

Non-combat illness Spiritual / existential struggles

Hearing loss tinnitus

C&P needs Mental health

VETERANS HEALTH ADMINISTRATION

Integrated Post-Combat Care

PDICI (Post-Deployment Integrated Care Initiative 2008)

Primary Care Provider

Veteran

Mental Health Provider

Social Worker
VETERANS HEALTH ADMINISTRATION

Core
C+P

Team members
Clinical Pharmacy Specialist: 3 panels Clinical Pharmacy anticoagulation: 5 panels

VBA

PT Ortho
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

PACT can care for special populations with support and training. The PACT expands as needed to meet the Veterans needs
Chaplain
Specialty Mental Health

Substance Abuse Pain

Vet Centers
PIDICI Champ

Teamlet PCP
Clinical Associate (LPN, MA, or Health Tech) Clerk

Polytrauma
Neurology

RN Care Manager OEF/OIF/OND Program staff

Environmental Clinician

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Combat Veteran

GWI Veterans: Exposures & Symptoms What do we know? What dont we know?

What we dont 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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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 multisymptom illness can be more challenging than living with a diagnosed disease

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To say that we cannot identify the cause of a Veterans symptoms is not to say
The Veterans symptoms are in their head or reflect a psychological etiology The Veterans health concerns are not real or are not physical The Veterans health concerns are not serious There is nothing we can do

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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 ones 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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What we do know about treating individuals with unexplained symptoms

To effectively manage CMI in GWI Veterans: Acknowledgement and appreciation of the Veterans service and sacrifice Validation of the Veterans 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
VETERANS HEALTH ADMINISTRATION
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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

VETERANS HEALTH ADMINISTRATION

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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. Fatigue sleep disturbance skin symptoms Headaches neurological symptoms muscle and joint pain respiratory symptoms GI symptoms cardiovascular symptoms weight loss menstrual disorders

Signs or symptoms of an undiagnosed illness include:

Disease and Illness in Health Care

Disease

Illness

Asymptomatic Disease

Symptomatic Disease

Symptomatic Health Impairment w/o Diagnosable Disease

Disease and Illness in Health Care

GW Veteran CMI

Disease

Illness

Asymptomatic Disease

Symptomatic Disease

Symptomatic Health Impairment w/o Diagnosable Disease

Disease and Illness in Health Care

GW Veteran

Disease

Illness

Asymptomatic Disease

Symptomatic Disease

Symptomatic Health Impairment w/o Diagnosable Disease

Disease and Illness in Health Care

Disease

GW Veteran

Illness

Asymptomatic Disease

Symptomatic Disease

Symptomatic Health Impairment w/o Diagnosable Disease

Post-Deployment Integrated Care

Disease

Illness

Asymptomatic Disease

Symptomatic Disease

Symptomatic Health Impairment w/o Diagnosable Disease

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 patients health needs.
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Chronic Multi-Symptom Illness in Gulf War I Veterans

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).

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For a Veteran Centered Case Definition

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

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For a Veteran Centered Case Definition

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
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Chronic Multi-Symptom Illness

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.
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