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Improving Care for Veterans with OCD

Melinda A. Stanley, PhD;a,-b, c

Elizabeth McIngvale, PhD; a,b,d

 Veronica Siffert, LCSW,e Terri  L. Barrera, PhD;a, b,-c
aHouston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center
b Menninger Department of Psychiatry and Behavioral Sciences,
Baylor College of Medicine
c VA South Central Mental Illness Research, Education and
 Clinical Center (a virtual center)
d Diana R. Garland School of Social Work, Baylor University
e Michael E. DeBakey Veterans Affairs Medical Center

 

         United States Veterans with OCD are in special need of improved care. The disorder occurs in 0.4% to 28% of Veteran populations (McIngvale et al., 2015b), with the highest rates among combat Veterans and those who also have post traumatic stress disorder (PTSD) and/or substance use disorder. As is true for civilians, Veterans with OCD have substantial physical and mental health impairment (Gros et al., 2013), but the disorder is poorly recognized and inadequately treated. In the Veterans Health Administration (VHA), for example, prevalence of OCD is about 2% (Gros et al., 2013), but fewer than 0.5% of Veterans have received the diagnosis (McIngvale et al., 2015a). Frequency of individual psychotherapy visits in the year after an initial diagnosis of OCD (3.9; McIngvale et al., 2015a) suggests that Veterans are not getting evidence-based care considering that 12-16 sessions of exposure and response prevention (ERP) is recommended for OCD symptom reduction.
           To evaluate further the needs for care among Veterans with OCD, our group conducted a national survey of mental health providers in the VHA, including psychologists, psychiatrists, social workers, and nurses (Stanley et al., 2017). Survey responses indicated that many VHA providers lack sufficient knowledge and expertise in diagnosing and treating OCD and related disorders. Although most respondents indicated moderate or higher confidence in diagnosing OCD and related disorders (82%), only about half (51%) reported the same level of confidence in treating these disorders. Moreover, fewer than half of survey respondents recommended evidence-based treatments such as ERP (47%) or medication (38%). Survey respondents also indicated that resources for Veterans with OCD and related disorders were inadequate within their VHA facilities, and they strongly endorsed the need for additional provider training in OCD assessment and treatment (Stanley et al., 2017).
            At the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) in Houston, TX, we have established a specialty program and referral system for Veterans with OCD and related disorders. In some cases, the onset of OCD coincides with deployment and combat service – for example, a Veteran who began to pray more during dangerous combat missions developed a post-deployment compulsive need to pray and perform other scrupulosity-related rituals to make sure he and his family would stay safe. In other cases, OCD or a related disorder has an onset separate from military service; for example, a woman Veteran who experienced hair-pulling symptoms only before and after her military service (see Veteran Case Examples box).
             Providers in the Houston MEDVAMC program include a social worker and psychologist who are trained in ERP, a senior ERP expert, and a psychiatrist with experience in medication management for OCD and related disorders. ERP and medication appointments occur either in person at the MEDVAMC or via video conferencing. Conducting appointments via video conference is particularly useful for Veterans who live too far from the MEDVAMC to have regular in-person appointments and for those with hoarding or other home-related rituals. We have recently drafted new program procedures that will allow off-site ERP exposure exercises to facilitate contact with OC related cues and fears in settings outside the VHA. Like other people with OCD, Veterans in our program have been initially hesitant to undergo ERP, and they are sometimes reluctant to try medication or increases doses to appropriate levels, but the collaborative nature of the treatment has allowed many to participate and experience anxiety reduction and improved quality of life.
         At a national level, our team is providing consultation as needed to VHA mental health providers working with Veterans with OCD. We are also available as a resource to the National PTSD Consultation Program for questions about integrating evidence-based care for OCD into treatment for Veterans with comorbid PTSD/OCD.  Additional national resources to improve care for Veterans with OCD might include more accessible educational material for providers, Veterans, and their families; workshops and/or online training modules on evidence-based treatments for OCD with follow-up expert consultation (Kauth et al., in press; Reese et al., 2016); or teleconsultation training programs that include education about OCD treatment, case-based discussion, and consultation (Kauth et al., 2015). These kinds of programs have been valuable for improving care for Veterans with PTSD and increasing services in women’s health, transgender health, and pain management. Our team is working to develop these resources that will improve care for Veterans with OCD and related disorders. We are committed to improving the care currently offered and connecting Veterans to resources that are already available, additional resources for Veterans with OCD can be found below.

 

References
Gros, D. F., Magruder, K. M., & Frueh, B. C. (2013). Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. General Hospital Psychiatry, 35(1), 71-73. doi http://dx.doi.org.ezproxyhost.library.tmc.edu/10.1016/j.genhosppsych.2012.09.004
Kauth, M. R., Shipherd, J. C., Lindsay, J. A., Kirsh, S., Knapp, H., & Matza, L.(2015). Teleconsultation and
                  training of VHA providers on transgender care: Implementation of a multisite hub system.
                  Telemedicine and e-Health, 21, 1012-1018. doi: 10.1089/tmj.2015.0010.
McIngvale, E., Lindsay, J.A., Amspoker, A., Teng, E., Van Kirk, N., Barrera, T., … Stanley, M.A. (2015a). An evaluation of OCD data from the VA National Care Patient Database. In Stanley, M. A., Mcingvale-Cegelski, E., Van Kirk, N., Shy, S., Mathew, S. Recognition and Treatment of OCD among Veterans and Active Duty Military Personnel, 22nd Annual Conference of the International OCD Foundation, Boston, MA, August 2.
McIngvale, E., Van Kirk, N., & Stanley, M. A. (2015b).  OCD and Active Duty members/Veterans:  A
                       Review.Poster presented at the 22nd Annual Conference of the International OCD Foundation,
  Boston, MA, July 31.
Stanley, M. A., McIngvale, E., Barrera, T. L., Amspoker, A. B., Lindsay, J. A., Kauth, M. R., Smith, T. L., Van Kirk, N., & Teng, E. (2017). VHA providers’ knowledge and perceptions about the diagnosis and treatment of obsessive-compulsive disorder and related symptoms. Journal of Obsessive-Compulsive and Related Disorders, 12, 58-63.10.1016/j.jocrd.2016.12.004
Orginially Published in the August 2017 Peace of Mind Newsletter