Presentation – Dr. Stephen Hunt - IOM Gulf War Illness "CMI" Panel

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)

Percent

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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5

10

15

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Mostly BiologicalInterventions

Mostly PsychologicalInterventions

Internal Medicine(n = 77)

Mental Health (n = 176)

Percent

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


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


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

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Substance Abuse

Polytrauma

PainSpecialty Mental

Health

Ortho

PT

Neurology

Vet Centers

EnvironmentalClinician

PIDICI Champ

Teamlet

VBA

C+P

Chaplain

GWI Veterans: Exposures & Symptoms

What do we know?What don’t we know?


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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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 multi-symptom 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 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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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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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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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


AsymptomaticDisease

SymptomaticDisease


Disease

IllnessDisease

GWVeteran

CMI


AsymptomaticDisease

SymptomaticDisease


Disease

IllnessDisease

GWVeteran


AsymptomaticDisease

SymptomaticDisease


Disease

IllnessDiseaseGW

Veteran

Post-Deployment Integrated Care

AsymptomaticDisease

SymptomaticDisease


Disease

IllnessDisease


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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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).


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


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


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.

Documents

Presentation – Dr. Stephen Hunt - IOM Gulf War Illness "CMI" Panel