Purpose of this book
The Department of Veterans’ Affairs (DVA) has developed this advice book to assist health practitioners to deliver the most effective mental health treatments for veterans. It draws upon the latest Australian and international best practice guidelines for the treatment of common mental health problems. The book aims to update practitioners who regularly treat veterans, as well as inform those who may be less familiar with veterans’ mental health issues.
This book is designed to help most practitioners apply their existing mental health knowledge and expertise to veterans. General practitioners (GPs) and mental health professionals can help veterans with mental health problems using many of the same approaches used to help other people with similar conditions. However, practitioners may need to modify aspects of their treatment to take into account the influence of military experiences on veterans and their family.
Common concepts and terminology are provided to assist in engaging the veteran and his or her family in the development of a treatment plan and to facilitate communication among health practitioners about treatment goals and approaches.
This book has been developed to support all community services in Australia to be more sensitive and skilled in assessing and treating veterans’ mental health needs and to increase awareness and knowledge of more specialist mental health advice and services.
How to use this book
Although the book can be read from cover to cover, it has been written so that practitioners can dip in and out of relevant chapters. As a result, there is some unavoidable repetition to ensure that readers can quickly obtain the information they require in the one place. The book has been divided into sections to help guide different health professionals to the information most useful to them. Some sections are aimed primarily at GPs while others have been written with mental health practitioners such as psychologists and social workers in mind.
Part 1 Understanding veterans and their families provides background information about Australia’s veteran community, the common mental health problems some may face and how these should be assessed.
Part 2 Advice for general practitioners is aimed primarily at GPs and comprises brief summaries outlining screening, patient advice, evidence-based treatment and referral options for common mental health disorders.
Part 3 Assessment, formulation and treatment of common mental health problems amongst veterans is aimed primarily at mental health practitioners and contains more detailed information on the assessment and treatment of common mental health disorders.
Diagnostic system used in this book
As a general rule, descriptions of mental health problems in this book are based on the Diagnostic and Statistical Manual (DSM) system. We are aware that some practitioners may be using other diagnostic systems. For example, Medicare treatment plans require an International Classification of Diseases (ICD) diagnosis. Therefore, our descriptions are intended to be as inclusive as possible and reflect the realities of day-to-day practice, and are not exact reproductions of DSM criteria.
Evidence for the advice in this book
This book is based upon evidence available up to the end of 2013, and has drawn on a number of best practice guidelines, as well as obtained evidence from evidence-based literature such as published reviews and meta-analyses. The following best practice guidelines have been drawn from:
- Fourth edition of the Management of Mental Disorders (WHO 2004)
- Australian and New Zealand College of Psychiatry guidelines for the treatment of depression and panic disorder and agoraphobia (available from www.ranzcp.org)
- Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder, 2013 (available from www.phoenixaustralia.org/)
- United Kingdom National Institute for Health and Care Excellence guidelines for the treatment of depression, panic disorder and agoraphobia, posttraumatic stress disorder (PTSD) generalised anxiety disorder, social anxiety, alcohol use disorders, and drug misuse (available from www.nice.org.uk)
- American Psychiatric Association guidelines on the treatment of depression, panic and agoraphobia and PTSD (available from www.psychiatry.org)
- United States Veterans’ Administration/Department of Defence Clinical Practice Guideline for Management of Post-traumatic Stress (2010) (available from www.healthquality.va.gov)
- Canadian Psychiatric Association Clinical Practice Guidelines for the Management of Anxiety Disorders (2006) (available from www.cpa-apc.org)
- National Health and Medical Research Council (NHMRC) Australian Guidelines to Reduce Health Risks from Drinking Alcohol (2009) (available from www.nhmrc.gov.au)
- Australian Government Department of Health and Ageing Guidelines for the Treatment of Alcohol Problems (2009) (available from www.health.gov.au)
- NHMRC Guideline for Screening, Assessment and Treatment in Problem Gambling (2011) (available from www.nhmrc.gov.au and www.med.monash.edu.au)
As there are no formal international or national guidelines in areas such as problematic anger, cognitive impairment, or somatic symptom disorders, advice regarding these conditions is based on the published reviews and meta-analyses of the evidence-based literature. It is important to note that recommendations regarding somatic symptom and related disorders have been made on the basis of limited empirical evidence.
This information has been synthesised by expert clinicians with extensive experience in veterans’ mental health from the Australian Centre for Posttraumatic Mental Health, a Centre of Excellence located at the University of Melbourne and supported by the Australian Government. The book was developed in liaison with the Mental Health Policy Section of the Department of Veterans’ Affairs (DVA) and is endorsed by the Principal Medical Adviser at the Department of Veterans’ Affairs (DVA), Dr Graeme Killer AO. The Royal Australian and New Zealand College of Psychiatry (RANZCP), Australian Psychological Society (APS), Australian Association of Social Workers (AASW), as well as representatives from VVCS - Veterans and Veterans Families Counselling Service (VVCS) and Defence Health Service were consulted during the review of this book. A range of metropolitan, rural and remote GP practices also tested relevant sections of the book, and the accompanying online resources developed for GPs (available from www.at-ease.dva.gov.au).
Limitations of this book
The advice in this book assumes that treatments are being provided by professionally qualified and competent health practitioners working in accordance with the National Practice Standards for the Mental Health Workforce, as well as discipline-specific practice standards and competencies.
The advice is not designed to substitute for the knowledge and skill of competent individual practitioners, which are best assessed against the professional standards prevailing at the time. It should not be used as an inflexible prescription concerning the content of treatment, but as a framework of best practice around which treatment should be structured. The advice is also not designed to limit treatment innovation and development based on scientific evidence, expert consensus and practitioner judgment for the needs of the client group concerned.
This book does not address less common mental health problems such as psychotic disorders, nor does it cover all of a veterans’ psychosocial difficulties such as relationship, family, social or vocational problems. These problems are important in their own right and should be addressed in the context of the focussed mental health interventions outlined in the book.
The recommendations represent best practice as at the date of publication and, given the pace of advances in knowledge, will require review and updating at three-year intervals.