September 13 - 15 2016 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury 2016 Summit State of the Science: Advances, Current Diagnostics and Treatments of Psychological Health and Traumatic Brain Injury in Military Health Care

News and Resources

* 2017 DCoE Summit Welcome Letter.pdf
2017 DCoE Summit Welcome Letter


Q&A: Expert Shares How VA Uses Academic Detailing to Reduce Opioid Abuse 

By DCoE Knowledge Translation Team Posted Sept. 21, 2017 

Last week we sat down with Dr. Melissa Christopher, Department of Veterans Affairs (VA) national director of Academic Detailing Services, to discuss the work her team does to combat the national opioid crisis.  

Dr. Christopher, also a pharmacist, will speak more on this topic during the 2017 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) Summit. She will join the “Approaches to Opioid Use Disorder: Getting Evidence-Based Practices to the Field in Federal Health Care and Prevention” panel 11:20 a.m.-12:20 p.m. (ET) Tuesday.  

Q1: For those unfamiliar with academic detailing, can you give a rundown of what the term means to the VA and what it encompasses? 

Academic detailing was developed in the 1980s as a clinician-to-clinician educational outreach intervention. The idea was to work one-on-one with a provider to identify their needs around a particular practice area. Simply put, it’s trying to empower shared decision-making while influencing behavior change for both clinicians and patients.   

Q2: What are some of the challenges providers typically experience when treating a patient with, or on the path to opioid use disorder? 

There are underlying risk concerns because our patients are exposed to war and other traumatic situations, and they have complex injuries or pain related to their service. For our patients, pain isn’t always just a physical ailment, but also emotional – and it’s challenging to instinctually know what the right next step is for them.   

Patients are usually worried about their medications, and there’s a lot of fear around being abandoned with their pain. Many of these patients also have comorbid mental health conditions – their pain likely started because of their combat service, and they have legitimate concerns that their condition will impact their quality of life. We have found that frontline clinicians need support handling these complex circumstances for their patients. 

Q3: How does your team work to help providers face these challenges? 

Our first steps are creating a solid foundation to work from --  a system that has the bandwidth to tackle these complex problems. Our system is user-friendly and should help providers do things like identify at-risk patients, as well as more easily access reviewed information.  

Additionally, there’s a lot of burnout in health care, so one of our focuses in academic detailing is to create that necessary network of providers so they’re not isolated as they tackle the opioid epidemic. We’re attentive to that in this intervention. We are always trying to look at ways to work smarter, not harder. 

Q4: In your presentation, you plan to detail some of the history behind the opioid crisis. From a high level, are there root causes of the problem among the military and veteran populations? 

The health care community was taught to treat pain as a fifth vital sign. Because of these standards, clinicians felt pressured to eradicate pain instead of subscribing to other potentially helpful methodologies. We now realize that it is critically important to approach pain management differently because of the risks posed by opioids. It’s extremely challenging -- We are fighting a spreading disease that is partly a problem of our own making. We are now trying to reduce the addiction rate in our population, while also treating those who suffer from opioid use disorder.  

Q5: Over the course of the past decade, your team rolled out several initiatives. This year alone, VA launched two new programs and helped publish the VA-DoD Clinical Practice Guideline on Opioid Therapy for Chronic Pain. Can you give a brief description of the naloxone initiative that VA launched this year? 

Just to give a brief background to readers who might not know what it is, naloxone is a drug that can be administered in an emergency to block or reverse the effects of an opioid overdose. Our opioid overdose education on naloxone distribution has been one of the biggest success stories that the VA has to share with folks who are looking to tackle opioid overdoses. We had an incredible response from our VA providers – there was a groundswell of people who took advantage of this opportunity to be educated on how to respond to an opioid overdose.  

All told, I am encouraged by the fact that nearly 100,000 units of naloxone have been released to our veterans. It means folks are taking this crisis seriously. 

Q6: What are some ways providers and patients can battle this crisis?  

I think part of raising awareness in the clinician community is realizing that there’s a lot gained from reexamining medications and examining who might be at-risk.  

Confronting potential addiction or misuse in a delicate way is never an easy conversation to have with patients, especially in a busy health care system like ours. We need to create the bandwidth necessary to have these types of interventions that can be life-saving for patients. Providers need the time and resources to create a relationship where their patients feel supported enough to really work through questions like, “What are the alternatives? What are our next steps together?”, because change can be very hard.  

Q7: What others in both the VA and Defense Department systems do to help combat this crisis? 

As a community of health care providers and as a community receiving treatment, we need to open our eyes to a paradigm shift in pain management so that we can more effectively fight this endemic. I don’t want to overstate – because there is still a place for opioids in pain management. But as we start embracing different ways of treating pain, we need to recognize the existing risks that are there.  

It’s not just the medical community either – even family members can be part of this effort. If you see a loved one experiencing side effects, bring it up with a provider. Truly fighting the opioid crisis means facing it head on. It’s a community effort; it’s happening across [a variety of] socioeconomic areas and age demographics … and it’s an opportunity for us to really get the community involved with how to prevent further devastation. 

Overall, I think you must bring people hope – we are making a difference and lives are being saved because of us taking this head on. We have an incredible organization. The people who work for the VA are very dedicated to serving a population that deserves our help and service.  

We’re changing and change is hard. But, I think if we approach these changes knowing that patients are improving, and changing their behavior and outlook then we’re doing it right. We’re bringing hope back to the table. 

Visit the 2017 DCoE Summit website to register and preview the agenda. 

Dr. Christopher oversees the implementation efforts for academic detailing expansion across all Veteran Integrated Service Networks. Most of her program efforts focus on developing tools to identify practice patterns with implementation efforts for the newly developed Academic Detailing Programs.

Identify, Intervene: Help Your Loved One with TBI

Posted by DCoE Public Affairs on September 19, 2017

This article is the second in a three-part series from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)on helping the loved ones of service members identify the signs of brain injury and mental health issues.

It’s not always the injured person who notices that something is “off.” In fact, it’s often a spouse or family member who recognizes the signs that something’s wrong. Many times, they are also the first to speak up. That was the case when Army Sgt. 1st Class Bradley Lee’s wife noticed her husband’s abnormal symptoms and took the risk to get him help.

When you know what a traumatic brain injury (TBI) is, and what may happen as a result of the injury, you are more prepared to help a loved one.

two individuals laughing
Retired Tech. Sgt. Chris Ferrell, a former explosive ordnance disposal technician with posttraumatic stress disorder and TBI after combat tours in Afghanistan and Iraq, shares a laugh about his new beard in the backyard of his in-laws home. (U.S. Air Force photo by J.M. Eddins Jr.)

What is a TBI?

A TBI occurs when a sudden jolt — from something like a motorcycle or bicycle accident, a fender-bender, a gun recoil on the shooting range, or a tackle in a friendly game of football — causes the brain to hit the skull. The resulting injury can be mild, moderate or severe. You may be more familiar with the term concussion, which is also known as mild traumatic brain injury.

The warning signs that your loved one may have a TBI aren’t always visible at first glance. A Head for the Future recommends watching out for the following signs and symptoms:

  • Complaining of headache or a sensation of pressure in the head
  • Loss of or alteration of consciousness
  • Blurred eyesight or other vision problems, such as dilated or uneven pupils
  • Confusion
  • Dizziness, feeling off-balance or the sensation of spinning
  • Ringing in the ears
  • Nausea or vomiting
  • Slurred speech
  • Delayed response to questions
  • Memory loss
  • Fatigue

TBI can also affect someone’s cognitive and emotional health. Symptoms include:

  • Trouble concentrating
  • Continued or persistent memory loss
  • Personality changes like irritability
  • Sensitivity to light and noise
  • Sleep problems
  • Mood swings, stress, anxiety or depression
  • Disorders of taste and smell

According to the Defense and Veterans Brain Injury Center (DVBIC) Caregiver Curriculum, it’s important to remember that the changes you may see are the direct result of the injury. Behavior changes aren’t a result of your loved one intentionally trying to act or think in a way that may be different or feel hurtful. It’s also important to remember that all cases are different.

Finding help

When you see something wrong with someone you care about, it’s natural to want to help. The good news is that TBI is a treatable condition and most people have a full recovery. And, there are a variety of treatment options available.

The Defense Center of Excellence for Psychological Health and Traumatic Brain Injury has a 24/7 Outreach Center dedicated to helping you find resources in your area. The DVBIC Recovery and Support Program ensures that service members are supported and connected — and stay connected — to appropriate resources as they progress through to recovery.

If you think someone you know experienced a TBI and are displaying symptoms, talk about your concerns. See if you can persuade your loved one to see a doctor.

Preventing a TBI

You can’t always prevent a fall or an accident, but there are ways to prevent or limit the severity of an injury! The following tips may help keep you and your loved ones safe:

  • Wear a helmet when you engage in any activity that may result in a head collision.
  • When playing sports like rugby or tackle football, make a conscious effort not to tackle head-first.
  • Always wear a seatbelt.

If you do suffer a blow or strike to the head, take a break from whatever activity you were doing; if you are really worried, go to the nearest clinic or hospital

Image of DCoE Resource Catalog and its contents

The DCoE Resource Catalog is your one-stop guide for information about current DCoE products and programs, such as:

  • Program websites
  • Educational materials
  • Mobile applications
  • Fact sheets
  • Clinical recommendations

Whether you are a service member, health care provider or family member, there is a section for you.

The catalog includes product and program descriptions, images of what the resources look like, and access information.

Presentations, Audio, and Transcripts

Opening Remarks
Presenters:  Dr. Richard Stoltz; Major General Jeff Clark


Psychological Health

(P1001) Providing Care to Transgender Service Members: Path Towards Competence

Presenter:  Holly O’Reilly, Ph.D.

(P1002) The Power of the Parallel: Using Culturally Appropriate Approaches to Create Positive Therapy Outcomes for Mental Health Providers Working with Service Members and Veterans
Presenter:  Marco Bongioanni, L.M.H.C.

(P1003) Approaches to Opioid Use Disorder: Getting Evidence-Based Practices to the Field in Federal Health Care and Prevention
Presenters: Richard Stoltz, Ph.D. (Moderator); Air Force Lt. Col. Ellen Roska, Pharm.D., M.B.A., Ph.D.; Melissa Christopher, Pharm.D.; Public Health Service Lt. Patrick High, Dr.P.H.; Laura Jacobus-Kantor, Ph.D.

(P1004) Delivering Clinical Practice Guideline–Concordant Care for PTSD and Major Depression in Military Treatment Facilities
Presenter:  Carrie Farmer, Ph.D.

(P1005) Quality of Care for PTSD and Depression Delivered by the Military Health System
Presenter:  Kimberly Hepner, Ph.D.

Traumatic Brain Injury

(T1001) Long-Term Impact of Traumatic Brain Injury: The 15 Year Longitudinal TBI Studies and IMAP Study
Presenters:  Louis French, Psy.D.; Risa Nakase-Richardson, Ph.D., F.A.C.R.M.

(T1002) Evidence from the Warrior Strong Longitudinal Study: Post Concussive Symptoms Common in Soldiers Who Have Returned Home
Presenters:  Karen Schwab, Ph.D.; Donald Marion, M.D.

(T1003) Gender Differences in TBI
Presenters:  Anne Bunner, Ph.D.; Katherine Helmick, M.S., C.R.N.P., A.N.P.-B.C., C.N.R.N.

(T1004) Management of Acute Concussion: From Injury to Return to Duty: Using the Military Acute Concussion Evaluation (MACE), Clinical Management Algorithm (CMA) & Progressive Return to Activity (PRA) Algorithms
Presenters:  Keith Stuessi, M.D.; Clint Pearman, M.S., C.S.I.B.


Psychological Health

(P2001) Advancing Clinical Best Practices through Implementation Science: DoD/VA Practice Based Implementation Network and Tech into Care
Presenters:  Kate McGraw, Ph.D.; Andrew Blatt, Psy.D., M.A., M.S.; Garnette Cotton, Ph.D.

(P2002) Overview of Neuroimaging in Military Traumatic Brain Injury

Presenter:  Gerard Riedy, M.D., Ph.D. 

(P2003) Remote Combat Stress:  Psychological Outcomes Related to Remote Combat/Graphic Media Exploitation Operations
Presenter:  Air Force Lt. Col. Alan Ogle, Ph.D.

(P2004) Combat and Operational Stress Control (COSC) Panel Discussion

Presenters:  Monique Moore, Ph.D.  (Moderator); Mark Bates, Ph.D. (Moderator); Army Maj. Osceola Evans, L.C.S.W. ; Jessica Jagger, Ph.D., M.S.W.; Air Force Maj. Joel Foster, Ph.D., A.B.P.P.; Navy Capt. Heidi Agle, M.S., M.B.A.

(P2005) Adverse Outcomes Associated with Sexual Trauma among U.S. Servicemen: Findings from the Millennium Cohort Study

Presenter:  Cynthia LeardMann, M.P.H.

Traumatic Brain Injury

(T2001) Bees in my Helmet: Role of Chronic Traumatic Encephalopathy in Mild Memory Impairment: A Practical Guide to Treatment
Presenter:  George Charpied, M.A., S.L.P.-C.C.C.
(T2002) Filling the Gaps: Capturing the 'Whole Story' Following Traumatic Brain Injury
Presenter:  Army Col. Beverly Scott, M.D.

(T2003) Adding Insults to Injury: Traumatic Brain Injury and Substance Use
Presenter: Lars Hungerford, Ph.D., A.B.P.P.-C.N. 
(T2004) Outcomes of Training Service Members With a History of mTBI in Assistive Technology for Cognition
Presenter: Carole Roth, Ph.D., C.C.C., B.C.-A.N.C.D.S.

(T2005) Visual Dysfunction in Traumatic Brain Injury: An Interdisciplinary Approach to Care
Presenters: Robin Winslow, O.D.; Abby Wicks, O.D., F.A.A.O. 

(T2006) Investigation and Treatment of Military Related Traumatic Brain Injury
Presenter: Navy Cmdr. Josh Duckworth, M.D.


Psychological Health

(P3001) The Intersection of Primary Care Behavioral Health and Specialty Behavioral Health: Strategies to Improve Care Coordination and Communication
Presenter: Public Health Service Capt. Anne Dobmeyer, Ph.D., A.B.P.P.

(P3002) National Military Family Bereavement Study: The Effect of Military Service Death on Family Members 
Presenter: Stephen Cozza, M.D.

(P3003) Screening, Assessing and Treating Gambling Disorder in the Department of Defense
Presenter: Loreen Rugle, Ph.D.

Traumatic Brain Injury

(T3001) Evaluation and Treatment of Behavioral Health Symptoms in TBI Patients
Presenter:  Jonathan P. Wolf, M.D.

(T3002) Unraveling the Gordian Knot of TBI, Polytrauma, and Chronic Pain
Presenter:  Edison Wong, M.D., M.S. 

(T3003) Interdisciplinary Care: The Trifecta for Patient Quality Outcomes, Medical Readiness and Return on Investment
Presenters:  Juan Rivera, M.D., F.A.C.S., M.B.A.; Kendra Jorgensen-Wagers, Ph.D., L.C.M.H.C., C.R.C.



Military Health System and Defense Health Agency seals