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Psychosis: Schizophrenia and Related Disorders

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Military and Veteran Mental Health

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Abstract

Mental disorders are the greatest source of medical and occupational morbidity among active-duty US military service members. Psychotic disorders, in particular schizophrenia and schizoaffective disorder, are among the most severe mental disorders and account for a substantial portion of hospitalizations and medical retirements. Service members who are medically retired due to schizophrenia or a related disorder generally have their care transferred to the Department of Veterans Affairs (VA), where comprehensive evidence-based treatment services are available that can effectively address all stages of the illness. This chapter focuses on schizophrenia because the evidence base for its clinical management is the best developed, but the principles of and strategies for treating schizophrenia are broadly applicable to related disorders, including schizoaffective disorder. Each illness stage—acute episode (initial and stabilization phases), maintenance and relapse prevention, and recovery—is discussed in detail, together with its unique challenges and treatment goals. Common comorbid conditions that can complicate the recognition and treatment of schizophrenia and related disorders—for example, post-traumatic stress disorder—also are considered. Finally, VA and non-VA systems of care are compared to provide a broader context for the discussion.

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Notes

  1. 1.

    It is interesting to note that the apparent drop in schizophrenia incidence among navy personnel followed the publication of DSM-III in 1980; this edition was the first in the series to provide objectively verifiable standardized diagnostic criteria for schizophrenia, which effectively narrowed its clinical definition (Tsuang and Tohen 2002).

  2. 2.

    The customary practice is to hospitalize an actively psychotic service member promptly, and when clinically stable enough to be treated as an outpatient, transfer him/her to a medical holding company, where the service member will await the outcome of disability and physical evaluation board reviews. This process, which may take up to 1 year, determines whether the service member will be medically retired from military service.

  3. 3.

    Prevalence measures the proportion of individuals who manifest a disorder at a specified time point, or during a specified time span. Point prevalence is the fraction of individuals at risk for a disorder who actually manifest that disorder at a narrow point in time (e.g., one or more days), whereas period prevalence references a longer time frame (e.g., 1 year). Lifetime prevalence is the fraction of individuals at risk for a disorder who manifest that disorder ever, who are alive on a given day. Lifetime morbid risk estimates the probability that a person will develop the disorder during a specified period in their life, or up to a particular age (Saha et al. 2005).

  4. 4.

    Service members can access several mental health treatment options before entering psychiatric treatment. These are (a) the chaplain, who is also a trained counselor attuned to military lifestyle issues and able to offer confidential, professional assistance, and referral services; (b) combat stress control teams, which are a field resource capable of supporting the mental and emotional well-being of service members during deployments; and (c) nonmedical programs (Military One Source and Military and Family Life Counseling) whose counselors possess a masters or doctorate degree in a mental health field, are licensed or certified to practice independently and provide confidential, short-term counseling to active-duty, National Guard, and reserve service members (regardless of their activation status), and their families. These sessions are available in three formats: face to face, by telephone, or online in a secure real-time “chat” format. In addition, the Family Advocacy Program is a supportive resource for service members and their families that assesses, refers, and provides counseling for families experiencing domestic violence or child abuse. If FAP identifies someone as suicidal, they refer the individual to an MTF (a military treatment facility), TRICARE, or local community resource for immediate professional, medical, mental health treatment (http://www.militaryonesource.mil/casualty?content_id=268934).

  5. 5.

    This authority is conferred by DoD Instruction 6490.04, “Mental Health Evaluations of Members of the Military Services” (March 4, 2013) (http://www.dtic.mil/whs/directives/corres/pdf/649004p.pdf), which incorporates and cancels the prior DoD Directive 6940.1, “Mental Health Evaluations of Members of the Armed Forces” (October 1, 1997) (http://biotech.law.lsu.edu/blaw/dodd/corres/pdf2/d64901p.pdf).

  6. 6.

    As of September 18, 2016, there are no current VHA treatment guidelines for schizophrenia or schizoaffective disorder (http://www.healthquality.va.gov/). According to the VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder in Adults (version 2.0, May 2010), the original VHA Clinical Practice Guideline for the Management of Persons with Psychosis, published in 2001, “was aimed to assist medical care providers in all aspects of mental health care for a cluster of medical conditions characterized as mood disorders” (p i).

  7. 7.

    Serious mental illness (SMI) is defined by VA as a mental, behavioral, or emotional disorder that meets Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria (excluding cognitive and developmental disorders and disorders due to a general medical condition) and meets all of the following criteria: (1) Single unremitting episode of symptoms or with frequently recurring and/or prolonged episodes of symptoms; (2) Symptoms result in impairments in mood, thinking, family or other interpersonal relationships, behavior (often resulting in socio-legal consequences), and/or self-care which substantially interfere with or limit major life activities; and (3) The impact of these symptoms results in a functional impairment equivalent to a Global Assessment of Functioning (GAF) score of 50 or below (VHA Handbook 1163.06, January 7, 2016, p. 3).

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Authors and Affiliations

  1. VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA

    Ronald J. Gurrera

  2. VA Boston Healthcare System, Boston, MA, USA

    Nicole L. Perry

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  1. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA

    Laura Weiss Roberts

  2. US Army Medical Department Active Duty, Fort Stewart, Georgia, USA

    Christopher H. Warner

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Gurrera, R.J., Perry, N.L. (2018). Psychosis: Schizophrenia and Related Disorders. In: Roberts, L., Warner, C. (eds) Military and Veteran Mental Health. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-7438-2_21

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