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2.21.2013

IOM Committee, Including Diana D. Cardenas, M.D., Recommends Customized Care for Veterans

Members of a blue-ribbon panel convened by the Institute of Medicine, including the Miller School’s Diana D. Cardenas, have found that many U.S. war veterans who served in Iraq and Afghanistan are suffering from the same set of medically unexplained symptoms as veterans who served in the 1991 Persian Gulf War.

In a recently issued report, the Committee on Gulf War and Health: Treatment for Chronic Multisymptom Illness, said there is no single therapy or universal treatment that will help all veterans afflicted with chronic multisymptom illness (CMI) and recommended the U.S. Department of Veterans Affairs customize care with an array of therapies tailored to meet each veteran’s individual needs. A prepublication copy of the report, which was sponsored by the VA, is available online.

“This is a serious problem for veterans,’’ said Cardenas, M.D., M.H.A., professor and Chair of Rehabilitation Medicine, who has been a member of the prestigious Institute of Medicine (IOM) since 2004 and previously served on the IOM Board on Military and Veterans Health. “One of the issues is that so many physicians discount their problems. Many soldiers told us, ‘Doctors make us think it’s all in our head.’ So one of our charges was to inform the VA how to improve care.”

Drafted as part of the IOM’s congressionally mandated Gulf War and Health series, the report presents a comprehensive evaluation of various treatments and recommends the best approaches for managing patients with CMI. The committee defined CMI as a spectrum of chronic symptoms in at least two of six categories – fatigue, mood and cognition, musculoskeletal, gastrointestinal, respiratory, and neurologic – that are experienced for at least six months.

Formerly dubbed Gulf War Syndrome, CMI affects roughly one-third of the 700,000 veterans of the 1991 Persian Gulf War, and now many personnel who served in the more recent conflicts in Iraq and Afghanistan are reporting similar sets of symptoms. They include physical symptoms, such as fatigue, joint and muscle pain and gastrointestinal discomfort, and cognitive symptoms, including memory difficulties, anxiety and depression.

Although there is no consensus as to the causes of CMI, and little hope of identifying a specific factor or agent, the IOM committee said CMI is “a serious condition that imposes an enormous burden of suffering on our nation’s veterans” and the legitimacy of veterans’ reports of symptoms should not be questioned.

To help tailor care to individual needs, the committee recommended that the VA:

• Establish CMI-focused post-deployment patient-aligned care teams (PD-PACTs). A relatively new model of care within the VA health system, PD-PACTs manage an individual patient’s care through teams of providers that may include a project manager, primary care physicians, nurses, mental health clinicians, social workers, and other specialists.

• Boost the VA’s ability to identify former service members with CMI by ensuring the VA’s electronic health record system prompts health care providers to ask patients about symptoms that characterize CMI. The committee also said veterans should undergo a comprehensive health examination immediately after they leave active duty, and the results of these exams should be available to clinicians both within and outside the VA health system to ensure continuity of care.

• Identify veterans who may benefit from cognitive behavioral therapy and from medications such as selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors. The committee said it’s also worth exploring the usefulness of alternative interventions and approaches, such as biofeedback, acupuncture, St. John’s wort, aerobic exercise, motivational interviewing, and multimodal therapies.

• Create the new position of “CMI champion” at each VA medical center to provide clinicians an internal resource of information and advice about how best to serve patients with CMI. Champions should be knowledgeable about the variety of therapeutic options, have easy access to a team of consulting clinicians, and be trained in communication skills.

Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides objective, evidence-based advice to policymakers, health professionals, the private sector, and the public.

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