WEBVTT

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Dr. Samantha Hack: VISN 5 Mental Illness 
Research, Education and Clinical Center,  

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or MIRECC, in partnership with the Employee 
Education System. The planning committee members  

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for this Webinar series include Daniel Bradford, 
Valerie Fox, Spencer Glipa, Catherine Lewis,  

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Marty Oexner, Kathryn Peacock-Dutt, Donna 
Russo, Tim Smith, my co-host Ralf Schneider  

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and myself Samantha Hack. Today’s Webinar is 
entitled, ‘Promoting Recovery, Resilience,  

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and Suicide Prevention with Holistic and 
Spiritually Integrated Treatment - Taking care of  

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Our Veterans and Ourselves’. Our presenter for 
today’s Webinar is Dr. Donna Ames. Donna Ames is  

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a staff psychiatrist at the Greater Los Angeles VA 
Healthcare System, and a Professor of Psychiatry  

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and Residence at the University of California 
at Los Angeles’ David Geffen School of Medicine.  

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Her research career spans four decades, since she 
was an undergraduate in college. Her research has  

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focused on optimizing the clinical care of people 
with serious mental illness, utilizing a holistic  

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recovery-oriented bio-psycho-social-spiritual 
approach. She served for ten years as a PRRC  

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program leader and five years as an unofficial 
local recovery coordinator until 2017.  

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She was involved in the system’s redesign 
to convert day treatment and day hospital  

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programs to PRRC. Prior to that, she had twenty 
years of inpatient and outpatient experience,  

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and she is now working in the general mental 
health clinic at Greater Los Angeles VAMC, where  

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she continues her efforts to promote 
recovery-oriented care. She has received grant  

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funding for her research from the VA Merit Review 
Program and private foundation. She has presented  

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nationally and internationally and she and her 
research team have over 100 publications in the  

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field. Most importantly, Dr. Ames is a daughter, 
wife, mother, sister, aunt and granddaughter.  

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Before I turn it over to Dr. Ames, I will mention 
that she has reserved time for questions at the  

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end of the presentation, but if she does not get 
to your question, you can E-mail her, she will  

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provide her E-mail at the end. So at this time I’m 
happy to turn the Webinar over to you Dr. Ames. 

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Dr. Donna Ames: Thank you so much for 
that introduction. I’ll add to the list,  

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one of my joyful, um, things that 
I do, is I’m a grandmother too.  

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That is really a joy in my life. So, I’m really 
excited to be here to talk about this subject and  

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hope that this will be helpful to you and that 
you could avail yourselves to me through E-mails  

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as Samantha mentioned, if we don’t get enough 
time for questions. This is my disclaimer slide.  

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So, I wanted to begin the talk by thinking about 
why we’re all here today and what it is that we’re  

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doing and this noble effort that we are here in 
the honor we have to help with preventing suicide  

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and helping promote recovery amongst our Veterans. 
This is a picture from a movie that came out about  

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the high rates of suicide amongst Veterans. And I 
met one of the young men on the motorcycles here,  

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because his friend was going to kill himself. He 
put a gun to his head and then he reached out to  

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his peers, to his friend, and he did not commit 
suicide, and they went on a motorcycle journey  

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across the country to raise awareness for the 
high rates of Veteran suicide. At the time it  

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was 22 Veterans committing suicide in 2013, and 
they went throughout the country to look at the  

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different ways that Veterans were recovering from 
post-traumatic stress disorder in particular.  

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It’s a wonderful movie if you get a chance 
to watch it, and incredibly powerful.  

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You can download it from, I think it’s on 
Public Television. So, my impression is that  

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there is still a need for better treatment to 
offer greater hope of recovery for Veterans. With  

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the case of post-traumatic stress disorder, 
medications are not necessarily the go to  

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treatment, and sometimes these evidence-based 
treatments are not necessarily acceptable  

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to all Veterans. So, the VA has mandated the 
recovery model for serious mental illness, and  

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it’s different than a medical model, it’s patient- 
centered, and it includes a holistic approach, it  

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is multidisciplinary. Recovery embraces the notion 
that people with serious mental illness can live a  

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meaningful life and happiness is a byproduct of 
living a meaningful life. Viktor Frankl, Man’s  

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Search for Meaning is a great resource, this, 
um, psychiatrist, who survived Auschwitz, and  

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his approach to helping people with recovery from 
post-traumatic stress. Mental health recovery is a  

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journey of healing and transformation enabling 
a person with a mental health problem to live  

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a meaningful life in a community of his or her 
choice while striving to achieve his or her full  

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potential. I love that. I love that mental health 
recovery can help heal and transform people.  

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And in my years of working at the VA I’ve seen 
these wonderful recovery stories happen. This is  

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from the most recent Veteran Suicide Prevention 
Annual Report, November 2020, and it shows the  

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different rates of suicide amongst Veterans 
and we see here that the blue line is  

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the youngest group of people with the increased 
rate of suicide over the years 2005 to 2018.  

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Each of these different age groups are 
characterized here. I wanted to show this slide,  

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because as I think about a holistic 
approach that is bio-psycho-social  

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and spiritual for the treatment of mental 
illness. I wanted to show this next slide,  

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this is from the Acute Research Center about 
religious practice amongst millennials. This  

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is a bit of an old slide from 2010, showing the 
attendance at religious services by generation,  

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and I thought about this, the fact that 
only 18% of millennials reported going  

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to any type of religious service in 2010. You 
see the other generations, the higher rates of  

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religious service attendance. And 
again, looking at the suicide risk here,  

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and increased suicide rates in our younger folks. 
This is an article that came out December 2020  

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about healthcare providers, and there were 
about 40,000 male participants and over  

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66,000 female healthcare providers in this study. 
The authors looked at religious service attendance  

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and deaths related to drug, alcohol and suicide, 
and they found that religious service attendance  

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was protective against these deaths from despair. 
So, again, my thought is as we work, we work with  

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Veterans, the recovery model embraces holistic, 
which is biological, psychological, social,  

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and spiritual. And when we work with Veterans that 
we have a multidisciplinary team that can approach  

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and help them from these different aspects, 
including chaplains as well in the spiritual part.  

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So, one of the things that we are doing with 
Veterans in looking at ourselves, is what we  

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must realize is that our Veterans and we, as 
healthcare providers, are very resilient. And  

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one of the things we are doing when we approach 
Veterans, is asking them what their strengths are.  

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What makes them strong? What helps them to bounce 
back and rebound? Resilience comes from that word,  

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resilio. And, our Veterans and ourselves, have 
a lot of perseverance and passion, and I think  

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one thing that when I talk to Veterans and when 
I think about ourselves is that we have to be  

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gentle with ourselves and realize that some 
of the things that we’ve all gone through  

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have made us more beautiful by our 
imperfections. Wabi Sabi is a Japanese  

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term that is related to a Japanese art, where if 
a pot had a crack in it they put a piece of gold  

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in it to make it more beautiful. And that’s how 
our Veterans are, and that’s how we are. We are  

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all made better by the things that we’ve gone 
through, and I like that my slide has this little  

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N to show that I’m not perfect (laughter), I 
typed my slide. So, um, resilient people have  

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intrinsic factors that cause them to be resilient, 
they have positive attitude, optimism, ability to  

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emotionally self-regulate, and see 
problems and failures as learning  

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experiences. Extrinsic factors also play a part 
in resilience. Social and environmental support  

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can help people with their resilience. So, 
for many of us in the healthcare profession,  

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we’ve had to endure a lot of training, 
a lot of struggles, many have endured  

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partaking on a lot of financial support, financial 
debt. So, we are resilient and we’re hardworking.  

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This is a scale that measures resilience that you 
can use to look at yourself, as well as to look at  

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your Veterans. It’s a very brief scale. I 
like brief scales. So, it has some pretty  

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quick questions to ask about resilience, such as 
“I tend to bounce back quickly after hard times”,  

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“It does not take me long to recover from 
a stressful event”. Some questions that  

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are raised to be scored in the reverse. Although 
resilient, what many mental healthcare providers  

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can develop for burnout, depression, moral 
injury, which I will be talking more about,  

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and substance abuse. The pandemic has 
been adding to increasing stress, um,  

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acute, and even post-traumatic stress symptoms in 
healthcare providers. And, of course, by the way  

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we’re seeing more and more increases in depression 
and symptoms in our patients due to the pandemic  

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as well. The loneliness, the isolation, adding to 
their struggle. This was a presentation at the APA  

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meeting, American Psychiatric Association meeting 
in 2018, showing that male physicians were at a  

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40% higher risk than other U.S. males for suicide, 
and female physicians at 130% higher suicide risk.  

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When this slide was made, it is estimated that 
Veterans were killing themselves at a rate of  

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20 per day in our country, and physicians 
are killing themselves at 1 per day in our  

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country. I think this is a very serious problem 
and that’s why we’re here, because I think we  

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have to take care of ourselves. In an emergency, 
you have to take care of yourself, if you’re on an  

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airplane, you gotta pull the air bag down, 
take deep breath, and then you help your child;  

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and it’s the same for healthcare providers with 
our Veterans. We must take care of ourselves.  

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Burnout is actually very toxic and 
costly and it’s an ICD-9 Code QD85,  

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resulting from chronic workplace stress. Burnout 
can cause people to have a lack of empathy and  

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cynicism and impaired job performance and impaired 
relations with family and friends. One thing that  

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is often cited is the electronic health record is 
invading the home. Physician burnout is considered  

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a public health crisis, unintentional accidents of 
billions of dollars of cost due to medical errors.  

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Burnout is also considered a loss of motivation. 
So, when we do think we have intrinsic motivation  

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or extrinsic motivation, we do things 
because we find them interesting or  

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we have a passion for it – that’s our 
intrinsic motivation. Our extrinsic motivation  

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are things like positive or negative, and so it’s 
interesting that paradoxically monetary reward  

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can undermine intrinsic motivation. 
However, the best extrinsic motivators  

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for, are annual pay raises, or annual bonuses, 
but when money is brought into the floor,  

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with each patient interaction, RVU’s, 
it decreases intrinsic motivation.  

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Burnout in clinicians and MDs is 
related to lack of control over  

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one’s schedule, not even being able to 
control the language used in charting, and  

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according to Hartzbrand and Groopman, in their 
recent New England Journal of Medicine article,  

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every hour of patient time is met with two hours 
of computer time. So burnout symptoms can be  

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thought of as, like reductions in energy account; 
you feel exhausted, you're depersonalized,  

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you lose physical energy, emotional energy, 
lack of efficacy or spiritual energy. Sometimes  

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burnout is referred as compassion fatigue.
In a survey of 15,000 doctors, they estimated 44%  

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were burned out, 11% colloquially clinically 
depressed. In the same survey, 25% of physicians  

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reported having thoughts of suicide. Burnout 
in therapists has been looked at as well,  

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American Psychological Association 2018 
estimated 21 to 61% of mental health providers  

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are burnout. In a review paper, 9,000 therapists 
across a bunch of studies, they estimated  

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50% suffered from burnout. So, in a Medscape 
National Survey, the one with 15,000 doctors,  

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it was estimated that 39% of psychiatrists were 
burned out. The highest burnout level was seen in  

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Urology, Neurology, and physical medicine 
and rehab. And these are things that doctors  

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mentioned more the things that contributed to most 
of their burnout. Too many bureaucratic tasks,  

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spending too many hours at work, increased 
computerization of practice, lack of respect,  

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insufficient compensation and reimbursement, lack 
of control or autonomy, government regulations,  

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feeling like just a cog in a wheel, emphasis 
on profits over patients and lack of respect  

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from patients. So these are the things 
that can contribute to a clinician’s  

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sense of feeling overwhelmed, or 
burned out, family responsibilities,  

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time pressure, chaotic environment, low control of 
pace, and of course the electronic health records,  

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which was originally set up to help clinicians, is 
actually deemed to be a slave master to clinicians  

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in many ways. So, there are three pillars 
that prevent burnout. Autonomy, competence,  

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and relatedness. By autonomy it means having 
more control over the time that you want to  

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spend with your patient. Flexible scheduling. 
Clinicians and patients as individuals.  

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Flexible scheduling allows clinicians to optimize 
the relatedness to their patients, as opposed to  

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their relatedness to the electronic health record. 
And one thing that is thought that might help  

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to start reducing burnout is purging 
the system of meaningless metrics and  

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really relatedness should be authentic and needs 
to adopt to the clinician and the patient’s needs.  

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Again, this comes from Hartzbrand and Groopman, 
New England Journal of Medicine. As I thought  

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about ways that we can help ourselves with 
preventing burnout, and improving our energy,  

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these are some tips, and after thirty years of 
working at the VA I wish I had taken some of  

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these tips earlier in my career, and so if there 
is folks new in the profession, I hope you really  

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think about these things because you want to 
maintain your energy. You want to be the best  

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you can be with your Veteran, though end 
your workday at the end of the payday.  

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Take your lunch, your rest daily. Take 
every earned vacation day every year.  

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Take at least one day off a month to recharge. 
Take a complete electronic Sabbath one day a week.  

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Don’t look at you’re EHR at the end of the workday 
or work E-mail. Lean into your relationships with  

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the people you love, and work on your own recovery 
plan. So, make sure that you’re always focusing on  

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what you want to do with your life. And so, when 
I worked at the PRRC I worked with Tom Fletcher,  

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and Rick Martin, local recovery coordinators, 
who developed this My Personal Recovery Plan,  

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and I think that this is a wonderful plan because 
I really also see recovery planning as suicide  

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prevention planning. So, when we get Veterans who 
worked on their vision of recovery, when we work  

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on our visions of recovery, this is really 
positive behavior. We work on folks' strengths.  

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I remember when I started doing 
the recovery plans with Veterans,  

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I would ask somebody with a serious mental 
illness, somebody say with schizophrenia,  

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what are your strengths? And they were always 
shocked, like, “Nobody’s ever asked me what my  

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strengths are.” So, what I love about the recovery 
model is that we really are looking our Veterans  

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for their strengths, for what they want. And 
this is what we’re doing with the My Personal  

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Recovery Plan. And, in helping them envision 
their lives and move forward on their goals.  

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So, as a psychiatrist, I can say, when 
I first started my career I was very  

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much interested in psychopharmacology and treating 
people with schizophrenia was my goal and I,  

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over my 30-year career, realized it’s not just 
psychopharmacology that helps people. And as  

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a matter of fact, Thomas Edison said the 
doctor of the future will give no medicine,  

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but will interest her or his patients in the care 
of the human frame and a proper diet, and in the  

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cause and prevention of disease. So one of the 
things  I noticed over the course of working with  

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Veterans and treating them with antipsychotic 
medications, was tremendous weight gain,  

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diabetes, and other metabolic problems 
from taking antipsychotic medication.  

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So, for ten years I did research on developing 
a program that would help Veterans lose weight  

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and focus a lot on exercise and nutrition with 
Veterans with serious mental illness, and we  

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had really good results. But after ten years 
of studying exercise and nutrition, I thought,  

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it’s more than this. There’s more things we can do 
to help Veterans. And Roger Walsh suggested that  

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there is therapeutic lifestyle changes, exercise, 
nutrition and diet, time and nature, recreation,  

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relaxation, stress management, religious and 
spiritual involvement, community involvement  

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or volunteerism, that all psychiatrists should 
be prescribing to their Veterans. That there's  

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evidence for these eight things to really help 
our Veterans. And so, after reading his article,  

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we developed a little research study, and in my 
clinical practice we started to ask Veterans to  

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come up with a TLC diary, a therapeutic lifestyle 
practice diary. Yeah, I think this is part of  

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suicide prevention. Working on these different 
eight things, and it’s remarkable how well  

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our Veterans can do. We don’t want to overwhelm 
them, but we can start with one or two things,  

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but we developed a workbook for TLC’s that a 
clinician can work with a Veteran and coach  

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them on developing goals in these areas. Again, 
exercise, nutrition and diet, time and nature,  

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relationships, recreation, relaxation, stress 
management, religious or spiritual involvement  

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and service in helping others. So, you can 
make smart goals for these TLC’s – specific,  

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measurable, attainable, realistic and time-bound. 
So, if you want these materials we have the  

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diaries, we have workbooks, we have a TLC training 
manual, and TLC single worksheets. In my practice  

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now, in the outpatient mental health clinic, I 
still use the TLCs, I still use the recovery plan,  

00:25:14.640 --> 00:25:23.840
and I have also really continued to 
train nurses who work in my clinic,  

00:25:23.840 --> 00:25:30.000
to work with Veterans on these things. So, this 
is an article that we published on TLC’s and how  

00:25:30.000 --> 00:25:36.320
it helps Veterans with weight and quality of life 
and psychiatric symptoms. This is our cover of  

00:25:36.320 --> 00:25:41.520
our little workbook, so feel free to E-mail me 
– we can send you this material, I can provide  

00:25:41.520 --> 00:25:45.840
anymore information your would like. If you 
would like to integrate this into your program.  

00:25:46.720 --> 00:25:53.920
Along my paths and journey, I have had the 
privilege when I was working in a PRRC, to work  

00:25:53.920 --> 00:26:04.640
with Chaplain Sam Adamson, and he introduced me to 
a researcher who was interested in studying moral  

00:26:04.640 --> 00:26:14.560
injury in Veterans. The researcher is Dr. Harold 
Koenig, whose expertise is in religion and health,  

00:26:14.560 --> 00:26:21.360
religion and mental health. And so, one of the 
things he developed was this model, moral injury,  

00:26:21.360 --> 00:26:26.960
and I want to mention that moral injury can impact 
not only Veterans not only combat Veterans or  

00:26:26.960 --> 00:26:34.560
non-combat Veterans, but also civilians, and 
it can impact us. Um, and this, we started  

00:26:36.720 --> 00:26:40.880
this research I think in about 2016 and, um, 

00:26:42.000 --> 00:26:47.840
based on this model, that there are 
events in our lives where, um, and

00:26:47.840 --> 00:26:54.080
in the lives of our Veterans, which may lead to 
a moral injury or inter-conflict in mental health  

00:26:54.080 --> 00:27:00.240
outcome. So, such event as killing, violence 
to others, witnessing violence, not protecting,  

00:27:00.240 --> 00:27:06.960
put in morally compromising positions – not 
protecting is something that resonates with me,  

00:27:07.520 --> 00:27:18.080
as a mom, or as a clinician. If something 
happens to one of my Veterans, I feel,  

00:27:18.080 --> 00:27:23.600
I may feel like what did I do wrong? What could 
I have done better to protect that Veteran?  

00:27:23.600 --> 00:27:32.000
So, Dr. Koenig has now developed a scale to 
measure moral injury in clinicians. We worked  

00:27:32.000 --> 00:27:39.520
together for several years to develop a scale for 
combat Veterans. And so these are the symptoms  

00:27:39.520 --> 00:27:46.160
of moral injury: guilt, shame, self-condemnation 
in his model, feelings of betrayal, difficulty  

00:27:46.720 --> 00:27:53.440
forgiving, loss of trust, meaning, hope, spiritual 
struggles, loss of faith. And then mental health  

00:27:53.440 --> 00:27:59.360
outcomes could be PTSD symptoms, depression, 
anxiety, substance abuse, sleep problems,  

00:27:59.360 --> 00:28:06.480
relationship dysfunction and pain issues. I 
know sometimes I just show this little slide  

00:28:08.720 --> 00:28:14.080
to my Veterans who walk into my office who 
have not responded to conventional treatment  

00:28:14.080 --> 00:28:22.080
for post-traumatic stress disorder, or substance 
abuse issues, or chronic anger issues. I feel like  

00:28:22.080 --> 00:28:30.720
moral injury is one of the emotions that really 
resonates with folks who have this is anger. So,  

00:28:30.720 --> 00:28:36.560
when I show this little graph to folks they go, 
“That’s me. That’s what happened. I was in combat  

00:28:36.560 --> 00:28:42.560
and I didn’t do this, or I did that”. And then, 
and they see this graph and I think it’s, this is  

00:28:42.560 --> 00:28:51.920
very educational for folks to think about this and 
to help them understand what’s going on with them.  

00:28:51.920 --> 00:28:58.800
So, definitions of moral injury are here on this 
slide, perpetrating, failing to prevent, bearing  

00:28:58.800 --> 00:29:04.880
witness to or learning about acts that transgress 
deeply held moral beliefs and expectations,  

00:29:04.880 --> 00:29:10.000
a betrayal of what’s right by someone who holds 
legitimate authority in a high stake situation,  

00:29:10.560 --> 00:29:16.240
a deep sense of transgression including feelings 
of shame, grief, meaninglessness and remorse when  

00:29:16.240 --> 00:29:22.480
having violating core moral beliefs. So again, 
you can see how this relates to combat Veterans,  

00:29:23.040 --> 00:29:30.400
to non-combat Veterans, to civilians, 
to front-line folks, healthcare workers.  

00:29:31.360 --> 00:29:36.720
Moral injury is not post-traumatic stress 
disorder. Persons with PTSD may also suffer  

00:29:38.880 --> 00:29:45.440
from moral injury, but persons with moral injury 
may not necessarily have all the symptoms of PTSD.  

00:29:45.440 --> 00:29:52.480
So I believe that the presence of moral injury 
may complicate the recovery of people with PTSD  

00:29:52.480 --> 00:29:58.960
only receiving treatment that is focused on PTSD, 
and resolving moral injury may also improve PTSD.  

00:29:59.520 --> 00:30:05.600
So for example, if you’re feeling really 
guilty about accidentally hurting somebody,  

00:30:06.400 --> 00:30:10.560
when you’re in the military, or killing 
somebody, that wasn’t a combatant,  

00:30:13.360 --> 00:30:18.000
and you’re up at night having insomnia 
about it, that may be something to  

00:30:18.000 --> 00:30:24.560
really work on with the Veteran. Of course 
there’s an overlap between moral injury  

00:30:24.560 --> 00:30:29.920
and the negative cognitions that are a part of 
the symptoms of post-traumatic stress disorder.  

00:30:31.760 --> 00:30:36.320
And again, I think one of the big emotions that 
I see in folks who are suffering with moral  

00:30:36.320 --> 00:30:43.840
injury is anger, and the lack of forgiveness 
of themselves. And these are questions that we  

00:30:43.840 --> 00:30:54.960
developed a short scale. Dr. Koenig and I work 
together and we developed a long scale that is  

00:30:54.960 --> 00:31:03.360
valid for being a Veteran to have moral injury, as 
well as a short scale, and these are the questions  

00:31:04.480 --> 00:31:10.320
that are on the short scale. So again, if you 
are interested in these scales let me know, I can  

00:31:10.320 --> 00:31:20.880
provide them to you. They are validated scales on 
moral injury short form, as well as a longer one.  

00:31:22.080 --> 00:31:29.920
One of the things we looked at we collected 
data on 570 Veterans and active duty military  

00:31:30.880 --> 00:31:40.480
and found that moral injury was related to 
a suicide risk index, and so I think that’s  

00:31:40.480 --> 00:31:48.400
something to think about when we’re interviewing 
folks who are feeling suicidal. Self-condemnation  

00:31:48.960 --> 00:31:57.120
seemed to have the highest subscale that 
correlated with moral injury. Religiosity did not  

00:31:57.120 --> 00:32:02.560
mediate the relationship between moral 
injury and suicide risk. We also looked,  

00:32:02.560 --> 00:32:07.280
with the scale that we collected throughout the 
country and validating the moral injury scale,  

00:32:08.400 --> 00:32:14.800
religiosity and spirituality, um, and 
in the past it has been shown that

00:32:15.840 --> 00:32:21.520
religiosity and spirituality was inversely 
related to post-traumatic stress symptoms,  

00:32:21.520 --> 00:32:29.200
and positively correlated with post-traumatic 
growth. In our study of 90% of Veterans with PTSD  

00:32:29.200 --> 00:32:34.960
reported moral injury symptoms and we 
found that religiosity was inversely  

00:32:37.040 --> 00:32:43.040
related to moral injury in Veterans with 
severe PTSD. We used a measure that was  

00:32:43.040 --> 00:32:49.760
valid for measuring religiosity in patients 
called a BIAC, developed by Dr. Koenig. So,  

00:32:50.400 --> 00:32:56.640
when we talk to Veterans, you know, or we’re 
providing Veterans centered care, some Veterans  

00:32:56.640 --> 00:33:03.760
might be interested in talking to chaplains, some 
may not. So it is important to ask Veterans about  

00:33:05.040 --> 00:33:14.560
their spiritual life and what they’re interested 
in. There is a push from VACO from the head  

00:33:14.560 --> 00:33:20.720
chaplain to incorporate chaplains into all 
areas of mental health care, which I support,  

00:33:21.440 --> 00:33:28.040
because I think some Veterans really resonate 
with speaking to a chaplain. Um, and, uh,

00:33:28.560 --> 00:33:34.160
In one recent publication by one of the colleagues 
that helped with the development of the scale in  

00:33:34.160 --> 00:33:41.360
2018, he showed that 80% of Veterans were 
open to spiritually oriented treatment. So,  

00:33:41.360 --> 00:33:46.240
toward that end, I’ve been working with 
Dr. Koenig and Dr. Michelle Pearce,  

00:33:47.200 --> 00:33:56.960
who developed a spiritually integrated form of 
CPT that explicitly draws on a client’s spiritual  

00:33:58.320 --> 00:34:04.800
religious resources and addresses spiritual 
struggles. Because in Dr. Koenig’s model for moral  

00:34:04.800 --> 00:34:12.160
injury, one of the consequences of moral injury 
can be that people turn away from spirituality,  

00:34:12.160 --> 00:34:21.760
they turn away, they feel betrayed by their 
higher power. So, if a Veteran is religious and  

00:34:21.760 --> 00:34:30.640
interested in this, we are now doing a research 
study to provide spiritually integrated CPT, and  

00:34:30.640 --> 00:34:38.880
it’s really targeting moral injury to reduce the 
PTSD symptoms and we have five religion specific  

00:34:40.960 --> 00:34:44.960
appendices. Again, if anybody is 
interested in this, let me know.  

00:34:45.920 --> 00:34:51.680
We’ve had very slow progress with our 
research, in part because of the pandemic,  

00:34:53.040 --> 00:34:58.640
but if people are interested we really 
want to get this information out to people.  

00:35:00.720 --> 00:35:08.720
Dr. Pearce has published an article about 
doing spiritually integrated CPT. And then,  

00:35:08.720 --> 00:35:14.080
we’ve also developed a chaplain intervention 
that could be provided by the chaplain,  

00:35:14.080 --> 00:35:19.680
and we’ve trained all our chaplains here 
at the VA in Los Angeles. um, it's a 12...

00:35:22.960 --> 00:35:28.880
It’s 12 sessions, it's 50-minute individual 
one-on-one pastoral care sessions with the  

00:35:28.880 --> 00:35:34.560
Veteran. The intervention is designed to 
specifically help those who indicate that religion  

00:35:34.560 --> 00:35:40.720
is important in their lives and to be adapted 
to specific religious beliefs of the Veteran. So  

00:35:41.760 --> 00:35:48.640
we’re right now testing this chaplain intervention 
which is based upon this model of healing,  

00:35:48.640 --> 00:35:54.720
conviction, lament, repentance, confession, 
forgiveness, reconciliation, atonement,  

00:35:56.800 --> 00:36:02.880
recovery and resilience and anger is an optional 
part of these 12 sessions that we’re testing with  

00:36:02.880 --> 00:36:07.600
chaplains here in Los Angeles. Again, if 
you are interested in any of my materials,  

00:36:07.600 --> 00:36:13.840
and what we’re doing, we want to get it out to 
you, I know it’s not proven yet to work, but if  

00:36:13.840 --> 00:36:20.480
you are interested in learning about this I really 
want to share this material. We’re looking at ten  

00:36:20.480 --> 00:36:26.960
moral injury dimensions – guilt, shame, betrayal, 
moral concerns, loss of trust, loss of meaning,  

00:36:27.600 --> 00:36:35.360
self-condemnation, difficulty forgiving, religious 
struggles and loss of religious faith. We’ve had  

00:36:35.360 --> 00:36:44.320
two Veterans in the chaplain intervention and, 
again, they came in with very high levels of moral  

00:36:44.320 --> 00:36:56.320
injury. You had to have scores over 250 – and, on 
the long moral injury scale, which is 45 items,  

00:36:56.320 --> 00:37:06.720
and then our chaplain collected the PCL-5 and the 
moral injury, these were self-rated forms at every  

00:37:06.720 --> 00:37:17.040
session, and so the blue line shows a decrease in 
PTSD symptoms with the chaplains working primarily  

00:37:19.200 --> 00:37:26.080
on moral injury. So, as I said, even 
though PTSD and moral injury are  

00:37:26.800 --> 00:37:32.960
different, I think if you help the moral 
injury, you can help the PTSD symptoms as we see  

00:37:34.320 --> 00:37:41.680
in this first Veteran who received 12-weeks of 
chaplain intervention in our study. And then  

00:37:41.680 --> 00:37:48.800
this is the data from the second Veteran as well. 
Again, we’re seeing the decrease in the PCL-5, the  

00:37:48.800 --> 00:38:00.240
PTSD symptoms, and the score on the moral injury 
scale is going below the threshold for serious  

00:38:00.240 --> 00:38:08.160
pathology and moral injury. So, um one thing that 
I think about is that we’re all spiritual beings  

00:38:08.160 --> 00:38:12.400
and that we’re all struggling with relationships. 
So, when somebody comes in my office,  

00:38:13.360 --> 00:38:17.840
they’re struggling with either a relationship 
in their past or their present. There’s  

00:38:18.480 --> 00:38:25.680
a very famous psychiatrist who used to 
work at our VA, Dr. Glazier postulated,  

00:38:25.680 --> 00:38:30.160
we’re all struggling with relationships. 
Is it a relationship with ourselves,  

00:38:30.160 --> 00:38:35.200
is it a relationship with others? Is it a 
relationship with our God or higher power?  

00:38:35.920 --> 00:38:43.040
How do these relationship problems affect our 
soul, our mind, our will, our emotions? So, um,  

00:38:43.040 --> 00:38:48.880
this is kind of a scale that I really 
would like to validate. It's looking at  

00:38:51.200 --> 00:38:58.160
these people’s relationships on a scale of 1 
to 10, how they feel about others, themselves  

00:38:58.160 --> 00:39:04.400
or higher power. If somebody walks in my office, 
and I only have a one half hour to meet with them,  

00:39:04.400 --> 00:39:08.880
I know that if they have no 
friends, they hate themselves,  

00:39:08.880 --> 00:39:13.280
they have no sense that there’s something bigger 
than them in their world. That’s a person that  

00:39:13.280 --> 00:39:21.840
I’m worried about. And so that would be a person 
at like the 1, 1, 1 on this scale. Even our work  

00:39:21.840 --> 00:39:29.040
with the Veterans, with the spiritually 
integrated treatment, we talk a lot about  

00:39:29.040 --> 00:39:37.680
forgiveness and the story of the prodigal son 
is used in letting people know that they are um

00:39:37.680 --> 00:39:44.560
they are forgiven and that they are always loved. 
And I think that, one of, an article that I read,  

00:39:44.560 --> 00:39:48.960
I’m sorry, a book that I read that was really 
powerful to me was “Tattoos on the Heart”  

00:39:48.960 --> 00:39:51.600
by Father Boyle, who started a  

00:39:52.320 --> 00:39:57.120
Home Boys Industry, where he would take 
convicted felons and give them jobs,  

00:40:00.000 --> 00:40:05.040
which I thought was amazing because nobody 
else would give them jobs. And so imagine  

00:40:05.040 --> 00:40:11.600
if we all treated each other with compassion, 
mercy, forgiveness, grace and unending love,  

00:40:12.320 --> 00:40:17.760
that the prodigal father had for him. I think 
that’s really the key to helping our Veterans  

00:40:17.760 --> 00:40:23.840
and ourselves. So, we’ve been doing some 
research with, doing focus groups, with  

00:40:24.640 --> 00:40:32.160
people in the faith based leaders in the community 
to find out how they are handling Veterans who are  

00:40:32.720 --> 00:40:39.200
struggling in their churches and synagogues, 
and we got a lot of good information from them  

00:40:40.080 --> 00:40:45.520
on how to help them with connecting Veteran 
faith, and mental health care at the VA,  

00:40:46.080 --> 00:40:51.280
and we’ve developed resources for these faith 
communities that have been approved by our  

00:40:52.160 --> 00:40:54.960
public relations people here to give to our  

00:40:57.200 --> 00:41:02.240
faith based leaders in the community. 
We’re hoping to continue the dialogue  

00:41:02.240 --> 00:41:07.440
with leaders in the community because they 
see a lot of struggles in mental heath and  

00:41:08.320 --> 00:41:13.120
we want them to also be aware that there 
are ways that they can help people with  

00:41:13.120 --> 00:41:19.360
PTSD and moral injury with spiritually integrated 
interventions. So, in summary, I believe that  

00:41:19.360 --> 00:41:25.040
mental health care and suicide prevention should 
be recovery-oriented, and include a holistic,  

00:41:25.040 --> 00:41:31.280
bio-psycho-social-spiritual approach. Moral 
injury should be recognized, as it may explain  

00:41:31.280 --> 00:41:37.200
why Veterans with post-traumatic stress disorder 
do not fully recover with currently available  

00:41:37.200 --> 00:41:43.280
treatments for PTSD, and Veterans may prefer, 
and actually benefit from treatments utilizing  

00:41:43.280 --> 00:41:50.320
spiritually integrated approaches. Spiritually 
integrated interventions for moral injury and PTSD  

00:41:50.320 --> 00:41:56.560
provide VA mental health providers opportunities 
to collaborate with chaplains and faith-based  

00:41:56.560 --> 00:42:02.560
communities to optimize care of Veterans. I 
believe a holistic bio-psycho-social-spiritual  

00:42:02.560 --> 00:42:07.680
recovery model must also be applied to 
ourselves, to optimize our well-being,  

00:42:07.680 --> 00:42:13.360
to support our resilience and prevent burnout. 
We must all engage in therapeutic lifestyle  

00:42:15.440 --> 00:42:20.400
changes, and support one another on our 
own recovery journey. And thank you so  

00:42:20.400 --> 00:42:26.880
much for listening today, and I just want to 
remind folks about the Veteran crisis line  

00:42:28.480 --> 00:42:32.480
and I want to thank all the folks in my lab who  

00:42:33.200 --> 00:42:41.680
have helped me with putting together this work 
and all our collaborators, research collaborators  

00:42:41.680 --> 00:42:51.840
and I just want to put out a special thanks to the 
PRRC staff that I worked with over the years. Um,  

00:42:51.840 --> 00:42:58.000
and if you have any questions, feel 
free to, um, E-mail me – I’d be really  

00:42:58.000 --> 00:43:04.880
happy to send you materials or answer any 
questions if we can’t get to them right now  

00:43:04.880 --> 00:43:10.000
during the question and answer period. Thank you.
Ralf Schneider: Hey, this is Ralf, some questions  

00:43:10.000 --> 00:43:17.680
are coming in, the first one, well, it was a 
little bit further back, was from Elizabeth Wiley.  

00:43:18.240 --> 00:43:25.520
She asked, “Would the spiritually 
integrated CPT be provided by someone at  

00:43:25.520 --> 00:43:32.000
the site by VVC – how does that work?”
Dr. Donna Ames: Right now, um,  

00:43:32.000 --> 00:43:40.480
because of the COVID situation, research was 
on hold for a while, so we got IRB permission  

00:43:40.480 --> 00:43:47.280
and now we can provide it by VVC. So, 
it’s a research project that we’re doing,  

00:43:49.920 --> 00:43:57.600
and we’re randomizing people to either get 
this spiritually integrated CPT provided by um,  

00:43:57.600 --> 00:44:05.200
psychologists trained in CPT, or they will get 
a chaplain intervention, pastoral counseling  

00:44:05.200 --> 00:44:11.840
as I explained, or they’re going to get 
the treatment, the regular treatment CPT. 

00:44:11.840 --> 00:44:18.000
Ralf Schneider: Great. Dr. Ames, we had a 
lot of folks who are interested in your,  

00:44:18.880 --> 00:44:24.160
in the moral injury scales, and 
we’ve gotten down their E-mails, 

00:44:24.160 --> 00:44:31.440
so we’ll make sure to get those to you at the end. 
So we have more time for questions from folks.  

00:44:32.960 --> 00:44:36.640
You can put them in the Chat box.
Dr. Donna Ames: I just want to say I  

00:44:36.640 --> 00:44:45.200
didn’t spend a lot of time talking about 
exercise and diet in this talk, but we  

00:44:47.280 --> 00:44:52.960
have a whole curriculum called the Lifestyle 
Balance Program that we developed through the VA  

00:44:52.960 --> 00:44:59.920
merit review. It is really all about helping 
our Veterans eat healthy, and I think it’s  

00:44:59.920 --> 00:45:08.720
so important, especially now that we provide 
nutritional counseling to our Veterans because  

00:45:08.720 --> 00:45:16.000
what you eat can really affect your mental and 
emotional health. It effects your gut micro biome,  

00:45:16.000 --> 00:45:22.080
so I’m always recommending the Mediterranean diet 
to my Veterans, I also think that supplements can  

00:45:22.080 --> 00:45:29.680
be really helpful for my Veterans. I’ve noticed 
that most of my Veterans are vitamin D3 deficient,  

00:45:30.400 --> 00:45:35.200
so I order labs to check on vitamin 
deficiencies, and I’ve been supplementing  

00:45:35.760 --> 00:45:40.800
my Veterans with vitamin D3, which can 
help with emotions – can help actually  

00:45:40.800 --> 00:45:47.640
with the immune system. And there’s been some 
discussion that vitamin D3 deficiency, um,  

00:45:49.840 --> 00:45:55.600
may be related to more of a risk for 
COVID. So, if you think your Veterans  

00:45:55.600 --> 00:46:00.240
are not doing well nutritionally, make sure 
that they’re getting looked at for that,  

00:46:00.240 --> 00:46:05.520
because we’re also seeing in a recent 
article that Veterans with schizophrenia are  

00:46:07.280 --> 00:46:14.880
more prone to getting COVID. So, if there’s 
obesity, if there’s inflammation, we know that  

00:46:14.880 --> 00:46:21.840
that’s a problem with COVID. So, I’ve been giving 
my Veterans vitamin D3, I give my Veterans Omega 3  

00:46:21.840 --> 00:46:26.800
supplements for their brain health. So 
again, I didn’t talk a lot about that today,  

00:46:30.080 --> 00:46:35.440
but if you want more information 
on nutrition or, there’s, you know,  

00:46:36.080 --> 00:46:40.480
I definitely think that when you look at your 
Veterans, ask them if they want help with that,  

00:46:40.480 --> 00:46:45.520
because what you eat affects your mood, 
it effects everything. It affects your  

00:46:45.520 --> 00:46:49.520
well-being, and even your immune system.
Ralf Schneider: Great. Are there anymore  

00:46:49.520 --> 00:46:57.520
questions? Oh yes, we have a long question 
that just came up that Ryan Parker sent. Uh,  

00:46:58.400 --> 00:47:07.360
I wonder if that’s a comment. He says, “Dr. Ames, 
in using the MISS-M-SF have you experimented  

00:47:09.600 --> 00:47:16.240
with having the Veterans fill out this scale, 
as if they were prior to service, and then  

00:47:16.240 --> 00:47:23.920
their actual post-service, but pre-intervention 
state.” He’s asking because with Vietnam Veterans  

00:47:23.920 --> 00:47:33.120
in particular, there seems to be both loss of 
faith and finding of faith in a narratively  

00:47:33.120 --> 00:47:40.960
progressing sense that isn’t necessarily 
the case for post-911 Veterans, wondering  

00:47:40.960 --> 00:47:45.680
how you navigate those sorts of dynamics?
Dr. Donna Ames: Yeah, I think it’s really  

00:47:45.680 --> 00:47:57.040
interesting because, um, depending on the 
generation, and how they were raised, um, how,

00:47:57.040 --> 00:48:04.240
what constitutes a moral injury for, you 
know for maybe a person who has never  

00:48:04.240 --> 00:48:10.560
been exposed to any kinds of religious training. 
So yeah, that’s a very interesting question.  

00:48:10.560 --> 00:48:16.000
And I think one of my colleagues, 
William Nash, the way I understand  

00:48:16.000 --> 00:48:25.360
his conceptualization of moral injury is that 
when a person has a moral injury, it changes  

00:48:25.360 --> 00:48:31.440
who they think they are. So, they no longer 
feel like they were that pre-Vietnam person.  

00:48:32.240 --> 00:48:39.440
A lot of times when we talk to Veterans, they 
feel like they’re no longer that same person,  

00:48:39.440 --> 00:48:45.520
right? That their character has been changed by 
whatever, morally injurious event that they had.  

00:48:46.400 --> 00:48:51.600
Certainly with military sexual trauma, a person 
feels like, “I’m never gonna be whole. I’m  

00:48:53.920 --> 00:48:59.680
I'm broken. You know, I’m a different person since 
this horrible thing happened to me.” And that’s  

00:48:59.680 --> 00:49:05.520
where recovery comes in, and that’s where I think, 
like the acceptance commitment therapy is so  

00:49:05.520 --> 00:49:11.040
powerful, and people are testing acceptance 
commitment therapy for moral injury to, you know,  

00:49:11.040 --> 00:49:17.680
help people realize how beautiful and how precious 
they are despite the things that happened to them,  

00:49:17.680 --> 00:49:24.480
and despite the things they did in their life that 
they really are strong and resilient. So, building  

00:49:24.480 --> 00:49:32.720
on their strength and helping them with their 
self-concept. But yeah I think that is a real,  

00:49:32.720 --> 00:49:37.920
can be a real consequence of moral injury, 
is having a different sense of who you are  

00:49:37.920 --> 00:49:43.840
altogether, like you’re no longer that innocent 
18-year-old who went over there, now you are  

00:49:44.400 --> 00:49:47.760
something else, and so yeah.
 
Ralf Schneider: Great.  

00:49:47.760 --> 00:49:56.720
Thank you. We have a couple people uh, that 
had a few more comments for you. Chad Wolks  

00:49:56.720 --> 00:50:04.480
added, “I’m interested in helping if the SI CPT 
can be extended toward other VA’s for this initial  

00:50:04.480 --> 00:50:13.120
research.” And he can certainly contact you uh, if 
he wants to learn more about that. We have Venice  

00:50:14.320 --> 00:50:20.160
Anderson who said, who wanted a copy 
of the Lifestyle Changes Program,  

00:50:20.160 --> 00:50:28.000
and asked, “What disciplines might be able 
to deliver that Lifestyle Changes Program?  

00:50:28.000 --> 00:50:31.520
Is it limited to certain clinicians?”
Dr. Donna Ames: That’s a good,  

00:50:32.400 --> 00:50:39.520
very good question. Um, when I had my 
funding I had two dietitians deliver the  

00:50:39.520 --> 00:50:47.440
program because it involved nutritional counseling 
and special expertise in that area. So, I think,  

00:50:49.920 --> 00:50:54.800
from my experience , working in the mental 
health clinic, I think the nursing staff  

00:50:54.800 --> 00:50:59.920
would like ideal. Um, and they’re very 
enthused and interested in helping Veterans  

00:51:00.800 --> 00:51:08.240
with this. There’s certainly, it could be done in 
an interdisciplinary fashion. So in other words,  

00:51:08.240 --> 00:51:13.120
if you have a PRRC where you have a nurse, or 
a mental health clinic where you have a nurse,  

00:51:13.120 --> 00:51:17.920
or an inpatient unit, maybe the nurses 
could do the exercise and nutrition portion,  

00:51:18.800 --> 00:51:25.280
maybe a social worker could work on the 
sections that relate to socialization, and  

00:51:25.920 --> 00:51:34.400
you know, recreation activities, maybe even have 
an occupational therapist who could help with  

00:51:34.400 --> 00:51:42.560
those sorts of things. But yeah, it could be 
done flexibly with multidisciplinary staff  

00:51:42.560 --> 00:51:49.760
or if you have a staff who is really gung-ho, 
and really helping and train them up with the  

00:51:52.800 --> 00:51:58.640
therapeutic lifestyle changes to work on. It’s 
really great to change the conversation with  

00:51:58.640 --> 00:52:04.320
Veterans about what, rather we’re not talking 
about taking a pill here – we’re talking  

00:52:04.320 --> 00:52:08.720
about making choices that are really 
positive for you. So let’s talk about  

00:52:08.720 --> 00:52:12.080
the food you're eating. Let’s talk 
about the exercise you’re doing.  

00:52:12.080 --> 00:52:17.600
Research shows that exercise is as powerful as 
antidepressants for depression, so why aren’t  

00:52:17.600 --> 00:52:23.920
you exercising? Let’s get going. Sometimes,  
some of my very amotivated, depressed folks  

00:52:26.400 --> 00:52:33.840
I will put in a consult to physical medicine and 
have a physical therapist start working with them. 

00:52:33.840 --> 00:52:41.280
Ralf Schneider: Thank you. So, um, we have Mary 
[inaudible52:37] who said she is very interested  

00:52:41.280 --> 00:52:49.840
in integrating more spirituality into her therapy 
work. “I sometimes worry about spirituality not  

00:52:49.840 --> 00:52:56.720
being within my scope as a psychologist. How do I 
approach this?” And I’m sure that sort of question  

00:52:56.720 --> 00:53:01.760
might apply to other professions too – Dr. Ames.
Dr. Donna Ames: Yeah, I think that’s a really good  

00:53:04.560 --> 00:53:08.800
question. I think it would be something 
to go over with one’s supervisor.  

00:53:09.920 --> 00:53:19.360
Michelle Pearce has published a spiritually 
integrated CBT book, and they’re done at least  

00:53:19.360 --> 00:53:26.400
eighteen articles on integrating spirituality 
into CBT – she and Dr. Koenig. So I think you  

00:53:26.400 --> 00:53:32.160
would have to talk to your supervisor, you 
would have to perhaps confer with chaplains,  

00:53:33.360 --> 00:53:42.320
and provide sort an interdisciplinary 
approach to integrating this. And I think

00:53:42.320 --> 00:53:48.720
I think it would be reasonable to give, you 
know, informed consent to your Veteran and  

00:53:48.720 --> 00:53:56.640
I think when we talk with Veterans, you know, I 
think it’s very important when we do an assessment  

00:53:56.640 --> 00:54:03.520
to understand where they are spiritually and 
who they want the help from. So, um, they may be  

00:54:03.520 --> 00:54:11.440
very interested in talking about their spiritual 
struggles with a psychologist, or they may prefer  

00:54:11.440 --> 00:54:20.160
to talk to a chaplain. So, good question, and I 
think that as we see the CBT that's spiritually  

00:54:20.160 --> 00:54:25.840
integrated has been validated, has been published, 
and now we’re in the process of developing the  

00:54:26.480 --> 00:54:34.160
CPT that is spiritually integrated. So I would 
imagine the future, if this proves to work,  

00:54:34.960 --> 00:54:38.320
could be added to the armamentarium.
Ralf Schneider: Yes.  

00:54:41.120 --> 00:54:47.200
We just have a little bit more time left for 
questions, we’ve got about 5 minutes. William  

00:54:47.200 --> 00:54:56.000
Butler asks, “How can this holistic model get 
patients and providers to reduce medications?”
  

00:54:56.000 --> 00:55:02.720
Dr. Donna Ames: Yeah, that’s a really great 
question. Um, so often I’ll see Veterans,  

00:55:02.720 --> 00:55:08.560
I have a very busy outpatient mental health 
clinic with I think about 600 patients,  

00:55:08.560 --> 00:55:14.320
and sometimes I see patients who have been 
treated for many, many years, and so we talk  

00:55:16.400 --> 00:55:23.280
about unraveling some of the psychopharmacology 
that has occurred, and trying to integrate  

00:55:23.280 --> 00:55:28.160
these TLC’s into their lives, and some of 
them are very relieved. They’ll be like,  

00:55:28.160 --> 00:55:34.240
“Why didn’t I meet you ten years ago before I put 
on all this weight on this medication or had this  

00:55:34.240 --> 00:55:42.320
extrapyramidal side effects?” So, what I talk 
about with the Veterans at my very first meeting,  

00:55:42.320 --> 00:55:47.760
is we’re going to work on a holistic approach, 
and that might involve lowering the doses of  

00:55:47.760 --> 00:55:55.584
medications or trying to reduce polypharmacy, and 
they’re very open to it, especially the people who  

00:55:55.584 --> 00:56:01.520
have been in the system a long time. Many of the 
younger Veterans who come in – I see people from  

00:56:01.520 --> 00:56:08.560
18 to their 90’s. So people, the younger folks 
are like, “I don’t really want to try medications  

00:56:10.720 --> 00:56:17.040
at this point, but I am really interested in this 
holistic approach”, and I can get them interested  

00:56:17.040 --> 00:56:24.160
in vitamins, nutritional supplements. We know 
that with PTSD, that medications for PTSD are  

00:56:24.160 --> 00:56:30.240
not the number one go-to treatment, that therapy 
is the go-to treatment, but some of our Veterans  

00:56:30.240 --> 00:56:37.200
really suffer from insomnia, stress, and so when 
we start looking at the holistic approach, um,  

00:56:37.200 --> 00:56:43.200
I will work up a lot of my Veterans for medical 
causes of their insomnia, and low and behold,  

00:56:43.200 --> 00:56:46.720
many Veterans with post-traumatic 
stress disorder have something called  

00:56:49.040 --> 00:56:55.040
sleep apnea ,and so you can make a Veteran’s life 
so much better by getting them evaluated for sleep  

00:56:55.040 --> 00:57:00.960
apnea or if they’re really nervous they could 
have a thyroid condition or a B12 deficiency or,  

00:57:00.960 --> 00:57:07.040
as I said, the vitamin D deficiency. So, I use 
magnesium a lot as a supplement for my Veterans  

00:57:07.600 --> 00:57:12.960
with post-traumatic stress to help with 
calming them. Um, and again, a lot of  

00:57:12.960 --> 00:57:20.160
Veterans are interested in this holistic approach 
and in minimizing medications. I’m finding that  

00:57:20.160 --> 00:57:24.960
many of my older Veterans want to get off and on 
fewer medicines, and it’s very important because  

00:57:25.520 --> 00:57:32.640
many of these medicines taken together can cause 
cardiac issues, especially in our older Veterans,  

00:57:33.360 --> 00:57:37.840
QT prolongation, which is a serious side 
effect when we combine too many medications. 

00:57:37.840 --> 00:57:47.120
Ralf Schneider: Thank you so much Dr. Ames, and 
we are about out of time. But before we sign off…