Screening, Assessment, and Management of Veteran Mental Health Challenges 

According to research shared by the National Library of Medicine, the mental health of veterans and service members in the US has become a major concern due to 2 decades of ongoing warfare.  

The most common mental health challenges these individuals face are posttraumatic stress disorder (PTSD) and depression, affecting approximately 14% to 16% of those deployed to Afghanistan and Iraq. However, other issues like suicide, traumatic brain injury (TBI), substance use disorder (SUD), and interpersonal violence also harm this population. These challenges can have far-reaching consequences for service members and their families, and not just those who have experienced combat or deployment.  

“Healthcare providers can enhance the quality of care they provide patients and potentially save their lives by comprehending the relationship between military service and a patient's physical and mental well-being,” said researchers.  

Posttraumatic Stress Disorder  

Military personnel are particularly at risk for PTSD due to the traumatic experiences they may encounter during deployment. The etiology of PTSD is not fully understood, but research suggests that it is a complex disorder influenced by both genetic and environmental factors, with risk factors including childhood trauma, combat exposure, lower rank, marital status, having a low level of education, and a lack of post-deployment support. 

The prevalence of combat-induced PTSD varies between 2% and 17% in US veterans, with lower and narrower ranges in other Western countries due to factors such as varying intensities of combat, sociopolitical contexts, changes in diagnostic criteria, and sampling methods.  

The assessment of military service in patients' medical histories is crucial for identifying military-related conditions such as PTSD. However, studies have shown that veterans and their families often do not disclose their military service to health care providers.  

Screening for PTSD is important for risk assessment and early prevention, and there are two commonly used tools for this: the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and the PTSD Checklist for DSM-5 (PCL-5). Both can be used to provisionally diagnose patients who meet the diagnostic criteria. Multiple assessment methods, such as self-report measures and clinical interviews, are recommended for an accurate diagnosis.  

Psychotherapy is considered the first-line treatment, and medications are seen as an alternative or adjunctive strategy when psychotherapy is not accessible. Effective psychotherapies for PTSD include exposure therapy, cognitive processing therapy (CPT), trauma-focused cognitive behavioral therapy (TF-CBT), and eye-movement desensitization and reprocessing (EMDR). Medications, such as selective serotonin reuptake inhibitors (SSRIs) and venlafaxine, can also be effectively reduce symptoms. Combination therapies, including SSRIs and TF-CBT, have shown comparable effectiveness in treating PTSD.  

Depression  

Depression is a prevalent mental health condition in the military, responsible for many health care network appointments. Factors such as separation from loved ones, combat stressors, and exposure to harm contribute to the increased risk of depression in both active-duty and veteran populations. It is crucial for health care providers to accurately screen, identify, and provide appropriate treatments for depression in this population, as it significantly affects the patient's ability to function. 

Extensive research on major depressive disorder (MDD) has not yet determined its exact cause, but there is a clear link to neurobiology. Various factors, such as unemployment, financial stress, gender, and military-related issues, can also predispose individuals to MDD. 

MDD is a highly prevalent mood disorder, particularly among females and Gulf War veterans. Veterans deployed to conflict zones face an increased risk, as 15% of returning troops exhibited symptoms of MDD. 

For diagnosing depression, a comprehensive medical history is essential. It is also important to explore family mental health history and social history for potential stressors and support structures. Screening for military service should be incorporated into patient questionnaires, as military members may not readily disclose their occupation. 

Implementing screening tools, such as the Public Health Questionnaire 9PHQ-2 and PHQ-9), the Beck Depression Inventory for Primary Care (BDI-PC), and the World Health Organization Well-Being Index (WHO-5), has been shown to reduce the risk of persistent depression and increase detection rates in the military population.  

A combination of pharmacological and psychotherapies is the most effective treatment strategy for MDD. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy are commonly used. Pharmacotherapy options include serotonin reuptake inhibitors (SRIs), SSRIs, monoamine oxidase inhibitors (MAOIs), and others, with the selection based on the individual patient's needs. In severe and resistant cases of MDD, electroconvulsive therapy (ECT) may be considered.  

Suicide  

The suicide rates among veterans in the US have reached their highest level ever recorded, with over 6000 veterans taking their own lives each year. Overall, suicide rates in the country have increased by 30% between 1999 and 2016, and veterans account for 17.8% of reported suicide cases. Twenty-one veterans die by suicide daily, a rate 50% higher than the general US adult population, while female veterans have a 50% higher incidence of suicide than their civilian counterparts. 

Research shows that veterans are particularly at risk during their first year after leaving the military, leading to efforts by the government and defense agencies to improve suicide prevention services for veterans during their transition to civilian life. 

Personnel may face numerous stressors such as disciplinary actions, physical problems, conflicts, transfers, rank reductions, and exposure to combat or combat-related injuries, as well as comorbid conditions like PTSD, MDD, and TBI. While young men have the highest risk of suicide, female veterans and those in the Marines and Army with shorter service commitments are also at increased risk. Exposure to death or killing, especially that of another service also increased risk.  

The risk of suicide among veterans diminishes after military separation, although military cohorts may possess protective factors such as a sense of duty, belonging, and strong interpersonal bonds. Demographic factors like higher education, marriage, higher income, and active religious practice potentially serve as buffers against suicidality. 

Many screening tools for identifying suicide risks are ineffective, with low predictive values and high false-positive and false-negative rates. However, these screenings are not harmful and can provide an opportunity for patients to discuss their thoughts and for clinicians to investigate further. One commonly used tool is Item 9 on the PHQ-9, but it is associated with many false-negative rates. Therefore, clinicians should use multiple assessment methods and conduct clinical interviews to properly evaluate suicide risks. Military medical services in particular play a crucial role in treating suicidal patients.  

Substance Use Disorder  

Substance use disorders (SUDs), including alcohol use, continue to be a problem among veterans and military members, with alcohol being frequently used for stress relief and socializing. These disorders have significant adverse effects on medical, psychiatric, interpersonal, and occupational outcomes. A study on military personnel found that a significant number of suicides and deaths resulting from high-risk behavior were attributed to alcohol or drug use. 

Changes in DSM criteria and varied access to care for veterans make it difficult to accurately determine the prevalence of SUDs in this population, but it is known that SUDs are more prevalent in male veterans, particularly those who are unmarried and younger than age 25 and are often associated with military experiences and mental health issues such as PTSD and depression. Alcohol use disorders are the most common SUDs among veterans, followed by smoking and opioid prescriptions, while illicit drug use, particularly marijuana, is comparable to the general population. 

The most effective screening tests for identifying high-risk, hazardous, or harmful drinking in primary care settings are the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-Concise Test (AUDIT-C). The CAGE questions are helpful in predicting alcohol use disorders and dependence. Various laboratory tests, such as liver function tests, can aid in assessing unhealthy alcohol use, but they may have varying degrees of specificity and accessibility. 

SUDs are also correlated with completed suicides and poor outcomes but can be somewhat relieved by access to care for military personnel. Abstinence from substance use is consistently associated with improved outcomes for individuals with PTSD, except for employment. 

Interactions and Enhancing Healthcare Team Outcomes 

Practitioners should understand and be familiar with military resources to help veterans and their families, make appropriate referrals to organizations like Military OneSource and Coaching into Care, utilize community peer groups and services like the Vet Center Call Center and Veterans Crisis Line, and be aware of the Military Command Exception for disclosing protected health information for active-duty patients. 

The Military Command Exception to HIPAA allows for notification of a patient's Commanding Officer in certain circumstances for the safety and well-being of the patient and national security, but routine mental health care typically does not require this notification.  

The stigma surrounding mental health in the military poses a challenge for those with depression, making it crucial to create a judgment-free environment for treatment. Suicide prevention involves using safety plans that outline steps for managing suicidal impulses, but they do not guarantee absolute protection. Treatment for substance use disorders involves therapy and, in some cases, medication, with counseling being a key component. Due to this, the military and VA offer free counseling programs that have shown positive outcomes. 

“All treatment and intervention should involve the patient and, when appropriate, the family as part of the interprofessional treatment team, as social support plays a crucial role in both the pathogenesis and recovery of these disorders,” said researchers. “Employing interprofessional methods will lead to better patient outcomes.” 

Reference  

Inoue C, Shawler E, Jordan C H, et all. Veteran and military mental health issues - statpearls - NCBI bookshelf. National Library of Medicine. Updated online August 17, 2023. Accessed September 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK572092/