As the United States faces two decades of continuous war, media and individuals with personal military connections have elevated public and professional concerns for the mental health of veterans and service members. The most publicized mental health challenges facing veterans service members are PTSD and depression. Some research has suggested that approximately 14% to 16% of U.S. service members deployed to Afghanistan and Iraq have PTSD or depression. Although these mental health concerns are highlighted, other issues like suicide, traumatic brain injury (TBI), substance abuse, and interpersonal violence can be equally harmful in this population. The effects of these issues can be wide-reaching and substantially impacts service members and their families. While combat and deployments are linked to increased risks for these mental health conditions, general military service can also lead to difficulties. There is no specified timeline for the presentation of these mental health concerns. Still, there are particularly stressful times for individuals and families, such as in close proximity to combat or when separating from active military service.
Current U.S. Census reports estimate roughly 18 million veterans and 2.1 million active-duty and reserve service members (https://www.census.gov/newsroom/press-releases/2020/veterans-report.html). Since September 11, 2001, there have been 2.8 million active-duty American military personnel deployed to Iraq, Afghanistan, and beyond, leading to increasing numbers of combat veterans amongst the population. More than 6% of the U.S. population have served or are serving in the military. However, this statistic fails to capture the even greater number of family members affected by military service. Understanding military service and its relation to a patient’s physical and mental health can help providers improve their quality of care and potentially help save a patient’s life.
Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) was first codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3 in 1980, driven in part by sociopolitical aftereffects of the Vietnam War. It has been alluded to in different forms throughout history, from “soldier’s heart” at the time of the Civil War, “shell shock” in the First World War, or “combat fatigue” around the Vietnam War. DSM criteria remained largely unchanged until the most recent update in 2013, although its classification continues to be debated. It is a complex and evolving biological, psychological, and social entity, making it challenging to study and diagnose. PTSD is often researched in war and disaster survivors but can affect anybody, including children. It is usually seen in survivors of violent events such as assault, disasters, terror attacks, and war, although it is also possible to experience PTSD from secondhand exposure, such as learning that a close friend or family member experienced a violent threat or accident. Many individuals exposed to trauma have transient numbness or heightened emotions, nightmares, anxiety, and hypervigilance but usually overcome symptoms within one month. In roughly 10 to 20% of cases, symptoms become persistent and debilitating. PTSD features intrusive thoughts, flashbacks, and nightmares regarding the past trauma, causing avoidance of reminders, hypervigilance, and sleep difficulties. Often, reliving the event can feel as threatening as inciting trauma. Symptoms can interfere with interpersonal and occupational function and manifest in psychological, emotional, physical, behavioral, and cognitive manners. Military personnel can be exposed to an array of potentially traumatizing experiences. Wartime deployments can result in witnessing severe injuries or violent death, sometimes occurring suddenly and not always on expected targets. Apart from the austere environment of deployment, active duty military members are at risk of experiencing non-military-related traumas such as interpersonal violence, physical or sexual abuse. Symptoms related to these traumas can sometimes be exacerbated in the deployed environment.
After two decades of continuous war in Afghanistan, a growing population of veterans with combat and deployment experience is presenting for mental health care. Providers must take into account not only the physical wounds these veterans may have sustained but also the less visible ones such as PTSD, acute stress disorder, and depression. Although the condition does not garner the same attention as PTSD, depression remains one of the leading mental health conditions in the military. In fact, studies show that up to 9% of all appointments in the ambulatory military health network are related to depression. The military environment can act as a catalyst for the development and progression of depression. For example, separation from loved ones and support systems, stressors of combat, and seeing oneself and others in harm’s way are all elements that increase the risk of depression in active duty and veteran populations. Military medical facilities saw an increase from a baseline of 11.4% of members diagnosed with depression to a rate of 15% after deployments to Iraq or Afghanistan. With such a high prevalence, providers must be responsible for identifying active duty and veteran patients who may be suffering from depression.
Major depression manifests through many symptoms, including depressed mood, loss of interest in activities, insomnia, weight loss or gain, psychomotor retardation, fatigue, decreased ability to concentrate, thoughts of worthlessness, and thoughts of suicide. These symptoms coalesce to significantly impact patients’ abilities to function fully. While the complement of symptoms is readily apparent on paper, a patient’s actual presentation can often be ambiguous. One out of every two depressed patients is not appropriately diagnosed by their general practitioner. Therefore, it is paramount to correctly screen for, identity, and follow through with appropriate treatments, especially in the active duty and veteran military population.
Veteran suicide rates are at the highest level in recorded history, with annual deaths by suicide at over 6,000 veterans per year. Overall suicide rates within the United States have increased by 30% between 1999 and 2016. A study involving 27 states estimated 17.8% of these recorded suicides were by veterans. The U.S. Department of Veterans Affairs (VA) published data in 2016 that indicated veteran suicide rates were 1.5 times greater than non-veterans. Research has shown that veterans are at significantly increased risk of suicide during their first year outside of the military. In 2018, a Presidential Executive Order was signed to improve suicide prevention services for veterans during their transition to civilian life. Additionally, the Department of Defense (DoD) and VA have made suicide prevention a major priority because of observed increases in fatal and non-fatal suicide attempts throughout the wars in Iraq and Afghanistan. Within the U.S. Armed Forces, suicide rates doubled between 2000 and 2012, but since 2012 there have been no appreciable changes in the annual rate, with approximately 19.74 deaths per 100,000 service members.
Substance Use Disorders
Despite public attention over recent decades, SUDs, including alcohol use, remains a problem among veterans and military members. In these populations, alcohol use is common and is often used for stress relief and socializing. SUDs are associated with significant adverse medical, psychiatric, interpersonal, and occupational outcomes. One study on military personnel found that approximately 30% of completed suicides and around 20% of deaths due to high-risk behavior were attributable to alcohol or drug use. In the general U.S. population, alcohol is the fourth leading cause of preventable death, and 31% of driving-related fatalities involve alcohol intoxication. The DSM-5 defines SUD as a cluster of behaviors surrounding compulsive drug-seeking. This includes impaired control of, dysfunctional social functioning due to, and physiologic changes caused by drug use. Addiction is the most severe stage, characterized by loss of self-control leading to compulsive drug-seeking despite a desire to quit. Substances include legal drugs such as caffeine, nicotine, and alcohol; prescription medications such as opioids, sedative/hypnotics, and stimulants; and illicit drugs such as marijuana, cocaine, methamphetamines, heroin, hallucinogens, and inhalants.
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