Veteran and Military Mental Health Issues

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Continuing Education Activity

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. This activity outlines the evaluation and management of mental health disorders affecting military service members and veterans, focusing on screening for military service and risk factors unique to these populations. Several of the most salient disorders, including post-traumatic stress disorder (PTSD), depression, suicidality, and substance use, are explored. This activity highlights the role of the interprofessional team in improving care for patients with these conditions.

Objectives:

  • Describe the epidemiology and diagnostic features of PTSD.
  • Review the effective therapies of depression in the military community.
  • Identify risk and protective factors for suicide in military and veteran populations.
  • Summarize management options by the interprofessional team for substance use disorders (SUDs) in military members and veterans.

Introduction

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.[1] 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.[2][3] 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.[4] 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.[5]

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.[6] 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.[7] 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.

Depression

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.[8] 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.[9] Therefore, it is paramount to correctly screen for, identity, and follow through with appropriate treatments, especially in the active duty and veteran military population.

Suicide

Veteran suicide rates are at the highest level in recorded history, with annual deaths by suicide at over 6,000 veterans per year.[10] 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.[11] 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.[12] Research has shown that veterans are at significantly increased risk of suicide during their first year outside of the military.[13][14] 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.[14] 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.[15][16]

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.[17] 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.[18] 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.

Etiology

PTSD

The etiology of PTSD is yet to be fully elucidated. Progress in neuroscience and genetics have helped characterize it as biological, not just psychological, disease. Current research points include fear conditioning, neural circuit dysregulation, memory reconsolidation, genetics, and epigenetics, especially childhood trauma on hypothalamic-pituitary-adrenal (HPA) axis regulation. Like other complex disorders, it is thought to be highly polygenic and influenced by external exposures.[19] Brain magnetic resonance imaging studies have demonstrated differences in the volume of anatomic structures, and there is a measurable difference in neurotransmitter levels compared to healthy controls.[20][21] Although the interplay between genetic predisposition, phenotype, and symptoms is yet to be elucidated, there are more quantifiable biomarkers. Individual factors such as prior trauma, belief systems, support structure, and other protective or exacerbating factors interplay in countless ways.[7]

Several risk factors exist before, during, and after inciting traumas. Childhood trauma places patients at higher risk for subsequent development of PTSD.[22][23] According to the VA, the most significant predictors of post-deployment PTSD are frequency and intensity of combat exposure. Lower rank, being unmarried, low educational attainment, proximity to direct contact with the enemy, low morale or unit social support, and lack of awareness of common psychological reactions upon return home were further risk factors identified in a large United Kingdom military study.[24] Similarly, a meta-analysis identified the following: risk factors existing prior to the trauma included female gender, being from an ethnic minority group, lower educational status, enlisted rank, service in the Army, serving in a combat specialty, higher number and longer cumulative duration of deployments, prior adverse life events, and premorbid psychological problems. Features of the traumatic event included ongoing combat exposure, firing a weapon, witnessing another getting wounded or killed, and other concurrent deployment-related stressors. After the event, the absence of post-deployment psychological and social support increased the risk of PTSD.[25][26]

Depression

Despite decades of research on major depressive disorder (MDD), its etiology is still not fully understood. There is a clear neurobiological link that exists for this mood disorder. However, exactly which markers and processes play the most critical role is still debated. Patients with major depressive episodes have shown increased responses to cortisol in the HPA axis, which could explain how stress is a substantial risk factor.[27] Another hypothesis revolves around the neurocircuitry of emotions. Specifically, it looks at how dysfunction of the cortico-striato-pallido-thalamic circuitry could produce emotions of a major depressive episode. Neurophysiological imaging brings forth evidence to support the hypothesis of neurocircuitry dysfunction.[28] As a piece of the neurocircuitry, neurotransmitters such as serotonin have been shown to play a role in regulating emotions in major depressive episodes. Studies have also examined how serotonin contributes to the neuroplasticity of the human brain.[29] As research continues, more definitive answers about the etiology of MDD will prevail.

Many factors predispose individuals to major depressive episodes. Some common risk factors in the general population include unemployment, financial stress, female gender, and personal or parental history of mental health concerns. The military brings additional risk factors that providers should consider, for example:[30]

  • Uniformed code of military justice actions (legal concerns)
  • Rank and promotion complications
  • Deployments
  • Combat exposure
  • Physical fitness concerns
  • Permanent changes of station (frequent relocations)
  • Command/leadership discord

Suicide

Studies on veterans and service members have attempted to characterize factors correlating military operations and suicide in an attempt to identify vulnerable patients and provide early intervention. While serving in the military, members may have stressors such as disciplinary actions, physical problems including pain, leadership conflicts, transferring duty stations, reductions in rank, or administrative separation from service.[31][32] Additional risks include comorbid conditions like PTSD, MDD, and TBI. Further exacerbating military features are combat exposure, combat-related injury, and access to lethal weapons.[33][34][15] While young men ages seventeen to nineteen have the highest risk, veteran women have been found to have up to 2.5 times the risk of non-veteran counterparts.[35][36] Veterans who served in the Marines and Army and those with shorter service commitments (two years or less) are at increased risk.[35] Amongst veterans, those exposed to death or killing have pronounced associations with suicide, especially if they witnessed another service member killed or wounded or if they were nearly killed or injured themselves in combat.[10][37] For veterans, suicide risk is time-dependent, with the greatest danger within six to twelve months after military separation.[5][13] 

Several protective factors may exist in military cohorts, such as a sense of duty to others, belonging or identity, strong interpersonal bonds, and access to healthcare. In particular, service members with family and friends with whom they can discuss deployments are less likely to experience suicidal ideation (SI). Another identified protective factor is a sense of purpose or control of one's life.[38] Certain demographic features like higher education, marriage, higher income, and active religious practice may also buffer against suicidality.[32][39][40] 

Substance Use Disorders

Neuroscientific advances have provided an increased understanding of drug effects on the brain. Addiction is a chronic relapsing disorder triggered by repeat drug exposures in those vulnerable due to genetics, development, and psychosocial conditions, including accessibility, drug use norms, and social support (or lack thereof). Drug use is driven by a substance’s pharmacological effects, which provide rewarding experiences. Its reinforcing effects depend largely on dopamine signaling at the nucleus accumbens. Chronic exposure triggers glutamate-mediated adaptations in the striato-thalamo-cortical pathway, primarily in the prefrontal cortex at the orbitofrontal and anterior cingulate cortices. Another identified pathway is the limbic system, which consists of the amygdala and hippocampus. Drugs cause changes in the extended amygdala, producing negative baseline emotional states, which the drug helps temporarily alleviate. Counterintuitively, drug use is associated with blunted dopamine release in brain reward regions. The drug use experience does not meet the expectations of reward triggered by conditioning to drug cues. Altogether, the substance creates enhanced motivations for drug seeking and impaired self-regulation through effects on the prefrontal cortex.[41]

Significant genetic influences contribute to SUDs, such as neurotransmission pathways, most importantly within the dopaminergic system. Other genetic influence points include drug processing and metabolism. Research on the gene-environment interaction has shed light on potential mechanisms of how the environment influences substance use biology. Epigenetic studies have demonstrated drug-induced changes in gene expression, which differ by stage of disease (substance initiation versus chronic use). Studies on epigenetic mechanisms such as methylation and microRNA with substance use are ongoing.[18]

Epidemiology

PTSD

Prevalence of combat-induced PTSD ranges from 2 to 17% in U.S. veterans but is lower and with a narrower range in other Western countries throughout the same conflicts. This variability is multifactorial, including the uniqueness of each theater and changes in diagnostic criteria. Each war exposes participants to varying intensities of combat and occurs in different sociopolitical contexts from which troops are pulled and returned. There are also noteworthy differences between studies, including sampling methods, measurement strategies, such as self-report versus structured interviews, and delays in assessment after combat exposure, oftentimes years or decades later, possibly increasing recall bias. The multifactorial, inherently subjective, and evolving nature of PTSD poses significant challenges to accurately defining its epidemiology.[26]

Depression

Major depression is the most prevalent mood disorder in the general population, with an estimated lifetime prevalence of up to 21%. Lifetime incidence for females ranges as high as 25%, and in males as high as 12%.[42][43][44] With such high rates in the general population, the VA and DoD are keenly interested in examining those figures for active-duty members and veterans. Gulf War veterans were found to have over twice the risk of suffering from depression than the general population.[45] The risk for a major depressive episode increases with each conflict that military members are deployed to, away from families, and exposed to new stressors. In 2012, 15% of troops returning from a deployment reported symptoms consistent with a major depressive episode.[43] 

Suicide

Before 2000, suicide rates within the military and veteran populations were lower than in civilians. However, rates have increased during the last twenty years and currently exceed the civilian rate. There are approximately 19.74 deaths per 100,000 members within the military service, and age-adjusted suicide rates (amongst 17 to 59 year-olds) in the U.S. population is 16.8 per 100,000.[15] Approximately twenty-one veterans die by suicide daily, at an incidence 50% higher than in the general U.S. adult population.[46][47] Concerns have grown amongst female veterans, as these women have a 50% higher incidence of suicide than civilian counterparts.[47] 

Substance Use Disorders

Changes to DSM criteria and the fact that not all veterans receive care through the VA make it challenging to know the true prevalence of SUDs in veterans. As with the general population, SUDs are more common in male veterans (10.5% alcohol and 4.8% other drugs, compared to 4.8% and 2.4%, respectively, amongst female veterans). Unmarried and veterans younger than 25 are at the most risk.[48] Military-specific exposures are thought to contribute to SUD development, including deployment, combat, post-deployment or post-separation reintegration, and other mental health issues associated with such stressors, such as PTSD and depression. Some join the military to escape adverse home conditions: history of childhood trauma is associated with risk of SUD among veterans.[49]

In military and veteran populations, alcohol use disorders (AUDs) are the most prevalent form of SUD. According to the National Survey on Drug Use and Health, compared to non-veterans, veterans were more likely to use alcohol (56.6% versus 50.8% over one month) and use heavily (7.5% versus 6.5% over one month). Problematic drinking was higher in those with more combat exposure: heavy and binge drinking were found at 26.8% and 54.8%, respectively, in those with high combat exposure, compared to other military personnel at 17% and 45%. Smoking is more common in veterans compared to age-matched civilians (27% versus 21%). Opioids are being given to veterans at increasing rates. From 2001 to 2009, the number of VA opioid prescriptions increased from 17% to 24%. A diagnosis of PTSD (17.8%) or other mental health disorders (11.7%) increased the likelihood of getting an opioid prescription compared to those without (6.5%). Illicit drug use among veterans occurs at similar rates to civilians, at around 4% over one month. Marijuana is the most common among veterans at 3.5% compared to 1.7% for other illicit drugs over one month. Cannabis use disorders increased by 50% between 2002 to 2009 among VA patients.[17]

History and Physical

Assessment of Military Service

The foundations of a thorough mental health assessment do not change when discussing mental health concerns with a service member or veteran. A challenge that practitioners face is identifying military service in a patient’s history.[50] Studies have shown that veterans and their families do not readily report their military service to medical providers; therefore, screening is essential in community-based or private clinics. Evidence suggests that fewer than half of primary care and mental health providers screen for service, meaning veterans are unlikely to be screened for military-related conditions such as PTSD. In 2013 the American Academy of Nursing began a national campaign in support of veterans and their families.[51] The initiative, “Have You Ever Served in the Military?” emphasized the importance of screening for military service during initial encounters. Additional recommended questions to ask include:

  • “Have you or someone close to you ever serve in the military?”
  • “When did you serve?”
  • “Which branch did you serve in?”
  • “What did you do while you were in the military?”
  • “Were you assigned to a hostile or combat area?”
  • “Did you experience enemy fire, see combat, or witness casualties?”
  • “Were you wounded, injured, or hospitalized?”
  • “Were you exposed to noise, chemicals, gases, demolition of munitions, pesticides, or other hazardous substances?”
  • “Have you ever used the VA for health care?”

PTSD

Some individuals may have difficulties being aware or forthcoming about the emotional or cognitive aspects of PTSD and may instead present with complaints about physiologic symptoms such as insomnia. Nonetheless, history will form the basis of diagnosis, as not all patients have physical exam findings. There are eight criteria and two specifiers for PTSD, which should be explored through thorough history-taking, and are outlined below (see “Evaluation”). 

Depression

The basis of a major depression diagnosis is found in the patient’s history. This should include a course of present illness, current symptoms and timeline, prior history of similar symptoms, alleviating or aggravating factors, impact on daily living, and complete medical history to include psychiatric history. Other categories to explore include family mental health history and social history, which includes job or relationship stressors as well as possible support structures. The same thorough history should be attained for military and veteran patients.[52] Providers should consider adding screening for current or prior military service to patient questionnaires since military members may not be forthcoming about their current or previous occupation.[51]

A pertinent physical exam is imperative for any encounter and is no different in patients presenting with mental health concerns. For example, patients experiencing depression often have physical manifestations such as fatigue, insomnia, or weight changes. Thorough consideration of organic etiologies must be given to those with somatic symptoms. Furthermore, providers must be willing to change a diagnosis if other symptoms and a more appropriate etiology are identified.

Suicide

Thorough histories are essential in evaluating patients with suicide risk. Specifically, clinicians should identify exacerbating and protective factors, particularly modifiable targets for intervention.[53] During the encounter, providers must inquire about prior suicide attempts, current and previous suicidal thoughts, and self-destructive behavior. Signs concerning impending suicide include establishing plans or taking actions towards suicide, such as purchasing a firearm, drafting a will, saying goodbye to loved ones, giving away personal belongings, or writing a suicide note. At-risk persons may mention suicide or death frequently and may visit their primary care manager or an emergency department in the weeks before an attempt. Patients may describe vague health problems at these encounters, so providers should be mindful to obtain a thorough mental health assessment beyond the chief complaint. Some at-risk individuals may have a family history of suicide, and the risk can be highest around the anniversary of their family member’s death. Stress from sudden negative life events can increase risk, but long-lasting problems such as disability, chronic pain, and mental health disorders also lead to increased risk. During the mental health assessment, clinicians should observe the patient’s appearance, affect, judgment, and insight. Patients may appear disheveled, unkempt, or unclean. They may have signs of self-harm like rope burns or scars on the arms, wrists, or neck. On exam, providers may notice that the patient seems anxious, depressed, or has a blunted affect. Providers should gauge how well the patient handles stress and whether they have impaired decision-making ability.  

Substance Use Disorders

SUDs are a pattern of drug use causing distress or impairment, with at least two of eleven symptoms categorized under four categories (impaired control, social impairment, risky use, and pharmacologic effects) occurring over one year. Detailed criteria are in the “Evaluation” section below. Following a positive screen (also discussed below), providers should obtain a thorough history and exam, including medical and mental health comorbidities, family history, and social history. Presentations vary depending on the substance(s) used, and individuals may have incentives to minimize them. A mental status exam (MSE) may be helpful in the presence of psychiatric symptoms. This is an assessment of appearance, behavior, speech, motor activity, mood and affect, perceptions, thought processes, thought content (including suicidal/homicidal ideation, hallucinations, and delusions), insight, judgment, and cognitive function. Abnormalities should alert providers to the possibility of a SUD, as they are often associated. The MSE, however, is usually normal in SUD except during intoxication, withdrawal, active psychosis, or cognitive impairment from chronic substance use. Beyond the history and physical, a multidimensional assessment is necessary to offer personalized, comprehensive management plans. Consider:

  • The pattern of substance use, treatment history, intoxication/withdrawal potential, and continued use potential
  • Emotional, behavioral, and cognitive conditions
  • Living environment
  • Employment and finances
  • Criminal justice involvement
  • Readiness to change

Alcohol use can manifest in many organ systems and the behavioral, psychiatric, and social realms and may not be attributable to drinking. Examples include:

  • Injuries from accidents or assault
  • Anxiety, depression, and suicidality
  • Concurrent use of other drugs
  • Central or peripheral neurologic symptoms
  • Sleep disturbances
  • Hypertension
  • Cardiac disease
  • Electrolyte disturbances
  • Gastrointestinal symptoms including reflux (GERD)
  • Bone marrow suppression
  • Macrocytosis
  • Malignancies, including oropharyngeal and gastrointestinal

The use of other substances is also associated with compromised function in virtually every organ system. Diseases may develop from direct toxicity, method of administration, and high-risk behaviors surrounding use such as needle sharing, unprotected sex, or poor hygiene. Possible physical indicators of substance use include:

  • Unintended weight loss or gain
  • Scars (“track marks”) in injection drug use
  • In inhalational use: nasal mucosal atrophy or septum perforation
  • In acute intoxication/withdrawal: unsteady gait, slurred speech, pupil changes, conjunctival injection, eye tearing, rhinorrhea, odd behavior, tachycardia, diaphoresis
  • Signs of medical comorbidities resulting from drug use (see “Complications” below)

Evaluation

PTSD

Screening: PTSD screening serves several functions, the first of which is risk assessment. This helps identify patients at risk of developing PTSD who do not yet meet full criteria, allowing them to be routed to early prevention efforts. Screening also allows for earlier detection of acute and sub-threshold cases or uncover unidentified chronic PTSD patients.[54] The Primary Care PTSD Screen for DSM-5, or PC-PTSD-5, is a five-item questionnaire with yes/no answer options designed to be administered by primary care providers. It has excellent diagnostic accuracy compared to semi-structured neuropsychiatric interviews. A cutoff score of 3 or higher showed the highest sensitivity. It was easily understood and tolerable to study participants.[55] The PTSD Checklist for DSM-5, or PCL-5, is a 20-item self-administered questionnaire. It is helpful for screening, provisionally diagnosing, and monitoring symptom changes pre- and post-treatment.[56] There is a 0 through 4 rating scale for each question, and it can be completed in five to ten minutes. Research on veterans showed that a cutoff score between 31 and 33 out of 80 indicates probable PTSD.[57] Questions are grouped by cluster corresponding to each of the DSM-5 diagnostic criteria B through E and can be used to provisionally diagnose patients meeting diagnostic rules.[56]

Diagnosis: DSM-5 diagnostic criteria for adults are:

  1. Exposure to death (actual or threatened), serious injury, or sexual violence by:
    1. Direct experience,
    2. Witnessing as it occurred to others firsthand,
    3. Learning that it occurred to a close friend or family member, or
    4. Experiencing repeat or extreme exposures to unpleasant details of the event(s), for example, police officers repeatedly finding human remains. This is not applicable if the exposure was through media unless as part of the patient’s work.
  2. One or more “intrusion symptoms”:
    1. Distressing memories of the event which are invasive, involuntary, and reoccurring
    2. Recurrent nightmares about the event
    3. Dissociative reactions such as flashbacks where the patient feels like they are reexperiencing the event
    4. Prolonged or intense psychological distress to cues resembling some aspect of the event
    5. Significant physiologic response to cues resembling some aspect of the event.
  3. Avoidance of trauma-related stimuli, as displayed by one or both:
    1. Efforts to avoid stressful memories or thoughts
    2. Efforts to avoid people, locations, topics, situations, etc. which trigger stressful recollections of the event.
  4. Negative mood or cognitions surrounding the event, as displayed by two or more of these criteria:
    1. Inability to recall significant features of the event, excluding other etiologies such as TBI and intoxication
    2. Exaggerated or persistent pessimistic beliefs about the self, others, or world
    3. Distorted ideas about the cause or consequences of the trauma
    4. Persistently negative emotional state, which can be fearful, angry, shameful, etc.
    5. Detachment from others
    6. Inability to feel good emotions such as satisfaction, love, and happiness.
  5. Altered arousal and reactivity, as shown by two or more of the following: 
    1. Irritability despite minimal provocation, often expressed as angry outbursts or physical/verbal aggression
    2. Recklessness or self-destructive behavior
    3. Hypervigilance
    4. Marked startle response
    5. Concentration difficulties
    6. Insomnia.
  6. Criteria B through E must be present for longer than one month.
  7. Symptoms must cause significant distress or impairment in social, occupational, or other important functional domains. 
  8. Symptoms cannot be due to substances or another medical condition.

The PTSD diagnosis is ideally made using multi-method assessments given limitations of individual tools. This practically includes a self-report symptom severity measure such as the PCL-5 and a semi-structured clinical interview. Biological measurements such as heart rate, sweat gland activity, and neuroimaging are areas of ongoing research and are not widely available. Semi-structured interviews, most commonly the Clinician-Administered PTSD Scale (CAPS-5), are conducted by trained interviewers and are the gold standard for diagnosis. They have the advantage of the ability to clarify responses, decreasing the likelihood of misinterpretation of questions, symptom exaggeration or minimization, and inconsistent responses.[54] CAPS-5 contains 30 items, can diagnose in the last week, month, or a lifetime, and quantify severity based on symptom frequency and intensity. It has well-established reliability and validity, including in veterans.[58]

Depression

Screening: Major depression is both prevalent and underdiagnosed in the general population. Because of this, the United States Preventive Services Task Force recommends screening for depression in those aged twelve or older. The youngest service members are eighteen years old. Therefore, screening for depression in the military community is highly recommended. Currently, a two-item (PHQ-2) and a nine-item (PHQ-9) Public Health Questionnaire are effectively used to identify patients warranting further investigation. They share similar sensitivities; however, the specificity of the PHQ-9 is higher at 91 to 94% compared to the PHQ-2 (78 to 92%).[59] Other screening tools for the primary care setting include the Beck Depression Inventory for Primary Care (BDI-PC) and the five-item World Health Organization Well-Being Index (WHO-5). The BDI-PC has been utilized in over 7,000 studies. The BDI-II, a variation of the BDI, has been shown to be useful as a severity scale. In the scoring of the BDI-II, a 0 to 13 indicates minimal, a score of 14 to 19 corresponds to mild, 20 to 28 moderate, and 29 to 63 severe depression.[43]

While still useful as a severity tool, the BDI-II was found to have high sensitivity but lower specificity at over 90% and 59%, respectively, than the PHQ tools.[60] Screening does entail some risk for false positives, and thus, unnecessary treatments. The WHO-5 is another user-friendly, self-administered questionnaire with a sensitivity of 86% and specificity of 81%.[61] These screening tests are vital to initiating engagement with the depressed patient. Studies have shown that the implementation of screening tools such as patient questionnaires and early feedback reduced the risk of persistent depression (summary relative risk of 0.87 with 95% CI of 0.79 to 0.95).[52] Given the prevalence of depression in the active duty and veteran populations, the use of screening tools is recommended. They have been shown to raise detection rates from 10% to 47%.[52] Catching the disorder early is effective in reducing the length of symptoms in our military population.

Diagnosis: according to DSM-5 criteria, a diagnosis of MDD can be applied when a patient experiences one or more major depressive episodes. A major depressive episode is defined as having five of the following symptoms present during a two-week period with a change in baseline functional status. Furthermore, depressed mood or loss of interest or pleasure in activities must be one of the endorsed symptoms. The full list of symptoms to consider includes depressed mood, loss of interest/pleasure in activities, weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feeling worthless or excessive guilt, decreased concentration, and thoughts of death or suicide. Physiologic causes, substance use, and other psychiatric disorders must be excluded.

Laboratory and imaging: Evaluations should be performed at the provider’s discretion, guided by the history and physical exam. Common laboratories drawn in the initial evaluation of a patient with depressive symptoms include:

  • Complete blood count
  • Serum chemistry panel
  • Urinalysis
  • Thyroid-stimulating hormone
  • Rapid plasma reagin
  • Human chorionic gonadotropin
  • Urine toxicology screen

Imaging is generally reserved for instances where structural brain diseases are suspected. Further laboratory and neuroimaging evaluations should be guided by findings in the history and physical examination.

Suicide

While many resources are available for identifying those at elevated risk of suicide, most such screening tools are ineffective in accurately predicting risk. They frequently have low positive predictive values, high false-negative rates, and high false-positive rates.[62] Nonetheless, these questions have been proven not to increase a patient’s suicidal ideation or behavior, thus screening ultimately presents no significant harm.[63] By contrast, patients may not feel comfortable admitting to suicidality without prompting and therefore may appreciate the chance to discuss their thoughts. Screening may also help direct clinicians towards an additional investigation into a patient’s behavioral health. One widely accepted method is Item 9 on the PHQ-9, which identifies suicide risk:

Item 9: “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?” 

Responses: “Not at all,” “Several days,” “More than half the days,” or “Nearly every day.”[64]

Generally, patients who respond with high levels of SI are associated with a higher risk of death by suicide.[34] However, a significant constraint of the PHQ-9 is that there are many false negatives. One study found 71.6% of suicidal deaths were by patients who endorsed “not at all” on Item 9.[62] Despite its limitations, the VA still maintains a weak recommendation for using it as a screening tool for suicidality.

Clinicians should conduct suicide risk evaluations on patients who screen positive. There are multiple analytic models and assessment tools for determining the future risk of suicide. These methods help standardize information gathering during the patient interview.[65] However, no single approach is sufficient to evaluate these patients, so providers should also conduct clinical interviews to assess suicide risk rather than rely on assessment tools alone.[66] 

Substance Use Disorders

Screening: Several alcohol-use screenings have been validated, but none have advantages over the single-item screening, Alcohol Use Disorders Identification Test (AUDIT), or AUDIT-Concise (AUDIT-C) in primary care settings. AUDIT was the most effective in identifying those with high risk, hazardous, or harmful drinking (51 to 97% sensitivity, 78 to 96% specificity depending on score cutoffs, and “harmful use” criteria used), while CAGE questions were best at predicting alcohol abuse and dependence (43 to 94% sensitivity, 70 to 97% specificity). Several single-item screening questions have been proposed. One validated example asks, “on a single occasion within the last three months, have you had five or more drinks containing alcohol?” An affirmative was 62% sensitive and 93% specific for problematic alcohol use. Brevity, memorability, and a lack of scoring make this easy to use. AUDIT is the most widely validated AUD screening. It contains ten items and takes two to three minutes to complete. Questions assess the frequency, quantity, drinking occasions, impairment, dependence, harmful use, and concern from others. Scores range from 0 to 40, with an 8 or higher considered indicative for unhealthy alcohol use. AUDIT-C contains three questions on excess consumption. It was proven primarily in male veterans, but other studies validating its use in other populations are being published. Studies show a 54 to 98% sensitivity and 57 to 93% specificity for varying definitions of “heavy drinking.”[67] The questions are:

  • How often do you have a beverage containing alcohol?
  • How many beverages containing alcohol do you have on a typical drinking day?
  • How often do you have 6 (male) or 4 (female) or more drinks on a single occasion?

CAGE is a series of four questions designed to detect substance abuse and dependence per DSM-4 criteria. It is most useful for identifying patients with severe problems (when two or more questions are positive) and must be supplemented with quantity and frequency questions if positive.[67] 

  1. Have you ever felt the need to Cut down on drinking?
  2. Have others Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about your drinking?
  4. Have you ever needed to drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Diagnosis: DSM-5 diagnostic criteria are below. The presence of two to three symptoms is considered mild, four to five moderate, and six or more severe.[18]

      Impaired Control:

  1. Taking the substance in larger amounts or over a longer period than intended
  2. Unsuccessful attempts or persistent desire to reduce or regulate the use
  3. Spending excess time to obtain, use, or recover from the effects of the substance
  4. A strong craving, or intense desire/urge, for the substance, can occur at any time

      Social Impairment:

  1. Substance use causes significant interference with work, school, or home roles.
  2. Continued use despite recurrent social or interpersonal consequences exacerbated by the use
  3. Reducing or abandoning important social, recreational, or occupational activities due to substance use

      Risky Use:

  1. Substance use in physically hazardous locations
  2. Use despite knowing of persistent physical or psychological consequences exacerbated by the drug.

      Pharmacology:

  1. Tolerance: increasing doses of substance needed to achieve the desired effect
  2. Withdrawal: physical or psychological symptoms occur with abrupt discontinuation/dose decreases.

Laboratory tests: Urine, blood, sweat, hair, saliva, and breath tests exist for alcohol and other drugs and can detect recent use. Patients are more likely to answer use-related questions more honestly when an objective measure has been taken. However, they cannot quantify the frequency or dose(s) used. Thus, they may be of higher utility in monitoring for abstinence. Basic screening tests exist for amphetamines, cocaine, cannabis, certain opioids, and phencyclidine. Except in emergencies, permission for obtaining a drug screen must be obtained. Several alcohol-specific laboratory tests exist but tend to require heavy, repetitive consumption to cause abnormalities. Most are non-specific to varying degrees. In the absence of other explanations, the following can aid in the assessment of unhealthy alcohol use:

  • Liver function tests: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) can be elevated with hepatotoxicity. An AST:ALT ratio of 2:1 is more specific to alcohol-induced liver disease. Bilirubin may be elevated. Albumin will be decreased in liver damage.
  • Complete blood count: anemia, pancytopenia, and macrocytosis can be seen in chronic alcohol use.
  • Gamma-glutamyltransferase (GGT): another enzyme primarily found in the liver, often elevated with excessive alcohol use (reference range: 8-40 units/L in females, 9-50 units/L in males).

The following are less widely available:

  • Carbohydrate-deficient transferrin (CDT): a level greater than 1.6 percent suggests chronic excessive alcohol use over an approximate two-week period. It is relatively specific but can be elevated in certain rare liver diseases, i.e., primary biliary cirrhosis.
  • Phosphatidylethanol (PEth): this is specific for alcohol use. A value greater than 20 ng/dL is seen in moderate alcohol consumption, while values greater than 200 ng/dL typically indicate heavy alcohol consumption.[68][67]

Treatment / Management

PTSD

Treatment for PTSD should be initiated soon after diagnosis when symptoms have persisted for at least four weeks, although most patients present months or years later. First-line treatment generally consists of psychotherapy, with medications as a reasonable alternative or augmenting strategy based on patient preference or when psychotherapy is unavailable. 

Non-pharmacologic therapies: Effective PTSD psychotherapies include exposure therapy, cognitive processing therapy (CPT), trauma-focused cognitive-behavioral therapy (TF-CBT), and eye-movement desensitization and reprocessing (EMDR). Exposure therapy is rooted in emotional processing theory and seeks to correct a dysfunctional fear cognitive structure. CPT is trauma-specific and takes twelve weeks. This also draws on emotional processing theory along with social cognitive theory and attempts to correct distorted cognitions about the self and world after trauma.[69] TF-CBT is a combination of exposure and cognitive therapies.[70] The patient’s dominant symptoms can help guide the selection of psychotherapy type: those primarily with fear and avoidance may benefit most from exposure techniques, whereas someone with guilt and mistrust may benefit more from cognitive therapies. Interpersonal psychotherapy is a treatment designed for depression that has shown an effect against PTSD but is less studied.[69]

Pharmacotherapy: Medications can be effective in reducing core PTSD symptoms and should be kept as an option. They are more effective against hyperarousal and mood symptoms and less so for re-experience, emotional numbing, and avoidance symptoms. No medication class has demonstrated better suitability or tolerability than others. However, the largest and greatest number of trials have been conducted on selective serotonin reuptake inhibitors (SSRIs). Multiple randomized control trials found reduced PTSD symptoms with SSRIs when compared to placebo. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI), has shown effectiveness and tolerability in a smaller body of literature.[71][72] Second-generation antipsychotics and prazosin, an alpha-blocker antihypertensive, are second-line and shown to reduce symptoms effectively.[73] The effectiveness of benzodiazepines remains debated, and expert consensus suggests caution. Few studies cover, and no clear benefit in symptom reduction has been shown, with tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and mood stabilizers.

Combining therapies: Some trials suggest that SSRIs, TF-CBT, and their combination are roughly equivalent in effectiveness, with some advantages to psychotherapy for patient preference. There was improved adherence when patients were given their preferred treatment modality.[74][75] A more recent meta-analysis showed that multi-component interventions were the most effective. The same study found that psychotherapy, especially trauma-focused modalities, was effective for PTSD, comorbid anxiety, depression, and insomnia. Pharmacotherapies were less effective than psychotherapy for addressing PTSD symptoms and improving sleep.[73]

Depression

Treatment for MDD remains the same for both the general and military populations. Combinations of pharmacologic and psychotherapies have been proven to be the most effective treatment strategy.[76]

Psychotherapy: Psychotherapy is a category of treatment options involving talk sessions between patient and provider. There are several types, including CBT, interpersonal psychotherapy, behavioral activation, problem-solving therapy, supportive psychotherapy, and psychodynamic psychotherapy. Although no type has been shown to be superior to another, CBT and interpersonal psychotherapy are often selected first because of the lengthy list of studies on those methods.[77],[78] CBT involves the patient talking through practices, behaviors, and beliefs that need to be changed or reinforced to help the patient.

Pharmacotherapy:  Evidence continues to support the use of pharmacologic agents in the treatment of MDD. Options include serotonin reuptake inhibitors (SRIs), SSRIs, MAOIs, SNRIs, and TCAs. Each class of medications works in slightly different ways and is beyond the scope of this article. The selection of the appropriate agent should be individualized to the patient. Patient factors include comorbid conditions, clinical presentation, side effects, and previous medication use.[79] For example, SSRIs are considered first-line for MDD; however, if a patient desires to quit smoking and lose weight, bupropion may be a better choice given its side effect profile and alternate uses. Stronger and more involved treatments such as ketamine infusions are available but typically reserved for refractory cases.

Electroconvulsive Therapy (ECT): ECT involves an electric current to stimulate the brain into a generalized cerebral seizure. It is widely viewed as efficacious and safe but is generally reserved for cases of severe, resistant MDD.[80] ECT is less frequently used because of the stigma associated with the procedure created by popular media.

Suicide

As part of treatment, the VA and DoD recommend a crisis response plan that includes assessing SI and history of previous attempts. Patients at imminent risk of suicide should be hospitalized, and a safety plan developed.[81] The provider and patient should discuss recent stressors and collaboratively identify behavioral, cognitive, or physical signs of crisis. The patient should also identify self-management skills to distract from the situation or decrease stress and consider the protective factors in their lives. Clinicians should provide emergency resources, including medical and mental health providers and suicide lifelines (see “Consultations” below). Follow-up and appropriate referrals are essential for continued care. Finally, if the patient is in the military, the provider should inform the patient’s leadership to enact safety measures for protecting the patient and unit missions. Current regulations mandate that a member with suicidal behavior be placed on a duty limitation, restricting them from entering exacerbating environments such as deployment to remote locations. Thus, military medical services must be involved in the care of suicidal patients. Detailed information can be found in the VA/DoD clinical practice guidelines (https://www.healthquality.va.gov/guidelines/MH).

Substance Use Disorders

Non-pharmacologic therapies: Psychotherapy is the mainstay of SUD treatment. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a “first aid” strategy designed to intervene on unhealthy drinking before progression to AUD and provide immediate treatment to those who have already developed it. If further treatment or evaluation is indicated, patients should be offered longer-term management in primary care or specialist settings. Evidence-based psychotherapy or behavioral interventions should be offered. This typically consists of short-term CBT to identify and modify maladaptive thoughts and behaviors around substance use. CBT can also help incentivize abstinence, manage contingencies, and improve stress management skills.[17] Patient-centered motivational interviewing encourages patients to engage in treatment. This has been shown to reduce weekly drinks consumed and alcohol dependence rates.[82] In those with comorbid PTSD, integrated therapies addressing both conditions have been developed. Studies show that substance use often decreases and is at minimum not worsened by the addition of trauma-focused interventions. PTSD outcomes improved with integrated approaches in multiple randomized controlled trials. However, there is not enough evidence to say integrated plans are superior to treating SUDs and PTSD separately but concurrently.[83]

Pharmacotherapy: Several pharmacotherapies have received support in managing SUDs, primarily by reducing cravings or withdrawal symptoms to incentivize abstinence or reduce barriers to quitting.[17] There are three medications approved by the Food and Drug Administration (FDA) for AUDs: naltrexone, acamprosate, and disulfiram. Methadone, buprenorphine, and naltrexone are approved for OUDs. There are currently no FDA-approved drugs to treat cocaine or marijuana use disorders.[84]

In addition to clinical interventions, veterans with SUDs can be introduced to self-help groups such as Alcoholics Anonymous or Narcotics Anonymous. They are generally free, available in most locations, and can be helpful as ongoing maintenance engagement in those seeking abstinence.[17]

Differential Diagnosis

PTSD

The differential diagnosis of PTSD is extensive and is complicated by high rates of psychiatric comorbidities, some of which are addressed under “Complications.” Below is a limited list focusing on adults:

  • Acute stress disorder: Individuals presenting with at least nine of fourteen symptoms in the five categories (intrusion, negative mood, dissociation, avoidance, and arousal), lasting between three days to a month after a trauma, and suffering functional impairment, qualify for this diagnosis. The majority of patients recover within this period. Those who remain symptomatic after thirty days are reclassified as having PTSD.
  • Adjustment disorders
  • Depressive disorders
  • Anxiety disorders: includes specific phobias, social anxiety disorder (social phobia), panic disorder, agoraphobia, and generalized anxiety disorder.
  • Substance use
  • Obsessive-compulsive disorder
  • Bereavement
  • Schizophrenia and other psychotic disorders 
  • Personality disorders, especially borderline personality disorder
  • Dissociative disorders
  • Conversion disorder
  • TBI

Depression

While the entire differential diagnosis for MDD is expansive and beyond the scope of this article, three other conditions must be considered before establishing this diagnosis: grief, adjustment disorder, and persistent depressive disorder (PDD). Grief usually occurs with the loss of a loved one. Patients experiencing grief often have symptoms that overlap with depression, such as decreased interest in activities, depressed mood, and thoughts about the deceased individual.[85] Auditory hallucinations are not uncommon in cases of grief. Adjustment disorder is characterized by a self-limited but out-of-proportion emotional or behavioral response to an acute stressor that does not meet diagnostic criteria for another mental health disorder. Rates of adjustment disorder are considered equivalent or higher than MDD.[86] PDD shares many of the same symptoms and diagnostic criteria as MDD. The distinguishing characteristics lie within the timeline of each disorder. In MDD, symptoms must be present for at least two weeks. Meanwhile, in PDD, symptoms must continue for two years without a break of two months or more.

Substance Use Disorders

Differential diagnoses depend on the substance in use and are numerous. In addition, most other DSM-5 diagnoses require ruling out substance-induced variants, which can manifest in similar ways or trigger the onset of such disorders. Categories of diagnoses associated with substances include psychotic, bipolar, depressive, anxiety, obsessive-compulsive and related sleep disorders, sexual dysfunction, delirium, and neurocognitive disorders.

Prognosis

PTSD

PTSD prognosis varies widely between individuals and can sometimes become a chronic condition. Approximately one-half of adults will recover within three months. Another one-third of patients will recover by twelve months, and a significant minority of patients may remain symptomatic after ten years. Those who will recover without treatment are likely to do so within the first year. Affected individuals are more likely to have educational or occupational problems, intimate relationship struggles, and less social support.[87] However, current treatments are effective in symptom reduction at a minimum and remission. In those with psychiatric comorbidities, it is generally recommended to treat all conditions concurrently.[73]

Depression

The course of MDD is variable, with less than half of cases resolving within 3 months of onset vs. approximately 80% improving within 12 months. A higher risk of recurrence is associated with major depressive episodes falling under the severe specifier and can sometimes become a chronic condition that will continue to require attention and maintenance. Studies have shown that patients who continued with pharmacotherapy for a minimum of six to twelve months following their first depressive episode experienced less risk of recurrence of symptoms compared to those who discontinued medication earlier (25% compared to 50%). While remission is the ultimate goal, trials show that continued care and collaborative treatment programs reduce the prevalence and incidence of major depressive episodes later in life.[88]

Suicide

Patients with non-completed suicide attempts have a significantly increased risk for subsequent attempts. Although the risk of completed suicide is highest in the first year after an attempt, the danger can remain elevated for a decade.[89][90] Several studies estimate that the risk of a repeat suicide attempt is approximately 5% to 10% over a five to thirty-five-year timeframe.[91] Providers should screen for depression and substance abuse, as they are correlated to completed suicides through an increased likelihood of further attempts.[92][93] 

Substance Use Disorders

One large study on VA patient-centered medical homes found that depression, severe mental illness (except for PTSD), and SUDs were associated with an increased one-year risk of hospitalization and death. The authors attributed the PTSD exemption to increased healthcare encounters in PTSD patients. This supports the idea that mental illnesses, including SUDs, are associated with poor outcomes but can be somewhat relieved by access to care.[94] In another study, veterans admitted into intensive PTSD programs were divided into seven groups (no substance use, or use of alcohol, opiates, sedatives, cocaine, or marijuana alone; and use of multiple substances). Changes in non-substance use outcomes (including PTSD symptoms, violence, suicidality, medical problems, and employment) before and after PTSD treatment were compared, and the effect of abstinence on each group was evaluated. Rates of abstinence differed between the groups, but abstinence was associated with improved outcomes except for employment in all groups.[95]

Complications

PTSD

Patients are subject to a variety of somatic and mental health comorbidities. The directionality and degree of overlap between diagnoses are complex. One study in OIF/OEF veterans with PTSD found that compared to veterans without mental health conditions, they had more medical diagnoses, the most common being lumbosacral spine disease, headache, lower extremity joint problems, and hearing loss.[96] PTSD co-occurs in patients with chronic pain, which in turn is associated with AUD risk.[97] Among obese VA patients, there is a correlation between obstructive sleep apnea and mood and anxiety disorders, most strongly in PTSD and MDD.[98]

PTSD and AUD have been linked over decades of research. Men have a higher prevalence of AUD, and women of PTSD, but individuals with either disorder are likelier to have the other. SUDs were four times more likely (55 to 75% rate) with PTSD in Iraq and Afghanistan veterans.[99] A 2018 review found no clear order of development between the two: some evidence suggests veterans with past trauma develop AUD, supporting a self-medication hypothesis. Other studies show that those with SUDs have more exposure to traumatic events and an increased risk of developing PTSD.[100] In veteran and civilian samples, poorer treatment responses, more severe use, social and legal problems, and suicide attempts were seen in comorbid SUD/PTSD patients compared to those with either alone.[101]

Similarly, depression and PTSD are associated. One study found that 36% of depression patients had positive PTSD screens. Those with both have higher medical illness burdens, worse prognoses, lower social support, higher SI rates, and prolonged treatment.[102] A single-center VA study examined rates of deliberate self-harm (DSH) and SI in male Iraq and Afghanistan veterans receiving treatment for PTSD. 57% reported lifetime DSH, 45% in the last two weeks. DSH was a significant predictor of SI, as well as PTSD symptom severity.[103] PTSD is associated with higher SI rates independent of other psychiatric disorders.[104] 

TBI and PTSD also have known comorbidities and are an area of extensive research. The largest studies of Iraq and Afghanistan veterans show an overlap rate between 5 to 7%. In those with mild TBI (mTBI), PTSD frequency ranged from 33 to 39%. As many as 23% of returning OIF/OEF veterans suffered TBI, the vast majority being mild. However, even mild cases can lead to somatic, cognitive, or behavioral alterations which confound PTSD symptoms. Whether treatments for mTBI or PTSD alone are helpful is still unknown. There is some concern that PTSD pharmacotherapies may exacerbate the cognitive symptoms of PTSD. Cognitive limitations, impaired emotional regulation and impulse control, and pain from TBI may limit PTSD treatment effectiveness and patients’ ability to engage in therapy.[105]

Depression

MDD comes with a constellation of symptoms which can lead to further complications. Weight gain and fatigue are common symptoms of depression. Studies show an odds ratio of 1.18 linking depression and obesity.[106] Obesity is associated with many comorbidities, including heart disease, high blood pressure, and diabetes. MDD is also associated with an increased risk of suicide. Veterans are especially prone, with over 6,000 committing suicide yearly.[10] Issues with pain and substance abuse are also much more prevalent in cases with MDD.

Suicide

Suicide attempts and completions are traumatic events that can affect the breadth of people and lead to long-term concerns. Friends and family members may experience a variety of emotions towards the patient, including anger, guilt, betrayal, anxiety, or helplessness. Post-suicide interventions can help family and friends understand suicide victims and reduce their inappropriate assumption of responsibility.[107] However, CBT for family members and friends has not shown clinically significant improvements in grief and depressive symptoms.[108] Nonetheless, monitoring family, friends, and coworkers of the suicide victim can be beneficial in reducing PTSD, depression, and suicide risks. 

Substance Use Disorders

Psychiatric symptoms, including distress, often precedes and worsens cravings. Comorbid psychiatric disorders make SUDs more severe and difficult to treat. Among OEF/OIF veterans with SUD, 82 to 93% had another mental health disorder. Those with a SUD were three to four times more likely to have PTSD or depression. Less than 1% had an isolated diagnosis of SUD. Dually-diagnosed veterans were more likely to be homeless and require disability benefits. Lower quality of life, poorer relationships, and aggression are also more common.[99] Interpersonal, legal, and professional consequences of alcohol use are twice as likely in binge drinkers compared to other drinkers (9% vs. 4%).[17] Additionally, those with SUDs have higher rates of medical comorbidities such as obesity, sleep disturbances, physical injury, and chronic pain.[109] Specific medical complications vary by the substance(s) used, routes of administration, and other factors, highlighting the need for thorough history-taking and a high index of suspicion. Medical conditions potentially resulting from, and possibly indicating, substance use include:[110]

  • Cardiovascular disease: hypertension, cardiomyopathy, endocarditis, heart failure 
  • Gastrointestinal disease: pancreatitis, cirrhosis, chronic liver disease, hepatitis B/C
  • Kidney failure
  • Central nervous system disease: dementia, memory/attention impairment, cerebral vasculitis, intraparenchymal hemorrhage, stroke/TIA, TBI
  • Pulmonary disease: chronic obstructive lung disease, bronchospasm, pneumonia, hypersensitivity pneumonitis, tuberculosis
  • Sexually transmitted infections
  • Impaired immunity
  • Bacterial infections
  • Pregnancy and birth complications

Consultations

Practitioners should be committed to understanding the unique challenges veterans and their families face and familiar with available military resources. Appropriate referrals are an essential aspect of continued care. Reasons to refer to military or VA-related organizations are wide-ranging; however, veterans often benefit from treatment plans, including providers and other veterans who understand their life experiences. The DoD and affiliated organizations provide programs to help with a broad range of concerns.

Military OneSource is one example that serves military members and families, with programs like non-medical counseling, financial coaching, employment resources. Coaching into Care is a VA telephone service connecting veterans and loved ones with relevant programs in local VA facilities or communities. It includes free coaching from licensed psychologists and social workers to help veterans adjust to civilian life and seek treatment. Community peer groups can be a valuable tool when available.

If there are no local VA services, veterans and family members can call the Vet Center Call Center, which provides twenty-four-hour readjustment counseling from staff who are also combating veterans or their family members. In moments of crisis, the VA offers the toll-free Veterans Crisis Line, which has trained responders, many of whom are veterans.

Deterrence and Patient Education

PTSD

The risk of developing PTSD and the effectiveness of treatments can be influenced by social support. However, it can be challenging for patients to admit to the effects of past traumas and initiate care. There may be a strong sense of fear, vulnerability, and confusion. PTSD affects physical and mental health in ways that are not always apparent. Thus awareness about the signs and symptoms is essential. Patient buy-in and commitment to treatment courses, often alongside treatment of comorbid conditions, are paramount to limiting illness burden for patients and loved ones.

Depression

Military members are at risk of developing MDD given risk exposures inherent to both the general population and military service. Despite the DoD’s renewed energy and devotion to providing members adequate access to care, the stigma around mental health remains. Military members and veterans report worrying about appearing weak or being overlooked for a position as reasons not to seek care.[43] Communicating the need to seek treatment in a judgment-free setting is crucial to patient follow-up. Support resources are in place across the DoD and VA. Educating patients on how to reach them is paramount to self-directed care. Utilizing social networks as a support system is also helpful in attaining patient buy-in of treatment programs. MDD is a significant concern within the active duty and veteran populations. Still, proper screening, diagnosis, and treatment programs within the military’s vast resource network can make strides in decreasing its prevalence.

Suicide

Due to high rates of suicide among veterans, safety plans are mandated by the VA for those at risk.[12] This widely-used tool specifies how patients can cope during recurrent suicidal urges. Safety plans have six hierarchical steps to mitigate suicide risk:[111] 

  • Step 1: Identify warning signs that indicate an impending suicidal crisis
  • Step 2: Employ internal coping strategies (meditation, pleasant activities, or relaxation techniques, etc.)
  • Step 3: Reach out to social contacts or visit locations that serve as distractions.
  • Step 4: Contact a family member or friend for help
  • Step 5: Contact a professional or agency (Veterans’ Crisis Line or therapist, etc.)
  • Step 6: Remove or reduce access to lethal means

It is important to note that safety plans do not protect patients or clinicians, and patients who agree to their safety plan may still be at high risk. Therefore, thorough evaluations and meaningful therapeutic interactions should also be utilized, particularly in impulsive patients.

Substance Use Disorders

Treatment of SUDs usually involves short-term therapy to identify and modify unhelpful thoughts and behaviors tied to substance use. Some, such as opioids, alcohol, and tobacco, are effectively treated medications as well. Others, like cocaine and marijuana, have no approved medications, making counseling the mainstay of treatment. The military and VA offer free counseling, including smoking cessation, which has been effective and improves long-term outcomes. Treatment can be individualized, help rebuild relationships with loved ones, and build valuable life skills.

Enhancing Healthcare Team Outcomes

Mental health disorders in military and veteran populations can be diagnosed through detailed history-taking; however, mental status or cognitive testing and labs may be needed to distinguish between several medical and psychiatric illnesses. Timely diagnosis and intervention are best achieved through interprofessional collaboration.

Primary care providers can screen populations at risk and can likely be the first to suspect PTSD, depression, suicidality, SUDs, and comorbidities. Nurses can be instrumental in patient education and monitoring and can be a conduit between care teams. Social workers serve as outpatient counselors and are indispensable in these disorders with such pervasive social effects. Pharmacists should be consulted when utilizing pharmacotherapy, especially in those with comorbid medical and psychiatric illnesses. Psychologists and psychiatrists can guide or provide care, especially for patients with high acuity or complexity.

All treatment and intervention should involve the patient and family as part of the interprofessional treatment team, as social support is an overarching driver in both the pathogenesis and recovery of these disorders. These interprofessional methods will result in better patient outcomes.


Article Details

Article Author

Catarina Inoue

Article Author

Evan Shawler

Article Author

Christopher Jordan

Article Editor:

Christopher Jackson

Updated:

5/24/2021 10:38:21 AM

References

[1]

Deahl MP,Klein S,Alexander DA, The costs of conflict: meeting the mental health needs of serving personnel and service veterans. International review of psychiatry (Abingdon, England). 2011 Apr;     [PubMed PMID: 21521090]

[2]

Gates MA,Holowka DW,Vasterling JJ,Keane TM,Marx BP,Rosen RC, Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. Psychological services. 2012 Nov;     [PubMed PMID: 23148803]

[3]

Liu Y,Collins C,Wang K,Xie X,Bie R, The prevalence and trend of depression among veterans in the United States. Journal of affective disorders. 2019 Feb 15;     [PubMed PMID: 30699861]

[4]

Sullivan RM,Cozza SJ,Dougherty JG, Children of Military Families. Child and adolescent psychiatric clinics of North America. 2019 Jul;     [PubMed PMID: 31076112]

[5]

Ravindran C,Morley SW,Stephens BM,Stanley IH,Reger MA, Association of Suicide Risk With Transition to Civilian Life Among US Military Service Members. JAMA network open. 2020 Sep 1;     [PubMed PMID: 32915235]

[6]

Gewirtz AH,Cozza SJ,Kizer KW, The Need for Clinicians to Recognize Military-Connected Children. JAMA pediatrics. 2020 Aug 10;     [PubMed PMID: 32797163]

[7]

Ross DA,Arbuckle MR,Travis MJ,Dwyer JB,van Schalkwyk GI,Ressler KJ, An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress Disorder: An Educational Review. JAMA psychiatry. 2017 Apr 1;     [PubMed PMID: 28273291]

[8]

Warner CM,Warner CH,Breitbach J,Rachal J,Matuszak T,Grieger TA, Depression in entry-level military personnel. Military medicine. 2007 Aug;     [PubMed PMID: 17803068]

[9]

Stanners MN,Barton CA,Shakib S,Winefield HR, Depression diagnosis and treatment amongst multimorbid patients: a thematic analysis. BMC family practice. 2014 Jun 19;     [PubMed PMID: 24947875]

[10]

Nichter B,Hill M,Norman S,Haller M,Pietrzak RH, Impact of specific combat experiences on suicidal ideation and suicide attempt in U.S. military veterans: Results from the National Health and Resilience in Veterans Study. Journal of psychiatric research. 2020 Nov;     [PubMed PMID: 32846327]

[11]

Stone DM,Simon TR,Fowler KA,Kegler SR,Yuan K,Holland KM,Ivey-Stephenson AZ,Crosby AE, Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015. MMWR. Morbidity and mortality weekly report. 2018 Jun 8;     [PubMed PMID: 29879094]

[12]

Green JD,Kearns JC,Rosen RC,Keane TM,Marx BP, Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk? Behavior therapy. 2018 Nov;     [PubMed PMID: 30316491]

[13]

Shen YC,Cunha JM,Williams TV, Time-varying associations of suicide with deployments, mental health conditions, and stressful life events among current and former US military personnel: a retrospective multivariate analysis. The lancet. Psychiatry. 2016 Nov;     [PubMed PMID: 27697514]

[14]

Kapur N,While D,Blatchley N,Bray I,Harrison K, Suicide after leaving the UK armed forces--a cohort study. PLoS medicine. 2009 Mar 3;     [PubMed PMID: 19260757]

[15]

Pruitt LD,Smolenski DJ,Bush NE,Tucker J,Issa F,Hoyt TV,Reger MA, Suicide in the Military: Understanding Rates and Risk Factors Across the United States' Armed Forces. Military medicine. 2019 Mar 1;     [PubMed PMID: 30423136]

[16]

Anglemyer A,Miller ML,Buttrey S,Whitaker L, Suicide Rates and Methods in Active Duty Military Personnel, 2005 to 2011: A Cohort Study. Annals of internal medicine. 2016 Aug 2;     [PubMed PMID: 27272476]

[17]

Teeters JB,Lancaster CL,Brown DG,Back SE, Substance use disorders in military veterans: prevalence and treatment challenges. Substance abuse and rehabilitation. 2017;     [PubMed PMID: 28919834]

[18]

Prom-Wormley EC,Ebejer J,Dick DM,Bowers MS, The genetic epidemiology of substance use disorder: A review. Drug and alcohol dependence. 2017 Nov 1;     [PubMed PMID: 28938182]

[19]

Tian Y,Liu H,Guse L,Wong TK,Li J,Bai Y,Jiang X, Association of Genetic Factors and Gene-Environment Interactions With Risk of Developing Posttraumatic Stress Disorder in a Case-Control Study. Biological research for nursing. 2015 Jul;     [PubMed PMID: 26002549]

[20]

Bromis K,Calem M,Reinders AATS,Williams SCR,Kempton MJ, Meta-Analysis of 89 Structural MRI Studies in Posttraumatic Stress Disorder and Comparison With Major Depressive Disorder. The American journal of psychiatry. 2018 Oct 1;     [PubMed PMID: 30021460]

[21]

Geracioti TD Jr,Baker DG,Ekhator NN,West SA,Hill KK,Bruce AB,Schmidt D,Rounds-Kugler B,Yehuda R,Keck PE Jr,Kasckow JW, CSF norepinephrine concentrations in posttraumatic stress disorder. The American journal of psychiatry. 2001 Aug;     [PubMed PMID: 11481155]

[22]

Breslau N,Chilcoat HD,Kessler RC,Davis GC, Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit Area Survey of Trauma. The American journal of psychiatry. 1999 Jun;     [PubMed PMID: 10360130]

[23]

Seifert AE,Polusny MA,Murdoch M, The association between childhood physical and sexual abuse and functioning and psychiatric symptoms in a sample of U.S. Army soldiers. Military medicine. 2011 Feb;     [PubMed PMID: 21366080]

[24]

Iversen AC,Fear NT,Ehlers A,Hacker Hughes J,Hull L,Earnshaw M,Greenberg N,Rona R,Wessely S,Hotopf M, Risk factors for post-traumatic stress disorder among UK Armed Forces personnel. Psychological medicine. 2008 Apr;     [PubMed PMID: 18226287]

[25]

Xue C,Ge Y,Tang B,Liu Y,Kang P,Wang M,Zhang L, A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PloS one. 2015;     [PubMed PMID: 25793582]

[26]

Richardson LK,Frueh BC,Acierno R, Prevalence estimates of combat-related post-traumatic stress disorder: critical review. The Australian and New Zealand journal of psychiatry. 2010 Jan;     [PubMed PMID: 20073563]

[27]

Ming Q,Zhong X,Zhang X,Pu W,Dong D,Jiang Y,Gao Y,Wang X,Detre JA,Yao S,Rao H, State-Independent and Dependent Neural Responses to Psychosocial Stress in Current and Remitted Depression. The American journal of psychiatry. 2017 Oct 1;     [PubMed PMID: 28618857]

[28]

Price JL,Drevets WC, Neurocircuitry of mood disorders. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. 2010 Jan;     [PubMed PMID: 19693001]

[29]

Kraus C,Castrén E,Kasper S,Lanzenberger R, Serotonin and neuroplasticity - Links between molecular, functional and structural pathophysiology in depression. Neuroscience and biobehavioral reviews. 2017 Jun;     [PubMed PMID: 28342763]

[30]

Selby EA,Anestis MD,Bender TW,Ribeiro JD,Nock MK,Rudd MD,Bryan CJ,Lim IC,Baker MT,Gutierrez PM,Joiner TE Jr, Overcoming the fear of lethal injury: evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide. Clinical psychology review. 2010 Apr;     [PubMed PMID: 20051309]

[31]

Zamorski MA, Suicide prevention in military organizations. International review of psychiatry (Abingdon, England). 2011 Apr;     [PubMed PMID: 21521087]

[32]

Pietrzak RH,Russo AR,Ling Q,Southwick SM, Suicidal ideation in treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support. Journal of psychiatric research. 2011 Jun;     [PubMed PMID: 21185033]

[33]

Fralick M,Sy E,Hassan A,Burke MJ,Mostofsky E,Karsies T, Association of Concussion With the Risk of Suicide: A Systematic Review and Meta-analysis. JAMA neurology. 2019 Feb 1;     [PubMed PMID: 30419085]

[34]

Cooper SA,Szymanski BR,Bohnert KM,Sripada RK,McCarthy JF, Association Between Positive Results on the Primary Care-Posttraumatic Stress Disorder Screen and Suicide Mortality Among US Veterans. JAMA network open. 2020 Sep 1;     [PubMed PMID: 32880649]

[35]

Zuromski KL,Bernecker SL,Chu C,Wilks CR,Gutierrez PM,Joiner TE,Liu H,Naifeh JA,Nock MK,Sampson NA,Zaslavsky AM,Stein MB,Ursano RJ,Kessler RC,Site Principal Investigators.,Army liaison/consultant.,Other team members., Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers. Journal of psychiatric research. 2020 Feb;     [PubMed PMID: 31865211]

[36]

Lyon J, New Data on Suicide Risk Among Military Veterans. JAMA. 2017 Oct 24;     [PubMed PMID: 29067409]

[37]

Butterworth SE,Green BA,Anestis MD, The association between specific combat experiences and aspects of the Interpersonal Theory of Suicide. Comprehensive psychiatry. 2017 Oct;     [PubMed PMID: 28704761]

[38]

Pietrzak RH,Goldstein MB,Malley JC,Rivers AJ,Johnson DC,Southwick SM, Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of affective disorders. 2010 Jun;     [PubMed PMID: 19819559]

[39]

Jakupcak M,Vannoy S,Imel Z,Cook JW,Fontana A,Rosenheck R,McFall M, Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment? Depression and anxiety. 2010 Nov;     [PubMed PMID: 20721901]

[40]

Ames D,Erickson Z,Youssef NA,Arnold I,Adamson CS,Sones AC,Yin J,Haynes K,Volk F,Teng EJ,Oliver JP,Koenig HG, Moral Injury, Religiosity, and Suicide Risk in U.S. Veterans and Active Duty Military with PTSD Symptoms. Military medicine. 2019 Mar 1;     [PubMed PMID: 29912418]

[41]

Volkow ND,Michaelides M,Baler R, The Neuroscience of Drug Reward and Addiction. Physiological reviews. 2019 Oct 1;     [PubMed PMID: 31507244]

[42]

Vilagut G,Forero CG,Barbaglia G,Alonso J, Screening for Depression in the General Population with the Center for Epidemiologic Studies Depression (CES-D): A Systematic Review with Meta-Analysis. PloS one. 2016;     [PubMed PMID: 27182821]

[43]

Greenberg J,Tesfazion AA,Robinson CS, Screening, diagnosis, and treatment of depression. Military medicine. 2012 Aug;     [PubMed PMID: 22953442]

[44]

Kessler RC,Berglund P,Demler O,Jin R,Koretz D,Merikangas KR,Rush AJ,Walters EE,Wang PS,National Comorbidity Survey Replication., The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003 Jun 18;     [PubMed PMID: 12813115]

[45]

Blore JD,Sim MR,Forbes AB,Creamer MC,Kelsall HL, Depression in Gulf War veterans: a systematic review and meta-analysis. Psychological medicine. 2015 Jun;     [PubMed PMID: 25697603]

[46]

Warren MB,Smithkors LA, Suicide Prevention in the U.S. Department of Veterans Affairs: Using the Evidence Without Losing the Narrative. Psychiatric services (Washington, D.C.). 2020 Apr 1;     [PubMed PMID: 31996117]

[47]

Hoge CW, Suicide Reduction and Research Efforts in Service Members and Veterans-Sobering Realities. JAMA psychiatry. 2019 May 1;     [PubMed PMID: 30758501]

[48]

Eisen SV,Schultz MR,Vogt D,Glickman ME,Elwy AR,Drainoni ML,Osei-Bonsu PE,Martin J, Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. American journal of public health. 2012 Mar;     [PubMed PMID: 22390605]

[49]

Jacobson IG,Ryan MA,Hooper TI,Smith TC,Amoroso PJ,Boyko EJ,Gackstetter GD,Wells TS,Bell NS, Alcohol use and alcohol-related problems before and after military combat deployment. JAMA. 2008 Aug 13;     [PubMed PMID: 18698065]

[50]

Romanoff MR, Assessing military veterans for posttraumatic stress disorder: a guide for primary care clinicians. Journal of the American Academy of Nurse Practitioners. 2006 Sep;     [PubMed PMID: 16958771]

[51]

Mohler KM,Sankey-Deemer C, CE: Original Research: Primary Care Providers and Screening for Military Service and PTSD. The American journal of nursing. 2017 Nov;     [PubMed PMID: 29035900]

[52]

Pignone MP,Gaynes BN,Rushton JL,Burchell CM,Orleans CT,Mulrow CD,Lohr KN, Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of internal medicine. 2002 May 21;     [PubMed PMID: 12020146]

[53]

Practice guideline for the assessment and treatment of patients with suicidal behaviors. The American journal of psychiatry. 2003 Nov;     [PubMed PMID: 14649920]

[54]

Wisco BE,Marx BP,Keane TM, Screening, diagnosis, and treatment of post-traumatic stress disorder. Military medicine. 2012 Aug;     [PubMed PMID: 22953436]

[55]

Prins A,Bovin MJ,Smolenski DJ,Marx BP,Kimerling R,Jenkins-Guarnieri MA,Kaloupek DG,Schnurr PP,Kaiser AP,Leyva YE,Tiet QQ, The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample. Journal of general internal medicine. 2016 Oct;     [PubMed PMID: 27170304]

[56]

Wortmann JH,Jordan AH,Weathers FW,Resick PA,Dondanville KA,Hall-Clark B,Foa EB,Young-McCaughan S,Yarvis JS,Hembree EA,Mintz J,Peterson AL,Litz BT, Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological assessment. 2016 Nov;     [PubMed PMID: 26751087]

[57]

Bovin MJ,Marx BP,Weathers FW,Gallagher MW,Rodriguez P,Schnurr PP,Keane TM, Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans. Psychological assessment. 2016 Nov;     [PubMed PMID: 26653052]

[58]

Weathers FW,Bovin MJ,Lee DJ,Sloan DM,Schnurr PP,Kaloupek DG,Keane TM,Marx BP, The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological assessment. 2018 Mar;     [PubMed PMID: 28493729]

[59]

Maurer DM,Raymond TJ,Davis BN, Depression: Screening and Diagnosis. American family physician. 2018 Oct 15;     [PubMed PMID: 30277728]

[60]

Homaifar BY,Brenner LA,Gutierrez PM,Harwood JF,Thompson C,Filley CM,Kelly JP,Adler LE, Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain injury. Archives of physical medicine and rehabilitation. 2009 Apr;     [PubMed PMID: 19345782]

[61]

Topp CW,Østergaard SD,Søndergaard S,Bech P, The WHO-5 Well-Being Index: a systematic review of the literature. Psychotherapy and psychosomatics. 2015;     [PubMed PMID: 25831962]

[62]

Crawford MJ,Thana L,Methuen C,Ghosh P,Stanley SV,Ross J,Gordon F,Blair G,Bajaj P, Impact of screening for risk of suicide: randomised controlled trial. The British journal of psychiatry : the journal of mental science. 2011 May;     [PubMed PMID: 21525521]

[63]

Dazzi T,Gribble R,Wessely S,Fear NT, Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological medicine. 2014 Dec;     [PubMed PMID: 24998511]

[64]

Kroenke K,Spitzer RL,Williams JB, The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine. 2001 Sep     [PubMed PMID: 11556941]

[65]

Large M,Myles N,Myles H,Corderoy A,Weiser M,Davidson M,Ryan CJ, Suicide risk assessment among psychiatric inpatients: a systematic review and meta-analysis of high-risk categories. Psychological medicine. 2018 May;     [PubMed PMID: 28874218]

[66]

Large M,Kaneson M,Myles N,Myles H,Gunaratne P,Ryan C, Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time. PloS one. 2016;     [PubMed PMID: 27285387]

[67]

Fiellin DA,Reid MC,O'Connor PG, Screening for alcohol problems in primary care: a systematic review. Archives of internal medicine. 2000 Jul 10;     [PubMed PMID: 10888972]

[68]

Andresen-Streichert H,Müller A,Glahn A,Skopp G,Sterneck M, Alcohol Biomarkers in Clinical and Forensic Contexts. Deutsches Arzteblatt international. 2018 May 4;     [PubMed PMID: 29807559]

[69]

Watkins LE,Sprang KR,Rothbaum BO, Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in behavioral neuroscience. 2018;     [PubMed PMID: 30450043]

[70]

Bisson JI,Roberts NP,Andrew M,Cooper R,Lewis C, Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. The Cochrane database of systematic reviews. 2013 Dec 13;     [PubMed PMID: 24338345]

[71]

Davidson J,Baldwin D,Stein DJ,Kuper E,Benattia I,Ahmed S,Pedersen R,Musgnung J, Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. Archives of general psychiatry. 2006 Oct;     [PubMed PMID: 17015818]

[72]

Stein DJ,Ipser JC,Seedat S, Pharmacotherapy for post traumatic stress disorder (PTSD). The Cochrane database of systematic reviews. 2006 Jan 25;     [PubMed PMID: 16437445]

[73]

Coventry PA,Meader N,Melton H,Temple M,Dale H,Wright K,Cloitre M,Karatzias T,Bisson J,Roberts NP,Brown JVE,Barbui C,Churchill R,Lovell K,McMillan D,Gilbody S, Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems following complex traumatic events: Systematic review and component network meta-analysis. PLoS medicine. 2020 Aug;     [PubMed PMID: 32813696]

[74]

Rauch SAM,Kim HM,Powell C,Tuerk PW,Simon NM,Acierno R,Allard CB,Norman SB,Venners MR,Rothbaum BO,Stein MB,Porter K,Martis B,King AP,Liberzon I,Phan KL,Hoge CW, Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial. JAMA psychiatry. 2019 Feb 1;     [PubMed PMID: 30516797]

[75]

Zoellner LA,Roy-Byrne PP,Mavissakalian M,Feeny NC, Doubly Randomized Preference Trial of Prolonged Exposure Versus Sertraline for Treatment of PTSD. The American journal of psychiatry. 2019 Apr 1;     [PubMed PMID: 30336702]

[76]

Chen P, Optimized Treatment Strategy for Depressive Disorder. Advances in experimental medicine and biology. 2019;     [PubMed PMID: 31784965]

[77]

Thoma N,Pilecki B,McKay D, Contemporary Cognitive Behavior Therapy: A Review of Theory, History, and Evidence. Psychodynamic psychiatry. 2015 Sep;     [PubMed PMID: 26301761]

[78]

Kuyken W,Hayes R,Barrett B,Byng R,Dalgleish T,Kessler D,Lewis G,Watkins E,Brejcha C,Cardy J,Causley A,Cowderoy S,Evans A,Gradinger F,Kaur S,Lanham P,Morant N,Richards J,Shah P,Sutton H,Vicary R,Weaver A,Wilks J,Williams M,Taylor RS,Byford S, Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet (London, England). 2015 Jul 4;     [PubMed PMID: 25907157]

[79]

Kennedy SH,Lam RW,McIntyre RS,Tourjman SV,Bhat V,Blier P,Hasnain M,Jollant F,Levitt AJ,MacQueen GM,McInerney SJ,McIntosh D,Milev RV,Müller DJ,Parikh SV,Pearson NL,Ravindran AV,Uher R,CANMAT Depression Work Group., Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Canadian journal of psychiatry. Revue canadienne de psychiatrie. 2016 Sep;     [PubMed PMID: 27486148]

[80]

Lisanby SH, Electroconvulsive therapy for depression. The New England journal of medicine. 2007 Nov 8;     [PubMed PMID: 17989386]

[81]

Nelson HD,Denneson LM,Low AR,Bauer BW,O'Neil M,Kansagara D,Teo AR, Suicide Risk Assessment and Prevention: A Systematic Review Focusing on Veterans. Psychiatric services (Washington, D.C.). 2017 Oct 1;     [PubMed PMID: 28617209]

[82]

Walker DD,Walton TO,Neighbors C,Kaysen D,Mbilinyi L,Darnell J,Rodriguez L,Roffman RA, Randomized trial of motivational interviewing plus feedback for soldiers with untreated alcohol abuse. Journal of consulting and clinical psychology. 2017 Feb;     [PubMed PMID: 27736113]

[83]

Roberts NP,Roberts PA,Jones N,Bisson JI, Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis. Clinical psychology review. 2015 Jun;     [PubMed PMID: 25792193]

[84]

Akbar M,Egli M,Cho YE,Song BJ,Noronha A, Medications for alcohol use disorders: An overview. Pharmacology     [PubMed PMID: 29191394]

[85]

Shear MK,Ghesquiere A,Glickman K, Bereavement and complicated grief. Current psychiatry reports. 2013 Nov;     [PubMed PMID: 24068457]

[86]

O'Donnell ML,Agathos JA,Metcalf O,Gibson K,Lau W, Adjustment Disorder: Current Developments and Future Directions. International journal of environmental research and public health. 2019 Jul 16;     [PubMed PMID: 31315203]

[87]

Kessler RC,Sonnega A,Bromet E,Hughes M,Nelson CB, Posttraumatic stress disorder in the National Comorbidity Survey. Archives of general psychiatry. 1995 Dec;     [PubMed PMID: 7492257]

[88]

Almeida OP, Approaches to decrease the prevalence of depression in later life. Current opinion in psychiatry. 2012 Nov;     [PubMed PMID: 22801360]

[89]

Finkelstein Y,Macdonald EM,Hollands S,Hutson JR,Sivilotti ML,Mamdani MM,Koren G,Juurlink DN,Canadian Drug Safety and Effectiveness Research Network (CDSERN)., Long-term outcomes following self-poisoning in adolescents: a population-based cohort study. The lancet. Psychiatry. 2015 Jun;     [PubMed PMID: 26360449]

[90]

Hawton K,Fagg J, Suicide, and other causes of death, following attempted suicide. The British journal of psychiatry : the journal of mental science. 1988 Mar;     [PubMed PMID: 3167371]

[91]

Weiner J,Richmond TS,Conigliaro J,Wiebe DJ, Military veteran mortality following a survived suicide attempt. BMC public health. 2011 May 23;     [PubMed PMID: 21605448]

[92]

Parra-Uribe I,Blasco-Fontecilla H,Garcia-Parés G,Martínez-Naval L,Valero-Coppin O,Cebrià-Meca A,Oquendo MA,Palao-Vidal D, Risk of re-attempts and suicide death after a suicide attempt: A survival analysis. BMC psychiatry. 2017 May 4;     [PubMed PMID: 28472923]

[93]

Brown GK,Ten Have T,Henriques GR,Xie SX,Hollander JE,Beck AT, Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005 Aug 3;     [PubMed PMID: 16077050]

[94]

Trivedi RB,Post EP,Sun H,Pomerantz A,Saxon AJ,Piette JD,Maynard C,Arnow B,Curtis I,Fihn SD,Nelson K, Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans. American journal of public health. 2015 Dec;     [PubMed PMID: 26474009]

[95]

Manhapra A,Stefanovics E,Rosenheck R, Treatment outcomes for veterans with PTSD and substance use: Impact of specific substances and achievement of abstinence. Drug and alcohol dependence. 2015 Nov 1;     [PubMed PMID: 26429726]

[96]

Frayne SM,Chiu VY,Iqbal S,Berg EA,Laungani KJ,Cronkite RC,Pavao J,Kimerling R, Medical care needs of returning veterans with PTSD: their other burden. Journal of general internal medicine. 2011 Jan;     [PubMed PMID: 20853066]

[97]

Curry I,Malaktaris AL,Lyons R,Herbert MS,Norman SB, The Association Between Negative Trauma-Related Cognitions and Pain-Related Functional Status Among Veterans With Posttraumatic Stress Disorder and Alcohol Use Disorder. Journal of traumatic stress. 2019 Apr;     [PubMed PMID: 30913347]

[98]

Babson KA,Del Re AC,Bonn-Miller MO,Woodward SH, The comorbidity of sleep apnea and mood, anxiety, and substance use disorders among obese military veterans within the Veterans Health Administration. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013 Dec 15;     [PubMed PMID: 24340286]

[99]

Seal KH,Cohen G,Waldrop A,Cohen BE,Maguen S,Ren L, Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment. Drug and alcohol dependence. 2011 Jul 1;     [PubMed PMID: 21277712]

[100]

Smith NDL,Cottler LB, The Epidemiology of Post-Traumatic Stress Disorder and Alcohol Use Disorder. Alcohol research : current reviews. 2018;     [PubMed PMID: 31198651]

[101]

Back SE,Killeen TK,Teer AP,Hartwell EE,Federline A,Beylotte F,Cox E, Substance use disorders and PTSD: an exploratory study of treatment preferences among military veterans. Addictive behaviors. 2014 Feb;     [PubMed PMID: 24199930]

[102]

Campbell DG,Felker BL,Liu CF,Yano EM,Kirchner JE,Chan D,Rubenstein LV,Chaney EF, Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of general internal medicine. 2007 Jun;     [PubMed PMID: 17503104]

[103]

Kimbrel NA,Johnson ME,Clancy C,Hertzberg M,Collie C,Van Voorhees EE,Dennis MF,Calhoun PS,Beckham JC, Deliberate self-harm and suicidal ideation among male Iraq/Afghanistan-era veterans seeking treatment for PTSD. Journal of traumatic stress. 2014 Aug;     [PubMed PMID: 25066891]

[104]

Guerra VS,Calhoun PS,Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup., Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. Journal of anxiety disorders. 2011 Jan;     [PubMed PMID: 20709493]

[105]

Carlson KF,Kehle SM,Meis LA,Greer N,Macdonald R,Rutks I,Sayer NA,Dobscha SK,Wilt TJ, Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence. The Journal of head trauma rehabilitation. 2011 Mar-Apr;     [PubMed PMID: 20631631]

[106]

Luppino FS,de Wit LM,Bouvy PF,Stijnen T,Cuijpers P,Penninx BW,Zitman FG, Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Archives of general psychiatry. 2010 Mar;     [PubMed PMID: 20194822]

[107]

Feigelman W,Sanford RL,Cerel J, Do Primary Care Physicians Help the Bereaved With Their Suicide Losses: Loss Survivor Perceptions of Helpfulness From Physicians. Omega. 2020 Feb;     [PubMed PMID: 29145772]

[108]

Wittouck C,Van Autreve S,Portzky G,van Heeringen K, A CBT-based psychoeducational intervention for suicide survivors: a cluster randomized controlled study. Crisis. 2014;     [PubMed PMID: 24901060]

[109]

Mertens JR,Flisher AJ,Satre DD,Weisner CM, The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug and alcohol dependence. 2008 Nov 1;     [PubMed PMID: 18571875]

[110]

Stein MD, Medical consequences of substance abuse. The Psychiatric clinics of North America. 1999 Jun;     [PubMed PMID: 10385938]

[111]

Bryan CJ,Mintz J,Clemans TA,Leeson B,Burch TS,Williams SR,Maney E,Rudd MD, Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial. Journal of affective disorders. 2017 Apr 1;     [PubMed PMID: 28142085]