Military and Veterans Issues

Many military veterans experience a group of mental health conditions that tend to disproportionately affect military personnel. These conditions may include posttraumatic stress (PTSD), depression, anxiety, traumatic brain injury (TBI), and substance abuse, among other issues. Due to the traumatic environment in which active military combatants serve, veterans are at a significantly higher risk for developing these health concerns. These concerns can often be addressed and resolved with the support of a mental health professional.

PTSD in Veterans

Posttraumatic stress is an anxiety issue that may develop after an individual is exposed to a traumatic or overwhelming life experience. While the human body tends to return to baseline levels after experiencing a stressful event, people experiencing PTSD continue to release stress-related hormones and chemicals. Posttraumatic stress is characterized by four basic types of symptoms:

1. Reliving the event

  • Repeatedly experiencing the event in flashbacks
  • Having intrusive, repeated, and upsetting memories of the event
  • Regularly having nightmares about the event
  • Having intense and discomforting reactions to objects or situations that remind you of the event

2. Avoidance

  • Staying away from people, places, or even thoughts that remind you of the event
  • Emotional numbness
  • Feelings of detachment

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  • Memory problems
  • Loss of interest in everyday activities
  • Being emotionally guarded
  • Feelings of hopelessness

3. Hyperarousal

4. Negative thoughts, moods, or feelings

  • Feeling guilty about the event
  • Criticizing or blaming other individuals for the event
  • Loss of interest in activities and people

Though traumatic incidents—such as participating in combat, experiencing sexual abuse, or having a car accident—must occur for a person to develop PTSD, not all traumatic experiences result in posttraumatic stress. Only a small percentage of people who go through trauma experience PTSD. The lifetime prevalence of PTSD among American women is 10%, while only 4% of American men will experience PTSD at some point during their life.

American combat veterans have a much higher prevalence of PTSD than American civilians. Between 11-20% of veterans from Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) experience posttraumatic stress in a given year. Approximately 12% of Gulf War (Desert Storm) veterans and 15% of Vietnam veterans are affected by PTSD on an annual basis. The lifetime prevalence of PTSD for Vietnam veterans is 30%.

Military personnel are at higher risk for developing posttraumatic stress because service members are intimately involved in wartime incidents that may be frightening, horrifying, and at times, life-threatening. One emotionally overwhelming incident may be enough for PTSD to develop, but combat often facilitates prolonged and repeated exposure to traumatic events.

Sexual Abuse in the Military

Military sexual trauma (MST), defined by the Department of Veteran Affairs (VA) as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military, regardless of geographic location of the trauma, gender of the victim, or the relationship to the perpetrator,” is a significant and pervasive concern in the military. 

Some studies estimate that approximately 1% of veteran males (32,000 men) and 22% of veteran females (23,000 women) are exposed to sexual assault or repeated sexual harassment during their military service. Between 10% and 33% of servicewomen may experience attempted rape during this time period. The prevalence rates of MST may range from 4% to as high as 85% based on the method of data collection and the definition of MST used.

There are a variety of emotional, behavioral, physical, and mental health issues that have been linked to MST.  Primary among these are depression, posttraumatic stress, anxiety, substance dependency, and an increased risk of suicide. Roughly 50-60% of female veterans who experience MST eventually develop posttraumatic stress. This rate is approximately three times higher than male veterans in similar circumstances. Of servicewomen who develop PTSD due to military sexual trauma, an estimated 75% develop co-morbid depression, and over 30% may develop anxiety.

Servicemen who experience posttraumatic stress due to exposure to military sexual trauma are more likely to abuse alcohol, drugs, and other substances than servicewomen who have experienced similar trauma. A study involving more than 2300 male and female military personnel who served in OEF/OIF revealed that sexual harassment was the only stressor that was independently linked to suicidal ideation among female veterans—even when accounting for depression and the misuse of alcohol.

Depression and Anxiety in Veterans

Mental health conditions that adversely affect mood, such as depression and anxiety, are also prevalent among military veterans—and veterans may experience these issues for many different reasons. Factors such as poor health (physical and mental), unemployment, and financial difficulties can contribute to negative thoughts and moods.

Upon returning home, some veterans report feeling disconnected from family members and friends. The belief that no one is able to relate to their experiences or offer meaningful emotional support can prompt service members to bottle up their feelings or even seek social isolation. Such actions though, may only serve to exacerbate the situation.

There are other factors which may also play a role in developing negative thought patterns. For example, the grief of losing one’s friends during combat, coupled with feelings of survivor’s guilt can lead to the development of depression and anxiety if they are not effectively treated.

Traumatic Brain Injury (TBI) and Veterans

Traumatic brain injury is currently one of the most discussed topics in the medical and mental health communities, as many veterans have returned home with the symptoms of the condition. It has even been called a “signature injury” of Operations Iraqi Freedom and Enduring Freedom. Traumatic brain injury may be caused by a blow to the head, the head striking an object, or by an explosion in close proximity.

People who experience a brain injury may become confused, disoriented, experience slow or delayed thinking, and may even slip into a coma. Memory loss of events preceding and immediately following the injury is also common. Other symptoms associated with TBI are headaches, dizziness, and difficulty paying attention. In some cases, traumatic brain injury can result in physical deficits, behavioral changes, emotional deficiencies, and loss of cognitive ability.

In the most recent conflicts in Afghanistan and Iraq, 78% of all combat injuries are caused by explosive munitions. Mild TBI or concussion is one of the most prevalent combat injuries, affecting roughly 15% of all active military combatants in Iraq and Afghanistan. Due to the devastating effect of roadside bombs in these countries, the ability to effectively treat traumatic brain injury is of great importance in veteran care.

Other Mental Health Issues Experienced by Veterans

While posttraumatic stress, depression, anxiety, and traumatic brain injury are at the forefront of most people’s minds when it comes to veteran care, there are other mental health conditions that warrant attention. These include:

An individual who serves in the military will not necessarily develop a mental health condition. Further, a mental health concern experienced by a veteran may have no relation to the veteran's military service. Mental health professionals who work with veterans will typically assess each person individually and take all symptoms and life experiences into consideration before making a diagnosis or starting treatment.

Therapy for Military and Veterans Issues

The U.S. Department of Veterans Affairs (VA) provides a wide range of mental health services and treatments to aid military veterans. Treatments may be given in a variety of settings: short-term inpatient care, outpatient care in a psychosocial rehabilitation and recovery center (PRRC), or residential care.

For veterans experiencing posttraumatic stress, antidepressant, anti-anxiety, and mood-stabilizing drugs may be prescribed by a doctor or psychiatrist. These medications can address depression and anxiety issues, reduce irritability, improve sleep patterns, and help to ease nightmares or intrusive thoughts.

While the use of mood-influencing medications is particularly common in treating depression and anxiety, talk therapies can also be very beneficial. For example, cognitive behavioral therapy, acceptance and commitment therapy (ACT), and interpersonal therapy (IPT) can help affected veterans reduce emotional pain and reestablish positive social relationships. Certain types of therapies--such as cognitive processing therapy (CPT) or prolonged exposure therapy (PE)--may also be used to promote positive thought patterns and behaviors in veterans experiencing mental health issues. Medical guidelines strongly recommend both CBT and PE for the treatment of posttraumatic stress. Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs), established by the VA, provide a 24/7 health care setting for veterans with PTSD.

Veterans with traumatic brain injury may experience a variety of mental health issues. Different therapeutic strategies may be applied, depending on which areas of a person's functioning are affected. Common treatments for TBIs include rehabilitation therapies (for example, speech-language therapy), medication, assistive devices, and learning strategies to address cognitive, emotional, and behavioral deficits.

Support and Therapy for Military Families

Military life and deployment can take a toll on each member in the family system. Children and teenagers may become irritable or rebellious, and the parent at home may have to cope with the increased burden of caring for the family alone on a daily basis. Deployment can lead family members to feel anxious, alone, or unsupported. Military families also have to face the possibility that the deployed family member may return seriously injured or may not return at all. A family who is out of touch with extended family members or the military community may be more likely to experience increased stress during this period. 

While happiness and relief may often be experienced when a deployed family member returns home, initial joy might give way to feelings of frustration as issues associated with reintegration arise. The returning parent may have experienced personality changes or developed mental or physical heath concerns, children may have been born or reached a different stage of development, and marital bonds may have weakened. The need to readjust to new roles within the family system may lead to increased tension between family members.   

Many resources are available for military families leading up to and during deployment. Family therapy programs help parents explain the deployment process to young children, while support programs are in place to help returning veterans and their family members go through the reintegration process with as few issues as possible. At present, the VA has identified six key ways to assist military families:

  • Increase behavioral health care services
  • Promote awareness that psychological health is as important as physical health
  • Promote housing security for veterans and military families
  • Increase opportunities for federal careers
  • Increase opportunities for private-sector careers
  • Provide more opportunities for educational advancement

Unused Resources Available to Veterans

Though the United States Department of Veteran Affairs (VA) has expanded its mental health services and integrated supplementary programs for the benefit of veterans who are experiencing mental health issues, a significant proportion of these services remain unused. Of all army veterans who have a mental health concern, approximately 60% do not seek assistance from a mental health professional. Studies indicate that roughly 70% of veterans with posttraumatic stress or depression do not seek help.

Surveys conducted among veterans experiencing mental health challenges have highlighted a number of reasons for the under-utilization of available resources. Common responses include:

  • Fear of being stigmatized within the military community
  • Fear of confronting trauma
  • Constrained access to care (due to location or wait time)
  • Lack of expertise among available mental health care providers
  • Belief that friends and family are able to provide all needed care
  • Lack of knowledge of available mental health resources
  • Lack of knowledge in how to access available mental health care

Case Example

  • Post-Deployment Depression, Anxiety, and PTSD Experienced by a Veteran: Harrison, 39, is a decorated military veteran who served in Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) as an active military combatant. He is married, with two children, and though he was previously known for his calm, friendly manner, Harrison has seemed detached and withdrawn since returning home from his last deployment. Harrison does not drive anymore, he has difficulty sleeping, and each day he walks to the local bar and has to be taken home each night. Harrison prefers to drink alone. A fellow veteran encouraged him to see a therapist, so Harrison decided to give it a try. During therapy, Harrison opened up emotionally and for the first time since coming home from Iraq, he spoke about the hidden improved explosive device (IED) that killed three soldiers inside the truck he was driving. Harrison explained that he has recurring nightmares about the incident, and that as the driver, he feels responsible for what happened. The therapist helped Harrison address his feelings of guilt by exploring the decisions he made leading up to the incident, the reasons for those decisions, and what he realistically could have done differently. After a psychiatric referral, Harrison is prescribed antidepressant medications to assist his mood and help dull his symptoms. Within a few months, Harrison reported safer drinking habits, healthier sleeping habits, and better family interactions to his therapist. Harrison hopes to start driving to therapy sessions soon.

References:

  1. Acosta, J. D. , Becker, A., Cerully, J. L., Fisher, M. P., Martin, L. T., Vardavas, R., ... Schell, T. L. (2014). Mental health stigma in the military. Retrieved from http://www.rand.org/content/dam/rand/pubs/ research_reports/RR400/RR426/RAND_RR426.pdf
  2. American Academy of Child and Adolescent Psychiatry. (2011). Facts for families, no. 88. Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/facts_for_families/88_families_in_the_military.pdf
  3. American Psychological Association. (2010). Mental health and related resources for assisting service members, veterans, and their families. Retrieved from http://www.apa.org/about/gr/issues/military/resources.aspx
  4. American Psychological Association. (n.d.).  The critical need for mental health professionals trained to treat post-traumatic stress disorder and traumatic brain injury. Retrieved from     http://www.apa.org/about/gr/issues/military/critical-need.aspx
  5. Anxiety and Depression Association of America. (n.d.). Tips for soldiers and veterans. Retrieved from http://www.adaa.org/living-with-anxiety/military-military-families/tips-soldiers-and-veterans
  6. Dingfelder, S. F. (2009). The military's war on stigma. Monitor on Psychology, 40(6). Retrieved from http://www.apa.org/monitor/2009/06/stigma-war.aspx 
  7. Gallegos, A. M., Cross, W. & Pigeon, W. R. (2015). Mindfulness-based stress reduction for veterans exposed to military sexual trauma: Rationale and implementation considerations. Military Medicine, 180(6), 64-689. doi: 10.7205/MILMED-D-14-00448
  8. Leal, R. (2015). Study shows risk for suicide lower among men and women veterans who use VA care. Retrieved from http://www.blogs.va.gov/VAntage/20612/study-shows-risk-for-suicide-lower-among-men-and-women-veterans-who-use-va-care
  9. National Institutes of Health. (2014). Post-traumatic stress disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001923
  10. National Institute of Mental Health. (n.d.). What is post-traumatic stress disorder (ptsd)? Retrieved from http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
  11. Shinseki, E. K. (n.d.). Military families. Retrieved from http://www.va.gov/opa/militaryfamilies.asp
  12. United States Department of Veterans Affairs, Employee Education System. (2010). Traumatic brain injury. Retrieved from http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf
  13. United States Department of Veterans Affairs. (2014). How common is PTSD? Retrieved from http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp
  14. United States Department of Veteran Affairs. (2014). About va mental health. Retrieved from http://www.mentalhealth.va.gov/VAMentalHealthGroup.asp
  15. United States Department of Veterans Affairs. (2014). Polytrauma/TBI system of care. Retrieved from http://www.polytrauma.va.gov/understanding-tbi
  16. Wieland, D. M., Haley, J. L. & Bouder, M. (2011). Military sexual trauma. The Pennsylvania Nurse, 66(4), 17-21.

 

Last updated: 08-12-2015

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