Veteran and Military Mental Health Issues

As the United States endures 2 decades of ongoing warfare, both the media and individuals with personal military connections have raised significant public and professional concerns about the mental health of veterans and service members. The most widely publicized mental health challenges veterans and service members encounter are posttraumatic stress disorder (PTSD) and depression. Research indicates that approximately 14% to 16% of the US service members deployed to Afghanistan and Iraq have been affected by PTSD or depression. Although these mental health concerns are prominently highlighted, it is crucial to acknowledge that other issues, such as suicide, traumatic brain injury (TBI), substance use disorder (SUD), and interpersonal violence, can be equally detrimental in this population. These challenges can have far-reaching consequences, significantly affecting service members and their families. Although combat and deployments are known to be associated with increased risks for these mental health conditions, general military service can also give rise to challenges. The presentation of these mental health concerns may not follow a specific timeline. However, there are particularly stressful periods for individuals and families, especially during periods of close proximity to combat or when transitioning from active military service. As per the recent reports released by the U.S. Census Bureau, there are around 18 million veterans and 2.1 million active-duty and reserve service members (https://www.census.gov/newsroom/press-releases/2020/veterans-report.html) in the United States. Since September 11, 2001, the deployment of 2.8 million active-duty American military personnel to Iraq, Afghanistan, and other areas has resulted in a growing number of combat veterans within the population. Over 6% of the US population has served or is currently serving in the military. Notably, this number also does not consider the significant number of relatives affected by military service. Healthcare providers can enhance the quality of care they provide patients and potentially save their lives by comprehending the relationship between military service and a patient's physical and mental well-being. PTSD was officially recognized and codified in the in 1980, driven partly by the sociopolitical aftermath of the Vietnam War. However, its manifestations have been alluded to in different forms throughout history, with terms such as "soldier's heart" during the Civil War, "shell shock" in the First World War, and "combat fatigue" around the Vietnam War. The DSM criteria have remained primarily unchanged until the latest update in 2013. However, there is still ongoing debate regarding its classification. As a complex and constantly evolving combination of biological, psychological, and social factors, studying and diagnosing PTSD poses significant challenges. Although PTSD is commonly studied in individuals who have experienced war or natural disasters, its impact is not limited to specific groups and can affect anyone, including children. This disorder is commonly observed in individuals who have survived violent events such as assaults, disasters, terror attacks, and war. However, even secondhand exposure, such as learning that a close friend or family member experienced a violent threat or accident, can also lead to PTSD. Although many individuals may experience transient numbness or heightened emotions, nightmares, anxiety, and hypervigilance after exposure to trauma, these symptoms resolve within 1 month. However, in approximately 10% to 20% of cases, the symptoms may worsen and become persistent, causing significant impairment. PTSD is characterized by intrusive thoughts, flashbacks, and nightmares related to past trauma, leading to avoidance of reminders, hypervigilance, and sleep difficulties. Frequently, reliving the event can evoke a sense of threat as intense as the original trauma. PTSD symptoms can significantly disrupt interpersonal and occupational functioning and manifest in various ways, affecting psychological, emotional, physical, behavioral, and cognitive aspects. Military personnel can be exposed to an array of potentially traumatizing experiences. Military personnel deployed during wartime may witness severe injuries or violent deaths, which can occur suddenly and unpredictably. These events can impact not only intended targets but also others in the vicinity. Active-duty military members risk non-military-related traumas beyond the challenging deployment environment, such as interpersonal violence and physical or sexual abuse. Symptoms related to these traumas may be exacerbated in the deployed environment. As a result of 2 decades of ongoing warfare in Afghanistan, there is a rising population of veterans seeking mental health treatment, with a significant portion having experienced combat and deployment. While caring for veterans, healthcare providers should consider the physical injuries they may have sustained during their service period and the emotional wounds they may be experiencing presently, including PTSD, acute stress disorder, and depression. Although depression does not garner the same level of attention as PTSD, this condition remains a prevalent mental health condition in the military. Research shows that depression is responsible for up to 9% of all ambulatory military health network appointments. The military environment can serve as a catalyst for the development and progression of depression. Factors such as separation from loved ones and support systems, the stressors of combat, and the experience of witnessing oneself and others in harm's way all contribute to an increased risk of depression in both active-duty and veteran populations. After deployments to Iraq or Afghanistan, military medical facilities witnessed an increase in diagnosed depression cases, rising from a baseline of 11.4% of members to a rate of 15%. Given this high prevalence, providers have a critical responsibility to identify active-duty and veteran patients who may be suffering from depression.  Major depression manifests through various symptoms, encompassing a depressed mood, loss of interest in activities, insomnia, weight loss or gain, psychomotor retardation, fatigue, reduced ability to concentrate, feelings of worthlessness, and thoughts of suicide. These symptoms dramatically affect the patient's capacity to operate at full potential. Although the array of symptoms is evident on paper, a patient's presentation can often be ambiguous. Surprisingly, it has been found that half of all patients suffering from depression are not correctly diagnosed by their general practitioner. Therefore, accurate screening, identifying, and following through with appropriate treatments is paramount, especially in the active-duty and veteran military population. Veteran suicide rates have reached their highest level in recorded history, with over 6000 veterans dying by suicide annually. Furthermore, overall suicide rates within the United States have increased by 30% between 1999 and 2016. According to a study conducted in 27 US states, it was estimated that veterans committed 17.8% of reported suicide cases. Data published by the U.S. Department of Veterans Affairs (VA) in 2016 indicated that veteran suicide rates were 1.5 times higher than those of non-veterans. Research has shown that veterans are at significantly increased risk of suicide during their first year after leaving the military service. In 2018, a Presidential Executive Order was signed to improve suicide prevention services for veterans during their transition to civilian life. Moreover, the Department of Defense (DoD) and VA have placed significant emphasis on suicide prevention due to the observed rise in fatal and non-fatal suicide attempts during the wars in Iraq and Afghanistan. The suicide rates in the U.S. Armed Forces doubled between 2000 and 2012. However, since then, there has not been any significant change in the annual rate of suicides, with approximately 19.74 deaths per 100,000 service members occurring each year. Despite receiving public attention over recent decades, SUDs, including alcohol use, continue to be a problem among veterans and military members. In these populations, alcohol use is prevalent and is frequently utilized for stress relief and socializing. SUDs are associated with significant adverse medical, psychiatric, interpersonal, and occupational outcomes. A study conducted on military personnel revealed that approximately 30% of completed suicides and around 20% of deaths resulting from high-risk behavior were attributed to alcohol or drug use. In the general US population, alcohol is the fourth leading cause of preventable death, contributing to 31% of driving-related fatalities involving alcohol intoxication. According to the DSM-5, SUD is a group of behaviors that involve compulsive drug-seeking, which includes impaired control over drug use, dysfunctional social functioning due to drug use, and physiological changes resulting from drug consumption. Addiction represents the most severe stage of SUD in individuals, characterized by a loss of self-control that leads to compulsive drug-seeking behavior despite a desire to quit. Substances encompass various categories, including legal drugs such as caffeine, nicotine, and alcohol; prescription medications such as opioids, sedatives or hypnotics, and stimulants; and illicit drugs such as marijuana, cocaine, methamphetamines, heroin, hallucinogens, and inhalants.