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Mental Health Needs of Returning Veterans

Terence M. Keane, PhD (Chair)

Director, Behavioral Science Division, National Center for PTSD, US Department of Veterans Affairs, Washington, DC, and Professor of Psychiatry and Assistant Dean for Research at Boston University School of Medicine, Boston, Massachusetts

John P. Docherty, MD

Adjunct Professor, Department of Psychiatry, Weill Cornell Medical College, and Attending Psychiatrist, New York-Presbyterian Hospital, New York

Robert L. Jesse, MD, PhD

Principal Deputy Under Secretary for Health, US Department of Veterans Affairs, Washington, DC

Jennifer Lee, MD

Special Assistant for Community Engagement Under the Principal Deputy Under Secretary for Health, US Department of Veterans Affairs, Washington, DC

Jessica McNurlen, MA, CRC

Project Director, Serving Together, Mental Health Association of Montgomery County, Rockville, Maryland

Eileen Zeller, MPH

Public Health Advisor, Suicide Prevention Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland

AV 1. Symptoms of PTSD (00:39)

Abbreviations are defined before the References

An estimated 400,000 military personnel who have served in Iraq and Afghanistan have psychiatric conditions, including PTSD (AV 1).1,2 About 60% of eligible people do not receive VA health care and, instead, get health care in places where their veteran status may go undetected.3 Therefore, clinicians in the private sector need to be knowledgeable about PTSD and other mental health conditions so that they can successfully assess and treat veteran patients.

This activity presents the highlights of a discussion among experts about the challenges that returning veterans face in receiving treatment for mental health conditions, the services needed to help veterans’ family members, and the ways that clinicians can support employers and communities in helping returning veterans.

What Challenges Do Veterans Face in Receiving Appropriate Treatment for PTSD and Other Mental Disorders?

Dr Keane: When you consider that over 2 million people have served in the most recent military operations4—and they have spouses, children, and parents—you realize that a significant part of the American population is affected by what has happened in these war zones. Many of those deployed are suffering from the invisible wounds of war: PTSD, TBI, and/or chronic pain. When service members return to civilian life, what barriers do they face in getting mental health care?

Ms McNurlen: One challenge we have experienced in Montgomery County, Maryland, is the need for increased awareness among private practitioners and nonmilitary serving organizations on military culture. In May 2012, Serving Together, a project of Mental Health Association of Montgomery County, hosted an education event on behavioral health and substance abuse issues among recently returning veterans. The goal of the seminar was to increase the knowledge of best practices for treating military and veterans. We believe that, as we increase the level of awareness in our community, more practitioners will understand how they can better serve our military and veterans.

AV 2. Services and Resources for Veterans and Their Families, Clinicians, and Employers

Abbreviations are defined before the References

See AV 2 for a list of several services and resources for veterans, their families, clinicians, and the community.

Ms Zeller: I agree. Another challenge that veterans face in receiving treatment is their own reluctance to seek mental health services. As SAMHSA has grappled with this challenge, we found that one answer lies in facilitating more peer support among veterans. Any combat veteran will feel a sense of camaraderie and trust with other combat veterans, and it helps if another veteran urges a peer to seek help for a mental health problem such as PTSD.

Dr Lee: Service members and veterans may not only view mental health problems as a sign of weakness but may also be skeptical about the effectiveness of treatment. They may misunderstand the types of available treatment or worry about the impact of mental health treatment disclosure on their security clearances or future career prospects.5

How Can Clinicians Help Family Members of Returning Combat Veterans With PTSD and Other Mental Disorders?

AV 3. Tips for Family Members of Veterans with PTSD (00:44)

Abbreviations are defined before the References

Dr Docherty: Practitioners who see veterans should understand the importance of educating the families and letting them know that effective interventions do not require a large commitment of the family’s or the provider’s time (AV 3).6 What I have found in my work is that certain patient-specific issues often arise, and that it is important to address specific, puzzling behaviors. For example, family members often need help understanding a veteran’s explosive anger. Why does their loved one lose his or her temper so quickly? How can they help manage bouts of anger or keep conversations from escalating into arguments? Clinicians should provide these tools to veterans and their families.

Ms Zeller: One issue of major concern for military families is suicide. While veterans comprise about 9% of the US adult population, veteran suicides are about 20% of the nation’s suicides.7

Dr Jesse: The VA and the DoD launched the “Stand by Them” campaign to enlist the help of friends, families, and communities to prevent veteran suicides. The VA provides a 24-hour Veterans Crisis Line, even for those who are not registered with the VA, including loved ones of veterans. Hopefully, signs of emotional distress in veterans can be recognized before problems reach the crisis point.

The VA is also working with the military chaplain service as well as with lay chaplains to detect warning signs in current and former service members.8 Marriage and relationship problems often contribute to suicide, and chaplains can help veterans and their families with these issues.

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How Can Clinicians Help Employers of Veterans With PTSD?

Dr Docherty: Clinicians can recommend that employers offer veterans with PTSD a flexible work schedule to facilitate their treatment appointments. Good communication with care providers can help employers manage veterans with PTSD. For example, a veteran I was treating spouted off complaints in his company’s instant messaging system, and his inflammatory words got picked up by their alert system. The company’s initial reaction would have been to expel him, but, because we had a coordinated effort in place, they called me. I saw him right away and realized that he was having a mini-meltdown but was fine, and he went back to work successfully. 

Ms Zeller: Clinicians should also remind employers that not every veteran returns “broken” or violent. The public believes that most returning veterans struggle with mental illnesses, but the reality is that about 4 in 5 service members do not have serious mental health problems. Of those who do, 88% can continue their work without changes, even while they receive treatment.9 Veterans may be changed from seeing combat, but they return with strengths gained from their experiences as well. Employers should learn what veterans can do for their companies and strive to make them successful employees.  

How Can Clinicians Help Communities Support Veterans?

Dr Keane: How can communities offer an environment that is conducive to helping returning veterans adjust to civilian life? 

Ms McNurlen: Serving Together is working to coordinate existing resources to ensure the service system is easier to navigate. Serving Together is working with local community service providers to better define who is a veteran and who has National Guard and Reserve status or active-duty status as well as to identify benefits and resources, including the VA, that may be available to veterans in the community. Most importantly, providers and nonprofit organizations should ask every person seeking services at intake about their military experience so that they know what the person may be eligible for and how they can best serve them. 

Conclusion

Returning veterans with PTSD and other mental health care needs may face challenges in accessing evidence-based treatment, such as the stigma associated with seeking help and a lack of practitioners who understand military culture and veterans’ issues. Mental health care providers can help veterans by learning more about the military, asking patients about their military experiences, educating the patients and their families, working with patients’ employers, and directing patients to appropriate resources online and in their communities. A coordinated effort is necessary to meet the mental health needs of returning service members, and informed clinicians are needed on the front lines of care. 

Clinical Points

 

  • Ask patients about their military service and veteran status
  • Learn about veteran resources and eligibility requirements locally and nationally
  • Equip veterans and their families with education, counseling, and coping mechanisms to deal with mental health issues, including PTSD symptoms

Abbreviations

DoD = Department of Defense, PTSD = posttraumatic stress disorder, SAMHSA = Substance Abuse and Mental Health Services Administration, TBI = traumatic brain injury, VA = Veterans Affairs 

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References

  1. Wounded Warrior Project. Who we serve. http://www.woundedwarriorproject.org/mission/who-we-serve.aspx. Updated January 1, 2013. Accessed March 13, 2013.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
  3. Burnam MA, Meredith LS, Tanielian T, et al. Mental health care for Iraq and Afghanistan war veterans. Health Aff (Millwood). 2009;28(3):771–782. PubMed
  4. Martinez L, Bingham A. US Veterans: by the numbers. http://abcnews.go.com/Politics/us-veterans-numbers/story?id=14928136. Published November 11, 2011. Accessed March 13, 2013.
  5. Tanielian T, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008. www.rand.org/pubs/monographs/2008/RAND_MG720.pdf. Accessed March 12, 2013.
  6. Disabled American Veterans. Living with traumatic stress. http://dav.org/veterans/documents/PTSDBrochure.pdf. Accessed March 12, 2013.
  7. Parrish K. Battaglia calls reducing suicides a top priority. American Forces Press Service. December 12, 2011. http://www.defense.gov/news/newsarticle.aspx?id=66431. Accessed March 12, 2013.
  8. US Department of Veterans Affairs. Mental Illness Research, Education and Clinical Centers: VA Mental Health and Chaplaincy. http://www.mirecc.va.gov/mentalhealthandchaplaincy. Updated October 27, 2011. Accessed March 12, 2013.
  9. Cloud R. An international approach to military mental health. http://www.whitehouse.gov/blog/2012/10/03/international-approach-military-mental-health. Published October 3, 2012. Accessed March 12, 2013.
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