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This course covers mental health conditions common to veterans.  Mental health disorders are more common among veterans, and there are often issues with access to resources. After returning home, these veterans may be forced to cope with Depressive Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Suicidal Ideation, and other conditions as a result of their service to their country. Nurses are on the front line of this mental health battle, and are in a unique position to advocate for the mental health of veterans, and their families. This course is mandated by the state of West Virginia for nursing professionals.  

Introduction   

The number of military service members, Veterans, and their families’ health needs are considerable and continue to grow. Mental health disorders are more common among Veterans, and there are often issues with access to resources. The invisible wounds of war are wreaking havoc on our Veterans and their families. After returning home, these Veterans may be forced to cope with Depressive Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Suicidal Ideation, and other conditions as a result of their service to their country. These conditions affect not only the Veteran but also their spouses, children, and extended family members. The transition from life in combat to reality can be trying. Nurses are on the front line of this mental health battle and are in a unique position to advocate for the mental health of Veterans and their families.   

Mental Health Conditions Common to Veterans

According to an article from the American Psychological Association on Mental Health Needs of Veterans, Service Members and Their Families,

“One-third of returning Operating Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members have reported symptoms of mental health or cognitive problems (1).”

This is a staggering statistic that nurses and other healthcare providers must take into consideration when screening and treating this population of patients. The IOM reports that the most common challenges experienced by service members and their families include fearing for the safety of the service member, feeling anxious or overwhelmed by deployment challenges, worry about their children, and vulnerability to other stressors that may result throughout their time in the military (1).    

War has been around for centuries. Mental health conditions common to veterans is not a new concept.

“Previous wars have demonstrated that Veterans’ needs peak several decades after their war service, highlighting the necessity of managing current problems and planning future needs (1).”

Veterans are faced with a variety of mental health conditions, including but not limited to Generalized Anxiety Disorder, Depressive Disorder, Post-Traumatic-Stress-Disorder, Bipolar Disorder, and Suicidal Ideation.  

Health service psychologists provide the appropriate behavioral and mental services including assessment, screening, counseling, diagnosis, treatment, prevention, consultation, and supervision. These specialists work in conjunction with other health professionals such as nurses and nurse practitioners collaboratively to conduct screenings, research, and program evaluation.

Screening Veterans and Families for Mental Health Conditions Common to Veterans

A military background may not always be assessed by practitioners or voluntarily shared by Veteran patients during a health history. Screening Veterans and their family members is an extremely important step in shaping a plan of care and can help to identify appropriate steps and resources. It could be the difference in preventing harm, or even more paramount, saving a life.   

It is essential to ask questions and retrieve a thorough history of a patient, determining not only if they are a Veteran but also asking if they have a loved one that has served in the military. There may be a child of a deployed parent, for example, that may exhibit behavioral health problems that would not be understood without prior knowledge of the parent’s current military experience (1). 

When reviewing a Veteran’s medical history, the provider should consider asking specifically about their military experience. Recommended questions to accurately address mental health conditions common to veterans could include (2): 

Have you or has someone close to you served in the military?
What was your branch of service and rank?
What specific jobs did you perform?
How do you feel about how your time in the military has affected you?
Were you ever injured or hospitalized?
Were you ever a prisoner of war?
Are there any other things that you would like to tell me about your time in the military?

Screening military service members and their families will ensure that this population of patients has access to health care and support services that they need to help manage potential mental health concerns.

Here are some strategies to help screen a Veteran or their family member (2):   

• Convey a willingness to listen to their experiences if they want to discuss them in the future; 
  Respect their choice not to discuss their experiences in depth;
  Ensure you have enough time available to allow the patient to expand on their answers or conversation if needed.

Importance of Encouragement from Healthcare Providers

Military personnel are known for taking care of their bodies physically, but their mental health may “fall by the wayside”. Mental health is vital to an individual’s success in their role as a veteran.

“Talking to healthcare providers about concerns as a military member as well as seeking treatment cannot affect their career (8).”

This is an important note to make when discussing a Veteran’s health history. Untreated mental illness, however, can damage a career. Military policy states that, “care providers can only share certain information and only in those situations involving safety (8).”   

It is equally important to educate family members and friends on the importance of speaking with a healthcare professional if they are concerned about their loved one. Family members may not realize that their “recognized concerns” about a family veteran are actually symptoms of a mental illness. Nurses can encourage family members to listen patiently and offer encouragement to their loved one who is experiencing these symptoms, reminding them that it can happen to anyone and encourage them to seek help.  

Despite grim numbers, the Department of Veterans Affairs (VA) has doubled their efforts to address challenges that veterans face from mental health issues. They passed the MISSION ACT of 2018, which makes aggressive efforts by extending outreach to Veterans. The MISSION ACT (14):   

• Includes provisions that enhance the recruitment of clinicians;  
  
• Authorizes access to community urgent care providers; 
  
• Expands telehealth services.  
  

Generalized Anxiety Disorder

Individuals suffering from Generalized Anxiety Disorder (GAD) typically feel worried or anxious about various activities of their daily lives and sometimes have difficulty stopping these feelings. Their worry can range from minor things such as being on time or running errands to issues involving money, relationships with others, or their health. As a result of these feelings of worry, they often experience tension, as shown by irritability, muscle tension, sleeping difficulties, and tiredness.   

Anxiety can have both physical and emotional symptoms. The signs of stress include nausea, trouble sleeping, and irritability. The troubling fact is that these symptoms are often mistaken or related to other things, and anxiety disorders may be misdiagnosed or missed entirely.   

The Generalized Anxiety Disorder Assessment (GAD-7) is a seven-item scale used to measure the severity of GAD. Each item asks the person to rate the severity of their symptoms over the past two weeks. Responses include “not at all,” “several days,” “more than half the days,” “nearly every day”. The score is calculated by assigning 0, 1, 2, and 3 to the response categories (3).   

Scores of 5, 10, and 15 are the cut-off for mild, moderate, and severe anxiety. As a healthcare provider, further evaluation is recommended when the score is ten or greater (3).   

Veterans often carry many responsibilities, including the people they serve, their loved ones, and their job responsibilities. They sometimes feel as if things are out of their control and unable to manage their thoughts. GAD is often diagnosed when a Veteran is unable to control their worrying for a timeframe of at least six months and has three or more symptoms. If left untreated, GAD can lead to depressive disorders and other challenges.   

Depressive Disorder

Depression causes sadness, loss of interest in activities that were previously enjoyed, withdrawal, and lack of energy. It can also cause people to have feelings of hopelessness and, potentially, thoughts of suicide (4). Some experts believe that stressful situations in life events, combined with genetics, can cause depression. According to the National Institute of Mental Health (NIMH),

“…Major depression is one of the most common mental health disorders in the United States. It also carries the heaviest burden of disability among mental behavior disorders estimating that 15.7 million adults 18 years or older had at least one major depressive episode within the last year (4).”  

The US Department of Veterans Affairs estimated that about 1 in 3 Veterans visiting primary care clinics had some symptoms of depression; 1 in 5 had serious symptoms suggesting the need for further evaluation and 1 in 8 had major depression requiring treatment (4).   

Researchers are currently developing models of family interventions and other forms of social support to help veterans recover from mood disorders, learning which risk factors will make a person more likely to suffer from depression and how they respond to a specific medication, and identifying and testing new drugs for depression (4).    

Oftentimes, the family of a veteran can give more insight into the severity of their loved one’s depression or other mood disorder than the patient themselves.   

The PHQ-9 is a scale that helps healthcare providers to monitor the severity of depression. It is a tool to help screen patients and can be very helpful in practice. The PHQ-9 score had a > 10 had a sensitivity of 88% and a specificity of 88% for major depression (5).   

Post-Traumatic Stress Disorder

Veterans who have served in the military and in combat have seen things that may have long-term effects on their mental health. These things can be horrific and traumatizing. These experiences can lead to Post-Traumatic Stress Disorder (PTSD).

“Post-Traumatic Stress Disorder is a serious potentially debilitating condition that can occur in people who have experienced or witnessed a natural disaster, serious accident, terrorist incident, sudden death of a loved one, war, violent personal assault, or other life-threatening events (16).”

According to the National Center for PTSD, the number of Veterans with PTSD varies by service area (9). Post-Traumatic Stress Disorder became a diagnosis from various historical events such as specific wars or the Holocaust. Research about Veterans returning from combat was very important in shaping the diagnosis of this mental health disorder (6).  

People respond to trauma in different ways. Some respond in feelings of concern, anger, or fear. Research has shown that people who have been through trauma or loss in the past may be more likely than others to be affected by new traumatic events that may happen in their lives (6).  On the anniversary of a traumatic event, some survivors may have more trouble with the increased stress that the memory of the day brings.

“About 11-20 of every 100 veterans (11-20%) who served in Operation Iraqi Freedom (OIF) and Enduring Freedom (OEF), experience PTSD in a given year (6).”   

There are other factors besides a direct combat situation that can contribute to PTSD. Sexual assault or sexual harassment is a prevalent, widespread occurrence in the military. This is known as Military Sexual Trauma or (MST). It can occur in both men and women during peacetime, training, or war. Among Veterans who use VA healthcare, 23 out of 100 women (23%) reported sexual assault when in the military; 55 out of 100 women (55%) and 38 out of 100 men (38%) have experienced sexual harassment while in the military (6). These are profound numbers that serve as hard evidence that the existence of the problem is actual and causes severe mental health problems.   

The main treatments for those with PTSD are specific short-term psychotherapies. Every person is different; therefore, a treatment that works for one person may not work for another. Some may need to try several treatments before finding one that works. They include cognitive behavioral therapy, person-centered therapy, and eye movement desensitization and reprocessing. Medications are often used in conjunction with one of the therapies above. The most common types of medicines prescribed to Veterans with PTSD are selective serotonin reuptake inhibitors (SSRIs). Benzodiazepines are sometimes used as well (15).  

Bipolar Disorder

Bipolar symptoms can change over time. In an “up” swing or manic episode, the person may feel extremely happy, energetic, on edge, or irritable. The person can also feel overly self-confident or willing to take dangerous risks. In a “down” swing, the person may feel depressed or hopeless (7). A person with bipolar disorder can experience “up” or “down” swings, and they can also feel themselves in between those experiences. They feel a constant roller coaster of emotions and often find it hard to cope with the continuous change.   

Signs of manic episodes associated with bipolar disorder may include (7):   

• Doing things they may later regret, such as big spending, engaging in a reckless activity such as sex, gambling, or heated arguments  
• Feeling as if their mind is racing  
• Appearing to be high even if no drugs have been consumed   
• Talking faster than usual   
• Taking dangerous risks or getting into unsafe situations   

Several effective treatments for this mental health disorder can allow patients to have a typical daily life. Treatments usually involve a medication regimen and counseling for the patient and the family.   

Counseling can help the patient and family members recognize early signs of ups and downs to establish steps to take to control the situations before they happen. The treatment should be tailored specifically to fit the needs of the patient. Some mood changes can still occur with treatment, so an ongoing relationship with a team of healthcare providers is the best option to cope. Bipolar disorder is a chronic condition requiring ongoing management (7).   

The Bipolar Spectrum Diagnostic Scale (BSDS) allows patients as well as providers to determine sensitivity and specificity in the detection of a wide range of presentations within the bipolar spectrum. The BSDS has two sections. The first section includes a series of 19 sentences that describe the main symptoms of bipolar disorders. Each sentence is linked to a blank space that can be checked by patients who decide that the statement is an accurate description of their feelings or behaviors. Each statement is assigned 1 point. The second portion asks the patient to select the degree to which the 19-item narrative includes their personal experience. There are four possibilities to choose from: “This story fits me very well, or almost perfectly” (6 pts); “This story fits me fairly well” (4 pts); “This story fits me to some degree, but not in most respects” (2 pts); and “This story doesn’t describe me at all” (0 pts) (9).  

Suicidal Ideation

Many Veterans do not show signs or an urge to harm themselves before doing so. Some may show signs of depression, anxiety, low self-esteem, or hopelessness (10). According to the American Addiction Center, “The suicide rate for Veterans is 1.5 times higher than that of the general population.” They also compared the rate of female veterans to non-veteran adult women, and the rate was 2.5 times higher in Veteran women (11). About 20 Veterans commit suicide every day, and nearly three-quarters are not under VA care. This number can be drastically impacted by the attentiveness of healthcare providers and the screening of patients (11).   

Information for Family, Friends, and Caregivers  

What are the signs that someone may be considering suicide?  

• Seeming sad, depressed, anxious, or agitated  
• Sleeping all the time or not at all  
• Not caring about their appearance or what happens to them   
• Withdrawal from friends, family, and society   
• Losing interest in hobbies or work   
• Expressing feelings of excessive guilt, failure, shame, or lack of purpose   

If a family member or friend of a Veteran expresses concern to you, you can help make a change as the healthcare provider.  It is important to educate them on what steps to take to save the life of their loved one.   

To connect with a Veterans Crisis Line responder anytime day or night:  

• Call 800-273-8255, then select 1.  
• Start a confidential chat.  
• Text 838255  

To speak with a VA coach:

• Call 888-823-7458, Monday through Friday, 8:00 a.m. to 8:00 p.m. EST.  

To get tips and resources for spouses, parents, and Veterans on mental health conditions common to veterans, visit the Coaching Into Care website.  

The Suicidal Ideation Attributes Scale (SIDAS) was designed to screen individuals for the presence of suicidal thoughts and to assess the severity of those thoughts. There are five items targeting elements of suicidal thoughts, including: frequency, controllability, closeness to attempt, level of distress associated with the thoughts, and impact on daily function. The responses are measured on a 10-point scale (11). 

Managing Loss Associated with Military

Losing a loved one is never an easy situation, even if one thinks they are prepared. Feelings of sadness, anger, grief, or anxiety after loss are normal parts of the process. Reactions to loss can vary by person and experience. For Veterans, grief may come from the loss of:   

• A military comrade who died in battle;  
  
• A bond that was had with fellow service members;  
  
• Identity as a member of the military;  
  
• Physical ability;  
  
• Mental health.  
  

“Some Veterans may also experience survivor guilt, which is a sense of remorse for having survived when others did not (12).”

Grief also causes those it strikes to react in various ways to different situations. Some Veterans experience traumatic grief following the sudden death of a family member or a friend after witnessing multiple casualties such as in a combat situation, natural disaster, or accident. Grief is a process. The military has an experienced notification process for informing military family members of loss with dignity and honor.   

As a healthcare provider, knowing your audience is very important. In dealing with veterans experiencing loss, or their families, who have experienced the loss of their loved one as a veteran, you must approach each situation with care. When the initial shock of loss begins to subside, many bereaved people pay tribute to their loved ones by finding a way to honor them (13). Engaging in this process is an excellent coping mechanism and can allow the person to give the loved one’s life continued meaning.   

For most people, acute grief begins to subside in the first 6 months after loss, but some people do not begin to recover from the loss. When this happens, it is known as complicated grief or “traumatic grief.” There are two important factors that put veterans and greater risk for complicated grief, and they are:

1. The sudden, violent nature of loss in a combat situation, and
2. The importance of cohesion in military closure (12).

Military bonds are extremely close, which can make loss much more devastating.   

There is currently no Veteran-specific treatment related to complicated grief. The treatment recommendations pull from existing research on this topic, which uses a Complicated Grief Tool to help manage painful and intrusive memories or thoughts of the loss process. This treatment also focuses on helping grieving individuals re-establish meaningful relationships.  It works to help them restore other functions important to everyday life, by overcoming the setbacks of mental health conditions common to veterans (12).  

Support Programs for Mental Health Conditions Common to Veterans

There are many support programs available to veterans and their families experiencing challenges after leaving the military. The VA has several resources listed on their website that help to address the stressors related to the experiences Veterans may face (18).  

Make the Connection
MakeTheConnection.net is a resource for veterans and their family members and friends who can explore information on life stressors and mental health symptoms. This resource has personal stories of Veterans on specific challenges they were faced with when transitioning from the service to civilian life, and how they addressed issues.   

Vet Centers
Vet Centers is another resource available that helps with Veterans and families related to readjustment counseling, including group, marital, and family counseling, as well as medical and benefits referrals. Please visit: VetCenter.va.gov

Veterans Crisis Line
The Veterans Crisis Line connects Veterans and active Service members in crisis as well as their family and friends with qualified responders through a confidential hotline, online chat, or text system. 24 hours a day, 7 days a week, 365 days a year.   

• Call 1-800-273-8255 and Press 1   
• Text 838255  

Women’s Veterans Call Center
This call centers provides VA services and resources to women Veterans and their families, for mental health conditions common to veterans, and beyond.   

• Call 1-855-VA-Women (1-855-829-6636)  

National Call Center for Homeless Veterans
This call center is for Veterans who are homeless or at risk of becoming homeless. The call center is also available to Veterans friends or family members, VA medical centers, VA partners, and community agencies.   

• Available 24/7 at 1-877-424-3838

Conclusion

Veterans risk everything for the sake of their country. Some return to civilian life with few difficulties, while others need a great amount of support from their families, friends, and healthcare providers. It is of great importance that Veterans themselves, their loved ones, and their providers learn to recognize signs and symptoms of mental health conditions, proper coping mechanisms, as well as interventions, to keep themselves and their families safe.  These necessary actions will allow them to have the best possible quality of life.  Anxiety, Depression, PTSD, and suicidal ideation should not be taken lightly. It is vital that friends, family members and healthcare providers work to identify risk factors and seek treatment accordingly, to give back to those who have willingly put their lives on the line for everyone around them.  In this course, you have learned about mental health conditions common to veterans, and how you can make a difference.

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