Veterans and their families may experience medical and mental health issues as they reintegrate into their communities during or after their terms of military service. The most common medical and mental health issues include PTSD, suicide, depression, grief, drug and alcohol abuse, and intimate partner violence or child abuse.
Signs of Mental Health Problems
Mental problems can cause physical problems, along with changes in thinking, feeling, and behavior:
- Feeling sad or nervous
- Changes in sleep, appetite, weight, or sex life
- Headaches or other physical pain
- Muscle tension and weakness
- Decreased energy, motivation, or interests
- Problems with attention, concentration, or memory
- Irritability, anger, or “short temper”
- Feelings of guilt, worthlessness, helplessness, or hopelessness
- Unhealthy behaviors (misusing drugs, alcohol, food, sex or other behaviors like gambling or spending too much money to cope with stress or emotions)
- Problems functioning at home, work, or school
Source: VHA, 2012.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD) is a condition that can occur at any age, including childhood. Women are more likely to develop PTSD than men. PTSD is seen in war Veterans and survivors of physical and sexual assault, abuse, accidents, disasters, terrorist attacks, and many other serious events.
Not everyone with PTSD has been through a dangerous event. Some people get PTSD after a friend or family member experiences danger or is harmed. The sudden unexpected death of a loved one can also cause PTSD (NIMH, 2015).Mentally reliving a traumatic event can be almost as stressful and frightening to people with PTSD as the original trauma.
People with PTSD often experience frustration, embarrassment, and confusion, in addition to the physical and psychological symptoms. PTSD strains relationships because many people with PTSD detach themselves from friends and loved ones and the activities that they used to enjoy.
The number of Veterans with PTSD varies by deployment:
- Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF): About 11–20 out of every 100 Veterans (or 11%–20%) who served in OIF or OEF have PTSD in a given year.
- Gulf War (Desert Storm): About 12 out of every 100 Gulf War Veterans (or 12%) have PTSD in a given year.
- Vietnam War: About 15 out of every 100 Vietnam Veterans (or 15%) were currently diagnosed with PTSD at the time of the most recent study in the late 1980s, the National Vietnam Veterans Readjustment Study (NVVRS). It is estimated that about 30 out of every 100 (or 30%) of Vietnam Veterans have had PTSD in their lifetime. (DVA/NCPTSD, 2016)
- In 2015 nearly 48,000 women Veterans received compensation for PTSD. PTSD accounted for roughly 12 percent of all service connected disabilities for women Veterans. (DVA/NCVAS, 2017)
DSM-5 Diagnostic Criteria for PTSD
Healthcare providers should be aware of the DSM-5 diagnostic criteria for PTSD. Currently, diagnosis of PTSD is based on eight criteria from the DSM-5. The first DSM criterion has four components, as follows:
- Directly experiencing the traumatic event(s)
- Witnessing, in person, the event(s) as it occurred to others
- Learning that the traumatic event(s) occurred to a close family member or friend
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s); this does not apply to exposure through media such as television, movies, or pictures
The second criterion involves the persistent re-experiencing of the event in one of several ways:
- Thoughts or perception
- Illusions or hallucinations
- Dissociative flashback episodes
- Intense psychological distress or reactivity to cues that symbolize some aspect of the event
Did You Know. . .
Unlike adults, children re-experience the event through repetitive play rather than through perception.
The third criterion involves avoidance of stimuli associated with the trauma and numbing of general responsiveness, as determined by the presence of one or both of the following:
- Avoidance of thoughts, feelings, or conversations associated with the event
- Avoidance of people, places, or activities that may trigger recollections of the event
The fourth criterion comprises two or more of the following symptoms of negative alterations in cognitions and mood associated with the traumatic event(s):
- Inability to remember an important aspect of the event(s)
- Persistent and exaggerated negative beliefs about oneself, others, or the world
- Persistent, distorted cognitions about the cause or consequences of the event(s)
- Persistent negative emotional state
- Markedly diminished interest or participation in significant activities
- Feelings of detachment or estrangement from others
- Persistent inability to experience positive emotions
The fifth criterion is marked alterations in arousal and reactivity, as evidenced by two or more of the following:
- Irritable behavior and angry outbursts
- Reckless or self-destructive behavior
- Exaggerated startle response
- Concentration problems
- Sleep disturbance
The remaining three criteria are as follows:
- The duration of symptoms is more than 1 month
- The disturbance causes clinically significant distress or impairment in functioning
- The disturbance is not attributable to the physiologic effects of a substance or other medical condition
PTSD Signs and Symptoms
PTSD can cause many symptoms. These symptoms may include:
- Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
- Bad dreams
- Frightening thoughts
- Staying away from places, events, or objects that are reminders of the experience
- Feeling emotionally numb
- Feeling strong guilt, depression, or worry
- Losing interest in activities that were enjoyable in the past
- Having trouble remembering the dangerous event
- Wanting to avoid thoughts about the trauma, including using alcohol or drugs
- Being easily startled
- Feeling tense or “on edge”
- Having difficulty falling or staying asleep
- Irritability or angry outbursts
- Difficulty concentrating
Other criteria for PTSD diagnosis
- Duration of at least one month
- Functional impairment (clinically significant)
It is natural to have some of these symptoms after a traumatic event occurs. Some people experience serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD, or acute stress response/reaction, or ASR. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. (SCEPHTBI, 2013).
According to the DoD, health professionals must evaluate patients who experience a traumatic event for acute stress reaction in these four areas:
- Physical: exhaustion, hyper-arousal, somatic complaints, or symptoms of conversion disorder
- Emotional: anxiety, depression, guilt/hopelessness
- Cognitive: amnestic or dissociative symptoms, hypervigilance, paranoia, intrusive re-experiencing
- Behavioral: avoidance, problematic substance use
Healthcare providers can learn more about PTSD in Veterans at the National Center for PTSD.
Afterdeployment.org offers trainings for healthcare providers on the topic of PTSD and special populations, including PTSD and aging; African American, Hispanic, Asian-American and Pacific Islander Veterans; and cross-cultural considerations.
Risk Factors for Developing ASD and PTSD
- Ongoing life stress
- Lack of social support
- Young age at time of trauma
- Pre-existing psychological conditions or substance misuse or family history of psychological conditions
- History of traumatic events or abuse
- History of PTSD
Peri-traumatic or trauma-related factors
- Severe trauma
- Physical injury to self or others
- High-risk trauma (eg, combat, killing another person, torture, rape, assault)
- High perceived threat to life of self or others
- Mass trauma
- History of peri-traumatic dissociation
- Ongoing life stress
- Lack of positive social support
- Bereavement or traumatic grief
- Major loss of resources
- Negative social support (blaming environment)
- Poor coping skills
- Distressed spouse or children
PTSD Treatment for Veterans
No matter where a Veteran lives, PTSD treatment is available through the Department of Veterans Affairs. Each medical center within the VA has PTSD specialists, and there are nearly 200 specialized PTSD treatment programs throughout the country. Twenty-nine medical centers have Women’s Stress Disorder Treatment Teams (WSDTT) outpatient programs and six VA medical centers have inpatient Women’s Trauma Recovery Programs (WTRPs). A program locator for specialized VA PTSD clinics is available online at https://www.va.gov/directory/guide/PTSD.asp. The VA also partners with mental health professionals in the community. Large community-based outpatient clinics offer PTSD care.
Did You Know. . .
If no nearby facilities exist, telemental health (using technology to communicate), or referral to Veterans centers or community clinicians, is appropriate.
PTSD programs involve education, evaluation, and treatment. Services for Veterans with PTSD include:
- One-to-one mental health assessment and testing
- One-to-one psychotherapy and family therapy
- Group therapy (covers topics such as anger and stress, combat support, partners) or groups for Veterans of specific conflicts or specific traumas
The VA provides treatments shown by research to be effective in treating Veterans. Not all VAs offer the same programs, and some specialty programs require a referral. Healthcare providers can help patients decide which program is best for them.
The U.S. Department of Veterans Affairs and the National Center for PTSD urge Veterans to seek treatment because it works. The two main types of treatment are psychotherapy, often called counseling or therapy, and medication. Many patients use a combination of psychotherapy and medication. The following treatments are effective for Veterans with PTSD:
- Cognitive Behavioral Therapy (CBT) includes Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE).
- CPT works by giving patients skills to handle distressing thoughts and memories that may leave them feeling stuck and unable to make sense of the trauma experienced. CPT helps patients come to terms with how the trauma changed the way they view themselves, the world, and others. By becoming aware of one’s thoughts and feelings, and then changing the thoughts, one can change one’s feelings.
- PE involves repeated exposure to thoughts, feelings and situations that the patient has been avoiding. PE includes four parts: education, breathing retraining, real world practice (in vivo exposure), and talking through the trauma (imaginal exposure).
- Eye Movement Desensitization and Reprocessing (EMDR), which has four parts: identification of a target memory, image and belief about the trauma; desensitization and reprocessing; installing positive thoughts and images; and body scan to change how the patient reacts to memories of the trauma.
- Medications called selective serotonin reuptake inhibitors (SSRIs), which raise the level of serotonin in the brain to make the patient feel better.
Screening for PTSD
Nurses should ask patients about PTSD. The American Academy of Nursing recommends asking the following questions of patients who are Veterans or family members of Veterans:
- Have you ever experienced a traumatic or stressful event which caused you to believe your life or the lives of those around you were in danger?
- Are you experiencing trauma-related thoughts or feelings?
- Having nightmares, vivid memories or flashbacks of the event?
- Feeling anxious, jittery?
- Experiencing a sense of panic that something bad is about to happen?
- Having difficulty sleeping or concentrating? (ADAA, 2017)
Several self-report measures exist to help screen patients for PTSD. Among these are:
- Chart: Adult PTSD Self-Report Measures
- Davidson Trauma Scale (DTS)
- Mississippi Scale for Combat Related PTSD (M-PTSD)
- Modified PTSD Symptom Scale (MPSS-SR)
- Posttraumatic Diagnostic Scale (PDS)
- Screen for Posttraumatic Stress Symptoms (SPTSS)
- Trauma Symptom Checklist–40 (TSC-40) (NCPTSD, 2015)
Descriptions and reviews of these tools are available on the National Center for PTSD website. There is no single best PTSD measure. The correct tool depends on the goal; for example, a quick screen self-report measure might be best, or a longer interview that assesses for frequency and severity of symptoms might be appropriate.
PTSD and Comorbidities
One study has examined rates of mental health comorbidity in OEF/OIF Veterans with PTSD. In an analysis of VA records of Veterans who served after 9/11, Dedert and colleagues found that 44% of those diagnosed with PTSD had comorbid current depression and 53% had comorbid lifetime substance use disorders (Dedert et al., 2012).
PTSD and Military Families
Families of Veterans and military service members may be affected by their loved one’s PTSD. Living with someone with PTSD can be difficult, especially if that person is experiencing symptoms such as being easily startled, having nightmares, and avoiding social situations. Veterans suffering from PTSD sometimes feel detached from others and avoid emotions. This can cause problems in their personal relationships with a spouse or children.
Family members of a Veteran with PTSD may experience the following:
- Sympathy for the loved one’s suffering (be careful not to treat him or her as a permanently disabled person)
- Negative feelings about the ways in which the loved one has changed
- Avoidance of situations that cause reminders of the trauma
- Depression among family members because the PTSD causes feelings of pain or loss; family members may lose hope that the family will ever “return to normal.”
- Anger and guilt because you cannot make a difference for your loved one; anger may also arise if the loved one is irritable, cannot work, or drinks too much.
- Health problems can arise if bad habits such as drinking, smoking, not exercising get worse while trying to cope with the family member’s PTSD. (DVA, NCPTSD, 2015)
Healthcare providers should encourage family members to care for themselves, even if their family member with PTSD doesn’t seek treatment, and learn more about trauma and its effects. Family members can encourage the trauma survivor to seek treatment, education, and counseling, but should not try to force the person to get help. Providers can recommend classes or treatment for stress, anger management, substance use and addiction, couples counseling, and parenting.
Veterans’ families can call Coaching Into Care at 888 823 7458 or log on to http://www.mirecc.va.gov/coaching/. Coaching Into Care is a free and confidential coaching service to help callers discover ways to talk with a Veteran in their life about their concerns and treatment options.
Secondary Traumatic Stress
Secondary traumatic stress is the emotional reaction to the traumatic experience of a significant other, such as a family member who is a Veteran. Secondary traumatization is the stress caused by providing help, or wishing to help, and offering emotional support to a traumatized person. Secondary stress disorder (SSD) as a syndrome is almost identical to PTSD except that indirect exposure to the traumatic event through close contact with the primary victim of trauma becomes the cause of the traumatic stress. The symptoms of secondary traumatization include nightmares about the person who was directly traumatized, insomnia, loss of interest, irritability, chronic fatigue, and changes in self-perception, perception of one’s own life, and of other people. Physical symptoms may also be present, including headaches, indigestion, susceptibility to infections, and increased use of alcohol, drugs, or tobacco (Frančišković et al., 2007).
Secondary traumatic stress is a common occupational hazard for healthcare professionals working with traumatized individuals. Healthcare professionals who work directly with traumatized people, and are in a position to hear the recounting of traumatic experiences, are at risk of secondary traumatic stress. The risk appears to be greater among women and among individuals who are highly empathetic by nature or who have unresolved personal trauma. Risk is also higher for professionals who carry a heavy caseload, are socially or organizationally isolated, or feel professionally compromised due to inadequate training. Protective against the development of secondary traumatic stress are factors such as longer duration of professional experience and the use of evidence-based practices in the course of providing care (NCTSN, 2015).
Relationships and PTSD
People with PTSD often experience strained relationships, even with close family and friends. Symptoms of PTSD can cause problems with communication, closeness, trust, and problem solving, which may negatively impact how the trauma survivor relates to others. They may feel detached, tense, angry or worried, or feel numb and distant from loved ones. Interest in social activities or sex may diminish, which can impair the ability to be intimate. Trauma survivors may become tense and demanding, or exhibit a need to protect their loved ones. Sleep with a spouse or partner may be diminished.
Family members, friends, and partners of people with PTSD may feel abandoned, hurt, or cut off from the trauma survivor. They may become anxious, angry, distant, depressed, or controlled. Family members of those with PTSD can sometimes experience some of the same feelings as the person who has lived through the trauma. In turn, the response of family members to the trauma survivor can affect the person who experienced the trauma.
Certain types of trauma appear to have a more severe effect on relationships. These include combat, terrorism, torture, prisoner of war, rape, domestic violence, or childhood sexual and physical abuse. Key symptoms in PTSD from these traumas are feelings of terror, horror, danger, and betrayal.
Good relationships can be maintained by:
- Building a personal support network while working on family and friend relationships
- Sharing feelings openly and honestly, with respect and compassion
- Building problem solving and connecting skills
- Incorporating play, creativity, relaxation, and ways to enjoy others
Partners of Veterans with PTSD should seek information and education about the effects of PTSD on trauma survivors and their families, support groups for themselves and their Veterans, individual therapy for themselves and their Veterans, and couples or family counseling. The VA Caregiver website (http://www.caregiver.va.gov/) has resources for families and partners of Veterans with PTSD.
Military Sexual Trauma (MST)
According to Title 38 U.S. Code 1720D, military sexual trauma (MST) is defined as:
psychological trauma resulting from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training. (DVA, 2016a)
Sexual harassment is defined as:
repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character. (DVA, 2016a)
Military sexual trauma refers to both sexual harassment and sexual assault that occurs in military settings. Veterans of all ages and genders; all ranks, branches, and areas of service; all racial, ethnic, and religious backgrounds; all sexual orientations; and all physical sizes and strengths have experienced MST. The perpetrator can be the same or different gender.
Sexual harassment is unwelcome verbal or physical conduct of a sexual nature that occurs in the workplace or an academic or training setting. Sexual harassment can include unwanted sexual attention, such as offensive comments about a person’s sexual activities or body, and sexual coercion (such as stated or implied special treatment if you were sexually cooperative).
Sexual assault is any sexual activity between at least two people in which one person is involved against his or her will. Physical force may or may not be used. The sexual activity can include many different experiences including unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an object, and/or sexual intercourse (Street & Stafford, 2014).
MST is associated with increased prevalence of a wide range of mental health disorders, including posttraumatic stress disorder among both men and women.
Some common difficulties related to MST are:
- Strong emotions: intense, sudden emotional reactions; feeling depressed, angry or irritable; feeling ashamed or “damaged”
- Feelings of numbness: feeling emotionally “flat”; difficulty feeling emotions like love or happiness
- Trouble sleeping: trouble falling or staying asleep; disturbing dreams
- Difficulties with attention, concentration, and memory: trouble staying focused; having a hard time remembering things
- Self-doubt or questioning: blaming yourself; questioning parts of who you are, like your masculinity/femininity or sexual orientation
- Problems with alcohol or other substances: drinking or using substances or getting “high” to cope or escape
- Self-harm or unsafe behaviors: suicidal thoughts or behaviors; cutting; risk-taking; aggression
- Difficulty with things that remind them of their experiences of sexual trauma: feeling on edge or “jumpy”; difficulty feeling safe; avoiding reminders of MST
- Difficulties in relationships: feeling isolated or disconnected; difficulty trusting; unsafe relationships; trouble with authority figures; frequent arguments
- Sexual difficulties: concerns about sex drive; problems with arousal, enjoyment, performance, or pain during sex; avoidance of physical intimacy
- Physical health problems: chronic pain; weight or eating problems; digestive problems (DVA, 2017b)
According to one study, MST is reported by 20% to 40% of female Veterans, resulting in PTSD, depression, and sleep difficulty (Maguen et al., 2012). Of those reporting MST, 66.4% suffered from chronic pain associated with abuse‐related trauma, physical health problems, and trouble sleeping. This is consistent with other research that found, among women with PTSD, 31% screen positive for MST with associated comorbid depression, anxiety, and eating disorder diagnoses (Maguen et al., 2012).
Military sexual trauma has negative impacts on Veterans’ physical and psychological health. Medical conditions identified with increased frequency in patients with histories of sexual trauma include arthritis, obesity, diabetes, hypertension, hyperlipidemia, myocardial infarction, chronic lung disease, endometriosis, miscarriage, and infertility.
Psychological and behavioral problems are common in people who have experienced MST. Depression, PTSD, suicidal ideation and attempts, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and substance abuse and dependence are frequently seen in women.
One study suggests that American servicewomen who are sexually assaulted do not seek medical care right away. Fewer than one-third of more than 200 women who said they had been sexually assaulted while in the service sought care after the attack. Only four received both medical and mental healthcare within six months. Military women face concerns regarding confidentiality and their military careers. Other research shows that women in the military experience higher rates of sexual assault than non-military women (Dotinga, 2015a).
Men who have experienced MST are often reluctant to talk about their experience. They may feel alone, assuming that MST does not happen to other men. They may blame themselves or believe they should have been able to stop or prevent the trauma. They may also have had uncontrollable biological reactions during the MST, such as an erection or ejaculation. Such biological reactions do not mean the man wanted or enjoyed the MST. It also does not mean anything about his sexual orientation (DVA, 2015).
Screening for MST
Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is national VHA policy that all Veterans seen in VA health care are screened for experiences of MST. This is an important way to make sure that Veterans are aware of VA’s MST-related services.
The American Academy of Nurses recommends that nurses in the community healthcare setting use the following questions to screen quickly for military sexual trauma:
- During military service, did you receive uninvited or unwanted sexual attention, such as touching, pressure for sexual favors, or sexual remarks?
- Did anyone ever use force or threat of force to have sexual contact with you against your will?
- Did you report the incidents to your command and/or military or civilian authorities? (AAN, 2017)
The DVA independent study course on MST recommends that clinicians use language that describes specific behavior rather than jargon or emotionally loaded terms such as “rape,” “sexual assault,” “domestic violence,” “sexual abuse,” or “incest.” Healthcare professionals should take a nonjudgmental stance, and avoid negative questioning (“You were never raped during your time in the service, were you?”). Rather, providers should use normalizing statements to help introduce the questioning, including the following examples:
“Violence is common in our society, so I ask all my patients about this.”
“Many of my patients have had upsetting experiences in their lives that may still bother them today.”
“In response to increased awareness that many men and women have experienced sexual harassment or sexual assault during their military service, VA has launched a national effort to identify those Veterans who may be in need of services, so all Veterans are now being asked about certain experiences.” (DVA, 2004)
Another approach to gather information is to give patients a trauma questionnaire.
Trauma Questionnaire for Military Personnel
Some people experience traumatic events during their military service. We are trying to find out about these events and how they affect Veterans’ lives. We also want to find out if Veterans want mental health help addressing these or other concerns. To answer a question, please check yes, no, or don’t know. Thank you for your time.
Have you ever been involved in an major accident or disaster?
Have you ever been physically assaulted or been a victim of a violent crime?
At any time, has a spouse or partner (significant other) ever threatened to physically hurt you in any way?
At any time, has a spouse or partner (significant other) ever hit you, kicked you, or physically hurt you in any way?
Did this happen to you while you were in the military?
Have you ever received uninvited and unwanted sexual attention (eg, touching or cornering, pressure for sexual favors, verbal remarks)?
Did this happen to you while you were in the military?
Has anyone ever used force or the threat of force to have sex with you against your will?
Did this happen to you while you were in the military?
Were you ever sexually assaulted or touched in a sexual way, by a person 5 or more years older than you, when you were younger than 13?
Would you like to talk to a mental health worker about any of the above problems?
Do you have any mental health questions or concerns that are not on this questionnaire?
Would you like to talk to a mental health worker about these other problems?
Unique Aspects of MST
Further investigation into the topic of military sexual trauma is needed. However anecdotal evidence suggests that some aspects of MST are unique and may be associated with qualitatively or quantitatively different outcomes than civilian sexual trauma (Street & Stafford, 2014).
For example, MST typically happens in a setting where the victim lives and works. Therefore, the victim often must continue to live and work closely with the perpetrator(s). Victims may experience increased feelings of helplessness and powerlessness, as well as feelings of being continually at risk. Sometimes victims must rely on their perpetrators to provide for basic needs.
Another aspect of MST is that, because the trauma occurs in the workplace, it can disrupt the victims’ career goals. Perpetrators may be peers or supervisors who make work-related performance evaluations and promotions. Victims may be forced to choose to continue their military careers where they have frequent contact with their perpetrators, or to sacrifice their career to protect themselves from further abuse. Furthermore, the high unit cohesion in the military, especially during combat, may play a negative role in the psychological effects associated with sexual harassment and assault. Victims may be reluctant to report any negative behavior of a fellow service member because it may affect their relationships with co-workers and peers (Street & Stafford, 2014).
Results of MST
Intensity, duration, and trajectory of psychological responses vary depending on the victim’s previous trauma history, their thoughts about the event, and the quality of their support systems. Gender may also play a key role. Military sexual trauma may be even more stigmatizing for men than for women because the victimization falls outside the proscribed male gender role. These men may feel more shame about the event and be less likely to seek professional help.
For both men and women who have experienced MST, outcomes include poorer psychological well-being, more physical problems, and lower satisfaction with health and work. Victims have readjustment problems following discharge and a higher incidence of not working due to mental health problems.
Studies show that posttraumatic stress disorder is a frequent outcome in civilian sexual assault. Major depressive disorder (MDD) is another common outcome, as is increased substance use. Feelings of anger, shame, guilt, or self-blame are common. Victims of MST report problems in their interpersonal relationships, such as difficulty with trust, social activities, or sexual dysfunction. Male victims worry about their sexuality or their masculinity (Street & Stafford, 2014).Veterans who have experienced MST have access to a wide range of services at the VA, free of charge. A VA MST Coordinator serves as a contact person for MST-related issues at the facility and can help Veterans access services and programs.
Approximately 1 in 4 women and 1 in 100 men seen at the VA report a history of MST when screened by a VA provider. Given the far greater number of men in military service, this means there are significant numbers of both men and women who have experienced MST. In fact, over 40% of the Veterans seen in VA who disclose MST are men (DVA, 2017b).
Suicide Among Veterans
Suicide is a serious public health problem that has shattered the lives of millions of people, families, and communities nationwide. Centers for Disease Control and Prevention (CDC) data released in an April 2016 report indicated that between 1999 and 2014, suicide rates increased among the general population, for both males and females and for all ages.
Healthcare providers are in a unique position to identify individuals at risk for suicide and act to deliver care. However, everyone can help prevent suicide by being aware of the warning signs of suicidal behaviors. Here are some facts about suicide:
- Suicide is the tenth leading cause of death in the United States, claiming more than twice as many lives each year as homicides.
- On average, more than 33,000 Americans died each year between 2001 and 2009 as a result of suicide—more than 1 person every 15 minutes.
- In 2007 suicide rates were significantly elevated across all branches of the military. History of deployment to combat was associated with increased suicides in the Army in 2005 and in all services in 2007. (SAMHSA, 2012)
- In 2014, Veterans accounted for 18% of all deaths from suicide among U.S. adults, while Veterans constituted 8.5% of the U.S. population. In 2010, Veterans accounted for 22% of all deaths from suicide and 9.7% of the population. (DVA, 2016b)
- It is estimated that 20 Veterans died of suicide each day in 2014. Of those, 14 were not users of VA services. (VHA, 2014)
- In 2010 nearly 300 service members committed suicide; about half of these were people who had deployed to Iraq or Afghanistan. (IOM, 2013)
- The rate of suicide among female VHA users has increased 18.9 per 100,000, compared to 7.2 per 100,000 for females in the civilian population, or 2.4 times higher. (VHA, 2014)
- Approximately 66% of all Veteran deaths from suicide were the result of firearm injuries. (DVA, 2016b)
- There is continued evidence of high burden of suicide among middle-aged and older adult Veterans. In 2014, approximately 65% of all Veterans who died from suicide were aged 50 years or older. (DVA, 2016b)
- After adjusting for differences in age and gender, risk for suicide was 21% higher among Veterans when compared to U.S. civilian adults. (VHA, 2014; DVA, 2016b)
- After adjusting for differences in age, risk for suicide was 18% higher among male Veterans when compared to U.S. civilian adult males. (VHA, 2014; DVA, 2016b)
Members of the Armed Forces and Veterans of military service are among the populations at increased risk of suicide, along with individuals who have mental and/or substance use disorders; individuals bereaved by suicide; individuals in justice and child welfare settings; individuals who engage in non-suicidal self-injury; individuals who have attempted suicide; individuals with medical conditions; individuals who are lesbian, gay, bisexual, or transgender (LGBT); American Indians/Alaska Natives; men in midlife; and older men (SAMHSA, 2012).
It is easy to understand how many military personnel and Veterans may belong to more than one of these at-risk populations. A study published in 2015 looked at changes in suicide mortality of Veterans and nonVeterans by gender and history of VHA service use. It found that suicides among women Veterans increased by 40% from 2000 to 2010, compared to a 13% increase in women non-Veterans. The study also showed that among women Veterans, those who use VA care have suicide rates as much as 75% lower than those who do not. Male Veterans also saw reduction in suicide rates, about 20%, for those who used VHA services (Hoffmire et al., 2015).
The VA believes every Veteran suicide is a tragic outcome: one Veteran suicide is one too many. Throughout VA the message is “Suicide Prevention Is Everyone’s Responsibility.” In recent years the Department of Defense, VA, and HHS have strengthened their partnership to build on their suicide prevention efforts using evidence-based and best practices in the clinical and public health arenas (DVA, 2016).
Substantial, coordinated efforts to expand suicide prevention include:
- Suicide Data Repository stores all mortality-related information including suicide-related data for service members and Veterans to support researchers and decision makers.
- Veterans Crisis Line answered 2.3 million calls and made more than 289,000 chat connections and more than 55,000 texts between 2007 and May 2016.
- Suicide Safe, a suicide prevention app for mobile devices from SAMHSA launched in 2016, helps providers integrate suicide prevention strategies into their practice and address suicide risk among their patients. Based on SAMHSA’s Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) card, the app has been downloaded 34,000 times in the first year.
- Outreach programs and campaigns to prevent suicide include Military OneSource (confidential, face-to-face, online, telephone, and video non-medical counseling and specialty consultation), and “Power of One” Suicide Prevention Campaign promotes the message that one person, one conversation, or one small act has the power to help prevent suicide. (DOD/DVA/DHHS, 2016)
U.S. National Suicide Prevention Lifeline
The number for the suicide prevention lifeline is
800 273 TALK (8255)
Healthcare providers should consult the Suicide Risk Guidelines published by the VA/DoD and available at
A convenient pocket guide helps in the assessment and management of patients at risk for suicide.
Suicide Risk Guidelines
The VA and Department of Defense published Clinical Practice Guidelines for Patients at Risk for Suicide in a pocket guide format. Key elements of the suicide risk guidelines include:
Assessment and determination of risk
- Identify warning signs for suicide
- Assess for suicidal ideation, intent, and behavior
- Assess risk and protective factors affecting suicide risk
- Evaluate patients at intermediate and high risk for suicide by behavioral health providers
Initial management of patient at risk for suicide
- Determine level of risk for suicide attempt
- Determine appropriate care setting
- Educate patient and family on risk and treatment options
- Limit access to lethal means
- Establish a safety plan
Treatment of a patient at high risk for suicide
- Interventions addressing the suicide risk:
- Suicide-focused psychotherapies shown to be effective in reducing the risk for repeated self-directed violence:
- Cognitive therapy for suicide prevention (CT-SP)
- Problem-solving therapy (PST) addressing the risk for suicide behaviors
- Suicide-focused psychotherapies shown to be effective in reducing the risk for repeated self-directed violence:
- Interventions addressing the underlying conditions:
- Optimize treatment for any mental health and medical conditions that may be related to the risk of suicide
- Modify care for the relevant condition-focused treatments
- to address the risk of suicide
- Provide psychotherapy/pharmacotherapy interventions for co-occurring mental disorders to reduce the risk of suicide (DVA/DoD, 2013a)
Recognizing Signs of Suicidal Behavior
Many Veterans may not show any signs of intent to harm themselves before doing so, but some actions can be a sign that a Veteran needs help. Veterans in crisis may show behaviors that indicate a risk of harming themselves.
Veterans who are considering suicide often show signs of depression, anxiety, low self-esteem, and/or hopelessness, such as:
- Appearing sad or depressed most of the time
- Clinical depression: deep sadness, loss of interest, trouble sleeping and eating—that doesn’t go away or continues to get worse
- Feeling anxious, agitated, or unable to sleep
- Neglecting personal welfare, deteriorating physical appearance
- Withdrawing from friends, family, and society, or sleeping all the time
- Losing interest in hobbies, work, school, or other things one used to care about
- Frequent and dramatic mood changes
- Expressing feelings of excessive guilt or shame
- Feelings of failure or decreased performance
- Feeling that life is not worth living, having no sense of purpose in life
- Talk about feeling trapped—like there is no way out of a situation
- Having feelings of desperation, and saying that there’s no solution to their problems
Their behavior may be dramatically different from their normal behavior, or they may appear to be actively contemplating or preparing for a suicidal act through behaviors such as:
- Performing poorly at work or school
- Acting recklessly or engaging in risky activities—seemingly without thinking
- Showing violent behavior such as punching holes in walls, getting into fights or self-destructive violence; feeling rage or uncontrolled anger or seeking revenge
- Looking as though one has a “death wish,” tempting fate by taking risks that could lead to death, such as driving fast or running red lights
- Giving away prized possessions
- Putting affairs in order, tying up loose ends, and/or making out a will
- Seeking access to firearms, pills, or other means of harming oneself
Veterans’ Self-check Quiz
The Department of Veterans Affairs and the National Suicide Prevention Lifeline have joined with the American Foundation for Suicide Prevention to create the Veterans Self-Check Quiz. This is a safe, easy way to learn whether stress and depression might be affecting you. Using this service is completely voluntary and confidential. The Self-Check Quiz is available at
Suicide Warning Signs
Warning signs are observations that signal an increase in the probability that a person intends to engage in suicidal behavior in the immediate future (minutes to days). Warning signs present tangible evidence to the clinician that a person is at heightened risk for suicide in the short term. Warning signs may be experienced in the absence of risk factors.
Direct and Indirect Warning Signs of Suicidal Behavior
Direct warning signs portend the highest likelihood of suicidal behaviors occurring in the near future.
Writing or talking about suicide, wish to die, or death (threatening to hurt or kill self) or intention to act on those ideas
Preparations for suicide
Evidence or expression of suicide intent, and/or taking steps towards implementation of a plan. Makes arrangements to divest responsibility for dependent others (children, pets, elders), or making other preparations such as updating wills, making financial arrangements for paying bills, saying goodbye to loved ones, etc.
Seeking access or recent use of lethal means
Owning or planning to acquire weapons, medications, toxins, or other lethal means.
Indirect warning signs are presentations or behavioral expressions that may indicate increased suicide risk and urgency in a patient at risk for suicide.
Increasing or excessive substance use (alcohol, drugs, smoking)
Expresses feeling that nothing can be done to improve the situation
Express no sense of purpose, no reason for living, decreased self-esteem
Rage, seeking revenge
Engaging impulsively in risky behavior
Expressing feelings of being trapped with no way out
Withdrawing from family, friends, society
Agitation, irritability, angry outbursts, feeling like wants to “jump out of my skin”
Dramatic changes in mood, lack of interest in usual activities/friends
Insomnia, unable to sleep or sleeping all the time
Guilt or Shame
Expressing overwhelming self-blame or remorse
Risk Factors for Suicide
Providers must be on the lookout for both acute risk factors and chronic risk factors for suicide. Acute risk factors include acute (of brief duration) and stressful episodes, illnesses, or life events. While not usually internally derived, these events can build upon and challenge a person’s coping skills. Chronic risk factors are pre-existing and include relatively enduring or stable factors that may increase a person’s susceptibility to suicidal behaviors, such as genetic and neurobiologic factors, gender, personality, culture, socioeconomic background and level of isolation.
- Suicide of relative, someone famous, or a peer
- Suicide bereavement
- Loss of loved one (grief)
- Loss of relationship (divorce, separation)
- Loss of status/respect/rank (public humiliation, being bullied or abused, failure work/task)
- Stressful life events (acute experiences)
- Breakups and other threats to prized relationships
- Other events (eg, fired, arrested, evicted, assaulted)
- Chronic stressors (ongoing difficulties)
- Financial problems
- Unemployment, underemployment
- Unstable housing, homeless
- Excessive debt, poor finances (foreclosure, alimony, child support)
- Legal problems (difficulties)
- DUI/DWI, lawsuit, criminal offense and incarceration
- Social support
- Poor interpersonal relationship (partner, parents, children)
- Geographic isolation from support
- Recent change in level of care (discharge from inpatient psychiatry)
- Mood or affective disorder (major depression, bipolar, postpartum)
- Personality disorder (especially borderline and antisocial)
- Anxiety (PTSD, panic)
- Eating disorder
- Sleep disturbance or disorder
- Trauma (psychological)
- History of traumatic brain injury
- Terminal disease
- New diagnosis of major illness
- Having a medical condition
- Substance withdrawal (alcohol, opiates, cocaine, amphetamines)
- Use of prescribed medication w/ warning for increased risk of suicide
- Physical symptoms
- Chronic pain
- Function limitation
- Disciplinary actions (UCMJ, NJP)
- Reduction in rank
- Career-threatening change in fitness for duty
- Perceived sense of injustice or betrayal (unit/command)
- Command/leadership stress, isolation from unit
- Transferring duty station (PCS)
- Administrative separation from service/unit
- Adverse deployment experience
- Deployment to a combat theater
Pre-existing and non-modifiable
- Age (young, elderly)
- Gender (male)
- Race (white)
- Marital status (divorce, separate, widowed)
- Family history of:
- Mental illness (including SUD)
- Child maltreatment trauma, physical/psychological/sexual
- Sexual trauma
- Lower education level
- Same-sex orientation (LGBT)
- Cultural or religious beliefs (VA/DoD, 2013)
Protective Factors Against Suicide
Social context support system
- Strong interpersonal bonds to family/unit members and community support
- Intact marriage
- Child rearing responsibilities
- Responsibilities/duties to others
- A reasonably safe and stable environment
Positive personal traits
- Help seeking
- Good impulse control
- Good skills in problem solving, coping and conflict resolution
- Sense of belonging, sense of identity, and good self-esteem
- Cultural, spiritual, and religious beliefs about the meaning and value of life
- Optimistic outlook—Identification of future goals
- Constructive use of leisure time (enjoyable activities)
Access to healthcare
- Support through ongoing medical and mental healthcare relationships
- Effective clinical care for mental, physical and substance use disorders
- Good treatment engagement and a sense of the importance of health and wellness (VA/DoD, 2013)
Suicide and Sexual Assault
Sexual assault and suicide are important concerns among both military and civilian populations. There are few published studies on the association between sexual assault and suicidal ideation, attempts, or death by suicide in American military populations.
According to a white paper published by the Military Suicide Research Consortium, research in civilian populations has provided evidence that sexual assault is associated with increased risk for suicidal ideation, attempts, and death by suicide. Much of this research has been conducted on women and has found that being sexually assaulted as an adult is significantly associated with higher rates of suicidal ideation and attempts.
Sexual assault also has been found to increase the risk for death by suicide by as much as 14 times for female victims compared to women who have never been assaulted, even after controlling for psychiatric diagnoses present prior to the assault. There is some evidence that civilian male sexual assault victims are at higher risk of suicide compared to those who have never been assaulted, and that they may have adverse mental health responses to sexual assault similar to civilian women (MSRC, 2012).
Sexual assault is also commonly associated with adverse mental health outcomes such as depression, anxiety, substance abuse, and non-suicidal self-injury, which are also commonly associated with suicidal ideation, attempts, and death by suicide (MSRC, 2012).
Veterans Crisis Line
The responders at the Veterans Crisis Line are specially trained and experienced in helping Veterans of all ages and circumstances—from Veterans coping with mental health issues that were never addressed to recent Veterans struggling with relationships or the transition back to civilian life. Veterans Crisis Line responders provide support when these and other issues—such as chronic pain, anxiety, depression, sleeplessness, anger, and even homelessness—reach a crisis point. Some of the responders are Veterans themselves and understand what Veterans and their families and friends have been through.
Confidential Help for Veterans and Their Families
The Veterans Crisis Line is a toll-free, confidential resource that connects Veterans in crisis and their families and friends with qualified, caring U.S. Department of Veterans Affairs (VA) responders.
Veterans and their loved ones can
- Call 800 273 8255 and Press 1
- Chat online at VeteransCrisisLine.net
- Send a text message to 838255
to receive free, confidential support 24 hours a day, 7 days a week, 365 days a year, even if not registered with VA or enrolled in VA healthcare.
Between its launch in 2007 and May 2016, the Veterans Crisis Line answered more than 2.3 million calls. In 2009 the Veterans Crisis Line added an anonymous online chat service and has engaged in more than 289,000 chats. In November 2011 the Veterans Crisis Line introduced a text-messaging service to provide another way for Veterans to connect with confidential, round-the-clock support, and since then has responded to more than 55,000 texts. The service has initiated the dispatch of emergency services to callers in imminent suicidal crisis over 61,000 times and provided over 376,000 referrals to a VA Suicide Prevention Coordinator (SPC), thus ensuring Veterans are connected to local care. In 2011 the National Veterans Suicide Prevention Hotline was renamed the Veterans Crisis Line to encourage Veterans and their families and friends, who may be the first to realize a Veteran is in emotional distress, to reach out for support when issues reach a crisis point, even if it is not a suicidal crisis.
VA is working to make sure that all Veterans and their loved ones are aware of the Veterans Crisis Line. To reach as many Veterans as possible, VA is coordinating with communities and partner groups nationwide, including community-based organizations, Veterans service organizations, and local healthcare providers, to let Veterans and their loved ones know that support is available whenever, if ever, they need it.
Major depressive disorder (MDD), or depression, is a persistent medical illness that manifests as sadness that doesn’t resolve within a few days. People with depression feel discouraged, sad, hopeless, unmotivated, and disinterested in life. If such feelings persist for two weeks or more, or when the feelings interfere with daily activities such as going to work, taking care of family, or spending time with people, it is likely to be a major depressive episode, or major depressive disorder (ADAA, 2015).
Depression affects how an individual functions, behaves, feels, and thinks. Some describe it as a total loss of energy or enthusiasm to do anything. Others describe depression as living with a constant feeling of impending doom. Depression can cause a variety of emotional and physical problems. However MDD is a treatable chronic illness.
Symptoms of Depression
A major depressive episode (MDE) may include these symptoms:
- Persistent sad, anxious or “empty” mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities, including sex
- Decreased energy, fatigue, feeling “slowed down”
- Difficulty concentrating, remembering, making decisions
- Insomnia, early-morning awakening, or oversleeping
- Low appetite and weight loss or overeating and weight gain
- Thoughts of death or suicide, suicide attempts
- Restlessness, irritability
- Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and pain for which no other cause can be diagnosed.
Major depressive episodes may happen once or twice in a person’s life, or may recur frequently. Some people with depression may decide that life is too painful to go on living and attempt suicide.
Persistent Depressive Disorder (PDD)
Also called dysthymic disorder, or dysthymia, persistent depressive disorder (PDD) is characterized by long-term (2 years or longer) symptoms that may not be severe enough to disable a person but can prevent normal functioning or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes (NIMH, 2011).
Major depression among soldiers and Veterans often occurs with other physical and behavioral health issues, including TBI, PTSD, and anxiety. As such, depression can complicate detection of and treatment for other physical or behavioral health issues that coincide with it. Both diagnosed and undiagnosed depression can increase the risk associated with other at‐risk outcomes such as suicide and partner aggression (Army Gold Book, 2012).
Those among the U.S. population “. . . with lifelong history of major depression, were 10 times as likely to report having thoughts of suicide.” Additionally, in one study the “presence of depressive symptoms was positively associated with the presence and severity of domestic violence. . . For each 20% increase in depressive symptoms, there was a 74% increase in the likelihood of husband‐to‐wife aggression”; this positive correlation was also found among Vietnam Veterans (Army Gold Book, 2012).
Substance abuse has also been linked to depression and PTSD. One study found that individuals suffering from depression were twice as likely to have a co‐occurring substance use disorder. The same study reported that 20% to 67% of the people who sought alcohol treatment had experienced depression.
Substance use may initially minimize or moderate the mood disorder symptoms, but withdrawal and chronic abuse typically exacerbate mood degradation, leading to abuse and dependence. Given the association of alcohol and drug use with mood disorders and particularly depression, soldiers and Veterans being treated for either substance use disorder or major depressive disorder should be evaluated for the other (Army Gold Book, 2012).
Screening for Depression
The PHQ-9 is the most commonly used screening tool to identify depression. It is a ten-question self-screening interview available at https://www.myhealth.va.gov. Veterans and family members can answer the questions to evaluate the last two weeks and determine their need for diagnosis and treatment.
Treatment for Depression
A variety of medications and therapies are available to treat depression. Antidepressant medications help to stabilize mood. Psychotherapy can help people manage their symptoms. Often a combination of the two is the most effective treatment.
Medications to treat depression are known as antidepressants. They work by affecting neurotransmitters in the brain, especially serotonin and norepinephrine. There are several classes of antidepressants, including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs). The medications that are included in these classes are numerous and each has different side effects. It is common for people with depression to need to try different medications to find one that relieves their depression and has tolerable side effects (SAMHSA, 2015).
Cognitive Behavior Therapy (CBT) blends cognitive therapy and behavioral therapy. By focusing on a person’s thoughts and beliefs, and how they influence feelings, mood, and actions, CBT works to change the depressed person’s thinking to be more healthy. The therapist encourages the patient to identify negative self-talk and distorted thoughts, change inaccurate beliefs, do more enjoyable activities, relate in more positive ways to self and others, learn problem-solving and coping skills, and change behaviors (MIRECC, 2011).
Assertive Community Treatment (ACT) is an effective approach for individuals who are in the greatest need, such as those who have been hospitalized more than once. In ACT, and interdisciplinary team of professionals, such as case managers, a psychiatrist, nurses, and social workers, substance abuse treatment specialists, and others, provide care and coverage 24 hours, 7 days per week. Treatment includes crisis intervention, medication management, individual therapy, substance abuse treatment, rehabilitation, and peer support (MIRECC, 2011).
Electroconvulsive Therapy (ECT) is a treatment procedure for severe or life-threatening depression. It is used when antidepressants and psychotherapy have not worked. The patient’s brain is stimulated by electrical currents via electrodes placed on the head. It is believed that ECT works to alleviate depression by altering neurochemicals including serotonin and endorphins. ECT is usually provided along with medication, psychotherapy, family therapy, and behavioral therapy (MIRECC, 2011).
Depression’s Effect on Family Members
Depression, as with all mental illness, affects family members as well as the person feeling depressed. Treating families can help the person with depression as well as his or her loved ones. Family psycho-education is a way to work toward recovery. A clinician meets with the family to discuss the problems they are having. Family members then attend educational sessions to learn about mental illness, coping skills, problem-solving skills, communication skills, and other ways they can work together toward recovery (MIRECC, 2011).
Family members can help their loved one with depression by encouraging the person to get treatment and providing support in following through with medication adherence and attendance of psychotherapy sessions. They can provide support by listening sympathetically to their loved one’s feelings, remembering the person is in pain, and being understanding and not critical (MIRECC, 2011).
It is important for family members to understand that depression is an illness, not a moral weakness or deficiency. Research shows that family members who believe that depression is a medical illness are less critical of their depressed loved one and have greater feelings of warmth, sympathy, and willingness to help (MIRECC, 2011).
Did You Know. . .
There is a strong relationship between critical and hostile attitudes on the part of family members and relapse among people who are depressed (MIRECC, 2011).
Family members of Veterans who have depression must remember to take care of themselves. They are not responsible for solving the problem of depression themselves.
Veterans reintegrating into civilian life after their military service frequently experience grief over the loss of friends and comrades. If the death was sudden or violent, as from combat or disaster, it can be even more distressing. Experiencing grief often involves the following emotions: denial, disbelief, confusion, shock, sadness, yearning, anger, humiliation, despair, and guilt. Acute grief is often experienced as physical symptoms, including stomach pain, loss of appetite, intestinal upsets, sleep disturbances, and loss of energy. Illnesses may worsen and new conditions may develop. Emotions brought on by grief can result in anxiety attacks, chronic fatigue, depression, and suicidal thoughts (MHA, 2015).
Veterans and Families Experiencing Grief
When a friend or loved one dies we must allow time to grieve. There are many ways to cope effectively. Mental Health America recommends these coping tactics.
- Seek out caring people. Tell relatives and friends how you feel; it will help you to work through the grieving process. Join a support group with others who have experienced similar losses and understand how you feel. Most military installations have support groups. Ask for help if you feel overwhelmed; it’s not a sign of weakness. Seek out companionship; do not become isolated. Talk about your feelings with a trusted relative, friend, family services staffer, minister or rabbi. Military chaplains can be helpful, as most receive training in pastoral counseling and crisis.
- Take care of your health. Eat properly, exercise, and get plenty of rest. Be aware of the danger of using medication or alcohol to deal with your grief. See your doctor regularly.
- Be patient. Absorbing a loss takes effort and time. You must accept that your life has changed and strive to live in the present and not dwell on the past.
- Seek help. If your feelings become too much to bear, seek professional assistance to work through your grief. It’s a sign of strength, not weakness, to seek help.
Helping Others Grieve
If someone you care about has lost a loved one, you can help him or her through the grieving process.
- Listen. Encourage the person to talk about his or her feelings and to share memories of the deceased. Remember, it may take the person a long time to recover from the loss.
- Don’t offer false comfort. It doesn’t help the grieving person to say “You’ll get over it in time.” Instead, offer a simple expression of sorrow and take time to listen.
- Offer practical help. You can help someone who is grieving by babysitting, cooking, and running errands.
- Encourage professional help when needed. Recommend professional help if you feel someone is experiencing too much pain to cope alone.
Tragedy Assistance Program for Survivors assists people who have lost family members in the Armed Forces. TAPS provides a survivor-peer support network, grief counseling referrals, and crisis information. TAPS can be reached at 800 959 TAPS (8277) or www.taps.org.
Substance use and abuse is a significant problem in the United States. It affects people of every race, ethnicity, gender, and location. Substance use disorder is to be suspected when using drugs or alcohol continues despite its causing physical, psychological, and emotional pain.
- 60.1 million aged 12 or older were current (past month) binge drinkers.
- 24.6 million aged 12 or older were current users of illicit drugs.
- 19.8 million aged 12 and older were current users of marijuana. (SAMSHA, 2014)
According to the DVA, about 20% of Iraq and Afghanistan Veterans come home with posttraumatic stress disorder, and more than 20% of Veterans diagnosed with PTSD also suffer from substance use disorder. A study of VA healthcare users reports that more than 11% of OEF and OIF Veterans have been diagnosed with a substance use disorder (SUD)—an alcohol use disorder, a drug use disorder, or both. In addition, the data available for alcohol use show that some Veterans use alcohol to self-medicate. VA data show that almost 22% of OEF and OIF Veterans with posttraumatic stress disorder (PTSD) also have an SUD (SAMHSA, 2012a).
Furthermore, a 2013 study by Golub and colleagues, published in Military Medicine using data from the 2004 to 2010 National Survey on Drug Use and Health, examined the prevalence of unmet mental health needs among Veterans aged 21 to 34. Researchers found that 16% of Veterans in the general population had an untreated substance use disorder (Golub et al., 2013). Veterans may turn to drugs and alcohol as a way to cope with trauma they have experienced during their military service.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a public health approach to the delivery of early intervention and treatment to people with substance use disorders and those at risk of developing these disorders. Health professionals in community settings can provide early intervention for people at risk before more serious consequences can occur. According to SAMHSA, SBIRT involves the following:
- Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.
- Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
- Referral to treatment provides those identified as needing more extensive treatment with access to specialty care. (SAMHSA, 2017)
Screening is incorporated into the normal routine in medical and community settings to identify individuals with problems related to alcohol and substance use. Adults are screened using tools such as ASSIST, AUDIT, and DAST. After the screening, the healthcare provider determines whether the patient receives brief intervention, brief treatment, or referral to a behavioral health clinician for more intensive treatment (SAMHSA/HSRA, n.d.).
From the Alcohol Use Disorders Identification Test (AUDIT):
- How often do you have a drink containing alcohol?
- How many drinks containing alcohol do you have on a typical day when you are drinking?
- How often do you have six or more drinks on one occasion?
- How often during the last year have you found that you were not able to stop drinking once you had started?
- How often during the last year have you failed to do what was normally expected from you because of drinking?
- How often during the last year have you been unable to remember what happened the night before because you had been drinking?
- How often during the last year have you needed an alcoholic drink first thing in the morning to get yourself going after a night of heavy drinking?
- How often during the last year have you had a feeling of guilt or remorse after drinking?
- Have you or someone else been injured as a result of your drinking?
- Has a relative, friend, doctor, or another health professional expressed concern about your drinking or suggested you cut down? (WHO, 1982)
After a screening test indicates moderate risk, healthcare providers should provide brief intervention, which includes motivational discussion to raise the person’s awareness of their substance use and its consequences, to motivate them toward behavioral change. Healthcare professionals should also provide support for the client’s empowerment toward making a behavioral change (SAMHSA/HSRA, n.d.).
After a result of moderate to high risk, brief treatment including motivational discussion and client empowerment. It also includes assessment, education, problem solving, coping mechanisms, and building a supportive social environment (SAMHSA/HSRA, n.d.).
Referral to Treatment
If the screening finds severe use or dependence, the healthcare provider should make a referral to treatment that facilitates access to more extensive care (SAMHSA/HSRA, n.d.).
Definition of Drinking Levels
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines drinking levels as follows.
Low Risk for Developing an Alcohol Use Disorder (AUD)
As defined by NIAAA, for women, low-risk drinking is no more than 3 drinks on any single day and no more than 7 drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have an AUD. Even within these limits, people can have problems if they drink too quickly or have other health issues (NIAAA, 2015).
Moderate Alcohol Consumption
According to the Dietary Guidelines for Americans, moderate drinking is up to 1 drink per day for women and up to 2 drinks per day for men.
NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as drinking 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days.
SAMHSA defines heavy drinking as drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days.
Substance Abuse and Its Effects on Families
Substance use disorder is called a family disorder because it affects the entire family and close friends, even if only one family member has it. Health problems, marital problems, emotional abuse or violence, legal problems, financial problems, and effects on children are significant stressors caused by substance abuse by Veterans. Divorce is 7 times more likely in families who have a family member with a substance use disorder. Substance use can lead to financial problems such as job loss, unpaid bills, loss of money spent on substances, and legal problems such as DUI and other crime.
Children whose parents abuse drugs or alcohol experience increased risk for:
- Substance use (they are four times more likely to develop a substance use disorder)
- Behavior problems, including frustration and an increased risk of aggression and crime
- Academic problems, such as learning difficulties, poor concentration, and disruptiveness
- Emotional problems, such as anger, poor self-esteem, withdrawal, and sadness
Family members of Veterans with substance use disorders should be reminded that the problem is not their fault. They did not cause the disorder and they cannot make it stop. Action steps that family members can take are:
- Ask for help; be open about the problem.
- Get help for their loved one.
- Find out about treatment options; many treatments for addiction work.
- Talk with children about what is happening and help them with their fears and feelings.
Providers can find more information about substance use disorder and recovery online at the SAMSHA store: https://store.samhsa.gov/.
Intimate Partner Violence and Child Maltreatment
Military and Veteran families experience family violence. “The Army has experienced a dramatic increase in domestic violence/child abuse referrals to the Family Advocacy Program (FAP), which reflects a dramatic increase in leader surveillance, detection, and response to potential domestic abuse offenses. Total referral numbers for soldier offenders of domestic violence increased by 50% while child abuse referrals increased by 62% from FY2008–2011” (Army Gold Book, 2012).
Research has found that the “presence of depressive symptoms was positively associated with the presence and severity of domestic violence. . . For each 20% increase in depressive symptoms, there was a 74% increase in the likelihood of husband‐to‐wife aggression” (Army Gold Book, 2012). Co-occurring PTSD, depression, and substance use disorder factor into intimate partner violence.
Intimate Partner Violence (IPV)
Intimate partner violence (IPV), commonly known as domestic abuse, is a repetitive pattern of behaviors to maintain power and control over an intimate partner. These are behaviors that physically harm, arouse fear, prevent partners from doing what they wish, or force them to behave in ways they do not want. Abuse includes the use of physical and sexual violence, threats and intimidation, emotional abuse, and economic deprivation. Many of these forms of abuse can be going on simultaneously (http://www.thehotline.org/is-this-abuse/abuse-defined/).
Victims of IPV are often afraid to get help. They may love their abusive partner, want to remain in the relationship, and hope that the abuse will stop. They may feel shame for tolerating abuse and may fear losing financial support provided by the abuser. They may also fear that seeking help or reporting the abuse will lead to a loss of benefits or damage to their partner’s career.
A 2005 review of literature on the prevalence, consequences, correlates, and treatment of IPV perpetration among military Veterans and active duty servicemen by Marshall and colleagues (2005) found that the rate of intimate partner violence across active duty and Veteran populations ranged from 13.5% to 58%:
For both military Veterans and active duty servicemen, IPV results in significant victim injury and negative child outcomes, and problematic substance use, depression, and antisocial characteristics are psychiatric correlates of IPV perpetration.
For Veterans, posttraumatic stress disorder is also an important correlate that largely accounts for the relationship between combat exposure and IPV perpetration. Additional correlates include military service factors, relationship adjustment, childhood trauma, and demographic factors. (Marshall et al., 2005)
According to the National Center for PTSD, IPV can happen to anyone. In the United States, about 1 in 4 women (27%) and 1 in 10 men (11%) report having been harmed by sexual or physical violence, or by stalking by an intimate partner at some point in their lives. People who have experienced IPV may have more physical health problems, and IPV can lead to depression, feelings of worthlessness, anxiety, emotional numbness and difficulty connecting with others, problems with substances such as alcohol and drugs, or suicidal thoughts and behavior. People who have experienced IPV may have posttraumatic stress disorder.
The VA has resources for men and women who have experienced IPV, and is in the process of implementing domestic violence coordinators at VA facilities. The VA coordinators can assist Veterans with safety planning, mental health counseling, and safe housing or shelter.
National Domestic Abuse Hotline
The National Domestic Abuse Hotline is available online at
or by phone at
800 799 SAFE (7233)
Furthermore, each VA Medical Center has a women Veterans program manager to assist female Veterans. “Some research suggests that women Veterans and active duty military personnel are even more likely than non-Veterans to have experienced IPV. Among women Veterans receiving healthcare in VA, 30% to 70% report having experienced IPV at some point in their lives. In active duty women, more than 36% report having experienced one or more types of IPV during their service” (NCPTSD, 2015).
The VA recognizes that, compared to male Veterans, women Veterans are more likely to have mental health conditions such as depression and anxiety, as well as co-occurring mental and physical health problems. These can influence treatment planning and the need for coordinated care among various specialists and clinics. Women Veterans are also more likely than their male counterparts to experience certain types of gender-based violence, such as intimate partner violence and military sexual trauma. For more information on VA’s mental health services for women Veterans, please visit Women Veterans Mental Health online (see box).
Individual risk factors for IPV include:
- Low self-esteem
- Low income
- Low academic achievement
- Young age
- Aggressive or delinquent behavior as a youth
- Heavy alcohol and drug use
- Anger and hostility
- Antisocial personality traits
- Borderline personality traits
- Prior history of being physically abusive
- Having few friends and being isolated from other people
- Emotional dependence and insecurity
- Belief in strict gender roles (eg, male dominance and aggression in relationships)
- Desire for power and control in relationships
- Perpetrating psychological aggression
- Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration)
- History of experiencing poor parenting as a child
- History of experiencing physical discipline as a child (CDC, 2015)
Child maltreatment is defined by the CDC as any act or series of acts of commission or omission by a parent or other caregiver (eg, clergy, coach, teacher) that results in harm, potential for harm, or threat of harm to a child.
Acts of commission (child abuse): Words or overt actions that cause harm, potential harm, or threat of harm. Acts of commission are deliberate and intentional; however, harm to a child might not be the intended consequence. Intention only applies to caregiver acts—not the consequences of those acts. For example, a caregiver might intend to hit a child as punishment (ie, hitting the child is not accidental or unintentional), but not intend to cause the child to have a concussion. The following types of maltreatment are acts of commission:
- Physical abuse
- Sexual abuse
- Psychological abuse
Acts of omission (child neglect): Failure to provide needs or to protect from harm or potential harm. Acts of omission are the failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm. Like acts of commission, harm to a child might not be the intended consequence. The following types of maltreatment involve acts of omission:
- Physical neglect
- Emotional neglect
- Medical and dental neglect
- Educational neglect
- Inadequate supervision
- Exposure to violent environments (CDC, 2015)
There is substantial evidence pointing to the association between child maltreatment (CM) and a broad range of emotional, behavioral, and physical health problems. These consequences may vary depending on a child’s age when victimized, duration and severity of the abuse or neglect, the child’s innate resiliency, and co-occurrence with other maltreatment or adverse exposures such as the mental health of the parents, substance abuse by the parents, or violence between parents. Aggression, conduct disorder, delinquency, antisocial behavior, substance abuse, intimate partner violence, teenage pregnancy, posttraumatic stress disorder, anxiety, depression, and suicide are among the emotional and behavioral problems associated with CM (CDC, 2014).
Individual risk factors for child maltreatment include:
- Parents’ lack of understanding of children’s needs, child development and parenting skills
- Parents’ history of child maltreatment in family of origin
- Substance abuse and/or mental health issues including depression in the family
- Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
- Non-biological, transient caregivers in the home (eg, mother’s male partner)
- Parental thoughts and emotions that tend to support or justify maltreatment behaviors
Family risk factors include:
- Social isolation
- Family disorganization, dissolution, and violence, including intimate partner violence
- Parenting stress, poor parent-child relationships, and negative interactions (CDC, 2015)
Healthcare providers should report signs of intimate partner violence or child maltreatment.