Although culture is a fluid concept, it is a central part of how we understand mental health. Culture influences what gets defined as a problem, how the problem is understood, and which solutions to the problem are acceptable. It has many layers, which interact with class, religion, language, nationality, and gender, each of which influences how an individual engages with and experiences mental health services (Salla et al., 2023).

Veterans and their families may experience medical and mental health issues as they reintegrate into their civilian communities during or after their terms of military service. The most common medical and mental health issues are PTSD, suicide, depression, grief, drug and alcohol abuse, intimate partner violence, and child abuse.

The VA estimates that close to 60% of veterans using VA healthcare services since October 1, 2001 have been diagnosed with mental health disorders. Because over half of the military veterans receive healthcare services outside the VA system, it is important that healthcare providers screen patients for military service (DVA, 2024, October 16).

4.1 Posttraumatic Stress Disorder (PTSD)

PTSD was first recognized as a psychiatric disorder in 1980 (Friedman, 2022). It is a complex, multi-faceted mental health condition that develops after experiencing or witnessing a life-threatening event. While trauma is always disruptive, PTSD can be debilitating, interfering with daily activities like going to work or school or spending time with friends and loved ones (NCPTSD, 2024, May). Both the American Psychological Association and the World Health Organization define traumatic events as experiences involving actual or threatened death, serious injury, sexual violence or events that are extremely threatening or horrific in nature (APA, 2024).

People who suffer from PTSD continue to re-experience memories of their trauma. These memories are accompanied by avoidance, negative thoughts and emotions, and hyperarousal, a state of heightened anxiety that can manifest as irritability or paranoia.

It is estimated that 60% of adults in the general population will suffer PTSD at some point in their lifetimes. The incidence among veterans is slightly higher, with 7 out of every 100 veterans experiencing PTSD. The average is increased by the 13% of female veterans who have suffered military sexual trauma, often from colleagues (NCPTSD, 2023, February).

PTSD can lead to a host of physical and psychiatric comorbidities, including suicide. A Swedish study found that 3.5% of suicides among women in Sweden were attributable to PTSD. More than half of the suicides among Swedes with PTSD were due to the diagnosis (Fox et al., 2021).

In the U.S., the risk for suicide among military veterans with combat experience is especially high, with combat survivors who were wounded at greatest risk. Some veterans suffering from PTSD experience recurring memories of trauma and guilt over actions taken during wartime (NCPTSD, 2022).

Though they do not experience combat as frequently as their male counterparts, female military veterans are also subject to experiences that lead to PTSD. Military sexual trauma (MST) is widespread among female military veterans, due to sexual assault and harassment from fellow soldiers. MST’s most common mental health impact is PTSD, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning (Galovski, 2022).

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) groups PTSD symptoms into 4 categories:

1. Intrusion Symptoms (formerly called re-experiencing symptoms)
   • Intrusive thoughts
   • Nightmares
   • Flashbacks
   • Emotional distress after exposure to traumatic reminders
   • Physical reactivity to traumatic reminders
2. Avoidance Symptoms (avoiding trauma-related stimuli)
   • Trauma-related thoughts or feelings
   • Trauma-related reminders
3. Negative Alterations in Cognition and Mood (negative thoughts or feelings that began or worsened after the trauma)
   • Inability to recall key features of the trauma
   • Overly negative thoughts and assumptions about oneself or the world
   • Exaggerated blame of self or others for causing the trauma
   • Negative or flat affect
   • Decreased interest in activities
   • Feeling isolated
   • Difficulty experiencing positive affect
4. Alterations in Arousal and Reactivity (trauma-related arousal and reactivity and reactivity that began or worsened after the trauma)
   • Irritability or aggression
   • Risk or destructive behaviors
   • Hyper-vigilance
   • Heightened startle reaction
   • Difficulty concentrating
   • Difficulty sleeping

Though PTSD is separate from substance use disorder (SUD), the use of alcohol or drugs may become a management strategy. Anxiety and obsessive-compulsive behavior may also be associated with PTSD. Negative emotions like anger, shame or humiliation, sadness and guilt may also persist.

Other symptoms may include dysphoria, dissociative states, suicidal ideation, panic attacks, and somatic complaints like trembling, headaches, dizziness, and shortness of breath. Women and girls who have been diagnosed with PTSD are especially prone to somatic symptoms and high levels of negative emotions.

4.1.1 Risk Factors for Developing PTSD

Some groups are disproportionately represented among those experiencing trauma. This means that they may be exposed to trauma at particularly high rates or be at increased risk for repeated victimization. For these groups, co-occurring issues and unique adversities can complicate recovery from trauma. Others face significant challenges related to access to services or require services that are specially adapted for their needs (NCTSN, 2024).

PTSD has long been associated with military combat. The first assessment techniques were developed by researchers working with Vietnam-era veterans (Friedman, 2022). Younger veterans, especially those who served in the Gulf War, Iraq or Afghanistan, may be more likely than veterans of earlier conflicts to suffer adverse psychiatric outcomes. According to an analysis of the 2019-2020 National Health and Resilience in Veterans Study, younger veterans showed the greatest burden of trauma and were more likely to screen positive for PTSD. One in four Iraq/Afghanistan veterans in the study reported recent suicidal thoughts (Na et al., 2023).

Many veterans of Iraq and Afghanistan have experienced post-concussive symptoms from traumatic brain injuries. In the aftermath of brain injuries, some people experience psychiatric symptoms that are similar to PTSD, such as difficulty sleeping and concentrating, irritability, and depressed mood. The overlap between PTSD and the symptoms that can persist after a brain injury is now being studied, with one study finding that participants’ post-concussive symptoms improved with treatments for PTSD (Porter et al., 2024).

Pre-existing attitudes can contribute to the likelihood of developing PTSD, including adherence to traditional masculine roles. Beliefs about the importance of adhering to masculine norms are strongly associated with the severity of patients’ PTSD symptoms. Discussing emotions and feelings of fear and shame are antithetical to masculine norms about control, rationality, and fortitude. Veterans who are working hard to maintain an appearance of powerful masculinity may be less inclined to seek help or follow through with a therapeutic program (Neilson et al., 2020).

Secondary traumatic stress (STS), also known as compassion fatigue or vicarious traumatization, is the emotional distress caused by indirect exposure to other people’s emotional hardship. The psychological symptoms are similar to PTSD, including anxiety and depression, insomnia and nightmares, intrusive thoughts, and maladaptive coping strategies such as alcohol and substance abuse (Maran et al., 2023).

STS is common among healthcare professionals and others in the helping professions, including unpaid family caregivers. Caregivers may suffer from self-criticism, a lack of self-compassion, and loss of compassion for others. This can lead to burnout and feelings of hopelessness (Halamová et al., 2022).

4.1.2 PTSD and Comorbidities

PTSD can lead to physical and mental health problems and affect emotional resilience. It is a complex diagnosis with links to neural disturbances, inflammatory conditions, and difficulties with regulating mood and attention.

PTSD can inhibit learning, interfere with executive function and concentration, and even prolong grief. People who survive a trauma but lose a loved one are at risk of developing PTSD. It can cause grief that is so unbearable it interferes with daily life and causes feelings of isolation from others. Researchers believe this may have implications for trauma survivors because it suggests that targeting the PTSD symptoms for treatment may also diminish the symptoms of complicated grief (Glad et al., 2021).

There also appears to be support for an association between asthma and PTSD, both of which afflict more women than men. A recent study in Atlanta involving more than 500 women with both conditions showed that the women with asthma had a higher risk of more severe PTSD and depression than those without asthma. Female military veterans with PTSD are more than one and a half times more likely to have asthma than those without PTSD (Lin et al., 2023).

PTSD is often traced to some form of violence. And there are some indications that people suffering from PTSD are more likely to commit violent crimes, themselves. Another Swedish study found that PTSD is linked to violent crime among veterans, though it is still unknown if such a link exists between PTSD and crimes committed by people in the general civilian population. However, the diagnostic criteria for PTSD include increased arousal, reactivity, and irritable behavior that often turns into aggression. Throughout 27 years of follow-up inquiry, the study found that individuals with a PTSD diagnosis had a higher absolute risk of being convicted for violent crime than individuals with no PTSD diagnosis (Paulino et al., 2022).

In addition to the social costs associated with violent crime, PTSD also creates an economic burden. Individuals who can’t function properly due to a psychiatric diagnosis drive unemployment costs, disability, and direct healthcare. In 2018, the total excess economic burden of PTSD in the US was an estimated $232.2 billion. That came out to $18,640 per civilian with PTSD and $25,684 for each veteran with the condition (Davis et al., 2022).

4.1.3 Treatment Options

The VA offers a variety of treatment options for veterans seeking mental healthcare, from evidence-based therapies and medications to mental health apps. Veterans have access to in-person care at a VA clinic or through Community Care referrals. They can also speak with a provider using video or telephone options that do not require travel. The VA also offers mental health apps and a self-help portal where veterans can anonymously take free courses to address a variety of concerns, including sleep issues, anger management or parenting (DVA, 2022, March).

The most effective evidence-based therapies include:

• Cognitive Processing Therapy (CPT) helps Veterans identify how traumatic experiences have affected their thinking, to evaluate those thoughts, and to change them. Through CPT, veterans may develop more healthy and balanced beliefs about themselves others, and the world.
• Prolonged Exposure (PE) helps Veterans to gradually approach and address traumatic memories, feelings, and situations. By confronting these challenges directly, Veterans may see PTSD symptoms begin to decrease.
• Cognitive Behavioral Conjoint Therapy (CBCT) helps couples understand the effect of PTSD on relationships and can improve interpersonal communications. Veterans may also experience a change in thoughts and beliefs related to their PTSD and relationship challenges.
• Eye Movement Desensitization and Reprocessing (EMDR) helps Veterans process and make sense of their trauma. It involves calling the trauma to mind while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone).

There are very few FDA-approved drugs for treating PTSD. The Veterans Health Administration recommends psychotherapies put forth by the APA but acknowledges that medications can be an effective option when psychotherapy is not available. Medications prescribed for PTSD act upon neurotransmitters affecting the fear and anxiety circuitry of the brain including serotonin, norepinephrine, gamma-aminobutyric acid (GABA), the excitatory amino acid glutamate and dopamine, among others (Holzheimer and Montaño, 2024).

Evidence for PTSD pharmacology is strongest for specific selective serotonin reuptake inhibitors (SSRIs)—sertraline (Zoloft) and paroxetine (Paxil)—and a particular serotonin norepinephrine reuptake inhibitor (SNRI), venlafaxine (Effexor). Currently, only sertraline and paroxetine are approved by the FDA for PTSD. From the FDA perspective, all other medication uses are off label (Holzheimer and Montaño, 2024).

Greater social and organizational support is needed for military caregivers, as well as treatment from informed medical providers who can guide them to the appropriate resources. Social support and task-focused coping strategies have been shown to be correlated with lower levels of STS, though there is little research into protective factors (Gagliano, 2020).

The Blue Star Families Caregiving Report of 2021 recommends identifying caregivers and what constitutes caregiving tasks, so that more caregivers can be informed about available resources. The report argues that caregiving needs to be normalized and included in discussions about personal and professional life. However, high-quality respite care for caregivers is a vital but scarce resource, which the report recommends expanding. Efforts to improve caregivers’ quality of life, like student loan relief and affordable childcare, could also ease financial strain and improve quality of life (Blue Star Families, 2020).

4.1.4 Screening for PTSD

There are several tools a healthcare provider can use to screen for PTSD. The CAPS-5, or Clinician-Administered PTSD Scale for DSM-5, is the gold standard, according to the VA’s National Center for PTSD. This is a 30-item structured interview that was designed to be administered by clinicians and clinical researchers who have a working knowledge of PTSD, but it can also be administered by appropriately trained paraprofessionals. The full interview takes 45 minutes to an hour. Non-VA providers can request the form and the curriculum from the VA.

Other screening tools include the PTSD Symptom Scale Interview (PSS-I and PSS-I-5), which are semi-structured interviews. The PSS-I is a 17-item interview about a single traumatic event. It is designed to assess the severity of symptoms in the past two weeks and takes about 20 minutes to administer. The PSS-I-5 is an updated version which corresponds with the DSM-5.

The Structured Clinical Interview, PTSD Module is a semi-structured interview designed to be administered by a trained mental health professional. This instrument can take anywhere from fifteen minutes to several hours, and all symptoms are coded as present, subthreshold, or absent.

Structured interviews and self-reporting screening tools are also helpful for determining treatment options (APA, 2023).

4.1.6 PTSD and Military Families

PTSD can have a huge impact on family life, as loved ones struggle to provide care to a family member whose behavior has changed abruptly. The Blue Star Families Military Family Lifestyle Survey found that over a quarter of caregivers felt excessively burdened by their caregiving tasks, that military caregivers report more financial stress than civilian peers, and that they experience a high degree of mental health challenges and sleep issues. Military caregivers also tend to be younger than civilian caregivers and are often caring for children and parents in addition to the wounded service member or veteran (Blue Star Families, 2020).

At a 2024 Policy Dialogue Series, the American Academy of Nurses focused on the health of military families. Distinguished speakers noted an increase in mental health and weight-related diagnoses in military children during the course the COVID-19 pandemic. Military spouses reported increasing levels of dissatisfaction with military life, which presents unique stressors like frequent relocation, isolation, lack of social support and continuity in professional lives or education, and exposure to physical and psychological injury. Speakers addressed the need for multi-faceted care for military families, with some framing their health as imperative to service members’ ability to focus on the mission. The AAN recommendations include promoting military cultural awareness among providers and expanding education and outreach to improve awareness among providers and families of the resources that exist to help them (AAN, 2024).

Caregivers are subject to emotional hardships themselves, as they struggle to adjust to new responsibilities and experience a decrease in their social, leisure, and professional opportunities. Being young, female, with low income and a low level of education are all risk factors for caregiver PTSD. The risk of PTSD climbs with time spent in the ICU or bedside with seriously ill patients. The type of relationship between the caregiver and patient, illness-related distress, and the availability of support networks and wholesome coping mechanisms also play their roles in the psychiatric well-being of caregivers (Carmassi et al., 2020).

Caring for people with severe mental illness can also lead to PTSD. In one study of caregivers for people with schizophrenia or bipolar disorder, 15.17% met the diagnostic criteria for PTSD. These caregivers work under a great deal of stress, with many of them being subject to aggression and experiencing a low quality of life. Like many others who suffer PTSD, caregivers often blame themselves for poor outcomes, experiencing high levels of stress over hospitalizations and keeping track of medications. Stress burden was higher among caregivers in developing countries, which may be due to better health facilities and less stigma surrounding mental illness in more developed countries (Rady et al., 2021).

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 expressing emotions. This can cause problems in their personal relationships with a spouse or children.

It is important that family members of people with PTSD understand that it is not selfish to take care of themselves. They can attend to their health by eating and sleeping regularly, getting plenty of sleep and exercise, and making sure they attend to their own medical appointments. It’s also important not to get isolated and to set boundaries for how much they can do to care for their loved one. Sometimes, getting therapy for their own feelings of stress and anxiety as they take on a caregiving role can be vital. Maintaining friendships and enjoyable activities are also key to well-being.

There are some resources available to military family members struggling to cope with their loved ones’ PTSD symptoms. A free, private and confidential hotline is accessible by dialing 988 or logging onto www.988lifeline.org. These are not only for crisis situations. They are also available for advice, help or just support. The VA caregiver support line at 1-855-260-3274 offers information about connecting with the caregiver support team at the nearest VA medical center.

Talking to children about an adult family member’s PTSD helps them cope with their own fear and confusion. Children should know what is causing their loved one’s behavior, but they don’t need graphic details about what caused the PTSD. Too much frightening information can cause secondary trauma. Children should know that the adult relative’s mental health condition is not their fault. They should know that they can talk about their own concerns and feelings. The VA has an extensive video series featuring veterans and their family members discussing PTSD and what helped them at https://www.ptsd.va.gov/apps/AboutFace/ (NCPTSD, 2024).

4.2 Depression

Depression is a highly prevalent health problem in the military, due to many factors like separation from loved ones and familiar support systems, and the stress of being deployed in combat. Depression manifests in many ways that can make a diagnosis difficult to ascertain. It is often a major contributing factor in suicidal ideation, suicide attempts, and suicide.

The World Health Organization estimates that the global yearly prevalence of depression is 4.4%, with 5.1% of females and 3.6% of males experiencing the condition. It is much more common among older people of both sexes, and the rates of depression went up 18.4% between 2005 and 2015 (Meade et al., 2020).

Major depressive disorder (MDD) may have a neurobiological basis, but there are several factors that can predispose someone to MDD. Unemployment and financial stress can contribute, as can female gender or family history of depression. Lifetime incidence for depression among females can be as high as 25%, while for males it can be closer to 12%. The risk for depression among Gulf War veterans is more than twice that of the civilian population (Moore et al., 2023).

4.2.1 Symptoms of Depression

Depression is far more complex than sadness, which occurs in response to a specific event. Typically, someone who is sad can muster up some enjoyment in some things, while depression prevents enjoyment of all kinds.

Symptoms include loss of interest in most or all activities, insomnia (inability or extreme difficulty falling or staying asleep), hypersomnia (sleeping excessively) or fatigue, fluctuations in weight, reduced ability to concentrate, feelings of worthlessness, excessive or inappropriate guilt, or even thoughts of suicide. Patients may also show psychomotor retardation (when thoughts and movements slow down significantly), or physical agitation or indecisiveness. To receive a diagnosis for a major depressive episode according to the Diagnostic and Statistical Manual of Mental Illness, or DSM-5, a patient must have five or more symptoms for over two weeks and show no manic or hypomanic behavior. A minor depressive episode consists of two to four symptoms for over two weeks (Truschel, 2022).

4.2.2 Comorbidities

Depression often occurs in tandem with other severe mental disorders, such as anxiety, PTSD, substance use disorder, and many physical ailments. Depression is a frequent companion to chronic physical health conditions like cardiovascular disease, stroke, diabetes, hypotension, arthritis, rheumatoid arthritis and COPD (Meade et al.). Untreated depression causes emotional suffering, reduced productivity, lost wages, impaired relationships, and increased comorbidity risk (Siniscalchi et al., 2020).

Multimorbidity, which is three or more disorders occurring in one patient, is especially high among veterans using the VA. In one large national sample of VA patients receiving treatment for depression, nearly all screened positive for one comorbidity. Over 75% screened positive for comorbid panic/phobia, PTSD, or Generalized Anxiety Disorder (GAD). Nearly half of the respondents screened positive for four or more comorbid mental disorders (Ziobrowski et al., 2021).

One study of veterans suffering from Cannabis Use Disorder (CUD) found that veterans who had been diagnosed with CUD and PTSD were also more likely to have comorbid diagnoses of depression, panic disorder, alcohol use disorder, opioid use disorder and insomnia, than veterans without a PTSD diagnosis. Younger veterans in particular have high levels of comorbidities, due perhaps to long deployments, high unemployment after separating from the military, and experiencing lifelong complications from surviving horrific injuries that were fatal in previous eras (Bryan et al., 2021).

4.2.3 Screening for Depression

Identifying and treating depression effectively includes the increased use of screening tools (Siniscalchi et al., 2020). There are many screening tools for depression, with the Public Health Questionnaire (PHQ) being the most common and effective. The PHQ-2 tool consists of 2 questions about frequency of depressed mood and anhedonia, scoring each as 0 (“not at all”) to 3 (“nearly every day”). The PHQ-9 consists of 9 items based on the 9 DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) criteria for major depressive disorder (Siniscalchi et al., 2020).

Another tool, the Beck Depression Inventory for Primary Care (BDI-PC) has been used in over 7,000 studies. A variation of the BDI is used to determine severity, but the specificity of this tool is lower than the PHQ (Moore et al., 2023). A simple self-administered five-question tool by the World Health Organization, the WHO-5, has a sensitivity of 86% and specificity of 81%. The questions are meant to reflect the respondents’ state in the past two weeks. Each question has a possible score of 1-5. The raw score is multiplied by four, with a score of zero representing the worst possible mental health and 100 representing the best possible state. Anything below 50 is an indication of poor mental health and the need for further assessment (WHO, 2024-01).

Depression is expensive, costing an estimated $210 billion in annual medical care and lost productivity. The US Preventive Services Task Force recommends depression screening for all adults, in addition to support systems and evidence-based protocols (Siniscalchi et al., 2020).

4.2.4 Treatment for Depression

A variety of medications and therapies are available to treat depression. Treatments should be tailored to the individual patient, since everyone experiences the disorder differently.

Psychotherapy encompasses several types of talk therapy, including CBT (cognitive behavioral therapy), interpersonal psychotherapy, behavioral activation, problem-solving therapy, supportive psychotherapy, and psychodynamic psychotherapy. The VA offers many of these treatments, both at VA clinics and through the Community Care referral program.

CBT is often a front-line treatment, with a wealth of research supporting its efficacy for many people. is a collaborative treatment plan that takes 16-20 weeks to complete. Clinicians work with patients to address treatment goals and assign a curriculum of interventions, from how to relax, how to deconstruct destructive thoughts, ask questions, and keep up with weekly assignments to achieve treatment goals. According to one treatment guide, CBT can be summarized this way (Crane and Watters, 2019):

• Cognitive refers to the act of knowing or recognizing our experiences.
• The cognitive model focuses on thinking and how our thoughts are connected to our mood, physiological responses, and behaviors.
• Cognitive therapy will teach you to change your thoughts, beliefs, and attitudes that contribute to your depression.

Further examples of treatments available to veterans suffering from depression include (DVA, 2023):

• Acceptance and Commitment Therapy for Depression (ACT-D) can help veterans overcome their emotional pain by promoting positive actions and choices that align with their values. Through this therapy, you may increase your ability to recognize and achieve what truly matters most to you in life.
• Cognitive Behavioral Therapy for Depression (CBT-D) is a structured, time-limited therapy that can help veterans with depression develop balanced and helpful thoughts about themselves, others and the future. CBT-D can help you modify your thought patterns to change negative moods and behaviors. It can also help you achieve personal goals by developing new skills.
• Interpersonal Psychotherapy for Depression (IPT-D) is focused on identifying and evaluating relationship issues that may be the cause or result of depression. IPT-D can also help you build social skills to deal with problems in your relationships and improve your overall quality of life.
• Problem-Solving Therapy (PST) helps veterans recover from difficult situations and learn skills to improve their daily life. This therapy can improve your ability to cope with major life circumstances and stressors and develop a response plan.
• Behavioral Activation helps veterans learn how their behaviors are connected to their moods, and how to develop responses to improve their daily satisfaction. This therapy will ask veterans to identify their values and goals and engage in more meaningful activities to achieve them.

Many medications are also available. Antidepressants may take 4-8 weeks to start working, and it is common for patients to try more than one category or dosage before finding the right regimen.

Serotonin reuptake inhibitors (SSRI’s), which increase the levels of serotonin in the brain, are often the first choice for major depressive disorder, though other classes of drugs, including ketamine and bupropion (which is also a treatment for seasonal affective disorder and to help patients stop smoking) are also options. Electroconvulsive therapy, which uses an electrical current in the brain to induce a cerebral seizure, is generally reserved for severe cases (Moore et al., 2023).

Serotonin and norepinephrine reuptake inhibitors (SNRIs) help regulate mood by increasing levels of serotonin and norepinephrine. Common SNRIs include venlafaxine and duloxetine. Sometimes these medications cause side effects or don’t work. Atypical antidepressants include Mirtazapine, which can also help with sleep difficulties or loss of appetite; or Trazodone, which can also help with insomnia and anxiety. An older category of medications includes tricyclics, tetracyclics, and monoamine oxidase inhibitors (MAOIs). Possible side effects include nausea and vomiting, weight gain, diarrhea, sleepiness, and sexual problems (NIMH, 2023).

Because depression so often co-occurs with other mental health and behavioral problems, the Substance Abuse and Mental Health Services Administration (SAMHSA) has created a treatment protocol for integrated treatment, calling for rigorous screening and assessment of co-occurring disorders, as well as training for practitioners in different but similar fields, stating that, “Counselors and other providers must understand how to recognize signs of highly comorbid mental illnesses, know how these disorders affect treatment decision making, and recognize the trauma history and risk of self-harm associated with these disorders. Equally important, clinicians should learn how to differentiate independent mental disorders from substance-induced mental disorders, as the latter are often treated differently than the former” (SAMHSA, TIP 42, 2020).

4.3 Substance Abuse

According to the 2020 National Survey on Drug Use and Health, 5.2 million veterans in the US over the past year had a mental illness and/or a substance use disorder. Twelve percent, or 2.4 million, had a substance use disorder, with 41.9% of those using illicit drugs, 70.1% struggling with alcohol, and 12% using both alcohol and illicit drugs (SAMHSA, 2020).

Marijuana is by far the most-used illicit drug, with three million reported users in the past year. Psychotherapeutic drugs came in a distant second, with 721,000 reported users. Methamphetamines, at just over a quarter million users, was the third most-used illicit drug, with cocaine and hallucinogens almost tied for fourth place, at just over 230,000 (SAMHSA, 2020).

Alcohol Use Disorder (AUD) is a brain disorder that includes alcoholism as well as alcohol abuse, dependence and addiction. It’s characterized by a limited ability to stop drinking or to drink in moderation, in spite of the negative consequences it has on social or professional life or overall health. While genetics do contribute to the disorder, environmental factors like trauma and early childhood adversities like abuse and neglect play a role as well.

AUD is also more common among men, which may offer some explanation as to why the rates of AUD among veterans are almost twice as high as they are among the general population (Horvath, 2023). However, researchers from the University of Pennsylvania who analyzed the VA’s Million Veteran Program found that, in that initiative, Black and Hispanic military veterans were more likely to be diagnosed with AUD than white veterans, even when reported drinking levels were the same, raising questions about the diagnostic process (Horvath, 2023).

The National Institute on Alcohol Abuse and Alcoholism (NIAA) recommends that healthcare providers integrate an Alcohol Symptom Checklist into primary care and have patient-centered, non-judgmental conversations to help destigmatize any conditions around alcohol so that patients will agree to treatment. A helpful checklist and more information are available at the National Institute on Alcohol Abuse and Alcoholism:
https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods

Alcohol screening and brief intervention can reduce drinking levels, which can decrease accompanying health problems. This may also help the entire family, since the relatives of people with AUD also suffer more health problems and have more costly health care than people who do not have a family member with AUD (NIAAA, 2022).

A quick and effective screening tool is the AUDIT-C, or Alcohol Use Disorders Identification Test—Consumption, which consists of three questions developed by the WHO.

Scoring:

• The minimum score (for non-drinkers) is 0 and the maximum possible score is 12.
• The Department of Veteran Affairs (VA) and Department of Defense (DoD) currently considers a screen positive for unhealthy alcohol use if the Alcohol Use Disorders Identification Test—Consumption (AUDIT-C) score is 5 points or greater (DVA, 2024, October 14).

After determining that a patient drinks heavily (which may not mean the presence of an AUD), the provider can administer brief interventions, typically 5-15 minutes and reinforced over future visits. These are not usually sufficient on their own but may lay the foundation for patients to develop the motivation to change their heavy drinking habits (NIAAA, 2022).

There are many treatments for alcohol as well as other substance use disorders. The VA recommends evidence-based treatments like CBT and other forms of structured talk therapies. Medications are also available for the most common substances that interfere with the health of veterans (DVA, 2024, August):

• Opioid Use Disorder. Options include methadone, buprenorphine and buprenorphine combination products like Suboxone, and injectable, extended-release naltrexone.
• Alcohol Use Disorder. Options include acamprosate, disulfiram, naltrexone and topiramate.
• Tobacco Use Disorder. Options include nicotine replacement therapy, bupropion and varenicline.

The VA also recommends having naloxone on hand. This is a nasal spray that can block the effects of an opioid during overdose and save the life of someone who has lost consciousness due to an overdose.

Though Substance Use Disorder (SUD) is separate from PTSD, many veterans suffering from PTSD or other mental health conditions also start misusing substances in an effort to mitigate their suffering from trauma. According to the National Center for PTSD, more than 20% of veterans with PTSD also have SUD. About 10% of veterans returning from Iraq and Afghanistan who seek medical care at the VA have an alcohol or drug problem. Each VA medical center has an SUD-PTSD specialist who is trained to treat both conditions, and evidence shows that the two conditions can be treated at the same time. (NCPTSD, 2023, November).

For veterans who may not be ready to talk to a provider about their SUD, there is an app called VetChange, developed by the VA's National Center for PTSD in partnership with VA Boston Healthcare System and Boston University.