#66342: Mental Health Issues Common to Veterans and Their Families

Military personnel may confront numerous potentially traumatizing experiences, including military-specific events and those experienced by civilians. Research suggests the most common traumatic events experienced during active duty are witnessing someone badly injured or killed or unexpectedly seeing a dead body. Events most likely to result in the development of PTSD include witnessing atrocities, accidentally injuring or killing another person, and other interpersonal traumas, such as rape, domestic violence, and being stalked, kidnapped, or held captive [6,12].

Exposure to multiple traumatic events is not uncommon during deployment, and exposure to real or threatened death and serious physical injury that can lead to PTSD is likely. Fundamental beliefs about self, the world, and humanity can become severely challenged by the nature of wartime traumatic events, such as exposure to the death of civilians and destruction of communities on an unimaginable scale with little preparation. Veterans may themselves have committed acts of violence they deem with hindsight as atrocities, shattering previously held beliefs about the self [12].

More than 2.77 million members of the U.S. Armed Forces have now served on 5.4 million deployments in the Iraq and Afghanistan wars beginning in 2001 and 2003, respectively. In these conflicts, nearly 7,000 soldiers died, close to 43,000 were wounded (ranging from shrapnel injuries to amputation and TBI), and more than 100,000 witnessed one or more traumatic events involving horrific injuries or loss of life in members of their unit [7,31]. Many have returned home with psychologically damaging memories. Combat veterans have often described feeling unable to relate to civilians, including their families, and of having lost the ability for true connectedness except with their comrades, which leads to a sense of loneliness and isolation [7].

With innocent civilians used as human shields, children used as "bait" for attacks, calm moments erupting into death and devastation in seconds, and violations of the rules of engagement, the nature of the Iraq and Afghanistan wars impose on the returning veteran an unnatural recalibration of security and sanity. Among returning war veterans, the most common problems involve somatic, emotional, cognitive, behavioral, interpersonal, and psychosocial components. Somatic concerns appear as primary and middle (sleep-maintenance) insomnia, fatigue, headaches, tinnitus, impotence, restlessness, and chronic pain. Emotional and psychological complaints may involve nightmares, racing thoughts (particularly at bedtime), generalized and social anxiety, anger and irritability, impulsive hostility, emotional numbing, hypervigilance, complicated grief, and despair [7].

Cognitive problems that may develop from combat trauma exposure include poor sustained and divided attention that partially reflects hypervigilance, poor concentration, impaired memory, rumination, and distorted thinking (e.g., jumping to conclusions, dichotomous decision-making). Common behavioral problems (often under-reported) include abuse of alcohol, illicit drugs, or prescription medications, and high-risk behaviors such as reckless driving or starting fights. Interpersonal concerns often involve feeling misunderstood, intolerance of others, distrust, isolation, and withdrawal. Frequent psychosocial concerns can involve spiritual crisis, domestic violence, child abuse, and general family dysfunction. The most common concerns of veterans seeking primary care are anger, sleep problems, and erectile dysfunction, and all are complicated if there is ongoing substance abuse [7,8].

Veterans frequently report sensitivity to triggers that stimulate sensory perception, such as sudden or loud sounds, noxious or unusual smells, high temperatures, foreign foods, or uneven terrain. Even less obvious triggers can produce anxiety, panic, fear, anger, and overall sympathetic nervous system arousal, including situations that appear unpredictable (e.g., crowds), beyond control (e.g., a room without an easy exit), or the precursor of potential danger (e.g., traffic or building complexes) [7].

Triggers can activate muscle memory of combat, including the readiness to fight, aggress, and escalate, and none of these are appropriate reactions in the civilian milieu. Combat immersion mode can become stuck in the "on" position, with the defensive or aggressive posture not easily turned off. For others, this heightened state of arousal is experienced as an adrenaline rush of battle that is reinforcing, driving some veterans to seek danger, risk, or excitement to maintain the "high" [7].

Comorbid Conditions

Biomechanical Injury/Traumatic Brain Injury

As PTSD may contribute to the overall burden of symptoms in some individuals following mild traumatic brain injury (TBI), particularly where problems persist for more than three months, the Scottish Intercollegiate Guidelines Network recommends that mental state should be routinely examined in patients with TBI.

(https://www.sign.ac.uk/media/1068/sign130.pdf Last Accessed: April 27, 2023)

Level of Evidence: C (A body of evidence including well-conducted case control or cohort studies, directly applicable to the target population and demonstrating overall consistency of results; or extrapolated evidence from high-quality systematic reviews of case control or cohort studies)

In Iraq and Afghanistan war veterans, biomechanical trauma to the brain caused by explosions and blast waves is the most frequent physical injury [17]. When severe enough, the brain trauma is termed traumatic brain injury or TBI. Even mild TBI elevates patient risk of psychiatric conditions, including PTSD, depression, anxiety, substance abuse, or suicide. TBI is characterized by three symptom types [7,18]:

• Cognitive: Problems with memory, poor attention, and limited concentration

• Emotional/behavioral: Irritability, depression, anxiety, impulsivity, and isolation

• Somatic: Insomnia, headache, tinnitus, and dizziness

The chaos and possible amnesia surrounding the TBI event can interfere with obtaining a proper history of the injury, but the provider should make an effort to document injury severity and type, previous brain injury history, and the extent of symptom overlap between TBI and PTSD. Common overlapping symptoms include depression, anxiety, irritability/anger, trouble concentrating, fatigue, hyperarousal, and avoidance [7,18].

Risk of Suicide and Violence

Since 2007, the suicide rates in the Army and Marine Corps have surpassed general population rates; these statistics remain unchanged as of data presented in 2019 [19]. Factors with the greatest association to suicide risk include depression, relationship strain, financial and vocational loss, and magnitude of life impairment. Clinical presentations with the highest prediction of potential future suicidal behavior are the presence of overwhelming negative thoughts and hopelessness over the future [20].

The potential for harm to others is another safety concern to address during assessment. Veterans with pronounced irritability, anger, and impulsivity may act aggressively toward others, and in one study, 63% of veterans seeking care for PTSD had been aggressive to their partners in the last year [7,21]. To gain a clearer picture of individual veteran risk of suicide or violence, the provider should assess the integrity of the veteran's support system, access to lethal means of self-harm, history of impulsivity and substance use, sleep adequacy, medication regimen, and outlook on the near and distant future [22].

Although the true incidence of suicide among military war veterans is difficult to estimate due to the lack of national suicide surveillance data, the U.S. Department of Veterans Affairs (VA) estimates that 17.8% of all deaths from suicide in the United States are in military war veterans [26]. According to the VA, in 2020 the suicide rate for veterans was 57.3% greater than nonveteran U.S. adults [5]. In addition, 12% of all U.S. Army suicides occur within 12 months of hospital discharge [27]. Although the majority of military suicides occur among young men shortly after their discharge from military service, military women historically complete suicide at a rate of nearly twice that of nonveteran women of the same age group [30,33].

The rate of suicide among the veteran population between 2001 and 2018 increased on average by 47 deaths per year, despite attempts at preventive measures taken by the military [26,28,29,30]. However, in 2018, the VA released the National Strategy for Preventing Veteran Suicide campaign, using increased outreach and clinically based interventions. Through partnerships with other VA and Department of Defense organizations, there were 343 fewer veterans who died from suicide in 2020 than in 2019, and 2020 had the lowest number of veteran suicides since 2006 [30]. These promising trends are an indication that increased outreach and knowledge of available services will continue to decrease suicide among veterans.

Risk Factors

The Department of Veterans Affairs recommends an assessment of risk factors as part of a comprehensive evaluation of suicide risk, including but not limited to: current suicidal ideation, prior suicide attempt(s), current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms (e.g., hopelessness, insomnia, and agitation), prior psychiatric hospitalization, recent biopsychosocial stressors, and the availability of firearms.

(https://www.healthquality.va.gov/guidelines/MH/srb Last Accessed: April 27, 2023)

Strength of Recommendation: Strong for

Veterans often possess many risk factors for attempting or completing suicide. These include combat exposure (particularly deployment to a combat theater and/or adverse deployment experiences), combat wounds, PTSD and other mental health problems, comorbid major depression, TBI, poor social support, feelings of not belonging or of being a burden to others or society, acquired ability to inflict lethal self-injury, and access to lethal means [28,36,37]. There is conflicting evidence of the role of PTSD in suicide risk, with some studies finding PTSD diagnosis to be protective while others indicating it increases risk. Other possible risk factors include [26]:

• Disciplinary actions

• 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

• Administrative separation from service/unit

With military service members, the command element should also be involved in education, safety planning, treatment planning, and implementation of duty limitations. Additional areas to address are medical, psychosocial, socioeconomic, or spiritual needs of the patient [26].

A Department of Defense report indicates that, among all military service members, the overall prevalence rate for heavy alcohol use in the past 30 days was 9.8% (compared with 6.6% in the general civilian population) [41]. The highest rates of heavy drinking were among Marines (15.3%), followed by the Navy (13.6%), Army (8.5%), Coast Guard (7.8%), and Air Force (5.0%) [41]. When comparing illicit substance use among civilian and military populations, civilian past-year usage is higher (16.6%) compared with military servicemen and women (0.7%). This lower rate of illicit substance use is due in part to the military's random testing procedures and zero-tolerance policies [41]. Binge drinking has spiked since the wars in Iraq and Afghanistan started; in 2008, almost half of active-duty military members reported binge drinking [42]. In that same time, the use of prescription pain medications (particularly opioids) has also increased; between 2001 and 2009, the number of prescriptions written by military physicians increased fourfold [42]. Because drugs and alcohol can inhibit negative feelings and disconcerting memories, it may be used to self-medicate, particularly among those who have witnessed or experienced suffering related to war and deployment.

Substance and alcohol abuse can cause tremendous harm, strain, and burden on the family system. It inevitably impacts communications, roles, finances, routines, parenting, employment, and other dimensions of family life [43]. The Stress-Strain-Coping-Support model has been employed to understand how substance and alcohol abuse impact the family [44]. This framework postulates that a family member using substances or alcohol causes stress and strain on the entire family; family members may exhibit stress or strain through a variety of physical, emotional, and psychological symptoms; family members frequently try to determine what is wrong and what they can do to fix the problem; and the way family members cope and respond to the situation is often influenced by how others in their immediate social support system respond [44].

For military families, deployment and reintegration trigger additional stressors that can lead to substance and alcohol abuse. For example, servicemen and women returning from deployment have a higher prevalence rate of new-onset drinking problems compared with nondeployed active-duty personnel [45]. In a study examining veterans returning from Iraq, 13.9% of the veterans were determined to have probable PTSD, 39% probable alcohol misuse, and 3% probable substance abuse [46]. Military members who have been in combat and who have PTSD are more likely use substances and alcohol to cope [47]. However, one study found that a clinical diagnosis of PTSD was a less important predictor of alcohol, substance, or aggressive behavioral problems than the presence of symptoms of a stress response [47].

The VA defines military sexual trauma as "sexual assault or repeated, threatening sexual harassment that occurred while the veteran was in the military" [48]. This can include rape (nonconsenting, forced, or coerced sexual activity); unwanted sexual touching or grabbing; threatening, offensive remarks about a person's body or sexual activities; and/or threatening or unwelcome sexual advances [30,48]. In 2021, the Department of Defense estimated that 35,875 service members, including 19,255 women and 16,620 men, experienced unwanted contact or penetrative sexual assault; however, only 20% of these individuals made a report of the incident [49]. In a survey of 60,000 veterans who served during the Operations Enduring Freedom and Iraqi Freedom eras, approximately 41% of women and 4% of men reported experiencing military sexual trauma [50]. Female Marines and Navy veterans were at an increased risk compared with female Air Force veterans, and both men and women who experienced combat exposure during deployment had increased risk for sexual trauma compared with those who did not [50]. In general, deployment was a protective factor for male veterans, but not for female veterans. In a separate study of 13,262 female military members, significant risk factors for sexual stressors included younger age, recent separation or divorce, service in the Marine Corps, positive screen for a baseline mental health condition, moderate/severe life stress, and prior sexual stressor experiences [51].

Although military sexual assault is relatively common, victims remain reluctant to report their experiences [52]. It is recommended that all health and mental health professionals ask their veteran patients about experiences of sexual assault, even if they served many years previously. The following questions may be included in history-taking [4]:

Clinical care providers should be alert for, and responsive to, the emotional trauma sustained by the sexual assault victim. In the hours following an assault, these patients exhibit a range of emotional responses, including fear, panic, shame, anger, mistrust, and denial. They are in need of emotional support, comfort, and the assurance of protection. Often, there is a need for reassurance that the victim is not at fault, no matter the circumstances surrounding the assault. Rape crisis counseling and social services should be enlisted early to assist in the care of the patient and to develop a discharge plan that addresses emotional needs, support systems, safety issues, and follow-up care.

The military also provides services for victims of sexual trauma. The VA provides free services to help veterans overcome sexual trauma, even for veterans who do not qualify for other VA care or who have not reported the incident(s) [53]. The Department of Defense offers anonymous crisis and support help for victims via its Safe Helpline https://www.safehelpline.org or (877) 995-5247. Resources available include one-on-one live chat, anonymous support group discussions, and resources for reporting retaliation [53].

It has been argued that because the military culture legitimizes violence, it places military family members at risk for various forms of violence [54]. Furthermore, the stressors associated with military lifestyle, such as the lack of social support systems, adjustments to a new region, or encountering different cultures, can heighten risk factors for domestic violence [55]. Often, military needs take priority over family issues. These factors contribute to stress, which can lead to domestic violence [56]. One study suggested that combat produces stress and antisocial behaviors among veterans, and these antisocial behaviors can affect marriage [57].

The U.S. Department of Defense has taken a proactive stance on domestic violence. In 2007, the Department of Defense instituted a policy that holds military-affiliated abusers accountable for their behaviors [58]. A unit commander is obligated and authorized to respond to domestic violence situations in order to safeguard victims and can discipline the alleged perpetrator. If the abuser is not a military member, there is no military recourse, but if the perpetrator is a member of the military, a commander can issue disciplinary actions such as restricting access to the post, forfeit of pay, extra duties, and/or reduction in grade [58].

Because state laws for mandatory reporting vary, in the 1980s the U.S. Army established its own definitions and policies for domestic violence [59]. When an incident of abuse (child abuse or spouse abuse) is reported, the Case Review Committee, which falls under the purview of the commander of the medical treatment facility, reviews the case to determine if it is substantiated or unsubstantiated. When the review is complete, the information is forwarded to the Family Advocacy Program [60]. The Family Advocacy Program is mandated to focus on identification, reporting, prevention, and treatment of child abuse and domestic violence. As part of the Family Advocacy Program's mission, the U.S. Military has a central registry that collects and maintains all cases of reported child abuse and domestic violence. Child abuse information has been collected since 1975, and domestic violence cases since 1983 [59].

In terms of prevention and intervention, the Family Advocacy Program provides a range of prevention strategies, including support groups for new parents, education programs for married couples to learn how to deal with stress, parenting classes, communicating and coping instruction, and anger management courses [61]. Training is also targeted to professionals such as law enforcement agents and social workers. Interventions include crisis intervention, marital counseling, emergency medical care, safety plan development, drug and alcohol treatment, support groups, case management, and anger control management groups.

As with domestic violence in the civilian population, military victims face a host of barriers in disclosing abuse. In addition to shame and embarrassment, fear of reprisals, feelings of isolation, and lack of available services, many military victims find when they do report abuse, military personnel are not sensitive to their needs [62].

Given the barriers to disclosure, it is difficult to assess the prevalence of domestic violence among military families. However, a few studies provide a glimpse of the scope of this problem. According to the Army's Central Registry, a total of 61,827 initial substantiated cases, 5,772 subsequent incidents, and 3,921 reopened cases were reported between 1989 and 1997 [59]. Victim rates varied between 8 and 10.5 per 1,000 married persons. More than two-thirds of the victims were female, and almost half of the referrals were from law enforcement agencies. The majority (93%) involved physical violence resulting in minor injuries. Some Department of Defense data indicate that 19 out of 1,000 wives of Navy and Air Force personnel and 21 out of 1,000 wives of Army personnel were abused in the last year [63]. Newer reports from the Congressional Research Service indicate that among the active-duty population, there were 16,912 reported incidents of spouse and intimate partner abuse in 2018. Among these, 8,039 reports (6,372 victims) met the DoD definitions. Physical abuse accounted for the highest number of reports (73.7%), followed by emotional abuse (22.6%), sexual abuse (3.6%), and neglect (0.06%) [64].

Deployment and moving are potential risk factors for domestic violence. In a 2013 study, 2% of married deployed personnel had perpetrated physical or emotional spousal abuse during the study period [65]. Rates of moderate and severe abuse and abuse involving alcohol were significantly higher in the post-deployment period.

Some studies show that female veterans are at increased risk of physical and sexual violence from their intimate partners (33%) compared with nonveteran counterparts (23.8%) [66]. Research indicates that female veterans who experienced previous childhood sexual abuse are three times more likely to be victims of spousal abuse, and those who experienced an unwanted incidence of sexual victimization during military service were more likely to have experienced interpersonal violence in the last year [67]. Being in the Army (versus other military branches) is also a risk factor for past-year victimization [67].

In another study, a total of 716 married military service men stationed in a U.S. Army post in Alaska participated in a survey. Almost one-third of the men (31.6%) reported engaging in some act of aggression against their partner in the last 12 months. Nine percent disclosed having engaged in at least one moderate-to-severe act of aggression [69].

Race is another factor. When researchers examined White and African American spouse abuse cases documented in the Army Central Registry, rates were higher among all age brackets for African Americans. It is not clear what specific factors are influencing these different rates, but a systematic bias may exist in the referral process [60]. It is also possible that referrals are made to the Family Advocacy Program due to stereotypical perceptions that African American families are more violent. The authors recommended further longitudinal studies to examine cultural-specific factors that contribute to these rates.

It has also been speculated that exposure to the trauma of combat and the development of post-traumatic stress symptoms provokes military veterans to be violent at home [56]. Furthermore, when these veterans do obtain treatment, either voluntarily or as mandated, many do not complete their treatment regimens [56].

In a similar vein, a study examined the extent by which recent military deployment predicted domestic violence against 368 wives whose husbands were deployed and 528 wives whose husbands were not deployed [70]. Wives who reported post-deployment domestic violence tended to be younger. The authors found that military deployment was not related to domestic violence during the first 10 months of the post-deployment period. However, when there was a history of pre-deployment domestic violence, the risk of post-deployment domestic violence was greater. Thus, age and previous history of domestic violence are important indicators to consider when developing prevention efforts [70].

The risk factors for domestic violence in military families are multi-faceted. The role of stress emanating from family, military life, culture, and environment and combat stress should be further researched to understand its influence on domestic violence.

Intermittent explosive disorder is included under the general category of disruptive, impulse-control, and conduct disorders in the text revision of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [71]. Approximately 2.7% of the general public meets the diagnostic criteria for this disorder, but it is much more common among military veterans. In one study of nondeployed U.S. Army personnel, 11.2% of participants met the criteria for intermittent explosive disorder in the past 30 days; it was the most prevalent mental disorder, surpassing PTSD and attention deficit hyperactivity disorder [72].

Intermittent explosive disorder is characterized by recurrent behavioral outbursts (manifested as verbal aggression, damage or destruction of property, and/or physical assault) representing an inability to control aggressive impulses [71]. The magnitude of this aggression is greatly out of proportion to the stressor or provocation, is not premeditated, and causes distress or impairment to the individual.

In many cases, intermittent explosive disorder occurs with comorbid depressive disorders, PTSD, and/or substance use disorder [73,74]. This can complicate diagnosis and treatment for some patients. In general, patients seek help only after they have committed significant violence or to address a comorbid disorder; the time from onset of symptoms to treatment is often more than a decade [75]. The recommended treatment approach is cognitive-behavioral therapy with or without pharmacotherapy [75,76]. There may be difficulty engaging persons with impulse-control disorders, like intermittent explosive disorder, in psychotherapy. If medication is necessary, selective serotonin reuptake inhibitors (SSRIs), specifically fluoxetine, are the agents of choice [76]. Patients should continue to be monitored throughout treatment, with assessment of aggressive and/or violent outbursts. There is some evidence that the number of outbursts may decrease over time, although aggressiveness as a trait persists.

During the post-deployment or reintegration phase, the service member returns, and the entire family is involved in helping him/her integrate back into the system [80]. There is usually a honeymoon phase, but awkwardness and tension often follow [81]. Family roles may have changed during this time, and the returning member will need time to adjust. For example, new parenting strategies may have surfaced in order to deal with being a "single parent" during the deployment. Upon homecoming, the military member should not expect family dynamics to have remained the same, but he/she may report feeling like a guest in his/her own home [82]. Some may not recognize their child, especially if the child was recently born or just an infant when they left. Similarly, children may not recognize the returning parent or express wariness of this returning stranger. As a result, the military parent may experience distress and hurt [83].

Some military families will encounter challenges during the post-deployment phase, including substance abuse, PTSD, and domestic violence. In fact, it is estimated that the rate of relationship and family problems is four times higher during this phase than the other phases [84]. In a study involving 19,227 active U.S. soldiers from brigade combat teams who served in Iraq or Afghanistan between 2003 and 2009, problems of marital quality and separation/divorce intentions increased during the reintegration period [85].