Mental Illness and the United States Veteran
About the Author
James Wittenauer, RN, MSN, MPA, RN-BC has been a registered nurse for 28 years with over 15 years critical care experience as well as experience in same day surgery, primary care, and cardiac care. Mr. Wittenauer received his associate degree and BSN from Lewis-Clark State College, his master's degree in public administration from Troy State University and his master's degree in nursing administration from the University of Phoenix. Mr. Wittenauer is board certified in pain management nursing. He has written for various journals, websites and continuing education series and serves as a peer reviewer for Federal Practitioner. Mr. Wittenauer is also a 20-year veteran of the United States Air Force
By the end of this course the learner will be able to:
- Recite the top six mental health illnesses facing veterans today.
- Articulate the treatments being used for the veteran with mental illness to include non-pharmacologic treatments.
- List the nursing implications in treating the veteran with mental illness.
Imagine for a moment that you are coming home from a long assignment for the company you work for. This company, while considered a necessary entity, is not always the easiest to work for. There are the long hours along with weekend and holiday shifts. There is also the fact that the work is very hard and not very many people understand the work that you do except the ones that work for the same type of employer. This work takes you very far away from you family for as long as weeks to months at a time. You continue to keep this job because it is a job you believe in and think it is best not only for you and your loved ones, but for the whole country as well.
Now imagine that after doing all you can do with this job and have given it your all you leave this job. Upon leaving this job, you do not feel like you fit in with anyone at your new job. In fact, you do not think you fit in at all with even your closest friends and your spouse keeps telling you that you are different now and is begging for you to get help.
The sad thing is that for a lot of people, they do not have to imagine this because they are living this. The company they work for is not just any company, it is the United States Armed Forces. The work that they do is the hardest work that will ever be done in the ongoing struggle to keep the citizens of our country safe. While some people may sympathize, empathize, or see it from afar, those who have never served truly don't know the challenges that the United States veteran faces upon returning to life as a civilian.
The United States veteran population faces a lot of very difficult problems, with mental illness being chief among them. The mental disorders either cause or contribute to drug and alcohol abuse, joblessness, homelessness, divorce, high suicide rates, high morbidity, and premature mortality.
This course will focus on the mental health issues that surround the United States veteran. We will look at statistics for mental health disorders and the most prevalent disorders that affect veterans. Current treatments used to treat the veteran with a mental health disorder will be discussed with a focus on the non-pharmacologic treatments used as well.
Statistics Regarding Mental Health and the Veteran
The statistics surrounding mental health issues and the veteran are sobering. According to Trivedi et al (2015), in 2011, of the 4 ,461, 208 veterans seen by the Department of Veteran Affairs (VA) medical center treatment teams called PACT, 1,147, 022 had at least diagnosis of either depression, PTSD, a substance abuse disorder, anxiety disorder or disorder called serious mental illness which is an illness such as schizophrenia or bipolar disorder. The National Alliance on Mental Illness (NAMI) (2020) reports that cases of PTSD are fifteen times higher than with the civilian community. The rate of depression reported by the Journal of the American Medical Association is five times higher for veterans than for civilians.
In 2018, veteran suicides accounted for 14% of all suicides in the United States with an average of 17.6 suicides per day. The rate of suicide is 1.5 times higher for veterans than their non-veteran counterparts.
Just Who is the Veteran?
While the term veteran is used in many fields to denote a person who has been in the field for a long time, the term military veteran means something totally different. According to the Code of Federal Regulations Section 38 (38 CFR §3.1(d) a veteran is defined as "a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable." This means that a person who served in the U.S. Armed Forces full-time, as long as they were not dishonorably discharged, is considered a veteran.
There are many similarities among veterans. However, analysis of data for veterans shows that there are stark differences with regard to the veteran, dependent on the time frame they served, where they served, the length of service, and their gender.
The experiences and mindset of veterans from World War II and the Korean War are very different than those who served in Vietnam War or the Gulf War. World War II and Korean War veterans tend not to talk about their experiences and may keep their feelings toward their service to themselves unless pointedly asked. When they speak of their service, they do so with pride.
The Vietnam Veteran, on the other hand, may not discuss their service with as much pride because the War was divisive to the country. Unlike those before them, veterans were not recognized with parades and fanfare upon their return to the United States. Nor were they well-supported to reassimilate into society. Both the health status and the attitude of the Vietnam Veteran was not improved by the fact that a large population of veterans from that war are victims of Agent Orange exposure with related health problems.
The Gulf War Veteran also have their own unique set of challenges such as chronic symptoms, sometimes referred to as Gulf War Syndrome. Because symptoms vary radically by individual, the VA prefers such terms as medically unexplained chronic multisymptom illness (MUCMI), chronic multisymptom illness (CMI) or medically unexplained illnesses. Those who served in the gulf war theater were exposed to a wide range of chemical and biological agents including fuels and vaccines that continue to be studied to understand associated adverse health effects.
With respect to gender, experiences in the military of women are different than that of men. During their service, females experienced more discrimination, bullying, sexual harassment, sexual assault and repeated coverups and scandals, such as the infamous Tailhook scandal in 1991, that was perpetuated by the upper echelon of the military leaders.
Top Mental Health Problems for Veterans
The top three mental health issues facing veterans today, according to Dellasanta (2017) are PTSD, depression, and traumatic brain injury or TBI. Other mental health problems veterans face are substance abuse, schizophrenia, and bipolar disorder. The rates of depression among veterans has increased from 9% in the 2007-2008 cycle to 14-18% in the 2015-2016 cycle per Liu et. al. (2019). According to the VA (2018), the rates of PTSD among veterans who served in either Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) range from 11-20% in any given year. The incidence of traumatic brain injury or TBI from the years 2000-2019 stand at 414,000 injuries per the VA (2020). Approximately 11% of veterans have a diagnosis consistent with a substance use disorder (SUD) The prevalence of substance use disorders is considered to be understated, since the data is collected from veteran's first visit to VA hospitals, according to Teeters et al (2017). Teeters also notes that 30% of successful suicides of military personnel are preceded by either alcohol or drug use.
According to the VA (2019), depression is one of the most common and costly of the mental health disorders. According to Liu et al. (2019), the condition comes with a high rate of comorbidity and mortality with white veterans experiencing a higher prevalence of depression than black or non-white Hispanic veterans. It is estimated that in 2008, 1 in 3 veterans who visited their primary care provider had symptoms of depression.
The National Institute of Mental Health, a part of the National Institute of Health, defines depression as a mood disorder which affects how the person thinks, feels and handles daily activities. There are many types of depression including post-partum, dysthymia, seasonal affective disorder, psychotic depression, and bipolar disorder where the patient experiences both depressive and manic episodes.
There are many signs and symptoms of depression; with the main caveat being that a person needs to be symptomatic for at least two weeks before a clinical diagnosis of depression can be made.
The signs and symptoms of depression can include, but are not limited to:
- Feelings of hopelessness
- Loss of interest in doing pleasurable activities
- Decreased concentration, memory, and/or decision-making capability
- Change in sleep habits
- Changes in weight and/or appetite
- Thoughts of death, suicidal ideation and/or attempts
- Somatic symptoms.
The person experiencing depression does not have to experience all of the above signs/symptoms for a diagnosis. The number of signs and symptoms along with the severity will determine the degree of depression and the treatment plan moving forward.
Treatment for depression needs to be tailored to the needs, experiences, and preferences of the patient. Treatment options for depression include measures such as medication therapy, cognitive behavioral therapy, acceptance commitment therapy and interpersonal therapy.
Medications used in the treatment of depression are many and varied, but basically work the same way to treat depression by affecting the neurotransmitters of dopamine, norepinephrine, and serotonin per Schimelpfening (2020). According to Schimelpfening, the five main classes of medications used are:
- Selective Serotonin Reuptake Inhibitors (SSRIs).
- SSRIs work by preventing the reuptake of serotonin into the brain so that more of the neurotransmitter is available. Examples of this class commonly used are sertraline HCl (Zoloft®), paroxetine (Paxil®), and fluoxetine (Prozac®).
- Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs).**
- SNRIs act by inhibiting the reuptake of both serotonin and norepinephrine. Examples of this type of antidepressant are duloxetine (Cymbalta®), venlafaxine (Effexor®) and desvenlafaxine (Pristiq®).
- Tricyclic Antidepressants (TCAs).
- TCAs mechanism of action includes the blocking of serotonin and norepinephrine, but the medications also blocks the reuptake of acetylcholine which affects skeletal muscles too. This medication is an older class with examples of the medication being amitriptyline (Elavil®), nortriptyline (Pamelor®), and desipramine (Norpramin®).
- Monoamine Oxidase Inhibitors (MAOIs).
- MAOIs work by stopping the degradation of the enzyme monoamine oxidase which breaks down neurotransmitters leaving more available for use. This is the oldest class of antidepressants with its start in the 1950s. Examples of MAOIs include medications such as phenelzine (Nardil®), tranylcypromine (Parnate®) and isocarboxazid (Marplan®). One problem with MAOIs is that they interact with foods with tyramine in them, so their use is not very common today.
- Atypical Antidepressants.
- Atypical are a class of antidepressants so named because although they affect the levels of serotonin, norepinephrine, and dopamine, they do so in differing ways. Medications in this class are a newer class of antidepressants and include medications such as mirtazapine (Remeron®) and bupropion (Wellbutrin®).
Although not specified in the descriptions above, it should be noted that every class of these medications carries the potential clinical benefits as well as potential side effects that the practitioner would need to discuss with the patient.
In addition to medications to relieve symptoms, the VA suggests the following psychotherapies as effective for depression.
Cognitive Behavioral Therapy for Depression (CBT-D) therapy designed for the patient to change their thought patterns by identifying what is the root cause of the problem. This type of therapy is short-term and used to establish goals in treatment. It is rooted in the theory, per Guatam et al (2020), that people are not affected by the events in their lives, but rather by their perception of them. The therapy works to change the patients thought process regarding events that have brought about their current state. Although there are no reported contraindications associated with CBT-D, practitioners will need specialized training for using it with patients who have subnormal intelligence, antisocial personality or a personality disorder. Patients who are psychotic as well as suicidal may also need medication therapy before starting CBT-D.
Acceptance and Commitment Therapy for Depression (ACT-D) is another form of talk therapy. The therapist works with the patient in accepting certain internal events such as thoughts, feelings, memories, images or perceptions, while at the same time helping the patient in making commitments that reflect his or her personal values. This form of therapy utilizes several strategies such as mindfulness, acceptance, commitment and behavioral change to help the veteran move on with their lives versus being stuck in their past. The VA offers the mnemonic ACT. Participants learn to ACT -- Accept. Choose. Take action. ACT therapy has shown to be successful in treatment of depression among veterans with a decrease of both depression, and suicidal ideation per Walser et. al. (2015).
Interpersonal Psychotherapy (IPT) is a short-term therapy comprised of three phases of therapy usually over sixteen sessions. The first phase of therapy, the initial sessions, focuses on exploring the signs, symptoms, life events, circumstances, and relationships that have led the veteran to this point. The therapist then gives the veteran what is called an interpersonal formulation which spells out a concise statement of the depression of the veteran along with other factors about the depression such as the causes, problem areas that will be the subject of the IPT focus, and most importantly, the goals of care.
The next phase of the treatment, the intermediate sessions focuses on implementation of the objectives set from the problems set out in the initial phase of treatment. Usually one or two problem areas are worked on at each session. The particular problem areas that may be dealt with are issues such as role transitions. An example of role transition may be a transition from military to civilian life or ambulatory to a non-ambulatory state. Other issues dealt with may be interpersonal conflicts within the veteran's life, grief issues and interpersonal insufficiencies that the veteran needs to come to terms with. Various counseling techniques are used to help the veteran deal with the issues that are causing the depression.
In the third and final phase of the sessions, the termination phase, topics covered are related to the ending of the therapy. including the end of therapy, the issues covered, progress made, review of life skills attained, evaluation of issues that may arise after therapy has been completed and warning signs of returning depression.
There are many and varied treatment options available to the veteran who is suffering from depression. Treatment options can be reviewed, changed and/or modified until the veteran can report an improvement in depression. The most important thing for the veteran to do is get help; as someone who would know, the author of this CE has a history of depression and has struggled with the disorder for eight to ten years.
Post-traumatic stress disorder or PTSD for short is a disorder that is one of the top disorders among veterans today. It is estimated that 13 to 30% of veterans experience PTSD, as compared to approximately 7% of members of the general population.
The disorder has been given a multitude of names that include battle fatigue, shell shock and Post-Vietnam Syndrome (Reisman, 2016). The term PTSD became the official term for the disorder in the 1970s. PTSD is a mental health disorder brought about after a person has been witness to or suffered from a life-threatening incident. The VA PTSD website (ptsd.va.gov) offers the following definition. "PTSD is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault." With respect to sexual assault, the VA states that of veterans using VA health care, 23% of women reported sexual assault when in the military and 55% experienced sexual harassment. The VA notes that of veterans with military sexual trauma more than 50% are men because there are many more men veterans than women veterans.
The numbers of veterans suffering from PTSD depends on which war/conflict that veteran was involved in. The VA reports the following rates of PTSD:
|Rates of PTSD|
|The Vietnam War||15%|
|The First Gulf War||12%|
|Operation Iraqi Freedom/Operation Enduring Freedom||11-20%|
In looking at PTSD with veterans, a practitioner should consider the combat conditions, geopolitical circumstances surrounding the conflict, location of the conflict, the role of the servicemember during the conflict and the type of enemy fought against during the conflict.
The signs and symptoms of PTSD are many and varied, but can include:
- Upset feelings when remembering the incident
- Experiencing nightmares, vivid memories, or flashbacks to the degree that the veteran believes it is recurring
- Feeling cut off from others
- Feeling emotionally numb
- Loss of interest in pleasurable activities
- Feeling of usually being on guard
- Difficulty sleeping, concentrating, and being easily startled.
The veteran suffering from PTSD may also have other mental health conditions, such as depression and anxiety as well as physical symptoms. 15-30% of PTSD victims report chronic pain upon returning from deployment. The veteran may also have a substance abuse disorder (SUD) co-existing with the PTSD. The SUD may be a separate issue, but more often, the SUD is intermixed with the PTSD. The reason for this may be due to self-medicating for symptom relief rather than seeing a mental health professional. Coming from a personal point of view, it is in the back of the mind of the veteran that to seek help for a mental health issues is a sign of weakness and could jeopardize the veteran's job or future career prospects.
The treatment for PTSD for the veteran is comprised of different therapies that depend on the severity of the PTSD. The first line of therapy is a trauma-focused psychotherapy; three types of these discussed below are Cognitive Processing Therapy (CPT), Prolonged Exposure (PE) therapy and Eye Movement Desensitization and Reprocessing or EMDR. The VA recommends these over treating with medication, as meta-analyses of effects show psychotherapies are more effective than pharmacotherapies, and without the risk of side effects or reactions from a medication.
The VA (2020) cites that CPT is usually a twelve-session therapy, but can be more, where the veteran is taught to assess the thoughts that trigger the PTSD and modify those thoughts. This type of therapy can be done on an individual basis or performed in group therapy. The sessions usually run 60-90 minutes and sometimes may involve written exercises and homework with the goal of getting the patient past the pain points in his or her life that have hindered the veteran moving forward with their life. To augment the therapy, the VA offers a treatment companion app for the CPT called the CPT Coach that the both the patient and therapist use during treatment.
The second type of therapy is called Prolonged Exposure or PE. This type of cognitive-based treatment is utilized in treating PTSD with patients who present with a complicated case of the disorder and with an accompanying substance use disorder. According to the American Psychological Association (APA) (2020), the treatment, which is usually 9-15 sessions, centers around imaginative and limited safe in vivo exposure to a trauma the patient has avoided in the past, due to the associated trauma of the event. This type of therapy helps the veteran process and modify those memories and the feelings that go along with them to move forward, and not be hindered by them anymore. According to the VA, PE therapy has the most promise for treatment of PTSD in all the patient presentations.
Eye Movement Desensitization and Reprocessing or EMDR, per the APA (2017), is a type of therapy first developed in 1987 specifically for the treatment of PTSD. The treatment, which usually lasts 6-12 sessions, is different than the CPT and PE therapy. Where CPT and PE focus on modifying the thoughts and responses to the traumatic event, EMDR focuses on how the traumatic event is stored in the brain. In short, the therapy utilizes a series of sessions where the patient focuses on the memory while at the same time engaging in another stimuli; usually a rapid eye movement which causes a diminution of the memory of the event.
The pharmacological treatments of PTSD are similar medications used in the treatment of depression. The medication classes are SSRIs and SNRIs such as sertraline HCl (Zoloft®), paroxetine (Paxil®), fluoxetine (Prozac®) and venlafaxine (Effexor®).
Although medications are used in the treatment of PTSD, psychotherapy, especially PE, appears to yield the most promise for long term results.
And now a word on pet therapy for PTSD. Therapy dogs help by bringing out positive feelings and help to get the patient out and about meeting other people and getting exercise. The VA has been using service dogs to assist disabled veterans for decades and briefly did allow for them to help treat veterans with PTSD from 2009-2012, but according to Weinmeyer (2015) the VA changed its position on therapy dogs citing a lack of scientific evidence to back up the claim that therapy dogs help the veteran. Clinical evidence is starting to come in on the side of dogs helping. In a study by O'Haire and Rodriguez published in 2018, they reported the primary outcome was that of a significant decrease in clinical symptoms along with a higher quality of life, improved functioning socially and decreased depression. However, the difference was not great enough to eliminate the PTSD. The authors suggest the inclusion of psychiatric service dogs as a complementary or integrative therapy.
Approximately sixty independent organizations match veterans with a service or therapy dog.
The non-profit, Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) maintains a list of organizations that work to provide service dogs to veterans that can be accessed here:
Traumatic Brain Injury
Traumatic brain injury or TBI for short is defined by the CDC as a disruption in normal brain function due to an outside injury such as a jolt, blow to the head, or a penetrating head injury. The TBI known as a concussion occurs when the brain moves back and forth rapidly due to a jolt from a hit or blow to the head or body. This can cause the brain to bounce around or twist in the skull. (CDC, 2020) The immediate impact of a TBI can lead to changes in consciousness, confusion and loss of consciousness as well as a loss of memory.
The Departments of Defense and Veterans Affairs have a collaborative unit called the Traumatic Brain Injury Center of Excellence to assist service members, veterans and their families with TBI. This center reports that there have been 417,503 TBIs between the years 2000-2019, with 185,000 veterans enrolled in the VA health system having at least one diagnosis of TBI.
Short-term and long-term conditions that come from TBI are many, varied and far reaching. They can affect thinking, emotion, sensation, and language. Among others, these include:
- Sleep disorders
- Memory loss
- Mood fluctuations
- Ability to focus
- Hearing problems
- Vision problems
- Slower cognitive ability
These symptoms can last from days to weeks, and in a small segment of the veteran population, they can persist for a longer period. It is known that at least 3% of people with TBI experience long term issues. Compared with veterans without a history of TBI, veterans with a history of TBI are 2.3 times more likely to receive a diagnosis of dementia, two times more likely to die of suicide, and 28% more likely to develop epilepsy.
In looking at the severity of a TBI, the assessment is done by way of:
- a CT scan which assesses internal cerebral bleeding, edema and/or bruising of cerebral tissue,
- the length of the original loss of consciousness,
- the length of memory loss,
- and degree of responsiveness of the veteran after the initial injury.
A mild TBI can be difficult to identify in the service member and veteran because of lack of observable injury, lack of CT evidence of trauma and confusion of the TBI with PTSD.
The VA reports that the main problem does not just lie in one TBI, but with the accumulation of TBIs over the course of the veteran's time in the military. There is direct evidence of the risk of veterans developing a degenerative neurologic type of encephalopathy from multiple TBIs called chronic traumatic encephalopathy (CTE). There is also research being done on an epidemiological level that shows a link with progressive neurological degenerative diseases such as Parkinson's Disease.
The first line of treatment after a TBI is the stabilization of the patient to prevent secondary complications. The next step is providing treatment to ensure that blood pressure and other vitals and body systems are stable to enable the brain to continue to receive adequate perfusion. After the patient is stabilized, the rehabilitation phase starts to help the patient return to as much of a normal life as possible.
The approved treatment in the rehabilitative phase for traumatic brain injury in veterans is very conservative. Treatment includes assistive strategies to help with behavioral issues, cognitive and other underlying health problems, all forms of rehabilitation therapies, assistive devices like hearing aids and learning devices and medications.
The VA is also researching investigative treatments for veterans suffering from TBI. These include the use of lithium, protein supplementation and neuroplasticity.
In experimental treatment of lithium as a mood stabilizer, in research with rats, lithium was found to give a modest improvement in cognitive function without any impairment of their motor function.
Another experimental treatment being investigated is protein supplementation. Researchers from VA Pittsburgh Healthcare System and the University of Pittsburgh found that the protein UCH-L1, when combined with other proteins, is expressed in the neurons in increased levels that can potentially improve cognitive functions and cell survival even after months after a TBI, or at least that is what it showed in their investigation using rats.
Harnessing the brain's ability to form new neural connections, neuroplacity, is being studied at the Brain Rehabilitation Research Center in Gainesville, Florida, is funded by the VA with the mission to develop and test treatments that can harness the brain's ability to form new neuronal connections, thereby improving and/or providing restoration to cognitive, motor and emotional functions that have been impacted by disease or injury.
Bipolar disorder is a mental health disorder that can affect both veterans and non-veterans alike. The typical signs and symptoms of bipolar disorder include clear-cut fluctuation in moods that can go from manic to depressive to sleeping. These episodes of manic to depressive can last for days to weeks.
The manic episode is comprised of behavior that the patient is awake and exhibits periods of extreme energy, increased level of activity, increased verbose speech, and little sleep.
The depressive phase of bipolar disorder is marked with feelings of sadness or hopelessness, difficulty with focusing, changes with sleep patterns and appetite, as well as the loss of wanting to do pleasurable activities and/or performing activities of daily living. Awareness of when this phase is occurring and seeking and adhering to treatment is especially important. Up to 60% of those with bipolar disorder will attempt suicide at least once during their lifetime. One in three attempts by an individual with bipolar disorder will end in a suicide death. Up to 20% of individuals with this disorder die by suicide. Most are by individuals that are not adhering to treatment, or by those who are untreated. Prevention strategies include educating the patient and the patient's support system to recognize and respond to warning signs of suicidal behavior. A patient actively involved in creating a plan for when depressive states occur with input and buy-in from the patient's support network can help to prevent crisis situations when episodes occur.
The treatment for bipolar is very individualized to the person. The VA suggests several treatments that can help. These treatments include:
- Medication therapy
- Cognitive behavioral therapy
- Illness management and recovery
- This form of treatment helps veterans to learn about bipolar disorder, acquire the necessary coping skills, and how to set goals that can assist with their recovery.
Schizophrenia, like other mental health disorders, is not specific to veterans but does affect them too. According to the NIH (2020), the disorder affects a person's perception of reality; how they think, feel, and behave. The onset of symptoms is seen earlier in males, when they are in their teens to twenties, as compared with onset for females which is in their twenties to thirties.
Signs and symptoms of schizophrenia include three sets of symptomatology along with alterations in perceptions to the senses of sight, sound, taste, touch, and smell. The psychotic symptoms are comprised of hallucinations, delusions, disorganized thinking along with disorganized speech. The negative set includes motivational loss, flat affect (emotional inexpressiveness), reduced speech, and loss of wanting to perform pleasurable activities. The set with cognitive symptoms includes inattentiveness, decision-making problems and cognitive-processing problems.
Risk factors for schizophrenia may include a genetic disposition, environmental factors and differences in the function and neurotransmission of the brain impulses.
The treatment for schizophrenia, like bipolar disorder, is not just centered on medications, but on a combination of medications and psychotherapy. The treatment for schizophrenia includes medications and psychosocial treatment and services.
The medications are in the antipsychotic class of medications. Some patients respond well with just medications and some do not.
Psychosocial treatments include:
- Cognitive Behavioral Therapy (previously discussed)
- Assertive Community Treatment (ACT)
- This form of treatment involves frequent visits by the provider going to where the veteran is versus the veteran going to a provider's office or treatment center. ACT therapy is believed to show a decrease in hospitalizations and assists the veteran to live a more independent life and to remain employed.
- Supported Employment
- This service helps the veteran to find and keep employment. It is reported that veterans who utilize this service can find jobs, keep their jobs and work for longer periods of time.
- Illness Management and Recovery (IMR)
- This program helps veterans diagnosed with schizophrenia to set goals and to learn the necessary skills to support their own recovery.
- Social Skills Training (SST)
- SST involves assisting the veteran to develop effective social skills. Techniques include education, breaking skills down to simple steps, role playing and group support. (VA, 2020)
Substance Use Disorders
Substance use disorder is prevalent among veterans and non-veterans alike. The disorder often can present itself as a separate co-existing disorder. For example, a veteran may have a diagnosis of PTSD and may suffer from a substance use disorder.
The statistics regarding substance use disorder among veterans overall average less than their civilian counterparts at 6.67% vs 8.6% respectively. However, the average hides that for veterans who have served in the military since September 2001, 12.7% have been diagnosed with a substance use disorder versus 3.7% for pre-Vietnam veterans. https://www.samhsa.gov/data/
The most prevalent substance abused among military personnel is alcohol; with a higher percentage of alcohol abuse noted in those who have been in combat situations. Of veterans who struggle with a substance use disorder, 80% struggle with excessive alcohol use. Alcohol abuse may result in poorer health, interpersonal violence, and increased mortality rate. 2.9% of veterans misuse opioids, with more than 90% of misuse being with prescription pain relievers. and the remainder being with heroin. Of illicit drug use, marijuana tops the list with 12.8% of veterans using marijuana. 24% of those veterans use it on a daily or almost daily basis. 4.6% of veteran users are classified as have cannabis use disorder, also known as marijuana use disorder, which is defined as continued use of marijuana despite impairment and dependence.
According to CDC (2018) 30% of veterans use some form of nicotine. Nicotine use is highest among veterans of the Marines at approximately 40% and lowest for Air Force Veterans at 21%. (Cooper, 2019) Nicotine use is also higher among veterans than non-veterans. VA websites discuss Nicotine Use Disorder (NUD) although no statistics for NUD are offered. The VA states that 70% of veterans who smoke would like to quit. Cigarette smoking is responsible for 23% of cancer-related deaths of former smokers and for 50% of cancer-related deaths for current smokers. According to the World Health Organization 14% of tobacco-related deaths are non-smokers exposed to second-hand smoke. This statistic is noteworthy and impactful for smokers and non-smokers alike.
The signs and symptoms for a substance use disorder among veterans may include:
- An increasing tolerance of the substance to achieve the desired effect.
- The inability to stop using the substance despite adverse consequences such a DUI, pancreatitis, or marital discord.
- Withdrawal symptoms when the substance is abruptly halted.
- An intense craving of the substance.
- Spending a large amount of time to obtain, use, and recover from the use of a substance.
- The substance interfering or taking the place of pleasurable activities.
- The substance interfering with the veteran's job.
There are a number of services and treatment programs available to veterans with a substance use problem that are behavioral-based and medication-based. These treatments include:
- Cognitive Behavioral Therapy for Substance Abuse Disorder or CBT-SUD
- Motivational Interviewing Therapy, Contingency Management Treatment, and
- pharmacological options
An approach that has shown promise even prior to the COVID-19 pandemic is online-based one-on-one sessions with recruitment using social media. Using social media has increased awareness and recruitment among younger veterans, in particular. Online sessions and telemental health (TMH) sessions have the advantage of fitting within people's schedules more easily. Early studies have shown increased compliance to showing up for scheduled sessions, and in the case of alcohol, decreased consumption and fewer binge sessions during and for the month following treatment. Researchers suggest there may be a reduced stigma with web-based at-home sessions. Likewise, they postulate there is a reduction in "no-shows" and less perceived stigma or shame for seeking treatment at health centers rather than at places advertised or named as addiction centers
Cognitive Based Treatment
Cognitive behavioral therapy for substance use disorder consists of weekly talk sessions, similar to the cognitive behavioral therapy for post-traumatic stress disorder. The therapist engages with the veteran on ways to look at themselves in a more positive light, to figure out what problem the veteran is trying to solve with the substance, ways to manage urges and cravings to stay away from the substances and how to set and achieve goals for the future.
Another treatment is called Motivational Interviewing or MI for short. In this type of talk therapy, the therapist draws out and helps to strengthen the motivational reasons for change. The therapist guides the patient to explore different avenues as to the reasons the veteran may want to make changes to their lives and the benefits in making those changes. A variation of the motivational interviewing is called Motivational Enhancement Therapy (MET). MET comes with an initial assessment session which is used when a veteran or loved one is first considering or not considering treatment for an alcohol or drug issue and is trying to gauge the extent of their issue. It is followed by feedback sessions to encourage change. The approach has been successful to motivate treatment in previously ambivalent individuals and is less effective as a drug treatment therapy to reduce drug use.
Another therapy, which has been adopted by the VA for use to promote abstinence from drugs, is called Contingency Management or CM for short. In this form of therapy, which is a positive reinforcement approach, the veteran earns rewards when the individual takes positive steps towards recovery such as getting a prize for therapy sessions, or money when they have negative results for urine screens that are done to ascertain the presence or absence of drugs in their system. According to the VA (2020), research is showing that contingency management helps veterans stay in treatment and continues to help with abstaining from drugs.
Medication Treatment Options for Substance Use Disorder
Certain medications are commonly used in the treatment of alcohol and drug abuse.
For helping with opioid addiction, medications used are buprenorphine, naltrexone, and methadone. Buprenorphine works as a partial opioid agonist, and its effects are weaker than full opioid agonists. The result is a lessening of the physical dependency on opioids, a lowered potential for mismanagement of the drug as well as a safer avenue in case of an overdose. (Samhsa.gov 2020).
Naltrexone works by blocking the effects of opioids at the receptor site which in turn blocks the euphoric and sedative effects of the opioids. The medication also reduces the desire for opioids and is not considered a risk for abuse because the medication itself does not contain any addictive properties. The medication is given either by mouth daily or as an extended release intramuscular injection once a month. Naltrexone should be started seven days after the last short-acting opioid and ten to fourteen days after the last long-acting opioid taken to reduce the chance of withdrawal symptoms.
Methadone is another medication used for opioid addiction even though it is a long-acting opioid agonist. The medication acts by blocking the actions of other opioids and reduces the desire for opioids. Methadone is not without its share of concerns as there are risks of addiction and overdosing. When used as specifically tailored to each patient, it is considered safe and effective according to SAMHSA.
The medications used for alcohol use disorder are acamprosate, disulfiram, and naltrexone. Acamprosate works in the brain to help restore a chemical balance that is disturbed in someone with an alcohol use disorder. The pharmacology is not well understood, however, it is considered safe, well-tolerated, and moderately effective. Acamprosate is used after a detox period in conjunction with psychotherapy to help minimize cravings. It should not be taken by those with severe renal impairment and should be used only with a reduced dosage and close monitoring of individuals with mild or moderate renal impairment.
In 1949, Disulfiram became the first medication to receive FDA approval for the treatment of alcohol dependence. When taken it creates a disulfiram-alcohol reaction. Disulfiram blocks the absorption of alcohol at the acetaldehyde stage causing a buildup of acetaldehyde in the system which causes a plethora of unpleasant symptoms including palpations, nausea and vomiting. The adverse reaction is meant to deter users from drinking alcohol. Disulfiram is taken once a day, preferably upon waking, to discourage to intake of alcohol. Patients should be reminded that alcohol-containing foods, such as vinegar-based salad dressing, and fermented beverages such as kombucha contain alcohol. Individuals taking disulfiram should also avoid using alcohol-based sanitizers, to avoid the unpleasant reactions.
Naltrexone, as previously discussed, is also used for the treatment of alcohol use disorder. The medication blocks the effects and feelings of alcohol for the patient. The medication needs to be started after the initial detox period to avoid the side effects of nausea and vomiting.
Topiramate, approved for migraines and seizures, is also used as a front-line treatment to reduce the desire to drink alcohol. The use of topiramate for the disorder is not approved by the FDA. Because topiramate no longer falls under patent restrictions, it is unlikely anyone would foot the bill to go through the FDA approval process for alcohol use disorder.
Medications used for nicotine use disorder are nicotine transdermal patches, varenicline and bupropion (sustained release).
Nicotine transdermal patches are suggested along with prescription medications and counseling.
Varenicline works by blocking the effects of nicotine on the brain and is a partial agonist for the nicotinic receptors, and therefore reduces the craving for nicotine. Side effects that have been noted with varenicline are especially vivid nightmares, insomnia, and headaches. The medication is contraindicated in those with suicidal ideation. Close monitoring of the patient is essential when starting the medication. Watch for severe rash and blistering, swelling and flu-like symptoms as Steven-Johnsons Syndrome may occur.
In addition, caution and close monitoring should be taken with patients with renal issues, psychiatric disorders, or history of seizures.
Bupropion, marketed as Zyban®, is also used for helping people to quit smoking. The medication was originally intended as, and is still used as an antidepressant, but it was given approval by the FDA for use in treatment of smoking cessation in 2000 after evidence supported that it had an antismoking effect. The complete mechanism of action for Zyban® is unclear, but the medication appears to work by blocking some of the substances in the brain that produce the pleasure response to smoking as well as a reduction in irritability, craving and loss of focus.
When a veteran is looking to get help in treatment for a substance use problem, there are many options available; the options depend on the severity of the problems, and if the veteran can be managed as an outpatient, or if an inpatient detoxification regiment is necessary.
The options available to the veteran for substance use problems, according to the VA are:
- Initial screening for alcohol and tobacco use in all outpatient facilities
- Outpatient counseling on a short-term basis with a focus on motivation
- Intensive outpatient treatment
- Residential (live-in) care
- Inpatient medically managed detoxification program to help stop use of the substance in a safe manner and setting
- Continuing care to include relapse prevention counseling
- Counseling for the family and marriage counseling
- Self-help groups including specially-focused counseling and therapy options for specific groups such as woman veterans, returning combat veterans, and homeless veterans
- Pharmacological and non-pharmacological therapies to reduce cravings
Mental Health Services Available to Veterans
There are many options available to the veteran and their family to support the mental healthcare of the veteran. Again, the circumstances surrounding the patient will dictate which services are most appropriate.
The Veterans Health Administration has approximately 1,255 health facilities as a part of the Veterans Integrated Services Networks or VISNs. The area of the country where a veteran lives determines which VISN the veteran will go to for healthcare; this healthcare includes medical, vision, dental, audiology and mental health services. Health care facilities also exist for veterans residing in most of the inhabited territories of the US and in the Philippines.
Within each VA health clinic or facility there are what is called patient aligned care teams or PACTs for short. These PACTs are teams of doctors, nurse practitioners, nurses, and medical technicians responsible for a specific number of patients. The team works with the veteran for "whole person care" with the objective being life-long health and wellness. Mental health services are also included in these PACTs to better serve the veteran as a more inclusive approach to the total wellbeing of the veteran.
At larger primary care facilities, this typically means a team of mental health care professionals is integrated with the PACT to streamline access and care with respect to mental well-being. Anxiety, depression, PTSD, and substance use are commonly treated. The integrated approach of the support team can help veterans to recognize that what they may be experiencing are actually symptoms. That acknowledgement, along with engagement by the team and veteran, can set the stage for treatment and better outcomes.
In looking to the mental health needs of the veteran the most important thing to know is that when a veteran, or anyone else, is displaying or verbalizing suicidal behavior to call 911; it is considered an emergency. The veteran can also get help by calling the Veterans Crisis Line at 1-800-273-8255 and Press 1, visiting the Veterans Crisis Line at http://www.veteranscrisisline.net/ to chat online or by texting the number 838255 for help. Note that 1-800-273-8255 is the phone number of the National Suicide Prevention Lifeline. Pressing 1 after connecting will put the veteran directly in touch with qualified responders from the Department of Veterans Affairs, many of whom are veterans.
As of December 2020, the VA launched a single customer service phone number. "1-800-MyVA411" (1-800-698-2411). If the veteran, veteran's family, caregivers, or survivors have any questions regarding services and assistance, they can call 1-800-698-2411. Pressing zero (0) after connecting will route directly to a live customer service agent, as opposed to going through a menu. The VA mental health website https://www.mentalhealth.va.gov/ is also a great resource. Note that certain mental health care services are available to those who do not qualify for VA health care. For example, needs related to military sexual trauma can fall under this umbrella.
In general, mental health treatment options for veterans are similar to the options for those suffering from substance use.
Short Term Inpatient Care – This type of care is given on an inpatient basis for the veteran suffering from a severe mental illness (SMI) that may be fatal.
Outpatient Care – This care is offered by a psychosocial rehab and recovery center or PRRC for short. These centers are for veterans with mental illness that is severe enough to hinder everyday functioning. An array of services is offered five days a week on an outpatient basis.
Residential rehabilitation treatment programs or RRTP for short - These 24/7 residential programs are for those veterans experiencing a wide range of mental health, substance use, or other rehabilitative issues such as homelessness. These programs help to get the veteran the things needed to become more functional such as a place to live, education assistance or job training.
Primary Care – Mental Health Integration (PCMHI) - The primary care team within each PACT is enabled to assist the veteran with common mental health problems that they have on an outpatient basis.
Services for Women Veterans – The VA Medical Centers each have a Women Veterans Program Manager to advocate for and advise women veterans. The VA offers mental health services for female veterans including for those suffering from substance use disorders, depression, anxiety, stress, PTSD, homelessness, intimate partner violence, and problems related to military sexual trauma or MST. Some services at the regional and national level may be available with a track or focus specifically for women.
Family Services – The VA offers a variety of mental health services to families of the veteran. These services include education for the entire family, short-term problem-oriented consultation, family centered psychoeducation and marriage and family counseling.
Coaching Into Care – This program is a telephone coaching program that can be utilized when a veteran's family or friends are seeking care for a veteran. It is commonly used when a family member or friend of a veteran starts to observe that the veteran is having difficulties. The coaching helps the veteran, and their loved ones discuss ways to talk about the veteran's problems and explore treatment options.
The coaches, who are social workers or psychologists, can help to educate about appropriate services and treatment options. They can also suggest ways to help friends and family to motivate a veteran who is apprehensive about seeking treatment.
Vet Centers (Readjustment Counseling) – Services at the 300 Vet Centers are available to veterans who served in a combat theater or area of hostility and to their families for "military-related issues when they aid in the readjustment of those who have served." Bereavement counseling is also available to families who have experienced an active-duty death. (https://www.vetcenter.va.gov/Eligibility.asp)
Nursing Implications in the Care of the Veteran
When caring for veterans, one should consider that the military culture in and of itself makes things different. It is important to remember that the military culture includes not only active duty service members and veterans, but also their spouses and family members, Department of Defense personnel and civilians as well. It can be very frustrating for veterans and their families when receiving care from a practitioner that does not have an adequate understanding of the military culture. Additionally, just as there are different ways to look at different populations and sub-populations of non-veteran patients; the same is true for veterans.
Are you a veteran? This simple question can open up a dialogue between the nurse and the patient regarding any health problems they have suffered as a result of military service such as physical injuries, cancers and mental health issues. Asking this question can go a long way in establishing a rapport between the nurse and the patient.
When caring for the veteran and assessing them, the VA recommends gaining permission from the patient to talk about their military experience, and asking all service members and Veterans the following:
For the above questions, please consider that some veterans may not wish to discuss their military service. Respect their wishes. It may be useful to provide the veteran with the Military Health History Pocket Card for Health Professions Trainees & Clinicians available at https://www.va.gov/OAA/pocketcard/ or with this QR code
Scars we often see from our patients are on the outside. But there are times when the scars that our patients bear are on the inside. The veteran can bear the scars of combat, loneliness from deployments, friends lost in combat and the scar of combat itself. Their internal wounds may be compounded or lessened by the care they received upon their return and in years to come. As providers, let's do our best to give veterans and their loved ones excellent care for their external injuries and their mental injuries; this is the best way we can thank them for their service to us and our country.
Dellasanta, J. (2017, May 19). 3 most common mental health concerns for veterans. https://blog.thetransitionhouse.org/3-most-common-mental-health-concerns-for-veterans
Eftekhari, A., Stines, L. R., & Zoellner, L. A. (2006). Do You Need To Talk About It? Prolonged Exposure for the Treatment of Chronic PTSD. The behavior analyst today, 7(1), 70–83. https://doi.org/10.1037/h0100141
Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive Behavioral Therapy for Depression. Indian journal of psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19
Clougherty, K. F., Hinrichsen, G. A., Steele, J. L., Miller, S. A., Raffa, S. D., Stewart, M. O., & Karlin, B. E. (2014). Therapist Guide to Interpersonal Psychotherapy for Depression in Veterans. Washington, DC: U.S. Department of Veterans Affairs. Retrieved April 26, 2021 from https://mothersmentalhealth.org/wp-content/uploads/2017/04/IPT-manual.pdf
Cooper, M., Yaqub, M., Hinds, J. T., & Perry, C. L. (2019). A longitudinal analysis of tobacco use in younger and older U.S. veterans. Preventive medicine reports, 16, 100990. https://doi.org/10.1016/j.pmedr.2019.100990
Ghosh, A., Mahintamani, T., Balhara, Y. P. S., Roub, F. E., Basu, D., Subodh, B. N., S K Mattoo, Mishra, E., Sharma, B. (2021). Disulfiram Ethanol Reaction with Alcohol-Based Hand Sanitizer: An Exploratory Study, Alcohol and Alcoholism, Volume 56, Issue 1, Pages 42–46. https://doi.org/10.1093/alcalc/agaa096
Institute of Medicine 2005. Gulf War and Health: Volume 3: Fuels, Combustion Products, and Propellants. Washington, DC: The National Academies Press. https://doi.org/10.17226/11180
Liu, H., Rose, M. E., Ma, X., Culver, S., Dixon, C. E., & Graham, S. H. (2017). In vivo transduction of neurons with TAT-UCH-L1 protects brain against controlled cortical impact injury. PloS one, 12(5), e0178049. https://doi.org/10.1371/journal.pone.0178049
Liu, Y., Collins, C., Wang, K., Xie, X., & Bie, R. (2019). The prevalence and trend of depression among veterans in the United States. Journal of affective disorders, 245, 724–727. https://doi.org/10.1016/j.jad.2018.11.031
Acamprosate. (2021, April 16). U.S. National Library of Medicine MedLine Plus. Retrieved April 26, 2021 from https://medlineplus.gov/druginfo/meds/a604028.html
Disulfiram. (2021, April 16) U.S. National Library of Medicine MedLine Plus. Retrieved April 26, 2021 from https://medlineplus.gov/druginfo/meds/a682602.html
National Alliance on Mental Illness. Veterans & Active Duty. https://www.nami.org/Your-Journey/Veterans-Active-Duty
NIDA. 2020, June 1. Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine). Retrieved on 2021, April 26 from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies/motivational-enhancement-therapy
O'Haire, M. E., & Rodriguez, K. E. (2018). Preliminary efficacy of service dogs as a complementary treatment for posttraumatic stress disorder in military members and veterans. Journal of Consulting and Clinical Psychology, 86(2), 179–188. https://doi.org/10.1037/ccp0000267
Reisman M. (2016). PTSD Treatment for Veterans: What's Working, What's New, and What's Next. P & T: a peer-reviewed journal for formulary management, 41(10), 623–634.
Sarkis, S. (2020, July 26). Cognitive-Behavioral Therapy May Be More Effective Online. psychologytoday.com. https://www.psychologytoday.com/us/blog/here-there-and-everywhere/202007/cognitive-behavioral-therapy-may-be-more-effective-online
Schimelpfening, N. (2020, December 20). The 5 Major Classes of Antidepressants. verywellmind.com. https://www.verywellmind.com/what-are-the-major-classes-of-antidepressants-1065086
Singh D, Saadabadi A. (2020 May 26\]. Varenicline. https://www.ncbi.nlm.nih.gov/books/NBK534846/
Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. E. (2017). Substance use disorders in military veterans: prevalence and treatment challenges. Substance abuse and rehabilitation, 8, 69–77. https://doi.org/10.2147/SAR.S116720
Trivedi, R. B., Post, E. P., Sun, H., Pomerantz, A., Saxon, A. J., Piette, J. D., Maynard, C., Arnow, B., Curtis, I., Fihn, S. D., & Nelson, K. (2015). Prevalence, Comorbidity, and Prognosis of Mental Health Among US Veterans. American journal of Public Health, 105(12), 2564–2569. https://doi.org/10.2105/AJPH.2015.302836
Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans. Behaviour Research and Therapy, 74, 25–31. https://doi.org/10.1016/j.brat.2015.08.012
U.S. Department of Veterans Affairs. (n.d.). Topiramate: Recovery-Focused Treatment for Alcohol Use Disorder. Welcome to the Veterans Health Library Retrieved April 26, 2021, from https://www.veteranshealthlibrary.va.gov/142,41571_VA
Weinmeyer R. (2015). Service Dogs for Veterans with Posttraumatic Stress Disorder. AMA journal of ethics, 17(6), 547–552. https://doi.org/10.1001/journalofethics.2015.17.6.hlaw1-1506
Westphal, R., Convoy, S. (2015, January 15). Military Culture Implications for Mental Health and Nursing Care. The Online Journal of Issues in Nursing Vol. 20, No. 1, Manuscript 4. http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No1-Jan-2015/Military-Culture-Implications.html
Centers for Disease Control and Prevention (2019, February 12) What is a Concussion? https://www.cdc.gov/headsup/basics/concussion_whatis.html
2020 Guide to Substance Abuse in Veterans (n.d.). 449 Recovery. Retrieved April 26, 2021 from https://www.449recovery.org/veterans-and-substance-abuse/
Office of Suicide Prevention, U.S. Department of Veterans Affairs. (2017, August) Suicide Among Veterans and Other Americans 2001-2014 Retrieved April 26, 2021 from https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf
PTSD: National Center for PTSD (2020, July 20) Retrieved April 26, 2021 http://www.ptsd.va.gov
How Common is PTSD in Veterans? (2018, September 24). National Center for PTSD. Retrieved April 26, 2021, from https://www.ptsd.va.gov/understand/common/common_veterans.asp
U.S. Department of Veterans Affairs. (n.d.). VA research on Traumatic Brain Injury (TBI). Office of Research & Development. Retrieved April 26, 2021, from https://www.research.va.gov/topics/tbi.cfm
U.S. Department of Veterans Affairs. (n.d.). RR&D Brain Rehabilitation Research Center (BRRC). https://www.brrc.research.va.gov/
U.S. Department of Veterans Affairs. (n.d.). Substance Use. Retrieved April 26, 2021, from https://www.mentalhealth.va.gov/substance-abuse/treatment.asp
U.S. Department of Veterans Affairs. (n.d.). Cognitive Processing Therapy for PTSD. PTSD: National Center for PTSD. Retrieved April 26, 2021, from https://www.ptsd.va.gov/understand\_tx/cognitive\_processing.asp
U.S. Department of Veterans Affairs. (n.d.). Depression Acceptance and Commitment Therapy (ACT). Retrieved April 26, 2021, from https://www.mentalhealth.va.gov/depression/act-d.asp
Walser, R. D., Sears, K., Chartier, M., & Karlin, B. E. (2015). Acceptance and Commitment Therapy for Depression in Veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. Retrieved April 26, 2021 https://www.treatmentworksforvets.org/wp-content/uploads/2017/05/ACT-D-Therapist-Manual.pdf
Society of Clinical Psychology. (n.d.). Diagnosis: Posttraumatic Stress Disorder Treatment: Prolonged Exposure Therapy for Post-traumatic Stress Disorder. Retrieved April 26, 2021 from https://div12.org/treatment/prolonged-exposure-therapy-for-post-traumatic-stress-disorder/
Eye Movement Desensitization and Reprocessing (EMDR) Therapy. (2017 July, 17). American Psychological Association Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder. https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessing
U.S. Department of Veterans Affairs. (n.d.). Treatment Programs for Substance Use Problems. Retrieved April 26, 2021 from https://www.mentalhealth.va.gov/res-vatreatmentprograms.asp
Guide to VA Mental Health Services for Veterans & Families. (2012, July).Retrieved April 26, 2021 from https://www.mentalhealth.va.gov/docs/MHG_English.pdf
U.S. Department of Veterans Affairs. (n.d.). How to Screen for Military Service. Community Provider Toolkit Serving Veterans Through Partnership. Retrieved April 26, 2021, from https://www.mentalhealth.va.gov/communityproviders/screening_howto.asp also Military_Service_Screening_recreated.pdf"
U.S. Department of Veterans Affairs. (n.d.). Bipolar Disorder. Mental Health Retrieved April 26, 2021, from https://www.mentalhealth.va.gov/bipolar/treatment.asp
Dome, P., Rihmer, Z., & Gonda, X. (2019). Suicide Risk in Bipolar Disorder: A Brief Review. Medicina (Kaunas, Lithuania), 55(8), 403. https://doi.org/10.3390/medicina55080403
Schizophrenia. (2020, May). Retrieved April 26, 2021, from https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml
U.S. Department of Veterans Affairs. (n.d.). PTSD. Make the Connection. Retrieved April 24, 2021, from https://www.maketheconnection.net/conditions/ptsd/
Buprenorphine. (2021, March 12), U.S. Department of Health & Human Services SAMHSA Substance Abuse and Mental Health Services Administration. Retrieved March 25, 2021, from https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine
Depression. (2018, February). National Institute of Mental Health. Retrieved April 26, 2021, from https://www.nimh.nih.gov/health/topics/depression/index.shtm
Office of Academic Affiliations. Military Health History Pocket Card for Health Professions Trainees & Clinicians. (2019). U.S. Department of Veterans Affairs. Retrieved March 5, 2021, from https://www.va.gov/OAA/pocketcard/
U.S. Department of Veterans Affairs. Office of Mental Health and Suicide Prevention. 2020 National Veteran Suicide Prevention Annual Report. (2020, November). Retrieved January 23, 2021, from https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf
Office of Research & Development (n.d.) VA research on Traumatic Brain Injury (TBI) Retrieved January 27, 2021, from https://www.research.va.gov/topics/tbi.cfm\#research3