Black military veteran talking with doctor, showing how mental health issues can impact our country's veterans.Healthcare providers are all too familiar with the scope and the devastating toll of depression, and they likely know that veterans are at increased risk. According to the VA Suicide Prevention Program, roughly 20 veterans commit suicide every day.

But because civilian healthcare providers often don’t ask their patients about military service, they may not know that many veterans – male and female, young and old – are among the patients they treat every day. Healthcare providers are in a unique position to help by educating themselves about the issues veterans face and the therapies and resources available.

“We know people go to their primary care providers before they will see a mental health professional,” says Kathleen Chard, PhD, director of the Trauma Recovery Center at the VA Medical Center. “They are the first line and there are resources out there to help them.”

Veterans and Depression

Major depression is one of the most common mental disorders in the United States. Roughly 6.7 percent of the U.S. adult population suffered a major depressive episode in 2015, according to the National Institutes of Mental Health.

High as that rate may be, it is dwarfed by the incidence of depression among military veterans. In a 2009 American Journal of Public Health study of nearly 300,000 veterans from the wars in Iraq and Afghanistan, researchers at the San Francisco VA Medical Center found 36.9 percent received a mental health diagnosis.1 Of those, 21.8 percent were diagnosed with PTSD and 17.4 percent with depression, a frequent comorbid condition.

Unfortunately, many veterans are reluctant to seek help for their emotional problems due to the stigma associated with mental illness, fear that doing so will damage their careers, or the misguided belief that their loved ones can provide the necessary support, according to research conducted by the non-profit RAND corporation. A RAND Corporation survey of nearly 2,000 service members returning from Iraq and Afghanistan found only 53 percent of those with PTSD or depression had sought help from a provider during the previous year. Left untreated, those conditions can lead to more suffering, including self-medication through substance use, and economic and relationship problems.

Young veterans and those who have recently experienced combat are not the only ones at risk. Eleven percent of veterans aged 65 years and older suffer from depression, according to the U.S. Department of Veterans Affairs, a rate more than twice that of the senior population as a whole. What’s more, veterans over the age of 50 – many of whom spent little or no time fighting in the most recent wars – are the most likely to commit suicide. Female veterans are likewise at greater risk of suicide.

Crumpled up pieces papers with one showing PTSD written on it, showing how veterans can struggle with mental health.Recognizing the Problem

Civilian healthcare providers can play a crucial role in helping veterans who may be suffering from mental illness, Dr. Chard says.

Although most veterans receive care in community settings – only about 30 percent of the nation’s 20 million veterans rely on the VA for healthcare – many healthcare providers neglect to ask their patients about their military service. In a survey of rural mental health and primary care providers 56 percent said they do not regularly ask their patients about military service.2 Even in urban centers major health systems do not include a question about military service on the intake forms, Dr. Chard says.

Asking basic questions about a patient’s military service can help clinicians better understand the issues their veteran patients may be facing, diagnose their symptoms with greater accuracy, and help patients access the care they need.

“PTSD and depression can look very similar,” and are often concurrent conditions, Dr. Chard explains. If civilian healthcare providers know about a patient’s military service they are more likely to screen for PTSD and treat the underlying problem. They can also point their patients to resources and services that may be available to them through the VA.

Resources for Patients and Providers

While depression and PTSD represent a daunting challenge, Chard notes numerous evidence-based treatments are now available to help patients.

Typically, individuals should be treated with psychotherapy before medication, she says, noting that Cognitive-Behavioral treatments (CBT) are considered front line. CBT is a type of psychotherapy in which a trained mental health provider helps a patient recognize unhelpful or negative ways of thinking and behaviors and replace them with ones that are more beneficial.

Importantly, she notes “patients should be informed that they do not have to talk about their trauma in order to get better and some treatments allow them to attend sessions with their significant other.”

Numerous on-line resources are available for healthcare providers. Here are just a few:

  • The PsychArmor Institute is a free online training resource for effectively engaging with members of the military community. PsychArmor’s School for Healthcare Providers includes courses on PTSD, substance use and suicide.
  • National Center for PTSD offers a variety of training and assessment tools for clinicians including the Primary Care PTSD Screen for DSM-5.
  • Vets.gov includes information on accessing VA mental health services.
  • Understanding Depression: A Resource for Providers and Patients published by the Department of Veterans Affairs
  • Service Transformed: Lessons in U.S. Veteran Centered Care. A free, open online course created by the University of Michigan designed to educate clinicians about the unique physical, mental and emotional needs of veterans.

Awareness is a powerful tool, Dr. Chard says. Simply knowing who your veteran patients are and recognizing the mental health risks they face is a critical first step.

PTSD and depression are very treatable, she says. “It is not a life sentence and with proper identification and early intervention, we can get people back to full functioning.”

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1 Karen H. Seal, MD, Thomas J. Metzler, MA , Kristian S. Gima, BA, Daniel Bertenthal, MPH, Shira Maguen PhD, and Charles R. Marmar, MD. Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans Using Department of Veterans Affairs Health Care 2002-2008. American Journal of Public Health. 2009 September, 99(9): 1651-1658 Am J Public Health. 2009 September; 99(9): 1651–1658. doi: 10.2105/AJPH.2008.150284 Accessed 10/12/17.

2 A. Lucile Burgo-Black MD, Jeffrey L. Brown MD, Ross M. Boyce MD and Stephen C. Hunt MD, The Importance of Taking a Military History. Public Health Rep. 2016 Sep-Oct; 131(5): 711–713. Published online 2016 Aug 1. doi: 10.1177/0033354916660073 Accessed 10/13/17.

Our articles are for informational purposes only and are reviewed by our Medical Information team, which includes PharmDs, MDs, and PhDs. Do not make any changes to your current medications or dosing without consulting your healthcare provider.

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Published: November 10, 2017
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