Diagnosis. PTSD is subdivided into acute (symptoms lasting more than one month but less than 3 months after the traumatic event) and chronic (symptoms lasting longer than 3 months after the traumatic event).28 The distinction of acute or chronic does not affect treatment, but it is useful information for the patient to have regarding prognosis and eventual outcome. Like mTBI, PTSD is a clinical diagnosis made only after a thorough, structured diagnostic interview. The use of a validated, self-administered checklist, such as the Post-Traumatic Checklist-Military (PCL-M), allows for an efficient review of a patient’s symptoms and a reliable way to track treatment progress (http://www.ptsd.va.gov/professional/ pages/assessments/ptsd-checklist.asp).
Treatment Options. Effective evidence-based treatments for PTSD are cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), and pharmacotherapy. SSRIs and serotonin- norepinephrine reuptake inhibitors (SNRIs) have the strongest evidence for pharmacologic benefit in the treatment of PTSD.28,29 Other helpful medications are prazosin for nightmares and trazodone for sleep. Family physicians can use these medications as part of a patient-centered collaboration with the rest of the integrated care team, to offer the best chance for treatment success.10,28,30
Depression: Vets are reluctant to self-report
Combat experience is a significant risk factor for major depression. Estimates of the lifetime prevalence of depression in the general US population vary from 9% to 25% in women and 5% to 12% in men. By contrast, the prevalence of depression in OIF/OEF veterans ranges from 2% to 37%.24,31,32
Screening can yield false negatives. Many combat veterans are reluctant to self-report behavioral conditions, including depression. Screening, therefore, is important to identify potential depression and allow for intervention. Validated screening tools for depression include the PHQ-2 and PHQ-9, which are easy to use in the office setting. (See http://www.cqaimh.org/pdf/ tool_phq2.pdf [PHQ-2] and http://www. integration.samhsa.gov/images/res/ PHQ%20-%20Questions.pdf [PHQ-9]). Importantly, some veterans will have a negative depression screen on return from deployment, and then test positive 6 to 12 months later.24 Explanations for the early false-negative results include the excitement of being home and patients intentionally answering questions inaccurately to avoid excessive screening at their home base.11
Treatment is most effective with a combination approach. As with most cases of depression, combining psychotherapy and psychopharmacology appears to be most effective for treating depression related to combat experience.33,34 While SSRIs and SNRIs are typical first-line pharmacologic agents, combat veterans often have comorbid mTBI, PTSD, or substance abuse issues that may influence the initial choice of therapy35 (TABLE 3).10
Suicide is on the rise in the military
Historically, the incidence of suicide has been 25% lower in military personnel than in civilian peers.36 However, between 2005 and 2009, the incidence of suicide in the Marine Corps and Army almost doubled.37 While the exact reasons remain unknown, it is likely due to prolonged and repeated deployments to a combat environment.12 While the incidence of suicide has been particularly high in the Army (22 per 100,000 active-duty and reserve personnel per year), all services have been affected. In fact, since 2009, the number of suicides among active duty service members exceeds those killed in action.37
Consider all veterans to be at risk for suicide, and screen accordingly. An effective screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is able to predict those most at risk for an impending suicide attempt.34 Service members identified as high risk for suicide require unhindered access to care. The VA has worked to improve access to care and provide evidence-based point-of-care treatment strategies.38 Available resources can be found in TABLE 1.
Unfortunately, even with effective screening and treatment, not all suicides can be prevented. Studies have demonstrated that approximately 65% of service members who commit suicide had no known history of communicating their suicidal intent. Sadly, 25% of service members who committed suicide had seen a mental health provider within the previous 30 days.39
Alcohol abuse is common; opioids present a unique risk
Excessive use of alcohol and recreational and prescription drugs is common among OEF/ OIF veterans, especially those with comorbid mental health disorders. Retrospective cross-sectional studies show that 11% to 20% of OEF/OIF veterans met DSM-IV-TR diagnostic criteria for substance use disorders.40-42 At highest risk are single enlisted men under the age of 24 in the Army or Marine Corps who serve in a combat-specific capacity. Interestingly, the prevalence of substance use disorders among OEF/OIF veterans closely mirrors that reported in epidemiologic studies of Vietnam veterans (11%-14%).41 This similarity, combined with the 39% lifetime prevalence of substance use disorders among Vietnam veterans, may foreshadow a similar lifetime prevalence of substance use disorders among OEF/OIF veterans.41