Returning Soldiers

Providing Care for Soldiers Returning From Iraq and Afghanistan

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A new article published in the Journal of General Internal Medicine[1] offers a comprehensive review of the health concerns of Iraq and Afghanistan veterans and practical management guidelines for primary care providers.

Since September 11, 2001, approximately 2.4 million military personnel have deployed to Iraq and Afghanistan. To date, roughly 1.44 million have separated from the military; when they return to the states, approximately half will use Veterans Affairs (VA) healthcare and the other half will be seen by non-VA primary care providers.[1]

So it’s likely you will be treating members of this population—many of whom have unique and complex healthcare needs. These include injuries associated with blast exposures and shrapnel, such as traumatic brain injury (TBI), as well as a variety of mental health conditions such as depression and posttraumatic stress disorder (PTSD). PTSD and depression are associated with higher rates of relationship distress and more negative interpersonal relationships with partners and children. Other important health concerns include chronic pain, complications from environmental exposures, heightened suicide risk, and sleep disturbances.

Among combat veterans, the prevalence of depression, anxiety, and PTSD has increased over the years and it’s not clear whether that’s due to better screening or to an increased burden of disease over time. Data suggest that female soldiers are at greater risk for depression, eating disorders, and weight loss than their noncombat counterparts. Younger male soldiers who return from active combat report heavy weekly drinking, binge drinking, and social problems related to alcohol.[1] Suicide rates are also higher in this group than in civilians of the same age. In addition, recent evidence suggests a higher incidence of mental health diagnoses in spouses of veterans who have deployed, particularly if there has been a prolonged deployment.[2]

What else might you expect to see?

Occupational Exposures

Many returning veterans report exposure to hazardous environmental factors, such as sand storms or smoke from burn pits, which can lead to dyspnea or a chronic cough. Women may come home with urinary tract infections because of dehydration and “holding it in” due to a paucity of private facilities. Others may come back with infection such as malaria, tuberculosis, skin infections, or diarrhea. A Department of Defense study[3] suggests that the prevalence of smoking in younger veterans is as high as 40%, compared with 20% in nonveterans. Active combat has also been linked to other cardiovascular risk factors, including hypertension and dyslipidemia.[4]

Chronic Pain

Musculoskeletal injury with chronic pain is the most common health concern among returning soldiers. Pain relief should include pharmacologic, behavioral, and alternative strategies that might include physical therapy, massage, transcutaneous electrical neural stimulation (TENS), thermal and aqua therapy, regular exercise, chiropractic treatment, and acupuncture. Behavioral strategies include cognitive behavioral therapy (CBT), biofeedback training, and stress management. Alternative techniques such as deep relaxation training, meditation, and yoga have also been shown to improve pain outcomes.[5] Comorbid mental health conditions or psychosocial stressors may lower the pain threshold and amplify pain experiences.[6] Thus, addressing mental health concerns with attention directed to family issues and vocational support may actually lower the pain threshold.

Given the high risk for abuse, opiates should be used with caution and reserved for refractory chronic pain conditions. Additionally, comorbid mental health conditions compound the risk for inappropriate use of opiates, as veterans may attempt to self-medicate their “psychological pain.” For combat veterans already on opiates, it may be appropriate to shift to more sustainable long-term pain management strategies, such as alternative pain relievers, referral to a chiropractor or physical therapist, and mental/behavioral health assessment and treatment.

Sleep Disorders

Deployment has a negative impact on both sleep quality and quantity.[7] Instruction in basic sleep hygiene, referral for CBT, and a trial of sedating antihistamines or trazodone can help with more severe insomnia. The use of benzodiazepines is strongly discouraged given risks for misuse, although partial benzodiazepine agonists such as zolpidem can be used in conjunction with sleep hygiene and CBT. In addition, there is evidence that prazosin—slowly titrated from 1 mg to 15 mg—is effective for PTSD-related nightmares that disturb sleep.[8]

Recognizing and Treating PTSD

It’s important to recognize the signs and symptoms of PTSD, formerly known as shell shock or battle fatigue. PTSD is a severe anxiety disorder that can develop after exposure to any event resulting in psychological trauma. Symptoms of PTSD include re-experiencing the original trauma through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increased arousal—such as difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria (DSM-IV-TR and ICD-10) require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning.[9]

Given the high rates of comorbid PTSD and depression, you should routinely assess for both. Because there is a potential for delayed onset and the rapid progression of symptoms, current VA/Department of Defense (DoD) guidelines recommend reassessment for PTSD and depression within three to six months of returning stateside and annually thereafter. Patients who screen negative for PTSD, but have trauma-related symptoms may carry a high risk for suicide[10] and should undergo assessment for possible suicide risk. Referral for specialty PTSD treatment may be indicated if symptoms are severe or disabling.

Cognitive behavioral therapy (CBT) has been validated as the most effective treatment for PTSD.[11] CBT can include exposure therapy or cognitive processing therapy, both of which involve repeatedly revisiting a single traumatic event in several extended sessions over several weeks. Other non-CBT approaches include stress and anger management, biofeedback, interpersonal therapy, and group therapy. Selective serotonin reuptake inhibitors (SSRIs) are also effective in treating PTSD, especially in combination with CBT.[12] Benzodiazepines should be avoided, due to the lack of data supporting benefit and potential for abuse.

Although there can be clear and lasting benefits from CBT, many veterans feel stigmatized by their symptoms and that seeking treatment is an admission of weakness. As a result, specialty mental health services remain underutilized,[13] stressing the importance of the primary care provider’s role. Even without formal training in psychotherapy, you can establish a safe place where patients feel comfortable sharing their experiences and where you can encourage patients to seek out mental health services. You might consider asking simple empathetic questions such as: “It sounds like you’ve been through a lot. Would you like to share some of what you’re going through?” Or perhaps: “Many combat veterans have a difficult time readjusting to life at home. How would you feel about a referral to a stress specialist?”[1]

Traumatic Brain Injury

Traumatic brain injury (TBI) is the result of a blow or jolt to the head or a penetrating injury that disrupts brain functioning. Among veterans, the source of the injury is likely to result from bullets, shrapnel, falls, or motor vehicle accidents. The injury may include a loss or decreased level of consciousness, a loss of memory immediately before or after injury, confusion or disorientation, or a neurologic defect such as weakness or balance and sensory changes. Headache is the single most common symptom associated with TBI and should be treated carefully to avoid medications with sedating properties.

Traumatic brain injuries can range in severity from mild (often called concussion) to severe. The symptoms of mild TBI range from physical to psychological (see Table); most patients with mild TBI require only supportive treatment and reassurance that their symptoms are likely to resolve within several months. Advise patients to get adequate sleep, avoid activities that can lead to a second brain injury—such as driving a motorcycle—and to avoid alcohol, caffeine, energy drinks, and other medications that have a sedative or stimulant affect. If the patient is amenable, she or he can learn coping skills to assist with memory or irritability.

You might consider subspecialty referral if there is a significant impact on daily activities, persistent neuropsychological deficits, psychosocial distress, or confusion regarding the appropriate diagnosis. VA/DoD clinical practice guidelines provide more detailed recommendations for management and referral of TBI.[14]

During the upcoming months, primary care is likely to be the first stop for many returning veterans and their families. While you can’t provide for all of their complex needs, you can provide four care components: screening, the provision of timely care, acknowledging the family unit, and integrating care from multiple specialties and disciplines.

 

Table. Categories and Symptoms of Mild to Moderate Traumatic Brain Injury[1]

  • Physical symptoms
    • Dizziness
    • Vertigo
    • Nausea
    • Headaches
  • Neurosensory symptoms
    • Vision problems
    • Light sensitivity
    • Hearing loss
    • Numbness
  • Cognitive symptoms
    • Poor concentration
    • Forgetfulness
    • Difficulty organizing
    • Completing tasks
  • Psychiatric symptoms
    • Insomnia
    • Anxiety
    • Irritability

 

Jill Shuman, MS, ELS
Published June 18, 2012

 

References

  1. Spelman JF, Hunt SC, Seal KH, Burgo-Black AL. Post deployment care for returning combat veterans [published online ahead of print May 31, 2012]. J Gen Intern Med. doi: 10.1007/s11606-012-2061-1.
  2. Mansfield AJ, Kaufman JS, Marshall SW, et al. Deployment and the use of mental health services among U.S. Army wives. N Engl J Med. 2010;362(2):101-109.
  3. Smith TC, Zamorski M, Smith B, et al. The physical and mental health of a large military cohort: baseline functional health status of the Millennium Cohort. BMC Public Health. 2007;7:340.
  4. Cohen BE, Marmar C, Ren L, et al. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA. 2009;302(5):489-492.
  5. Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: a cluster randomized trial. JAMA. 2009;301(12):1242-1252.
  6. Clark ME, Scholten JD, Walker RL, Gironda RJ. Assessment and treatment of pain associated with combat-related polytrauma. Pain Med. 2009;10(3):456-469.
  7. Seelig AD, Jacobson IG, Smith B, et al. Sleep patterns before, during, and after deployment to Iraq and Afghanistan. Sleep. 2010;33(12):1615-1622.
  8. Taylor HR, Freeman MK, Cates ME. Prazosin for treatment of nightmares related to posttraumatic stress disorder. Am J Health Syst Pharm. 2008;65(8):716-722.
  9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
  10. Jakupcak M, Hoerster KD, Varra A, et al. Hopelessness and suicidal ideation in Iraq and Afghanistan War veterans reporting subthreshold and threshold posttraumatic stress disorder. J Nerv Ment Dis. 2011;199(4):272-275.
  11. Bisson J, Andrew M. Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2007;3:CD003388.
  12. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement update on posttraumatic stress disorder from the international consensus group on depression and anxiety. J Clin Psychiatry. 2004;65(Suppl 1):55-62.
  13. Seal KH, Maguen S, Cohen B, et al. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress. 2010;23(1):5-16.
  14. VA/DoD Clinical Practice Guidelines. Management of Concussion/Mild Traumatic Brain Injury. http://www.healthquality.va.gov/management_of_concussion_mtbi.asp. Published 2009. Accessed June 13, 2012.