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Veterans and Families Mental Health

2.00 Contact Hours
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    David Tilton (RN, BSN)

Outcomes

This course reviews mental health issues common to military veterans and their families.

Objectives

After completing this course, the learner will be able to:

  • Identify the current state of mental health military veterans and families.
  • Discuss identification of adjustment disorder.
  • Discuss diagnosis and treatment of traumatic stress disorders.
  • Identify three symptoms of major depression.
  • Consider the impact to functioning associated with traumatic brain injury.
  • Awareness of the role a safe environment plays in suicide prevention. 
  • Be able to articulate the role grief plays in normal bereavement processing.

Introduction

At the beginning of 2015, there were an estimated 23.4 million living veterans of United States military service. This is in addition to the 2.2 million currently active service men and women with their more than 3 million immediate family members. These men and women, heroes all, have placed themselves into harm’s way to protect our country and further our way of life. As a health professional I want to say straight up, thank you. Thank you for your service and the support of your families who share the burden of your trails while experiencing the joy and sorrow along with you (SAMHSA Veterans, 2014).

Going into harm’s way is polite speak for stating that there will be risk with hopes for reward, boredom interspaced with sudden moments of sheer horror. Each person facing the perils accompanying military service will be changed by them. Many for the better, some for the worse, and all will gain memories and life experiences which may well become intrusive or a burden.

Mental health is as important, if not more so, then physical health. Just as our minds and emotions control our body, injury to our mind and spirit can lead to loss of control and critical life functions. There is no way to emphasis the serious role that mental health and mental healing plays in the lives of our military, our veterans, and their families.

Together we will look at some of the more pressing issues related to mental health for military past, present, and the ones closest to them.

Mental Health

43.8 million adults in the United States possess a mental illness as of 2013 according to the National Survey on Drug Use and Health (NSDUH). This is 18.5 percent of the adult population. This amount compares with the nearly 25 percent occurrence rate of active duty military showing signs of a mental health conditions in a 2014 JAMA Psychiatry study(NIMH Prevalence, 2015;NAMI Veterans & Active Duty, 2015).

Conflict and war have always placed a heightened toll on the delicate balance we term sanity. Current conflicts particularly bring us to the brink with multiple deployments into distinctly different cultural settings and occurrences that challenge fundamental beliefs about ourselves, our humanity, and world in which we live.  

Exposure to events such as civilians or “friendly” forces suddenly turning violent and deadly, or the use of children as both human shields and as the mobile platform for suicide bombs destroys our belief in safety and trust. Death and destruction of communities by their fellow countrymen committed from inconceivable motives shakes the concepts of civilized behavior to the very core. Repeated exposures to terror and horror which go beyond what most civilians will ever see except in nightmares are life changing. It is no wonder many veterans return home dramatically altered.

The demands and stresses which are placed on the loved ones of service members is equally intense. Occurrences such as frequent relocation, the chance of sudden deployment, continual preparation for bad news concerning their loved ones gone away to danger zones all take a toll on mind and body. Add to this the fact that the person they are most close too will, in all probability return to them different, perhaps even as though they were strangers to one another, and may not return at all.

An increase in the signs of mental issues amongst military members, present and past, demonstrates the need for preventive services, as well as ongoing mental and emotional help for active military, for our veterans, and for the families of service men and women. 

Adjustment Disorder

One of the most common and, in some ways, most problematic to achieve timely recognition of the emotional and mental conditions for veterans and their families is an ailment known as adjustment disorder. Adjustment disorder (AD) is an extreme response to the stresses of major life changes. Things such as marriage, deployment, parenthood, divorce, school, work problems and many more can initiate adjustment disorder. For veterans and their families the return to civilian life after service can create stresses and uncertainties that result in adjustment disorder for them, or for their loved ones.

Case Study: Glenda

Glenda returned two months ago from her second combat tour. Now home, she is having a hard time adjusting to a life that’s not the same as it was when she left. Her husband takes care of their five year old daughter and works from home. Recent changes in the economy mean that he has lost much of his business and isn’t keeping up the way he had been with work, home, and daughter.

Glenda finds herself struggling over anger at her husband for losing his former work clients, and tells him directly he should just man-up and handle things. Their daughter cries when she reaches out to pick her up, and if she disciplines their daughter her husband intervenes saying she is expecting too much from the child, leading to sharp words and angry shouting between the adults.

Glenda frequently goes out to “run”, spending more and more time away from home. When she is home she sits for hours on end ignoring what is happening around her. This time, coming home is harder than being away.

Adjustment disorder can happen to anyone who’s coping with a major source of stress. Even when you’re glad to be home, returning from a deployment is stressful.

Adjustment disorder can happen to those you are returning home to as well. A military spouse is used to acting independently, handling everything without needing to negotiate or converse concerning choices and course of action. Suddenly having a spouse return adds a major change to what the family is doing and how they are doing it. 

Adjustment disorder is a stress related, short-term condition that may occur when a person is faced with a stressful event or situation. It is common for feelings of distress, discomfort, and emotional/mental turmoil to be present and ramifications can be considerable, up to a potential for suicidal feelings and thinking.

Unusual feelings associated with a change may begin soon after the stress occurs or within three months of the event. These feelings typically resolve when the stressing situation goes away, or the person affected has had an opportunity to adapt to the change, usually within six months.

Symptoms associated with adjustment disorder focus on things that are unusual for that person and may include such items as;

  • Depressed mood
  • Worry
  • Sadness
  • Anxiety
  • Sleep disturbances
  • Poor concentration

Many of those recovered from adjustment disorder report having felt unusual feelings of hopelessness, being trapped in an unwanted situation with the lack of good options while being cut off or isolated from others who would typically be of help

Treatment for Adjustment Disorder

Because adjustment disorder is typically a time limited occurrence treatment focuses on help dealing with the changes and stresses occurring right now that are triggering the condition. Support in the form of individual, couples and group counseling can have a positive impact on the situation and feelings. Medications may serve as a short term help for some of the symptoms, however as adjustment disorder typically resolves on its own with time and support, it is important to realize that a long term course of pharmacotherapy is generally not warranted. Of help in the short term are agents such as;

  • Anxiety lowering agents – benzodiazepines
  • Antidepressants – particularly SSRIs or SNRIs
  • Plant extracts with medicinal qualities – kava-kava or valerian

Traumatic Stress

A major focus of attention for returning and retired service personnel has been stress disorders. Both acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are real diseases. They are psychiatric conditions with changes in neural functioning that occur when a person has been exposed to overwhelming stress, trauma, or horror. Being a witness to or learning of horrific events can set the stage for stress disorder, just as readily as the event happening to that person.

For most survivors or witnesses of trauma, life returns to somewhat near normal given time and support. Sometimes stress reactions refuse to fade and symptoms move from an acute response to the stress event into a long lasting and life impairing condition. 

When a sudden, horrific event occurs it is common for our minds to reel away from the unexpected, unwanted reality. The condition referred to as acute stress disorder may occur as we struggle to make sense of the traumatic event and come to terms with what has happened.

Acute stress responses, reactions that occur within us immediately after a violation of our sensibilities and our perceptions of the world, include such feelings or alterations of perceptions as; dissociation or detachment, the feeling that something unwanted is intruding on us, negative moods, the impulse to avoid situations or persons associated with the event, and even a heightening of our senses and automatic responses such as startle reflexes (Bryant, 2015).

There are no available blood tests or diagnostic imaging studies that can reliably diagnose stress disorders, although interesting research is being done with imaging scan technology. It is important therefore to be able to spot acute responses to stress and catch ASD before it turns into PTSD so that we can better prevent and ameliorate, rather than wait to treat a well-established condition.  

Acute Stress Disorder Diagnosis

Most of us, at some time in our lives will experience acute stress symptoms. In general acute stress progresses through four sets, or phases, of symptoms;

ASD phase 1, the Impact Phase – The effected person feels stunned, disbelieving during the first few days after the initial stress event. Feelings of confusion, numbness or fear to the point of mental and emotional disorganization may occur.

ASD phase 2, the Crisis Phase – Following immersion in the impacting event, feelings may go back and forth between denying the event or aspects of it, and intrusive symptoms such as emotional and physical hyperarousal. Emotional surges of anger, irritability, apathy or social withdrawal may intersperse or coincide with physical/somatic symptoms such as headaches, fatigue, dizziness or nausea. Anger at authority figures or caregivers who failed to prevent, resolve or successfully handle the event is common.

ASD phase 3, Resolution Phase – Depression, grief, guilt are commonly present up to a year after the stressing event as the person works to reconcile and cope with losses suffered.

ASD phase 4, Reconstruction Phase – The stressing event and its aftermath are reconciled with the person’s reappraisal of themselves. New meanings and goals replace former disrupted self-appraisals, and a new self-concept emerges. 

DSM-5 Diagnostic Criteria – Acute Stress Disorder

The first criterion is exposure to actual or threatened death, serious injury, or sexual violation in 1 (or more) of the following ways:

  • Directly experiencing the traumatic events(s)
  • Witnessing, in person, the event(s) happening to others
  • Learning that the event(s) occurred to a close family member or close friend (in cases of actual or threatened death of a family member or friend, the event[s] must have been violent or accidental)
  • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains or police officers repeatedly exposed to details of child abuse) 

The second criterion is the presence of at least 9 of 14 symptoms from any of 5 categories—intrusion, negative mood, dissociation, avoidance, and arousal—beginning or worsening after the traumatic event(s) occurred. 

Intrusion symptoms include the following:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s); children may engage in repetitive play during which themes or aspects of the traumatic event(s) are expressed
  • Recurrent distressing dreams in which the content or affect of the dream is related to the event(s); children may experience frightening dreams without recognizable content
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring
  • Intense or prolonged psychological distress or marked physiologic reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) 

Negative mood consists of the following:

  • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings) 

Dissociative symptoms include the following:

  • Altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, or feeling that time is slowing)
  • Inability to remember an important aspect of the traumatic event(s), typically resulting from dissociative amnesia and not from other factors (e.g., head injury, alcohol or drugs) 

Avoidance symptoms include the following:

  • Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Efforts to avoid external reminders (e.g., people, places, conversations, activities, objects, or situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) 

Arousal symptoms include the following:

  • Sleep disturbance (e.g., difficulty falling or staying asleep or restlessness during sleep)
  • Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
  • Hypervigilance
  • Problems with concentration
  • Exaggerated startle response 
The third DSM-5 diagnostic criterion for ASD is that the duration of the disturbance is 3 days to 1 month after trauma exposure. Although symptoms may begin immediately after a traumatic event, they must last at least 3 days for a diagnosis of ASD to be made. 
The fourth criterion is that the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 
The fifth and final criterion is that the disturbance cannot be attributed to the physiologic effects of a substance (e.g., a medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and cannot be better explained by a diagnosis of brief psychotic disorder. 
ASD may progress to PTSD after 1 month, but it may also be a transient condition that resolves within 1 month of exposure to traumatic event(s) and does not lead to PTSD.
(American Psychiatric Association DSM-5, 2013; Lubit, 2014)

Acture Stress Disorder Treatment

The focus of treatment following a stressful or violent event is the identification of those most seriously impacted, and initiation of care for emotional traumatization. First for those most effected, and all others present at the traumatic event as quickly as possible.

The reduction of continuing stresses must be emphasized. This means pressures from situations or events other than the impacting event, as well as removing ongoing dangers or risks from the event that initiated this situation. Physical safety is important. If possible, relocate the individuals exposed some distance away from the stress impact point. Encourage supporting contact with persons that each victim of the stress feels are safe, such as contact with family and loved ones, contact with trusted colleagues, religious support and health caregivers. Many of the acutely stressed feel isolated or cut off from the people around them. This is a normal response so focus on social supports and a sense of community.

It is important to support an individual’s self-concept, their self-esteem. Let them know that distressing thoughts or feelings will likely occur and are a normal response to an abnormal event, not a sign of weakness. It is common for survivors of trauma to feel that they are in some way guilty of what occurred, so assist with reframing or putting into a proper context distressing thoughts and beliefs. Find out what the coping mechanisms, the thoughts – behaviors – habits which that person has to deal with stress are, and work to promote healthy coping with the emotions now being felt.

Medications are important adjuvants to emotional support and what are sometimes referred to as talk therapies, however medications will not fix stress problems by themselves. Use appropriate medications that help to decrease symptoms interfering with function and healing, such as the emotional arousal created by ASD.

Common pharmacological adjuvants include such items as; beta-blockers, alpha-antagonists, benzodiazepines, and/or non-activating SSRI’s (selective serotonin reuptake inhibitors that are not stimulating or energizing).

Above all diminish stress, including pressure to talk about the trauma and the feelings held, which is very important yet must come as that person is ready for it.

The good news is half or more of those diagnosed with acute stress disorder find it resolved within the first weeks after the stressful event. Those who do not find a resolution go into a subsequent PTSD – post traumatic stress disorder (Bryant, 2015).

Post-Traumatic Stress Disorder Diagnosis

The role of the military is such that they and their loved ones are at extremely high exposure for stress and traumatic events. Some reports indicate that approximately 30% of the men and women who have spent time in a war zone as military, contracted civilian, reporter, or aid worker go on to later experience PTSD (Gore, 2015).

Stress disorders have been described as complex somatic, cognitive, affective, and behavioral consequences of psychological trauma. Stress disorders are caused by experiencing, witnessing, or being confronted with an event/events involving serious injury, death, or threat to the physical integrity of that person or someone close to them. These are accompanied by a response involving helplessness, intense fear, or horror.

Post-traumatic stress disorder is characterized by intrusive thoughts and feelings, nightmares and flashbacks of past traumatic events, desires to avoid reminders of trauma, and the presence of hypervigilance and sleep disturbances. All of which lead to considerable occupational, social, and interpersonal dysfunction, particularly with those who know them best.

It has been shown in various studies that a direct relationship can be observed between the severity of a traumatic event and the risk of developing a stress disorder. Prior exposure to repeated traumatic events as well as such factors as the duration, severity, and proximity of the event may also contribute to the degree of stress that the individual experiences.

Events Often Associated with PTSD Onset
  • Military combat
  • Terrorist attacks
  • Violent physical assault
  • Severe physical injury
  • Life threatening illness
  • Severe motor vehicle accidents
  • Natural Disasters
  • Serious accidents
  • Sexual assault
  • Incest                    
  • Childhood sexual abuse
  • Observes or learns about a traumatic event
(Ciechanowski, 2015)

The initiating events associated with PTSD are generally the same as in ASD, acute stress disorder. PTSD can be thought of as being an extension of ASD and has subtypes which are acute, chronic, or delayed in nature.

Acute PTSD typically has symptoms lasting three months or less, while chronic PTSD symptoms last longer than three months. In delayed onset PTSD the symptoms that characterize the condition tend to be unnoticeable for at least the first six months following the traumatic event, creating a time lapse which may make linking the symptoms with an initiating event tricky (Friedman, 2015).

Research into identifying and treating stress disorders have led to recent changes in diagnostic criteria. In the recently released Diagnostic and Statistics Manual of the American Psychiatric Association, fifth edition (DSM-5), greater focus is placed on the behaviors that accompany PTSD. Four distinct clusters or groupings of behaviors are proposed as significant indications for diagnosis.

Re-experiencing behaviors; For example, spontaneously occurring memories of the past traumatic event such as nightmares or recurrent dreams related to the incident or incidents, illusions or hallucinations, flashbacks – the sudden powerful re-experiencing of past events, or other intense prolonged forms of psychological distress.

Avoidance behaviors; Take the form of abruptly shying away from or pre-planned evasion of situations which might bring distressing memories, thought reminders of past events, feelings associated with the initiating traumatic experience, or external reminders of the event.

Negative cognitions and mood related behaviors; Include such items as persistent blame of themselves or others, distorted feelings or overpowering emotions related to events or persons associated with stressing events, estrangement from others, marked decrease in activities that formerly interested that person, or the inability to remember aspects of what occurred.

Arousal behaviors; Can be demonstrated by reckless, aggressive, self-destructive behaviors. Sleep disorders, hypervigilance, the formation of protective habits such as always sitting with a back to the wall, sleeping facing a locked door, etc. are all examples of arousal. Please note current diagnostics emphasize an element of avoidance or flight from traumatic reminders. A strong flight response or reaction is also typical of the arousal behaviors of stress disorders.

In addition to the presence of key behaviors are three conditions or criteria that aid in making a diagnosis of PTSD. These three criteria are;

  • The duration of symptoms for the person has been longer than one month,
  • The disturbance causes significant distress or impairment in that individuals functioning,
  • The disturbance is not attributable to the effects of a substance or other medical conditions.

While there are no physical diagnostic tests that can readily catch the presence of a stress disorder, there are physical signs to be on the lookout for. The presence of poor hygiene, or poor personal appearance in general can be a tip off to poorly functioning cognitive processes. The presence of unexplained bruises or injuries, such as bruised or lacerated knuckles from punching inanimate objects, and indications of fatigue from poor sleep may indicate difficulties. Heightened startle responses to sudden noises or shadows may be clues as well.

Mental status checks can also be helpful, as orientation to person and place can be affected by stress disorders. Not knowing the current time or date may offer clues as to where an individual’s internal attention is focused. Perhaps the area most commonly affected by stress disorders such as PTSD is memory. Reports of forgetfulness, particularly in details associated with a specific traumatic event, are frequently reported. Poor concentration, pressured or abnormally slowed speech may also be an indicator. Mood changes are common with stress disorders as are feelings of generalized nervousness, fear, anxiety, guilt and depression.

Please be alert for suicidal thoughts or feelings when PTSD is suspected as changes in mood and struggles with core beliefs brought about by an intense trauma can be very difficult for an individual to deal with. A small percentage of stress disorder clients may also become homicidal during the difficulties of dealing with delusional feelings, new phobias, hallucinations, and reliving experiences such as flashbacks (Gore, 2015).

Core Beliefs are “…unconditional beliefs that serve as a basis for screening, categorizing, and interpreting experiences”.

Core beliefs are the foundational bedrock of our mind. They are the fundamental beliefs about our world, ourselves, and everything around us that we measure all experiences by.

Core beliefs form the rules by which we perceive and interpret what is happening all around us.

Core beliefs typically bypass conscious thought and operate outside of an individual’s perceptions. 
(Pretzer, 2014)

Post-traumatic Stress Disorder Treatment

Helping a person come to terms with how they are, and who they will be after an extremely traumatizing event is the goal of treatment. It is impossible to go back in time and make the event not happen, or even to undo consequences and results of the event. For this reason, those who have experienced trauma are often referred to, not as victims, but as survivors of trauma. 

Example Goals for PTSD Resolution
  • Safety and stabilization of symptoms
  • Resolution of distress with traumatic memories
  • Reintegration of core beliefs establishing greater function and sense of identity

Coming to a resolution with the trauma often is best facilitated with a combination of medication to lower the impact of symptoms and nonpharmacologic therapies that help reconcile disrupted cognitive and emotional processes.

Pharmacotherapy concentrates on decreasing intrusive thoughts and images such as flashbacks and hallucinations while diminishing arousal symptoms like hypervigilance, irritability and anger. Helping to stabilize mood symptoms such as depression is also important, as is relieving sleep disturbances.

Selective serotonin reuptake inhibitors (SSRIs) are considered first line medications for treatment of PTSD, although other categories of antidepressants such as the serotonin-norepinephrine reuptake inhibitors are occasionally used. Both beta blockers and atypical antipsychotics have been used in conjunction with SSRIs with mixed results.

Beta blockers such as propranolol are used in some stress disorder clients to decrease the symptoms of hyperarousal. Decrease in exaggerated hyperarousal state and explosive bouts of anger have been seen (Gore, 2015).

Atypical antipsychotics have shown little to no effect as an aide to antidepressants in recent trials with military veterans, though physician judgement should always preside for individual cases (Stein, 2015).

Alpha-adrenergic receptor blockers such as prazosin have shown use in reducing nightmares and improving sleep in both veterans and civilian trials. Use of alpha blockers demonstrated an increase in normal dreaming and sleep patterns. Caution should be taken to avoid hypotension or orthopedic hypotensive events when used due to their blood pressure lowering effect.

Benzodiazepines are typically used for symptoms of anxiety or hyperarousal, such as can be seen in the stress disorders. While useful in controlling acute anxiety be cautious if a tendency toward substance abuse that may accompany stress symptoms.

Nonpharmacologic therapies provide the mainstay of stress disorder treatment, typically in conjunction with medication to diminish symptoms.

The goal of treatment is to aid the individual in coming to a resolution with distressing memories and regain function following extreme traumatic events. Friends and family are essential to this resolution and it is important to also give support to the loved ones of the survivor of trauma. Individual and family therapy is essential, psychotherapies of use include;

  • Cognitive behavior oriented therapies
    • Cognitive therapy
    • Cognitive behavior therapy (CBT)
    • Desensitization/ Exposure therapy
    • Eye movement desensitization and reprocessing (EMDR)
    • Couples therapy
  • Support therapies
    • Mindfulness based stress reduction
    • Recreation therapy
    • Art therapy
    • Animal therapy
    • Relaxation therapy
    • Anxiety management therapy
    • Coping skills training
  • Psychotherapy
    • Psychodynamic psychotherapy
    • Eclectic psychotherapy
  • Hypnosis

Cognitive behavior and support oriented therapies tend to be the mainstay for acute and posttraumatic stress disorders.  Cognitive behavioral approaches include CBT, exposure therapy, EMDR and a handful of less commonly used approaches, all of which center on aspects of mental avoidance the survivor has developed toward the past injury or traumatic event. The general premise from which cognitive therapies operate is that the traumatic incident has established a deep rooted fear response in the mind of the survivor of trauma which in normal instances would, with time, become reconciled with the survivor’s world view and core beliefs. However, due to the extent of this new conditioned fear response, the survivor of trauma actively avoids any thoughts or situations which remind them of the traumatic event, shying away from the process which would allow healing and reconciliation. This aversive pattern of avoidance occurs unconsciously in the mind, though there are also some conscious aspects. It is as though the individual is making every effort to avoid an operation that might heal a serious illness, all without being aware of their avoidance and actively slamming the door on any helpful realization that occurs. Needless to say this makes aiding a stress disorder survivor challenging!

Eye Movement Desensitization and Reprocessing
(EMDR)

EMDR is a relatively new form of cognitive therapy that uses rhythmic motions to aid awareness of body sensations occurring during distressing thoughts or remembrances.

Several studies have shown positive results with PTSD clients, although more and better crafted research is needed.

While thinking of troubling memories or images, the client is guided to pay attention to outside stimuli such as following a moving light, or finger tapping on alternate hands. Discussion of thoughts and somatic feelings follow each session with the objective of lowering feelings of distress as session’s progress. 
 (Rothbaum, 2015; Tull, 2010)

Support oriented therapies focus on general adaptation and wellness skills, such as being able to function in group settings, regaining the ability to handle daily life stresses, and so forth. Please do not dismiss the importance of support therapies such as recreational, play and art therapy. Easing into healthy activities and situations provides an incredible foundation for the mental reconciliation processes that continue within the stress disorder sufferer behind the scenes. 

Military Sexual Trauma

Often linked with PTSD is the unacceptable phenomenon of rape and sexual abuse among our armed forces and their families. Sexual abuse is much more common than most professionals are aware, frequently due to pressure on abuse survivors to remain silent, and there are victims of both sexes.

The 2013 Sexual Assault in the Military report commissioned by congress from the U.S. Commission on Civil Rights shows 38 percent of military sexual assault victims to be male, a number that might seem surprising until reminded that sexual assault, sexual abuse, and rape has little to do with sex, and everything to do with having power and control over the victim.

Major Depression

The mood disorder known as major depression is both common and disabling. Population studies in more than a dozen countries show the lifetime incidence rate of major unipolar depression at around 12 percent. WHO, the World Health Organization, ranks major depression as the 11th greatest cause of disability and death worldwide, and here in the United States major depression ranks second among all disease and injury leading to disability. The slightly less disruptive condition of persistent depressive disorder is also a factor and ranks twentieth among disabling conditions (Simon & Ciechanowski, 2015).

Veterans of military service and their families are at a high risk for developing conditions such as depression. Greater than one in ten veterans 65 years of age or older fit the diagnostic criteria for major depressive disorder. More than 27 percent of current service members self-report experiencing depressive symptoms, according to a 2010 U.S. Department of Defense Medical Surveillance Report. Spouses and children report struggles with depression as well due to such issues as prolonged or multiple deployments of their loved ones (Kerr, 2012).

Depression frequently shows up among active service personnel experiencing stress disorders. Several studies among those with PTSD revealed as many as 45 percent also showed symptoms of depression. The families of service members, particularly spouses, show higher incidence of symptoms of depression than the general population (Udesky, 2014).

Major depressive disorder, aka unipolar major depression, is recognized when a person suffers at least one episode of severe depressed mood lasting at least two weeks in those with no history of hypomania or mania. Five or more accompanying symptoms should be present to confirm the diagnosis. Symptoms of depression include;

  • Irritability
  • Fatigue or lack of energy
  • Difficulty concentrating
  • Feelings of hopelessness, helplessness, worthlessness, guilt, self-hate
  • Social isolation
  • Insomnia or hypersomnia (excessive sleeping)
  • Loss of interest in once pleasurable activities
  • Changes in appetite with weight gain or loss
  • Suicidal thoughts or behaviors

Major Depressive Disorder Tretment

Major depression is extremely reoccurring with an estimated return rate greater than 40 percent. Evidence strongly supports treatment that includes medication, psychotherapy, and lasting support measures.

Pharmacotherapy for major depression begins with use of antidepressants. Choice of medication is best determined by the clinician, taking into account client needs. Should a trial of one antidepressant prove unsatisfactory, other antidepressants are available to try.

Antidepressant types include;

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Atypical antidepressants
  • Serotonin modulators
  • Tricyclic antidepressants
  • Monoamine oxidase inhibitors (MAOIs)

Psychotherapy for major depression generally centers around cognitive behavior therapy (CBT) and interpersonal psychotherapy, though other therapies are available which also show efficacy. One good finding from treatment with the psychotherapies is that after a course of treatment improvement often persists, leading to what is often lasting relief from serious bouts of depression.

Psychotherapies used with major depression include;

  • Cognitive behavior therapy
  • Interpersonal psychotherapy
  • Behavioral activation
  • Family and couples therapy
  • Problem solving therapy

Supportive care found useful for major depression includes such things as;

  • Guided self-help
  • Relaxation and positive activities
  • Exercise
  • Support groups

Traumatic Brain Injury

TBI, traumatic brain injury, may be the medical area most associated with the recent conflicts in Iraq and Afghanistan, however it is not just our service members that TBI effects. Currently traumatic brain injuries are the leading cause of death in North America for those aged 1 to 45 years of age (Hemphill & Phan, 2015).

Blows or concussive injuries to the brain occur when the head is suddenly exposed to an explosive wave of pressure, or when an object forcefully impacts or penetrates the surface of the head.

Causes of TBI may include, yet are not limited to the following;

  • Struck in the head
  • Nearby blast or explosion
  • Sudden abrupt stops or changes in movement

The damage that occurs, and the symptoms arising from that damage, can range from mild to severe. Mild traumatic brain injury (MTBI) commonly goes by the term concussion. MTBI may lead to a brief loss of consciousness or disorientation, commonly up to 30 minutes in duration. Damage may or may not be visible with imaging studies and can include such symptoms as; headache, dizziness, blurred vision, tired eyes, ringing of the ears, odd or foul taste in the mouth, fatigue or tiredness, changes in sleep patterns, mood and behavioral changes, memory and attention changes.

Severe traumatic brain injury symptoms may include all of those found in mild injuries as well as headaches which gets worse and fail to go away. Vomiting, nausea, convulsions, inability to awaken from sleep, dilation of one or both pupils of the eye, slurred speech, weakness, loss of coordination, confusion, restlessness and agitation may also occur. Diagnostic imaging studies are helpful for diagnosis, revealing skull fractures and evidence of swelling or bleeding into tissue. When a head injury is associated with loss of consciousness for over 30 minutes or amnesia, health professions should suspect severe traumatic brain injury.

TBI Treatment

Treatment of brain injury revolves around adequate oxygenation and blood flow to all areas of the brain. Resolution of acute oxygenation deficits and adequate circulation can be addressed by either surgical intervention or conservative treatment, depending on the situation, such as; diuretics, anti-seizure medications, coma inducing drugs, blood clot removal, repairing damaged tissue, or opening a window into the skull.

Lingering neurological deficits resulting from the acute brain injury are very individualized. Some of the more common problems show as;

  • Mental processing - cognition, memory, thinking, and reasoning
  • Mood and behavior – depression, anxiety, personality changes, aggression, acting out, social difficulties
  • Communication – understanding, expression
  • Sensory processing – hearing, sight, taste, touch

Rehabilitation post injury is an important facet of TBI treatment;

  • Physical therapy
  • Occupational therapy
  • Speech and language therapy
  • Recreational therapy
  • Psychotherapy
  • Family and group therapies

Depression, PTSD, and suicidal thinking are all associated with TBI and its recovery.

Military Suicide

Active service men and women, along with their families, are afflicted with high rates of suicidal thinking and behaviors.

Suicidal ideation, willingly or unwillingly thinking about ending one’s own life, and suicidal behaviors are perhaps the most serious and common psychiatric emergency worldwide. In 2015, the Department of Defense released numbers indicating that the suicide rate among active duty U.S. military personnel dropped in 2013 to roughly the same rate as among U.S. civilian populations. Their findings showed in 2013 active duty suicide rates were 18.7 per 100,000 - down from a 2012 rate of 22.7 per 100,000 (Kime, 2015).

Military veterans also show unacceptably high rates of suicide. According to the National Alliance on Mental Illness (NAMI), veterans represent 20 percent of suicides nationally, or, to view it from another angle, each day roughly 22 veterans end their own lives by suicide (NAMI, 2013).

Military Suicide Rates

Historically, suicide death rates in the U.S. Army have been below the civilian rate. The suicide rate in the U.S. Army began climbing in the early 2000s, and by 2008, it exceeded the demographically-matched civilian rate (20.2 military suicide deaths per 100,000 vs.19.2 civilian).

Currently U.S. military suicide rates range around 18.7 per 100,000.
(NIMH NIH, 2014)

The presence of certain positive factors are known to protect individuals from suicidal thoughts. Good social supports and family connections are chief among these protective elements. Being a parent or currently expecting a child, possessing a religious faith and being active in religious activities are all associated with a lower risk of suicide (Schreiber & Culpepper, 2015).

Suicide Prevention

The treatment for suicide related issues with the greatest positive impact for active duty, veteran, and military family members is prevention. Recently the veterans’ administration, along with the department of defense have focused on early identification of those having difficulties and ways to promote prevention. Warning signs to be alert for include;

  • Anxiety, agitation, sleeplessness, or mood swings
  • Hopelessness, feeling like there’s no way out
  • Feeling like there is no reason to live
  • Unusual rage, anger, frustration
  • Engaging in risky activities without thinking
  • Increasing alcohol or drug abuse
  • Withdrawing from family and friends

Some warning signs should provoke higher levels of concern, these include;

  • Self-destructive behavior such as drug abuse
  • Stockpiling or obtaining weapons, strong prescription medications, items associated with self-harm
  • Talking or thinking about hurting or killing yourself
  • Looking for ways to kill yourself
  • Talking about death, dying, or suicide

Suicide Evalutaion

The long standing advice that asking about suicide will initiate suicidal thoughts or actions has been shown to have no support in any known study. What has been shown repeatedly is that many clients appreciate and welcome the opportunity to discuss disturbing thoughts and suicidal feelings that they have been wrestling with. It has also been found that many suffering from suicidal thoughts would not have spoken of their feelings without questioning prompts from those concerned about them. Please be aware that the best intervention may be a spouse, friend, or health professional having the courage to care enough to ask about suicide thoughts or feelings.

A number of suicide evaluation scales have been developed, however none have been associated with a consistently high predictive value. Depression rating tools also show a poor predictive value for suicide. Two tools have shown reasonable success with risk of suicide screening, the Patient Health Questionnaire Nine Item (PHQ-9), and the Beck Hopelessness Scale (Schreiber & Culpepper, 2015).

The following questions may be helpful in eliciting information concerning the presence of suicidal feelings or a suicide plan;

  • “Have you made any preparations for suicide?” (e.g., gathering pills, changing wills, suicide notes) Or, “How close have you come to completing a suicide plan?”
  • “Have you practiced the suicidal act?” Or, “Have you already made an actual attempt to end your life?”
  • “How strong is your intent to carry out your suicidal thoughts and plans?”
  • “How assessable are your support systems when you have suicidal thoughts?”
  • “Do you have a specific method, place, and time planned to end your life?”
  • “Are the means of committing suicide available or readily accessible?”, “Do you know how to use these means?” 

Management and Treatment of Suicide

Three factors are the focus of managing the acute risk of suicide;

  • Reducing immediate risk
  • Managing underlying factors
  • Monitoring those at risk and follow-up

Reducing the immediate risk associated with strong suicidal feelings is the first step of acute management. Immediate control of stresses and environment are essential in controlling self-harm actions. This generally is accomplished with inpatient psychiatric services, such as hospitalization.

The highest priority is safety of the client at risk, that is, clients who have a plan and the intent to end their life. In the environment objects should be cleared that might be used to inflict harm, and possessions should be searched for items that might also be used.

For those with an elevated risk of suicide, yet not an imminent risk, for example no specific plan or intent, inpatient hospitalization may not be needed. 

Suicide Prevention Hotlines
Suicide prevention and veteran support hotlines are important resources that allow 24/7 access to communicate with a nonjudgmental person who can guide the suicidal minded to help and support services.

Veterans Crisis Line

  • Dial 1-800-273-8255 and Press 1 to talk to someone
  • Start a confidential online chat session at www.VeteransCrisisLine.net/chat
  • Send a text message to 838255 to connect to a VA responder
  • Connect through chat, text, or TTY if you are deaf or hard of hearing

National Suicide Prevention Lifeline

  • www.suicidepreventionlifeline.org  Funded by the U.S. Department of Health and Human Services
  • 1-800-273-TALK (also chat on website)
  • Spanish language line 1-888-628-9454. 

Managing underlying factors takes the form of reconnecting clients who have suicidal feelings with close family or friends that can remind the person that they are cared for, that they have others in their lives and are not alone. The feeling of aloneness, or that everyone would be better off with them dead are common intrusive thoughts. The presence of caring family and concerned friends helps to counter unwanted thinking, allowing time for the underlying cause of negative thoughts to be treated with individual and group therapies.

It is important to remove items that can facilitate suicidal actions, especially if those items or ones like them are in the person’s suicide plan. Removing firearms from the access of a person with life-ending feelings is essential as completed suicide is three or more times more likely when guns are accessible.

Monitoring those at risk and follow-up activities complete the acute care plan. Note the inclusion on following up what is being done on an emergent basis, as it is not enough to stop one attempt or near-miss suicide act. Unless there is continuing care and the presence of support suicidal feelings are likely to return.

The practice of “contracting for safety” is a valuable tool to help offset active feelings of suicide. Contracting safety, or having the client agree to do themselves no harm helps the client offset the impulse to act on suicidal thoughts. Safety contracts cannot be predetermined, as they must be specific to each individual’s needs, however the idea is that the person promise their care givers that they will not try to harm themselves when they are suicidal. Such contracts as well as open dialog about what the person wants to do and what they are feeling can aid in building therapeutic rapport and an alliance against the suicidal thoughts.

Antidepressants and Suicide

Retrospective reviews of 1990’s concerns show no clear evidence that treatment of depressed persons with antidepressant medications increases their risk of suicidality (e.g., suicidal fixation, action to prepare for a suicide attempt, attempt, non-fatal self-harm, or death).

Some studies hint there may be an age-specific increase in the risk of suicide attempts (non-fatal, self-harm) when persons aged 18-24 expressing suicidal thoughts are placed on antidepressants during the first several weeks of depression treatment. The same literature reveals no increased risk with persons 25-30 years, and what seems to be a lowering of suicidality in persons 31 years of age and older in those same first weeks of treatment with antidepressants.

Clinician discernment regarding the individual and their needs should be the deciding factor regarding antidepressant use for depression in the potentially suicidal.

Heightened awareness by clinicians and family should be present when beginning treatment for depression and/or suicidal feelings whether antidepressants are used or not.
(Simon, G., 2015)

Pharmacotherapy for suicide prevention focuses on treating underlying mood or anxiety conditions. Antidepressants can be helpful, however there is an underlying concern that in select individuals their use may increase the chance of a suicide attempt during the first few weeks of antidepressant treatment. Good clinician judgement of the individual and their risk factors is called for with the use of any antidepressant in individuals at higher risk for suicidal thoughts and feelings.

A recent meta-analysis of multiple drug trials indicates that the use of lithium in clients showing depression (unipolar major depression as well as bipolar depression) can lower the risk of suicidal actions. The action of the lithium which may create this effect is not currently known, however suicidal acts appeared to occur fewer times in clients treated with lithium than with other compounds (Schreiber & Culpepper, 2015).

Following suicidal acts family, friends, and coworkers may themselves be at an increased risk for suicidal thoughts and feelings, as well as for PTSD, major depression, and other anxiety disorders. A need for healing grief and support in the grieving process is essential whenever there is a loss, or perception that a loss is pending.

Grief

Grief is an ugly, gut-wrenching companion to life. Acute grief reactions are painful, mentally and physically impairing, yet still very normal and indeed extremely valuable as each of us come to terms with new circumstances that surround our lives after a loss. Bereavement, the loss felt upon the death of a loved one, is frequently the trigger for the grieving process to begin, however other situations such as crippling injuries, or memory/cognitive losses in a loved one can also be a starting point for grief.

Differing cultural backgrounds and personalities play a role in how grief is expressed, however general patterns are recognized. Such as acute separation distress, or what is referred to as the stress/trauma reaction to acute grief.

Indications of separation distress include;

  • Intense longing for, yearning, and seeking proximity to the deceased
  • Loneliness, social withdrawal, disinterest in other people
  • Painful and contradicting emotions - sadness, crying, guilt, anger, anxiety
  • Somatic symptoms such as unusual pains, disrupted sleep, loss of appetite, nausea, etc.
  • Feeling drawn to items or persons associated with the deceased
  • Confusion as to your own identity, and feeling lost or uncertain without the deceased person’s presence

Indications of a stress/trauma reaction to grief include;

  • Intense disbelief, denial
  • Shock, numbness
  • Sudden impairment of attention, concentration, or memory

Thoughts and images of a person lost occur frequently in grief. These images may be detailed and vivid to the point of hallucination. The presence of auditory, visual, or tactile illusions indicate an intense longing for the presence of the deceased and can be very frightening. Please remember as care givers to assure grieving family experiencing these unnerving sensations that missing a person to the extent of feeling their presence can be unsettling yet is not abnormal and tends to be a transient display of how much they miss their lost loved one. 

Case Study: Yolanda
Yolanda’s husband Henry received a medical discharge after an IED (improvised explosive device) explosion took his left leg below the knee and caused intracranial bleeding due to concussion forces. Now, three years after Henry returned home, Yolanda finds herself sobbing silently each night after she helps him from his wheelchair into bed. Henry doesn’t really remember her, his memories are shattered, just like the man she loved and had married, the man that came home in many ways, just a shell.
Yolanda feels the acid come up her throat again; the reflux and muscle aches had been with her since Henry came home. She still loved him, yet this wasn’t really Henry, was it?

The loss of a loved one, to death or change, is one of the hardest forms of loss we know. Grieving is not limited to the death of loved ones, as any great loss must be reconciled.

Emotional and somatic symptoms, as well as confusion and uncertainty may all accompany grief. Support from outside, from friends, family, support groups are all essential during the struggle to reconcile grief.

The course of acute grief does not follow a specific fixed-order series of stages. Grief is erratic in nature, and the process of adaption to loss is somewhat unique in each individual. The course of acute grief tends to run from six to twelve months. For some the time spent in grief is greatly shortened, and occasionally the process takes longer. Not feeling grief at all is an abnormal occurrence to great loss, especially the loss of a loved one. The adjustment process grief promotes is a progression from that person being preeminent in our thoughts to their new home of residing comfortably in our heart (Shear, 2015).

Please be aware that while the loss of a person becomes less keen with time, grief may never completely resolve. The person is not forgotten and will still be missed, particularly during special times such as holidays, anniversaries, or times of stress.

Grief coping tips:

  • Take one day at a time, long-term planning can wait for a while.
  • If you need to plan a funeral, get help, yet still be involved.
  • If you work, do your best to return to work as soon as possible. It helps to keep busy doing familiar tasks.
  • Continue current hobbies or groups, and consider taking up new activities while meeting new friends.
  • Speak to family and friends about what you are feeling and thinking, share remembrances.
  • Find a reason to go out every day. Plan ahead and remind yourself that you have something to do tomorrow.
  • Cry. Tears have their place, grieve and allow feelings out. Be careful not to spend too much time in self-pity, moderation is the key to every success and you have a precious life yet to live.
  • Exercise, eat well, and take care your health.

Remember, grief is terrible and normal. Group and individual therapies can be helpful, as well as joining face-to-face and online support groups. The best therapy of all is finding someone with grief who you can help through the process. 

Conclusion

Our veterans are the “greatest generation”, every generation. They have risked everything for us and our support of them and their families should be just as giving. It is important to recognize that mental wellness is just as important as physical health. Our minds and emotions control our body and interpret everything happening around us. Injuries to mind and spirit lead to the loss of control over our lives. Conditions such as adjustment disorder, stress disorders, traumatic brain injury, suicidality and grief are situations where we can give back to those who mean so much to us. Mental health and quality healing play crucial roles in the lives of our active military, our esteemed veterans, and we, the people who love them.  

References

American Psychiatric Association DSM-5. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bryant, R. (2015). “Acute Stress Disorder: Epidemiology, Pathogenesis, Clinical Manifestations, Course, and Diagnosis”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Ciechanowski, P. (2015). “Posttraumatic Stress Disorder in Adults: Epidemiology, Pathogenesis, Clinical Manifestations, Course, and Diagnosis”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Friedman, MJ., (2015). “PTSD History and Overview”. National Center for PTSD. Retrieved December 19, 2015 (Visit Source).

Gore, TA. (2015). “Posttraumatic Stress Disorder”. Medscape Emedicine.com. Retrieved December 15, 2015 (Visit Source).

Hemphill, JC., & Phan, N., (2015). “Traumatic Brain Injury, Epidemiology, Classification, and Pathophysiology”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Kerr, M. (2012). “Depression and the Military”. Healthline. Retrieved December 30, 2015 (Visit Source).

Kime, P., (2015). “DoD: Military Suicide Rate Drop”. Military Times. Retrieved December 30, 2015 (Visit Source). 

Lubit, RH., (2014). “Acute Stress Disorder”. Medscape Emedicine.com. Retrieved December 15, 2015 (Visit Source).

NAMI Veterans & Active Duty. (2015). “Veterans & Active Duty”. National Alliance on Mental Health. Retrieved December 3, 2015 (Visit Source).

NAMI, (2013). “Mental Illness Facts and Numbers”. National Alliance on Mental Illness. Retrieved January 4, 2016 (Visit Source).

NIMH NIH, (2014). “Suicide in the Military: Army-NIH Funded Study Points to Risk and Protective Factors”. National Institute of Health. Retrieved December 30, 2015 (Visit Source).

NIMH Prevalence. (2015). “Any Mental Illness among Adults”. National Institute of Mental Health. Retrieved December 3, 2015 (Visit Source) .

Pretzer, J. (2014). “Schemas, Assumptions, and Beliefs, Oh MY!”. Behavior Online. Retrieved December 23, 2015 (Visit Source).

Rothbaum, BO. (2015). “Psychotherapy for Posttraumatic Stress Disorder in Adults”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

SAMHSA Veterans. (2014). “Veterans and Military Families”. SAMHSA Substance Abuse and Mental Health Services Administration. Retrieved November 27, 2015 (Visit Source).

Schreiber, J., & Culpepper, L., (2015). “Suicidal Ideation and Behavior in Adults”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Shear, MK., (2015). “Grief and Bereavement in Adults: Clinical Features”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Simon, G., (2015). “Effect of Antidepressants on Suicide Risk in Adults”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Simon, S., & Ciechanowski, P., (2015). “Unipolar Major Depression in Adults, Choosing Initial Treatment”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Stein, MB. (2015). “Pharmacotherapy for Posttraumatic Stress Disorder in Adults”. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Tull, M. (2010). “EMDR”. About Health. Retrieved December 24, 2015 from (Visit Source).

Udesky, L., (2014). “Depression and PTSD in Veterans”. Health Day News for Healthier Living. Retrieved December 25, 2015 (Visit Source).


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, Medical Surgical, Psychiatric, West Virginia APN Requirement


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