Chapter S6: Health Care for Military Veterans

The health care needs of military veterans differ from the health care needs of the nonveteran population. The purpose of this chapter is to review historical and current challenges in addressing the health care needs of those who have served in the military. Many physicians in the United States are acquainted with health care for military veterans offered through the Department of Veterans Affairs (VA), as ~70% of current physicians in the United States received some portion of their medical training in VA health care facilities. In over 1700 sites, the VA health care system serves nearly 9 million of the 19 million U.S. veterans. While physician trainees often have some exposure to military culture and veterans’ health care as trainees in VA facilities, the long-term incorporation of this knowledge into their practices appears to be minimal. Most health care providers do not ask patients about their military service and are not aware of resources available to veterans and their families. More than half of the veterans in the United States receive some or all of their health care from the private sector. Ensuring optimal health care for military veterans is a responsibility shared by all physicians and health care providers and is integral to the security and well-being of the nation.

Serving in the military is the ultimate form of service and sacrifice as it includes the willingness to give one’s life in the service of others. Military service involves immersion in a culture that has distinctive uniform, language, rituals, values, social structures, behavioral norms, and daily activities; it also often includes rigorous training and occupational responsibilities that expose service members to unique health risks. Such risks are increased if an individual’s military service involves deployment to a combat zone or working in military occupational specialties with potential for unique injuries, psychological traumas, or exposure to toxic or infectious agents. Health consequences associated with military service can occur while the individual is serving in the military or may emerge many years later.

The branches of the U.S. military include Army, Navy, Marine Corps, Air Force, and Coast Guard. All service members, enlisted and officers, have a shared initiation into military life through basic training (boot camp) where drill instructors push recruits to their limits, both physically and mentally. Each branch of the military has its own advanced training in military jobs and each branch has explicit “core values” including such principles as loyalty, duty, respect, selfless service, honor, integrity, courage, commitment, excellence, and devotion. To know patients in the context of their military service is to begin to know them in the light of their values and their commitment to those values, fostering a more informed and trusting provider-patient relationship.

“Active duty” status means that the individual is serving in full time capacity in a branch of the military, which may involve full time employment in the military or for Reservists periods of active duty service alternating with returning to civilian status. Each service branch has a Reserve force (as well as National Guard in the case of Army) composed of civilians, who train together on a regular basis, including monthly weekend trainings as well as more extended periods of training at least annually. Reserve/National Guard personnel may be mobilized to active duty status in times of national emergencies (either natural disasters or other threats to the civilian population), as well as for deployment to international conflicts or humanitarian emergencies when augmentation of full time active duty forces is needed. In the recent U.S. conflicts in Iraq and Afghanistan, up to half of the U.S. military personnel deployed were from Reserve and National Guard forces; many deployed on more than one occasion, often for a year or more for each deployment. In addition to health risks of training and deployments, the demands of repeated transitions between active duty and civilian status posed unique challenges for these Reserve and National Guard members and their families, as well as for the providers caring for them. In nations with universal conscription, “citizen soldiers” are the rule, normalizing reintegration challenges for both the veterans and their families and care providers.

Military culture includes numerous subcultures. Service members and veterans will identify with their branch of service, commissioned officer or enlisted status, era of service, and the conflicts in which they served. For most military personnel, there is an overarching identification as “one who has served,” sharing a common mission, a willingness to sacrifice, and a selfless commitment to the safety and well-being of the nation. Only when clinicians have a basic understanding of military culture and military history and an awareness of the military experiences of their patients will they be able to provide veterans with optimal health care.

The largest cohorts of living U.S. veterans who have been involved in wartime service include those who were deployed during World War II (WWII) (1941–1946), the Korean War (1950–1955), the Vietnam War (1961–1975), the Gulf War (1990–1991), and the conflicts in Iraq and Afghanistan that began in 2001. There have been numerous other deployments of U.S. military personnel to combat theaters including Lebanon (1982–1984), Grenada (1983), Panama (1989), Somalia (1993), Bosnia (1993–1995), and Kosovo (1998–1999) all of which resulted in deployment-related deaths, injuries, and illnesses (Fig. S6-1). Any veteran, whether involved in combat or not, may have service-related health concerns subsequent to military service.

The rates of chronic disease among veterans, particularly those being seen in VA facilities, are known to be higher than those seen in the general population; this includes a variety of medical conditions and health concerns such as obesity, hearing impairments, cancer, arthritis, cardiovascular disease, and diabetes. Tobacco use and the abuse of alcohol and other substances are also more common among veterans, setting the stage for related health conditions in later life.

Among veterans who have deployed to war zones, particularly those involved in combat, there are higher rates of musculoskeletal injury, chronic pain, and a variety of mental health conditions, all of which contribute to an elevated postdeployment risk of suicide as well as risk of death and injury from trauma such as motor vehicle accidents. Combat veterans also commonly experience psychosocial challenges affecting family and social relationships, finances, educational performance, and work life. Deployment to certain geographical regions can involve risk for acute, chronic, or latent infectious diseases (Chap. S5) as well as risk for injury related to heat and cold exposure.

Military service carries risk for numerous forms of psychological traumas occurring during combat, training, noncombat experiences during deployment or as result of military sexual traumas (MSTs). In a war zone, these traumas often occur recurrently and concurrently. One in five serious injuries and deaths in a combat zone are a result of accidents. Rape or assault by a fellow service member, which affects a greater number of women veterans but also occurs in men, can be particularly devastating because it undermines the vital feeling of safety that individuals derive from their own unit peers, particularly in a war environment. When working with veterans it is important to consider the potential impacts of complex and multiple lifetime trauma experiences, including early life traumas, on a veteran’s mental health, physical health, personal relationships, and health care utilization. It is not unusual for veterans to live for decades with compensated or subthreshold posttraumatic stress disorder (PTSD) symptoms which become more problematic when changes in life circumstances occur, such as retirement, loss of a spouse, or cognitive decline. A brief and sensitively acquired lifetime psychological trauma history is an important step in the initial assessment.

Transitioning from military service to civilian life, while particularly challenging for combat veterans, poses challenges for most individuals leaving the military. This transition affects family, vocational activities, financial stability, and housing needs. Shifting one’s health care from the military health care system to VA or community providers may lead to disruptions in the continuity of care for routine as well as more serious health conditions. There are numerous Department of Defense (DoD) and VA programs involving specialized transition support personnel and nonprofit organizations that provide support for service members transitioning out of the military.

Military service often has physical, psychological, and reproductive health consequences for women veterans. Despite there being increasing numbers of women veterans living in the United States, many women do not identify themselves as veterans, and may be even less likely than men to be asked about their service. Women who have served in the military have unique health concerns that differ from women who have not served (see Chap. 391: Women’s Health).

Since the 1960s, when a 2% cap on women in the military was lifted, women have been serving in the armed forces in increasing numbers. Currently, ~15% of active duty and 18% of National Guard and Reserve personnel are female. This has resulted in an increasing number of women veterans (currently estimated to be 2.1 million in the United States) and a doubling of women using VA health care in the last decade. Over 650,000 women veterans enrolled for VA care in 2015.

Women were excluded from combat roles until 2013, but due to the nature of the conflicts in Iraq and Afghanistan, many women service members serving in support roles such as logistics, police, pilots, and truck drivers have been exposed to direct combat threats including enemy fire, improvised explosive devices, rocket propelled grenades, mortars, risk of capture, and environmental stressors including extreme temperatures and toxic exposures. Female soldiers may have to carry heavy loads, potentially in excess of 90 pounds, and participate in strenuous physical training and combat exertion equal to that of men. Women in military service sustain higher rates of musculoskeletal injuries than men, and are particularly prone to certain injuries such as stress fractures, which can lead to a higher prevalence of other musculoskeletal conditions. Activities such as heavy lifting or paratrooper training have been found to be associated with injuries resulting in increased rates of stress incontinence or pelvic organ prolapse. Overactive bladder symptoms also appear to be more common in veteran than nonveteran women. Average fitness levels for women entering the military in the United States are lower than for men; when adjusted for level of fitness it appears that women’s injury risks are similar to those of men overall.

Female veterans have higher rates of depression compared to male veterans and female nonveterans. In a 2014 analysis of U.S. national population based data, 27% of female veterans compared to 21% of female nonveterans had a diagnosis of depression. Among those using VA care, 45% of female veterans compared with 34% of male veterans were diagnosed as having a mental health or substance use disorder diagnosis. In contrast, female veterans have similar or lower rates of PTSD compared to male veterans.

Factors impacting reproductive health needs of women veterans include early life situations, military experiences such as trauma exposure or combat, and coexisting medical or mental health conditions. Additional studies are needed in this area as well as on specific impacts of deployment-related stressors on reproductive health concerns such as sexual dysfunction, unintended pregnancy, infertility, pelvic pain, and dysmenorrhea. While the causes of infertility among women veterans have been found to be comparable to the general population, data linking infertility to military occupational activities and environmental exposures are lacking.

Veterans using VA care maternity benefits have high rates of mental health comorbidities when compared to their nonveteran counterparts. Mental health conditions in pregnancy, particularly depression and PTSD, are potentially associated with increased risk of pregnancy complications such as preeclampsia and gestational diabetes, as well as spontaneous preterm birth. Compared to nonveterans, veterans using VA maternity benefits are at 30–40% increased risk of gestational diabetes and hypertensive disorders of pregnancy. Additionally, management of medical and mental health comorbidities may require the use potentially teratogenic medications. For these reasons, preconception care is particularly important for women veterans. Women veterans undergoing menopause may be more impacted by menopausal symptoms than their nonveteran counterparts at least partially due to higher rates of depression or PTSD, which may increase intolerance of menopausal symptoms.

Between 10 and 30% of female veterans report MST, involving either assault or threatening sexual harassment, compared to 1% of male veterans. MST increases the risk of a range of mental, physical, and psychosocial health disorders including chronic pain, depression, PTSD, suicide, alcohol and drug use, disrupted social networks, and occupational difficulties.

Women veterans have been found to have a 13% higher all-cause mortality than nonveteran women and greater declines in physical activity over time. Despite higher rates of educational and occupational attainments, women veterans were found to have greater cognitive decline over time compared with nonveteran women. Additionally, the women veterans in the Women’s Health Initiative data had higher rates of smoking, lung cancer, and hip fractures than nonveteran women.

Service in a war zone can involve extreme physical stress in austere environments, prolonged sleep deprivation, physical injury, exposure to life-threatening events, and hazards such as explosive devices, sniper fire, ambushes, indirect fire from rockets and mortars, and chemical pollutants. These exposures and experiences result in higher rates of physical injury with associated chronic pain, health effects of exposure to environmental agents, and the full spectrum of mental health conditions including PTSD, depression, anxiety, and substance use disorders as well as traumatic brain injuries. Certain events, such as loss of a close friend in combat or the innumerable experiences carrying moral consequences, leave indelible scars. These experiences have cumulative effects on health, many of which are mediated through physiologic mechanisms involving dysregulation of neuroendocrine and autonomic nervous system (ANS) functions.

Veterans of virtually all wars have reported elevated rates of generalized and multisystem physical, cognitive, and psychological health concerns that often become the focus of treatment months or years after returning home. These multisystem health concerns may include sleep disturbance, memory and concentration problems, headaches, musculoskeletal pain, gastrointestinal dysfunction (including irritable bowel syndrome [IBS] and gastroesophageal reflux), residual effects of wartime injuries, fatigue, anger, hyperarousal symptoms, high blood pressure, rapid heart rate (sometimes associated with panic symptoms), sexual dysfunction, and symptoms associated with PTSD and depression. This complex array of symptoms and health conditions is best addressed in clinical settings that offer integrated, interprofessional assessment and care.

The overlapping and multisystem health concerns reported by combat veterans from every generation have been given different labels and have led to debates among medical professionals as to the extent to which these are mediated primarily by physical or psychological causes. Following World War I there was extensive debate about whether “shell shock,” diagnosed in >80,000 British soldiers, was neurologic (“commotional” from the brain being shaken in the skull by concussive blasts) or psychological (“emotional” or “neurasthenia”) in origin. World War II veterans were said to suffer from “battle fatigue,” Korean War veterans developed “combat stress reactions,” and Vietnam veterans developed the “post-Vietnam syndrome.” The overlapping contributions of psychological causes (e.g., PTSD, depression, and substance use disorders), toxic chemical exposures (e.g., Agent Orange), the general demands of combat in hostile environments, and sociopolitical factors associated with the Vietnam War continue to be debated. Our greater understanding of the physiology of psychological trauma and psychiatric disorders has helped to reject the notion that mental health conditions are somehow less substantive or physiologically based than other illnesses and injuries, which has thereby helped to reduce the stigma of mental health care. Fig. S6-1 projected numbers of surviving U.S. veterans by conflict.

Numerous advances in medical care have emerged from the treatment of military personnel during and following combat. These include trauma care, burn care, management of infections, assessment and management of toxic exposures, and the treatment of mental health conditions. Improvements in personal protective body armor, armored vehicles, battlefield resuscitation, and the speed of evacuation to tertiary care have considerably improved the survivability of battlefield injuries. The survival rates of U.S. military personnel injured in battle have climbed from around 50% during the time of the American Civil War, to 66% during WWII, to 75% in the Vietnam War, and up to 90% in the recent U.S. conflicts in Iraq and Afghanistan. As a result, there are more veterans living longer lives with more significant residuals and impairments related to combat, including amputations, spinal cord and brain injury, and complications of burns and polytrauma.

The basic categories of postcombat health care needs follow predictable patterns: physical injuries often involving long-term impairments and chronic pain, mental health conditions (both those meeting diagnostic criteria as well as those with subthreshold levels of symptoms), nonspecific signs, and symptoms (headaches, bowel changes, fatigue, chronic pain, and mild cognitive impairments in memory, concentration, and attention), hearing loss/tinnitus, and a broad spectrum of effects from traumatic brain injuries. Suicide risk is elevated in veterans compared to nonveterans and screening and ongoing risk assessment is essential. Specific conflicts, due to geographical factors, have involved risks for certain infectious diseases, cold injuries, heat-related injuries, and toxic environmental exposures. Less well understood are the links between combat exposure and chronic health conditions such as elevated rates of cardiovascular risk factors including obesity, hyperlipidemia, diabetes, tobacco use, and hypertension. Elevated rates of cardiovascular risk factors in combat veterans are even more pronounced when comorbid mental health conditions are present. Chronic pain is more common in veterans than in nonveterans and is often complex; 50% of older veterans and up to 75% of female veterans experience chronic pain. Chronic pain syndromes often co-occur with PTSD, depression, and traumatic brain injury (TBI). These comorbidities, commonly related to deployment and combat experiences, are often complicated by substance use disorders. While veterans constitute 8.5% of the U.S. population, they represent 18% of the suicide deaths.

Neuropsychiatric sequelae are common in veterans, particularly following combat deployments. Increasing survival rates of combat injured individuals and increasing attention on individuals, who have not sustained observable physical wounds but who experience significant difficulties with postwar readjustment, have resulted in a greater awareness of the “invisible wounds” associated with service in a combat zone: PTSD, TBI, and toxic agent exposures. Although psychiatric and neurologic problems have been well documented in veterans of prior wars, during the recent conflicts in Iraq and Afghanistan, research has led to more proactive population-level screening, evaluation, and integrated treatment initiatives to address these conditions.

Management of postwar physical and cognitive health concerns is often symptom focused and ideally carried out within primary care-based settings. Studies suggest that optimal strategies for treatment of multisymptom health concerns include regularly scheduled primary care visits with brief physical examination at each visit, protecting patients from unnecessary diagnostic tests and non-evidence-based interventions, judicious use of consultations that protect patients from unnecessary specialty referrals, proactive care/case management, and communication that enhances positive expectations for recovery. Concussion research has shown that negative expectations are one of the most important risk factors for persistent symptoms.

PTSD (Chap. 444) is the most common mental disorder documented following war-zone service. PTSD has strong biologic correlates, based on fear-conditioning responses to threat and responses to extreme stress involving neuroendocrine dysregulation and ANS reactivity. Numerous studies have shown that PTSD is highly correlated with cognitive symptoms and a variety of physical health conditions, including hypertension, chronic pain, and cardiovascular disease, as well as cell-mediated immune dysfunction and shortened life expectancy. PTSD frequently co-occurs with other mental disorders such as major depressive disorder, generalized anxiety, substance use disorders, and high risk behaviors (e.g., aggression, accidents). It has been estimated that up to 80% of patients with PTSD exhibit one or more comorbid mental health conditions. Misuse of alcohol or substances is most prevalent, often reflecting self-medication. PTSD is also associated with tolerance and withdrawal symptoms related to prescription pain and sleep medications, as well as nicotine dependence (Chap. 448).

Between 6 and 25% of veterans involved in recent conflicts reported symptoms of PTSD at some point following their deployment, with the strongest risk factor being the intensity of combat exposure. Studies from veterans of earlier conflicts suggest that, while many symptoms abate over time, a significant number will have ongoing symptoms, at least intermittently, for the remainder of their lives; some individuals will only begin manifesting clinically significant symptoms later in life. Veterans with persistent PTSD have a death rate that is twice that of those who never had PTSD or had recovered from PTSD in the decades following their combat experience. Chronic pain is much more prevalent in veterans with PTSD or depression, and these individuals are more likely to be taking opioids for pain as well as benzodiazepines for co-occurring mental health conditions, putting them at greater risk for medication-related substance use disorders.

PTSD and depression frequently co-occur in combat veterans, and the evidence-based treatments are similar, involving antidepressant medications, psychotherapy, or both. Psychoeducation that assists veterans to understand that their symptoms of PTSD have a basis in adaptive survival mechanisms and skills they exhibited in combat can facilitate therapeutic rapport. Remaining hypervigilant to threat, being able to shut down emotions, being able to function on less sleep, and using anger to help focus and control fear are all adaptive beneficial survival skills in a combat environment. Therefore, PTSD for warriors is both a medical disorder and a set of reactions that have their roots in the physiologic adaptation and skills they successfully applied in combat.

Current clinical guidelines recommend trauma-focused psychotherapies as the first-line treatment for PTSD. If a veteran chooses not to engage in trauma-focused psychotherapy, or if such therapies are not available to the veteran, the next step is to offer a nontrauma focused psychotherapy or medication (specifically SSRIs/SNRI). In some cases, a primary care provider may start a veteran on medications alone as a step toward engaging the individual in psychotherapy. A patient-centered approach that allows for a discussion of treatment options between the veteran and the provider and then encouraging the veteran to engage in the most effective psychotherapies is the ideal. Involving a mental health professional is recommended if there are more severe symptoms, significant comorbidity, safety concerns, or limited response to initial treatment.

There are several evidence-based trauma-focused psychotherapies, including prolonged exposure, cognitive processing therapy, eye-movement desensitization and reprocessing (EMDR) and others, based largely on cognitive-behavioral or extinction learning (systematic desensitization) therapy models. Although they involve different techniques they have similar core components, including narration (oral, written, or through visualization, often called “imaginal exposure”), in vivo exposure focused on retraining the body not to react to stimuli related to traumatic reminders (e.g., a crowded mall), cognitive reframing, and techniques to modulate physiologic hyperarousal (e.g., diaphragmatic breathing and progressive muscle relaxation).

Complementary and integrative medicine approaches including acupuncture, mindfulness meditation, yoga, and massage are also being used as adjunctive approaches in treating PTSD. Although these are not evidence-based treatments targeting PTSD per se, they can be useful to facilitate a relaxation response and reduce hyperarousal, chronic pain, or sleep impairment. The primary care provider plays an extremely important role in the management of PTSD by educating the veteran, destigmatizing treatment, and supporting adherence not only to specific treatment modalities but also to general health habits related to diet, exercise, substance use, and stress management. Sleep disturbances should be addressed initially with sleep hygiene education, followed by consideration of cognitive therapy for insomnia approaches, followed by medications such as antihistamines or trazodone. Benzodiazepines and nonbenzodiazepine sedative-hypnotics should be used with caution in veterans because they can lead to tolerance and rebound sleep problems. Benzodiazepines are relatively contraindicated in veterans with PTSD, as they can exacerbate and worsen PTSD symptoms. Co-prescribing of benzodiazepines with opioid pain medications should be avoided, given the suicide risk and high prevalence of substance use disorders in veterans.

All PTSD treatments are associated with a sizable proportion of individuals who fail to respond adequately, and it is often necessary to add modalities or switch treatments. Antidepressants also are likely to be useful in comorbid depression, which is common in veterans with PTSD. All antidepressants have potential drug-drug interactions that must be considered.

It is difficult to establish a clear causal connection between a concussion injury incurred during deployment and persistent postconcussive symptoms months or years after return from deployment (Chap. 435). This is often confounded by other postwar conditions that are associated with similar symptoms, including injuries not involving the head, other medical disorders, sleep disorders, PTSD, depression, grief, substance use disorders, chronic pain, and the generalized physiologic effects of wartime service.

General recommendations for the clinical management of persistent, chronic post-concussion syndrome (PCS) include treating physical and cognitive health problems based on symptom presentation; managing coexisting health problems; remaining sensitive to individual preferences; and addressing coexisting depression, PTSD, substance use disorders, or other factors that may be contributing to symptom persistence. Headache is the most common symptom associated with concussion/mild TBI, and the evaluation and treatment of headache parallels that for other causes of headache (Chaps. 13 and 422). Stimulant medications for alleviating neurocognitive effects attributed to concussion/mild TBI are not recommended. Clinicians should be aware of the potential for cognitive or sedative side effects of certain medications that may be prescribed for depression, anxiety, sleep, or chronic pain.

Treatment of neuropsychiatric problems must be coordinated with care for other war-related health concerns, with the goal of treatment to reduce the severity of symptoms, improve social and occupational functioning, and prevent long-term disability. Understanding the context of war-related health concerns is important in communicating with veterans and developing a comprehensive treatment strategy.

Given the interrelationship of various postwar health concerns, care must be effectively coordinated. Specific techniques that have been found to be helpful include scheduling regular primary care visits (rather than as-needed visits), establishing care management, using good risk-communication principles, and establishing a consultative stepped care approach that draws on the expertise of specialists in a collaborative manner. The availability of behavioral health support directly within primary care clinics (both for referrals and to provide education and support to primary care professionals prescribing treatment for depression or PTSD) will reduce stigma and enhance effectiveness of mental health care. Seamless integration of specialty care services such as rehabilitation care, pain care, and addiction care will also improve outcomes. Evidence-based clinical practice guidelines have been developed for assessing and managing these conditions.

It is important not to implicitly or explicitly convey the message that physical or cognitive symptoms are “just psychological” or “simply due to stress.” Even if depression, anxiety, or current stressors play a role in the etiology of physical health symptoms, the treatment approach should be designed within a patient-centered primary care structure, and referrals should be managed from within this framework. For example, it might help to explain that the primary goal of involving a mental health professional is to improve sleep and reduce physiologic hyperarousal, which in turn will help with treatment of war-related chronic headaches, concentration problems, or chronic fatigue. If, however, the primary care professional conveys the message that the cause of headaches, concentration problems, or other unexplained somatic symptoms is anxiety or depression, and this conflicts with the patient’s own viewpoint, this could damage therapeutic rapport, undermine the commitment to the care plan, and in turn exacerbate the symptoms.

Exposures to environmental hazards during military service are not uncommon, occurring as a part of training activities, performance of many military occupation specialties, as well as in deployment and combat environments. Many veterans have concerns about the potential health impacts of such exposures. Occupational and environmental hazards may be encountered in many forms: fuels, petrochemicals, solvents, hydraulic fluids, sand, dust, pesticides, herbicides as well as biological/chemical weapons and various forms of radiation. Military service in general is a risk factor for toxic environmental pulmonary exposures.

In WWI, there was large-scale use of chemical weapons including mustard gas and chlorine gas. In the recent conflicts in the Persian Gulf region, cholinesterase inhibiting nerve agents appear to have been used although the extent of the use and potential exposures to such chemical weapons is not clear; there were also concerns about and preparations made to respond to the potential use biological weapons, specifically anthrax and smallpox.

The 1990–1991 Gulf War (Operation Desert Shield/Desert Storm), following Iraq’s invasion of Kuwait, led to extensive debates regarding the etiology of Gulf War syndrome, also known as chronic multisystem illness. Veterans were exposed to numerous potentially toxic environmental agents (e.g., oil fires, depleted uranium, pesticides, multiple vaccinations, prophylactic medications), the psychological stress of deployment to a war zone where there was prolonged anticipation of combat, repeated chemical/biological weapons alerts, and use of impermeable full-body protective uniforms (made from rubber, vinyl, charcoal-impregnated polyurethane, and other materials) under desert conditions in extreme temperatures. Although no singular clinical syndrome with clearly established etiology has yet been definitively identified among the nearly 1 million coalition forces service members who deployed in 1990–1991, studies consistently found that military personnel who served in the Gulf experienced significantly elevated rates of multisystem, undiagnosed symptoms impacting all health domains (e.g., physical, cognitive, neurologic, psychological) compared with service members who deployed elsewhere or did not deploy. In addition, there is good evidence that deployment to the Persian Gulf region during this period was associated with subsequent development of PTSD; other psychiatric disorders including generalized anxiety disorder, depression, and substance use disorders (Chaps. 445, 446, 447, 448); and functional gastrointestinal symptoms such as irritable bowel syndrome (Chap. 320); and chronic fatigue syndrome (Chap. 442).

Nuclear weapons, most specifically the atomic bombs used at the end of WWII, resulted in large-scale destruction both from the explosive effects as well as the residual radiation effects on the populations and environments involved. Military personnel stationed in these areas, as well as those involved in further testing of nuclear weapons in the subsequent decades, were at increased risk for numerous malignancies and radiation-related illnesses.

A prominent environmental exposure during the war in Vietnam (1962–1971) involved defoliants, including one that was referred to as “Agent Orange” (because it was transported in 55 gallon drums labeled with an orange painted stripe). The defoliant was contaminated with dioxin (2,3,7,8-tetracholordibenzo-p-dioxin or TCDD) which was subsequently found to potentially contribute to numerous health effects. Research results from various sources including VA, Center for Disease Control (CDC), and National Academy of Medicine examining the potential health impacts of dioxin exposure are published every 2 years. Conditions that have been identified as having potential associations with Agent Orange exposure include amyloidosis, chronic B-cell leukemia, chloracne, type 2 diabetes, Hodgkin’s disease, ischemic heart disease, multiple myeloma, non-Hodgkin’s lymphoma, Parkinson’s disease, peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft tissue sarcomas. Services and benefits are available to all U.S. veterans with potential exposures to Agent Orange who are diagnosed with any of these conditions.

Prophylactic medications and vaccinations (often multiple and concurrent) associated with deployment also carry potential side effects and may be of concern to veterans. In recent conflicts in the Persian Gulf region, vaccinations for potential biological weapons such as anthrax and smallpox were common. During deployment to the 1990–1991 Gulf War, many military personnel took pyridostigmine bromide as a prophylactic against cholinesterase blocking nerve agents. Taking malaria prophylaxis is frequently required during deployments to malaria endemic regions; concerns about neuropsychiatric side effects of mefloquin in veterans with combat trauma and PTSD arose during the 1990–1991 Gulf War and has remained an ongoing concern.

In addition to exposures that may occur during deployment, there are occasional toxic chemical exposures that occur when military personnel are in garrison (based in military facilities in the United States). From the 1950s through the 1980s, people living or working at the U.S. Marine Corps Base Camp Lejeune, North Carolina, were potentially exposed to drinking water contaminated with industrial solvents (perchlorethelene and trichloroethylene), benzene, and other toxic chemicals. There have been similar concerns related to potential toxic chemical exposures at other military bases and facilities in the United States.

The Department of VA has created several Registry Programs to respond to the medical conditions and health concerns of Veterans exposed to Agent Orange, Ionizing Radiation, Gulf War exposures and other deployment-related toxic environmental exposures. These programs provide Veterans with information and access to services, resources, and other benefits available to them as a consequence of these exposures. The DoD and VA approaches to assessing and addressing such exposures have become much more proactive over the years, as is evidenced by the Airborne Hazard and Open Burn Pit Registry for military personnel and veterans involved in conflicts in the Gulf beginning in August 1990.

Given that wartime service is so often associated with multiple coexisting and overlapping health conditions, postcombat health services, particularly in the early years following combat, must be able to address the physical, psychological, and psychosocial concerns in an integrated manner. Specific questions related to military service (Table S6-1) combined with screening for depression, PTSD, and alcohol use disorders should be a routine part of care for all veterans. Three screening tools, which are in the public domain, have been validated for use in primary care, and have been used frequently in veterans: the four-question Primary Care PTSD Screen (PC-PTSD), the two-question Patient Health Questionnaire (PHQ-2), and the three-question Alcohol Use Disorders Identification Test-Consumption module (AUDIT-C). Screening for TBI events, tobacco use, other substance abuse and psychosocial impairments is also important.

A positive screen for depression or PTSD should prompt follow-up questions related to these disorders (or use of a longer screening tool such as the nine-question Patient Health Questionnaire or National Center for PTSD Checklist), as well as risk assessment for suicide or homicide. It is important to assess the impact of depression or PTSD symptoms on occupational functioning and interpersonal relationships. A positive screen for alcohol misuse should prompt a brief motivational intervention that includes bringing attention to the elevated level of drinking, informing the veteran about the effects of alcohol on health, recommending limiting use or abstaining, exploring and setting goals related to drinking behavior, and follow-up and referral to specialty care if needed. This type of brief primary care intervention has been found to be effective and should be incorporated into routine practice. One way to facilitate dialogue about this topic with veterans is to point out how hyperarousal associated with combat service can lead to increased craving for alcohol as the body searches for ways to modulate this. Veterans may consciously or unconsciously drink more to help with sleep, reduce arousal, or avoid thinking about events that happened “downrange.” A key educational strategy is to help the veteran to learn that drinking to get to sleep actually damages sleep architecture and makes sleep worse (e.g., reduces rapid eye movement [REM] sleep initially followed by rebound REM activity and early morning wakening).

Postdeployment care services should include primary care-based collaborative medical and mental health care, with well-integrated specialty care services including rehabilitation/polytrauma, pain management, and addictions care. Veteran peers and chaplains often play important roles on care teams. Proactive care coordination is essential for returning combat veterans. Educational, financial, vocational, family, and spiritual support services are also important, particularly in the initial years following deployment. Vet Centers, often located in community-based settings, are an important source of mental health care for veterans and their families, offering a more peer-based, discrete and culturally oriented approach to care. Veteran service organizations offer support to veterans in a number of ways, including assisting veterans in accessing benefits and resources available to them and their families.

Stigma and other barriers to care add to the challenge of treating veterans. Despite extensive education efforts among military leaders and service members, stigma persists related to veterans acknowledging health concerns or expressing a need for help. Veterans are often concerned that they will be perceived as weak by peers or leaders if they seek care. Studies have shown that less than one-half of service members and veterans with serious mental health problems receive needed care, and upward of half of those who begin mental health treatment for depression or PTSD drop out before receiving an adequate number of treatment sessions. Many factors contribute to this, including the pervasive nature of stigma in society in general (particularly among men), the critical importance of group cohesiveness of military teams, the nature of avoidance symptoms in PTSD, orientation toward self-sufficiency, mistrust of government agencies, and in some cases negative perceptions of mental health care and skepticism that mental health professionals will have anything helpful to offer them. Creating environments of care that are sensitive to military culture and work to address these stigma will lead to greater engagement of veterans in care and will ultimately improve outcomes. Such environments should offer behavioral health and social work support as integral aspects of care rather than as referral services.

It is important for all health care providers in all settings, as part of a psychosocial and/or occupational history taken at the time of initial evaluation, to ask their patients if they have served in the military. Men and women who have served may not identify themselves as Veterans or Reservists or National Guard. Asking the question “Have you or someone close to you served in the military?” acknowledges service and gives providers an opportunity to inquire about service experiences that may have impacted the mental, physical, and psychosocial health of the patient. Partners, dependents, and family members of veterans may also be impacted by the veteran’s service and in some cases may be eligible for resources or benefits.

In addition to providing insight into specific health conditions for which the individual may be at increased risk, obtaining a military service and deployment history also contributes to the quality of the clinician-patient relationship. For most individuals who have served in the military, their service was a significant life experience, the sharing of which is often very meaningful for the veteran. Taking a military service and deployment history also gives the clinician an opportunity to express gratitude for the veteran’s service and can deepen the levels of trust and appreciation between the veteran and the clinician, which in turn has been shown to contribute to both satisfaction in health care encounters as well as improved outcomes. It only takes a few minutes to review the basic elements of the Military/Deployment History (Table S6-2).

Taking a brief military and deployment history in all patients at the time of initial assessment serves three purposes: creating a stronger and more meaningful connection with the veteran, providing an opportunity to acknowledge the veteran’s service, and potentially identifying specific health care needs in the veteran. When this is done consistently in all health care settings, it will be a significant step toward the creation of a national network of care for veterans. This will in itself be a tribute to their service, a way of expressing our appreciation for that service, and will ensure that military veterans receive the health care that they need and deserve.