Information provided by the Substance Abuse and Mental Health Services Administration(SAMHSA) indicates the following regarding veterans and substance abuse:
- Many of the more than 23 million veterans in the United States face issues such as homelessness, trauma, suicidal thoughts, and involvement in the criminal justice system.
- Combat experiences bring a significant risk for the development of a trauma- or stress-related disorder. For instance, about 18.5 percent of returning veterans from Iraq or Afghanistan receive a diagnosis of post-traumatic stress disorder (PTSD).
- Nearly half of returning service personnel who need mental health treatment actually seek such treatment, but only slightly half of those get adequate care.
- Between 2004 and 2006, 7.1 percent of US veterans met the criteria for a substance use disorder.
- Research indicates that over 20 percent of veterans active in substance use disorder treatment were homeless and that about 70 percent of homeless veterans experience a substance use disorder.
- Suicide rates for veterans continue to be high relative to individuals with no military background.
In a separate report from SAMHSA, it is also noted that there are special at-risk populations among military family and veterans. These groups are more likely to be affected by substance abuse or to develop substance use disorders:
- Children of veterans and military families
- Minority groups who are heavily represented in the veteran population
- Women, due to special challenges faced as family members of veterans, as veterans themselves, or as military personnel
Associations with Substance Abuse and Being in the Military
There is a great deal of research looking at the links between substance use disorders, mental health disorders, stress, and veterans. There is information from research studies published in the journals Substance Use and Misuse, Military Medicine, and Quality of Life Research to indicate the following:
- Strong links between substance abuse in veterans and depression indicate that depression is often a driving factor in the development of substance use disorders in this population. Data indicates that rates of depression and substance use disorders have increased among active members of the military and that the rate of suicides among military members has also increased.
- There are strong links between substance use disorders in veterans and stress related to being in the military (especially for women), non-combat experiences (e.g., harassment), and disillusionment with expectations regarding military life and the overall military experience.
- Obviously, veterans in combat are at a greater risk to develop trauma- and stress-related disorders, such as PTSD. In addition, nearly one-fourth of all female veterans report some type of sexual assault during their military time and a surprising number of male veterans report the same experience. The association between substance abuse and having a diagnosis of PTSD as a result of military combat, having a diagnosis of PTSD as a result of other experiences in the military, or displaying symptoms that resemble PTSD but do not warrant a formal diagnosis of the disorder is so strong that a great deal of research emphasis has been placed on it.
PTSD, Stress, and Substance Abuse
A number of veterans with substance use disorders have co-occurring PTSD. PTSD is associated with the development of a significant set of clinical symptoms as a result of either being involved in a stressful or traumatic experience, witnessing a stressful or traumatic situation, or learning of a loved one being involved in a stressful or traumatic situation. According to the American Psychiatric Association (APA), symptoms of PTSD can include:
- Flashbacks of the stressful experience
- Feelings of hopelessness
- A poor sense of self-worth
- Issues sleeping, decreased appetite, and inability to enjoy aspects of life that are typically enjoyable for the individual
- Issues with suspiciousness, irritability, aggression, depression, and panic attacks
- Significant issues with relationships
- Cognitive issues, such as difficulty concentrating, difficulty with memory, and issues with problem-solving
- An increased tendency to engage in self-destructive behaviors that can include impulsive behaviors, substance abuse, and potential suicidality
The US Department of Veterans Affairs reports that:
- Veterans of the Vietnam War may have rates of PTSD as high as 30 percent.
- Veterans of the Gulf War have rates of PTSD around 12 percent.
- Veterans who are involved in Operations Iraqi Freedom and Enduring Freedom have reported rates of PTSD that vary between 11 percent and 20 percent.
- The exact rates of PTSD that occur in the relatively large number of military personnel and veterans who report experiencing sexual harassment or sexual abuse is not known, but also expected to be relatively high and certainly higher than rates of PTSD occurring in the general population.
Substances of abuse associated with individuals who are diagnosed with PTSD often include:
- Prescription medications, such as narcotic pain medications or benzodiazepines
- Cannabis products
- Other illicit drugs of abuse, including heroin, cocaine, methamphetamine, etc.
Many of the symptoms of PTSD, such as flashbacks, can be triggered by reminders of the specific traumatic event that is associated with the development of PTSD in the person. Some of these reminders or triggers can be quite vague and may be specific to the individual. This can make them difficult to identify. Some veterans with symptoms that would qualify for formal diagnosis of PTSD or those with subclinical symptoms (having some symptoms of the disorder but not quite enough to warrant the diagnosis) may go a significant length of time without having their issues recognized. The longer the individual suffers with the symptoms, the more likely they are to develop other co-occurring issues.
Nearly 20 percent of veterans with PTSD also develop a substance use disorder. The substance use disorder may occur as a result of individuals attempting to self-medicate their PTSD symptoms or may represent inherent vulnerabilities that individuals have to developing mental health disorders as a result of their experiences.
The relationship between PTSD and substance abuse is not as simple as it is often depicted. Research indicates that this relationship is not just a simple matter of an individual self-medicating their PTSD symptoms with alcohol or drugs, although this certainly does happen. As it turns out, the relationship between PTSD and substance abuse is bidirectional, such that individuals who are diagnosed with PTSD have a higher probability of developing a substance use disorder; however, individuals who have significant problems with substance abuse are also at a higher risk to later develop PTSD as a result of experiencing some traumatic event later. In addition, an individual has a higher risk for either or both disorders if they have a family history of mental illness.
Treatment for Veterans
Because there is a significant chance that a veteran diagnosed with a substance use disorder suffers from either depression, an anxiety disorder, PTSD, or some other co-occurring mental health issue, it is extremely important that the individual receives adequate treatment for co-occurring disorders. This begins with a full assessment of the individual’s physical and mental functioning. The assessment should include a full physical examination, a complete mental health examination, and a cognitive examination. The results of the examinations will determine the specific issues that need to be addressed during the integrated treatment program.
An integrated treatment program consists of the delivery of treatment by a multidisciplinary team of physicians and other treatment providers to address all issues that were uncovered in the initial assessment. It is crucial to the success of the treatment that co-occurring mental health disorders receive treatment at the same time as the substance use disorder as opposed to trying to address one disorder first and then treat another disorder later. Typically, different specialists will treat each disorder separately (some may treat more than one issue), but all services will be integrated.
The treatment team will often consist of:
- One or more physicians who specialize in specific fields of practice, such as addiction medicine, psychiatry, or particular health issues
- Psychologists and counselors who are trained in treating depression, PTSD, other mental health disorders, and substance use disorders
- Other treatment specialists, such as occupational therapists, social workers, vocational rehabilitation counselors, etc.
The team typically meets periodically regarding the progress of the client. Treatment team members work together on defined goals for the individual. Treatment will often consist of:
- Physician-assisted withdrawal management participation when appropriate
- Medically assisted interventions, including medications
- Therapy for the individual substance use disorder and any co-occurring disorders
- Involvement in support groups, including PTSD support groups, other support groups for specific mental health disorders, and support groups for the specific substance use disorder
- Other interventions, as needed
Depending on the individual case, treatment may initially begin as inpatient treatment and then transition to outpatient treatment, or it may be performed on an outpatient basis for its entirety. Because of the complicated nature of veterans with PTSD and substance use disorders, treatment should be approached as a long-term and ongoing intervention.
It is crucial that individuals with co-occurring disorders like PTSD and substance use disorders remain in treatment for a significant length of time in order to realize the full benefit of the intervention. The major focus of long-term treatment is most often participation in social support groups and continued medical management of concerns, such as depressive symptoms, anxiety, and other medical issues. Formal therapy is typically time-limited and may last for several years; however, individuals will most often participate in social support groups for a significantly longer period of time and may return to therapy for maintenance sessions or to address new issues periodically.
The results of the integrated treatment program should be assessed periodically to ensure that the client is progressing. During these periodic assessments, the treatment team will often meet and discuss potential ways to improve on the recovery program for the individual.