1. 
   

   Why should we care about combat stress and related disorders?

   
   
2. 
   

   How do you define cultural competence regarding military service members, veterans, and their families?

   
   
3. 
   

   What are the medical problems associated with military service and deployment stress?

   
   
4. 
   

   How would you describe point-of-care strategies to improve the care of military service members, veterans, and their families?

   
   
5. 
   

   What resources are available to provide information, support, and access needed by military service members, veterans, and those who care for them and about them?

An estimated 2.2 million American military members have served in Operation Enduring Freedom (OEF) in Afghanistan and/or Operation Iraqi Freedom (OIF) since the first of these wars began in 2001. As of November 2006, these two conflicts have exceeded the duration of World War II. The attention rightfully paid to OEF in Afghanistan and/or OIF war fighters should also alert the public that there are 23.4 million living American veterans, three-quarters of whom served during an official period of conflict. Approximately one in every four Americans is eligible for benefits from the United States Department of Veterans Affairs (VA) because they are either veterans or the dependents of veterans. Yet only one in four veterans is enrolled for VA health services. The remaining 75% of veterans and all their dependents receive health care outside of VA.

The composition of those currently serving is described:

• 12% of those serving in a combat area of operations are women.
  
• 58% of the military forces are 29 years of age or younger.
  
• 63% are active duty (AD) component members, and 37% are the Reserve component (RC) including Reservists and National Guard Members.

AD component members have the support of a strong military community due to their serving a continuous “hitch” on a military base. The RC “Citizen Soldiers,” however, move back and forth between military and veteran status. They may live hundreds of miles from the nearest military community and thousands of miles from the troops with whom they are deployed. Spouses may be the only person in their workplace who has had a wife or husband deployed in the military. Their children may be the only ones in their school to have a parent serving overseas.

The nature of our volunteer military requires multiple deployments per member. Each time a military member deploys, the individual’s risk of developing a postdeployment mental health problem increases. When a service member deploys, a family serves too. As yet, there has been little research on how the health of military family members may be affected in the course of the deployment cycle.

At the time of this writing, there are still two dependents of American Civil War Veterans receiving VA benefits. Going to war is a very long-term investment. Yet, despite the large number of veterans and their dependents and an enduring obligation to serve those who have served our country, few health care providers routinely enquire about military history or about the effects of deployment on military families. Providers are often ill prepared to recognize or treat health problems associated with military service and/or deployment stress. This chapter will focus on postdeployment mental health and articulate a public health approach that requires the development of Department of Defense (DoD)/VA/state and community partnerships in service to military service members/veterans and their families.

A November 2007 study from the Walter Reed Army Institute of Research followed 88,235 U.S. Soldiers returning from Iraq. Each soldier completed both a Post-Deployment Health Assessment (PDHA) and then, an average of six months later, completed a Post-Deployment Health Reassessment (PDHRA). These global health screening tools include standard screens for posttraumatic stress disorder (PTSD), major depression, alcohol abuse, and traumatic brain injury (TBI).

While the Milliken study contained the good news that about half of those who reported significant PTSD symptoms upon arrival home had improved at the six month mark, the bad news was that twice as many new Soldiers screened positive for PTSD at that six month follow-up. During those first six months postdeployment, the depression rate doubled among the AD component and tripled among the RC. The self-report rate for alcohol abuse was 12% for the AD and 15% for the RC; yet only 0.2% of those who screened positive were referred for treatment (likely because they had the option of not being referred and feared the impact of referral upon their military careers). Respondents also reported a fourfold increase in concern about losing control of their anger.

Overall, 20.3% of the AD component and 42.4% of the RC were identified as requiring further mental health assessment and/or treatment by the six month mark. Little is known about the health status of their family members and significant others.

The health burden of returning service members and their families is by no means confined to mental health issues. Consideration of the full health impact of service in OEF/OIF is well beyond the scope of this chapter but it should be noted that a 2009 study by Cohen and colleagues found that veterans with mental disorders had 42% to 146% greater utilization in VA nonmental health settings than those without a mental disorder. Those with PTSD had the highest utilization in all categories. Female gender and lower rank were also independently associated with greater health care utilization. Comparison data is not available for non-VA settings but these findings strongly support the importance of screening for military history as a routine component of medical intake within all health care systems.

Military Culture

Medical providers are increasingly sensitive to the importance of cultural competence, but few recognize that the military is a unique culture in itself. The clinician’s understanding of military life, the deployment cycle, and the stresses of living and working in a war zone are critical to establishing credibility with patients who are either military members, veterans, or their significant others. Being in the military or in a military family is not like any other kind of life. There is strong support within a well-defined, coherent social system, but there is also little privacy. Military families may truly get to “see the world,” but they rarely have much choice about where they will live or for how long. Above all, military life is defined and structured by a high standard of discipline. Few outside of the armed services understand that military culture is primarily rooted in a professional ethos of loyalty and self-sacrifice. This is necessary to maintain order during battle.

A distinct set of military ceremony and etiquette reinforces shared rituals and common identities. An enduring emphasis on group cohesion and esprit de corps connects service members to one another. Above all, military members and their families understand that the mission must come first. As a corollary to this, nonmilitary clinicians need to understand that the purpose of military medicine is to preserve the fighting force. This is distinctly different than the goal of providing patient- and family-centered care.

Military customs and concerns can generate tension in the doctor-patient relationship when military members and their dependents are seen in nonmilitary health care settings. Patients and their family members may hesitate to report postdeployment health problems because of concern that what they say may get back to the commanding officer. While such breach of medical privacy is unlikely, even in military health care settings, confidentiality is a serious concern among military members and their families that should be addressed openly and early. The stigma associated with mental health problems may be the single greatest barrier to accurate assessment and timely care of deployment-related health concerns.

It is not necessary for a clinician to become an expert on military history or military life in order to achieve the cultural competency needed to be effective in working with this population, but it is critically important to remain aware and respectful of the military way of life. For example, calling a Marine a Soldier may convince that Marine that you have no interest in either him personally or the Corps. What might feel like a small slip may be taken as a clear sign that “My doctor doesn’t get it,” after which important information may be left unsaid.

Clinicians who understand the nature of military training and deployment will routinely enquire about exposure to head trauma, travel-related disease, and physical or psychological trauma. Providers must be willing to ask questions and show interest when specific places or military events “pop up” in a conversation or when military “lingo” is suddenly injected. Veterans often drop such clues to see if their provider “gets it” before sharing their military experiences. It is unfortunate that some medical professionals are hesitant to ask about terms outside their own expertise. Genuine, expressed interest in the patient’s military experiences is essential if the necessary bridges of trust and respect are to be built.

As of this writing, more than 1.2 million OEF/OIF veterans are eligible for VA health care services. Although only about 23% of American veterans receive their health care through the VA, an impressive 50% of all OEF/OIF veterans eligible to use VA have already presented for at least one episode of care. Because the VA has a national electronic database, it is possible to draw some conclusions about the health issues of the 625,384 veterans. Large as this help-seeking sample is, this information cannot be reliably extrapolated to those OEF/OIF veterans who have not sought health care or who are seeking it in the community.

VA records show that the three most common health issues among OEF/OIF veterans are, in descending order, musculoskeletal, mental health, and “symptoms, signs, and ill-defined conditions.” The most common musculoskeletal injuries are knee and back problems rather than the grievous injuries seen in news coverage from the war zone or military treatment facilities. Only 3% of all OEF/OIF veterans return home by way of the medical evacuation system and the remainder comes home at the appointed time with less obvious injuries. Rather than expect to treat the war as seen on television, it is important to realize that most combat veterans who come to your office will look pretty much like anyone else. This makes it all the more important to routinely take a military history.

Although the Gulf War Syndrome, which appeared among those who served in the early 1990s, is still under careful study, there is no evidence of a particular Gulf War Syndrome among those serving in OEF or OIF. Veterans and their family members will, however, often express concern about possible long-term health risks that might arise from health risks indigenous to the combat area or related to inoculations or toxic exposures that may have occurred during deployment. Such concerns should be respected, discussed, recorded, and evaluated. While clear answers may not always be available, sincere listening and appropriate documentation will strengthen the bond between patient and provider.