I became a veteran on Sept. 1, 2020, after nine years on active duty and a combat deployment to Iraq. I became a part of a small group of veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom. Fewer than one percent of Americans have served in those. (Forbes. March 20, 2020; https://bit.ly/34Fc94S.)
This has resulted in a chasm in understanding what it means to be in the military and the impact of prolonged wars. The number of deaths is lower compared with other American wars, but the number of patients surviving with traumatic brain injuries (TBIs) is much higher.
TBI patients have higher rates of depression, anxiety, and suicide. (J Head Trauma Rehabil. 2016;31:191; Am J Epidemiol. 2017;186:220.) Our military personnel have endured frequent and extended deployments, often every other year for six to 12 months at a time. The impact of these deployments is complex and multifaceted. Imagine the interpersonal impact on being removed from family and support systems this frequently in addition to the physical danger ever present.
Every veteran has a unique experience, but as a group, their suicide risk is much higher: Seventeen veterans die by suicide each day. (Department of Veterans Affairs. https://bit.ly/3jLYoaV.) Active duty, Reserve, and Guard members also face many stressors that lead to higher rates of depression, anxiety, and suicidality.
All of these groups often present to civilian emergency departments for many reasons, and it is important for civilian emergency physicians to know how to best care for them. Many who die by suicide are seen by a medical professional in the month prior to the suicide. More than half of active duty military members who died by suicide were seen by the military mental health service in the previous 90 days. (MilitaryTimes.com. Oct. 22, 2019; https://bit.ly/3iMsp9h.)
Service members and vets often experience pressure to downplay their depression, anxiety, and suicidality. Mental health concerns, especially suicidality, can be career-altering and potentially career-ending for those currently serving in the military. Service members have a lot of pride in their positions, and mental health visits may result in their being forced to relinquish a service weapon or reassignment to another unit, which can add humiliation and lead to the service member feeling even more isolated.
A profound stigma still surrounds mental health in the military. Service members and veterans often feel that asking for help is a sign of weakness. That makes it all the more important to inquire about the history of military service. Once a service history is established, I will say, “Tell me about your time in the military. How do you feel about your service?” This open-ended question allows the patient to convey his unique experience and provide insight into the impact the service has on the visit.
Families and friends are an important link to veterans' mental health. They can provide context to the ED visit. Finding the time to call family and friends is challenging during a busy shift, but this may change the trajectory of a visit. Of course, it is required and important to get permission from the patient to contact family and friends. You'll find that veterans or service members are often hesitant. They know their family and friends have been through a lot with their military service, and they often feel like their involvement may burden them further.
I often say, “I know your family and friends care a lot about you. I think they would actually feel better and less concerned if we contacted them.” I also say, “You have served your country honorably. It is your turn to let us help you. I will be able to help you more if I can get some additional information from your family and friends.”
Keep Weapons Safe
Veterans and military personnel have a higher rate of gun ownership and access than civilians. (Inj Epidemiol. 2017;4:33; https://bit.ly/3nBGU3p.) Access to lethal means translates into higher suicide completion. It is especially critical to ask this population about access to weapons. These patients are particularly sensitive to losing access to weapons.
When broaching the topic, try asking, “Do you have a friend who could keep your weapons safe for you right now?” This subtle change in language is much better received than “we're going to need to take your guns away.” It is important that you follow all state and local laws about notifying law enforcement about weapons. The language and tone health care professionals use around guns can drastically affect the receptiveness and the patient's trust in the health care system.
Emergency physicians are constantly asked to do more with less time. I understand the pressures we're all under. I have had firsthand experience with a psychiatry consultant playing down a service member's suicide risk. A few extra minutes of obtaining history and collateral information enabled me to advocate for my patient and facilitate a psychiatric admission. This may very well have saved a life. We often leave our shifts reflecting on a life saved through a harrowing resuscitation. We should feel the same sense of accomplishment when we positively help our mental health patients.
When people hear I'm a veteran, they often say, “Thank you for your service.” To my EM colleagues: Thank me by taking a few extra minutes with your patients who are veterans and service members. You honor our service through empathetic interactions that just may be life-saving.
Dr. Austin extends thanks to Aleha Landry, an Air Force wife, a mother of four, and a passionate military mental health advocate, for her help with this article.
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Dr. Austinis a Navy veteran who deployed to Iraq in 2016. She works as an emergency physician at the University of California, San Diego, and the San Diego VA Emergency Department.