Over the last decade and in the coming years, more than 1 million American servicemen and women have returned or will return home from war.1 Increasing demand for healthcare services has prompted restructuring efforts within the Veterans Health Administration (VHA) that include hiring more physicians, nurses, and physician assistants (PAs); however, as more veterans opt out of Department of Veterans Affairs (VA) health services, a substantial proportion of their care will occur in the private sector.2 A Department of Defense task force and multiple recent media reports highlight the significant number of veterans facing barriers to healthcare when they return to their communities. Among National Guard members and reservists, one-third report choosing civilian care because they live too far from a military treatment facility.3 In addition, more servicemen and women are returning from war with mental health diagnoses. The rising need for timely veteran care is nothing new, and the latest news coverage suggests that the problem may be larger than once thought, yet serious deficits in the delivery of care exist in many VA facilities.
Multiple factors contribute to the issue, including limited access to mental health specialists, long appointment wait times, federal funding limitations, and veterans' own perceptions about VA care.2 Veterans are in fact increasingly seeking healthcare outside of the VA system. Current estimates indicate that upwards of 75% of younger veterans have private healthcare coverage.2 In addition, the Affordable Care Act provides options for healthcare coverage to low-income veterans, and the VA is under pressure to further expand veteran access to private healthcare. The Veterans Access, Choice, and Accountability Act, signed into law earlier this year by President Obama, enables eligible veterans to obtain healthcare from non-VA providers when they either cannot obtain an appointment within VHA established wait time goals or when they face geographic barriers to VA care (such as living more than 40 miles from a VA facility).4 In light of these developments, the private sector is facing an influx of veterans with significant and unique healthcare needs.
Because limited access to VA facilities is most prominent in rural areas, many veterans seeking care from the private sector are in outlying communities. VA data indicate that rural veterans make up about 41% of the total number of veterans enrolled in the VA healthcare system.5 Through the years, PAs and NPs across the country have demonstrated a willingness to practice in rural areas. Therefore, at a time when changing healthcare needs have come to include veteran care in rural areas and outside of the VA system, clinicians practicing in private facilities have opportunities to provide meaningful services to an important population in need. This article aims to review some of the important healthcare needs of veterans and to provide resources for managing veteran care in the primary care setting when appropriate.
Veterans have some specific healthcare concerns that present in higher proportion than in the general population. For the first time since the Vietnam War, the suicide rate is higher among veterans than the civilian population.6 In addition, veterans are at a higher risk for mental health issues such as posttraumatic stress disorder (PTSD).6 An estimated 10% to 20% of veterans of Operation Enduring Freedom and Operation Iraqi Freedom may suffer from PTSD; the statistic fluctuates in the literature but is similar to previous wars. The consequences of PTSD are life-altering, and if the condition goes unrecognized or untreated, the prognosis is poor. Veterans with PTSD have increased rates of morbidity and mortality due to attempted and completed suicide.6 Notably, the overall rate of suicide among veterans remained constant for several years; however, according to a 2014 VHA report, from 2009 through 2011, the suicide rate among veterans who do not use VHA services increased 60%, while the rate decreased 30% among those who do.7
Female veterans are particularly likely to suffer from mental health issues and may be affected by military sexual trauma (the VA's term for sexual assault or repeated, threatening sexual harassment experienced during military service). As many as one in five suffers from PTSD related to military sexual trauma, an issue that has risen to the front lines of concern partly due to increasing numbers of servicewomen coupled with increasing media coverage surrounding their sexual assault. Unfortunately, the prevalence of male military sexual trauma is more difficult to distinguish.
Traumatic brain injury (TBI) is another considerable health consequence specific to the current war. TBI can occur concomitantly with other mental health diagnoses such as PTSD, depression, and substance abuse.6 Although this is by no means a comprehensive picture of veteran healthcare needs, suicide, PTSD, and TBI have manifested with increasing frequency in this population and can lead to devastating if not fatal outcomes.
Suicide is a prevalent cause of death among veterans, and the risk of suicide continues for many years after service.6 Every day about 22 veterans take their own lives.8 The VHA Suicide Data Report Update in January 2014 indicated that although the rate of suicide has not increased overall compared with previous years, suicides have increased among female veterans and young male veterans (specifically those ages 18 to 25 years).7 The report also showed that suicides by female veterans enrolled in the VHA for healthcare usually result from poisonings and firearms; firearms remain the most common means of suicide for male veterans enrolled in the VHA system.7
Evaluating patients with previous suicide attempts, suicidal ideation, or those who are at increased risk for suicide is imperative, along with appropriate management and early intervention.6 Assessing for warning signs is an important aspect of primary care for patients at risk for suicide or already suffering from a mental health disorder. Providers must know what separates suicidal thoughts from suicidal intent. The thought, “I'd be better off dead,” for example, is much different than, “If I just pull the trigger, it will all be over.” The former expresses a belief while the latter expresses a plan and requires immediate referral for psychiatric care.
Multiple exposures to trauma, comorbid conditions such as PTSD and depression, as well as the presence of persistent guilt related to combat are strong risk factors for suicide.6 Furthermore, factors such as whether a veteran has social support, is married, or owns firearms can influence the decision about whether to refer the patient for immediate evaluation. Providers should ask veterans with suicidal ideation whether they own firearms and suggest that guns and ammunition be safely secured or removed from the home when depression or crisis is experienced.8
Suicide prevention programs for veterans attempt to help address this important public health issue and can be a valuable resource. The VHA has a Veteran Crisis Line that will take calls 24 hours a day, 7 days a week, and transport any suicidal veteran to be evaluated for inpatient treatment (Table 1). This service can be used for any crisis, even if suicidal ideation is absent, and has expanded to include chat service and texting options. Printable flyers and other resources are available at www.veteranscrisisline.net. Because veterans seeking care outside the VHA system seem to be at a higher risk of suicide, the VA is attempting to fill the gaps with additional resources such as the Community Provider Toolkit, which has information about connecting with the VA, understanding military culture and experience, and tools for working with various mental health conditions (Table 1).
PTSD AND MILITARY SEXUAL TRAUMA
Up to 20% of combat veterans suffer from PTSD and many will present to civilian providers. The article “Posttraumatic stress disorder in combat veterans” (JAAPA, May 2014) provides a thorough overview of the disorder and its treatment approach in the primary care setting.9 Several additional resources also can be used by primary care providers for veterans with PTSD (Table 1). The Vet Center is a community-based group of facilities associated with the VHA that provides free psychotherapy to combat vets and their families.10 The program has a self-referral process and serves as a primary care resource for providers who wish to recommend therapy for patients. Vet Centers can be found in many rural areas; a locator tool is available online. Other resources include a service dog program, Soldier's Best Friend, which acts to mitigate the effects of PTSD through social interaction, exposure to stressors, and development of communication and coping skills.
Although female veterans are particularly likely to suffer from PTSD related to military sexual trauma, men also may be affected. Conservative reports estimate that about 20% of women and 1.1% of men at VA medical centers report military sexual trauma.11 Statistics on this issue, however, are riddled with error due to inefficient data collection among veterans who do not participate in VA healthcare and an unwillingness of some victims to report military sexual trauma. Although the rate of military sexual trauma appears to be increasing, the true scope is concealed by underreporting. Many victims are reluctant to report military sexual trauma for a variety of reasons including shame, stigma, feelings of guilt, accusations of homosexuality, and fear of retaliation.12,13 Because many veterans seek at least some of their healthcare outside the VA system, primary care clinicians are likely to encounter victims of military sexual trauma.
Military sexual trauma usually occurs in the workplace and the perpetrator often is known to the victim.12 This can create a particularly hostile environment for servicewomen and men who have to continue to live and work closely with their offenders, and may contribute to the development of military sexual trauma-related PTSD. A growing body of medical research focuses on military sexual trauma affecting women, but studies on men are limited. Some differences have been identified between male and female victims, and may be useful for recognizing and treating the problem. Correlational evidence suggests that veterans of military sexual trauma are as much as three times more likely to have a mental health diagnosis; associations between military sexual trauma and psychosis, schizophrenia, and bipolar disorders specifically are stronger among male veterans than female veterans.11 Although both female and male victims of military sexual trauma tend to suffer from alexithymia (the inability to identify and process feelings), men tend to report more severe and longer-lasting symptoms compared with women, and men perceive their health as more damaged.11 Both sexes experience sleep disruptions, difficulty with interpersonal relationships, and comorbid conditions such as PTSD, depression, and substance abuse.
Female victims of military sexual trauma often present with complaints other than the experience of sexual violation, such as pelvic pain, gastrointestinal symptoms, chronic fatigue, insomnia, anxiety, dyspareunia, and chronic back pain.12 Providers evaluating any female veteran presenting with these complaints should screen for military sexual trauma using the following two questions: “While you were in the military, did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks? Did someone ever use force or threat of force to have sexual contact with you against your will?”12 Depression screening tools, inquiries regarding suicidal ideation, and severity assessments of PTSD also are warranted.
If a clinician discovers evidence that a patient has experienced military sexual trauma, consider a mental health referral as well as address any physical symptoms.13 Although all honorably discharged veterans are eligible to receive treatment for military sexual trauma within the VHA and Vet Centers, a shortage of military sexual trauma therapists and facilities may limit access to care. Both military and nonmilitary resources for PTSD and military sexual trauma are listed in Table 1. Psychotherapy such as cognitive therapy, exposure therapy, and eye movement desensitization and reprocessing may be beneficial in the treatment of PTSD related to sexual trauma.12 Medications that can be considered for symptomatic treatment include selective serotonin reuptake inhibitors (SSRIs); anxiolytics such as buspirone; and prazosin, which is used off-label to reduce nightmares related to PTSD.12 The patient may also benefit from a referral for couples therapy, financial counseling, or other social resources.
Medical providers are in a position to build long-term, trusting relationships with these patients, an advantage that can easily be overlooked. Providers should inform victims of military sexual trauma that they can recover from their trauma and that positive action combined with stress reduction can accelerate recovery. Exercise, relaxation techniques, positive self-talk, sufficient sleep, and good nutrition are recommended.12 The patient should be counseled about avoiding activities that could potentially delay recovery, such as alcohol and drug abuse, social isolation, and denial.12 Regular follow-up is imperative to reassess symptom severity and effectiveness of any medications prescribed. Most importantly, providers must be vigilant by regularly assessing and reassessing the patient's risk of suicide.4 Patients need inpatient treatment when thoughts of self-harm or harming others is combined with intent.13
Proximity to blast explosions from various ranges has made TBIs a considerable health consequence in combat veterans of the wars in Afghanistan and Iraq. Up to 20% of US veterans who served in Afghanistan and Iraq suffer from a range of symptoms attributable to TBIs.14 Veterans with a history of blast exposure are at an increased risk for developing a TBI, and blasts account for an estimated 70% to 85% of TBIs.14 Other causes of TBI include forceful injuries to the head, such as blunt or sharp trauma resulting in a disturbance of brain function.
Combat veterans may experience multiple modes of injury resulting in TBIs. Multiple TBIs confer a poorer prognosis, a situation quite possible with the multiple deployments often faced by veterans. In addition, second-impact syndrome (catastrophic brain swelling following a head injury that occurs before symptoms from the head injury have resolved) can lead to lasting cognitive effects or death.15
The symptoms of TBI can range from mild to severe, and cover the gamut of light-headedness, headaches, memory loss, confusion, mood changes, and seizures.14 The American Congress of Rehabilitation Medicine classifies TBIs as:
- mild, also known as a concussion. Symptoms include altered mental status, posttraumatic amnesia, focal neurologic impairment, or brief loss of consciousness (up to 30 minutes).14
- moderate. Symptoms of mild TBI, with posttraumatic amnesia for up to 1 week and loss of consciousness for up to 24 hours.
- severe. Symptoms include loss of consciousness for more than 24 hours and Glasgow Coma Scale score less than 8 out of 15; patients may have permanent neurologic damage.14 Because severe TBIs require specialty care and follow-up, only mild-to-moderate TBIs should be considered in the scope of primary care.
Postconcussion (mild TBI) symptoms often reported by patients include dizziness, poor concentration, light and noise sensitivity, irritability, and headache. Fatigue and sleep disturbances are symptoms often missed in relation to TBI.
Concussion symptoms tend to resolve completely in most patients within 3 months after injury.14 When symptoms persist well beyond the anticipated recovery time, postconcussion syndrome may be diagnosed. Postconcussion syndrome is treated in the primary care setting symptomatically, with agents such as nonsteroidal anti-inflammatory drugs, SSRIs, and muscle relaxants. When symptoms cannot be adequately treated with pharmacotherapy, patients should be referred for behavioral health interventions. Interventions that may be used in primary care include sleep hygiene, relaxation techniques, and symptom tracking. Consider neuropsychologic and cognitive rehabilitation referrals for patients with persistent or substantive cognitive deficits.14 In addition, VA and defense department guidelines suggest that referrals be considered when patients experience an atypical recovery trajectory, increased life stress, or notable functional difficulties.14
The relationship between mild TBI, depression, PTSD, and substance abuse among combat veterans is well documented. Therefore, beyond treating symptoms, clinicians also must treat affective disturbances that could be contributing to or confounding TBI symptoms. Screen for TBI through basic questioning, assess current symptoms, provide patient education, validate patient concerns, encourage coping skills, and reinforce safety. A simple three-question screening tool from the Defense and Veterans Brain Injury Center website can be downloaded and used once patients are identified as needing TBI screening (Table 1).16
Topics presented here are of the utmost importance to veteran health but do not represent the entire spectrum of veterans' medical needs. In addition to mental health issues and TBIs, veterans may suffer a number of other combat-related conditions including toxic exposure, infectious disease, hearing loss, and orthopedic trauma.17 Although some of these conditions fall outside the scope of primary care, others can be appropriately assessed and treated in primary care settings. The War Related Illness and Injury Study Center is a national VA postdeployment resource that provides clinicians with fact sheets and assessment guides covering common deployment-related health conditions (Table 1).17 Primary care clinicians also can help veterans by completing disability benefits questionnaires that can be used in combination with relevant medical records to support veterans' disability claims (Table 1). These forms can help speed the processing of veterans' disability compensation and pension claims and can be filled out by VHA clinicians or a veteran's private treatment providers.18
At its 2008 conference, the American Academy of Physician Assistants demonstrated its strong support for veteran care when the House of Delegates approved a resolution aimed at providing better care for war veterans and their families. In 2013, the PA student academy of the AAPA House of Delegates bolstered this support by passing a resolution to make veteran health part of the PA core curriculum.
By 2010, 1,872 PAs were working in VA medical centers and community-based outpatient clinics across the country, although more than a third are within 5 years of retirement eligibility.19 PAs play an integral role in the VHA system and a plan to employ more PAs is under way.19 However, with the increasing trend of veterans seeking care from the private sector, PAs in private practice, especially in rural communities, will certainly encounter this important patient population.
Fifty years ago, during the Vietnam War and at a time of civil unrest, military corpsmen helped forge the PA profession. With our nation again in the midst of war, the PA profession, seeded by servicemen, would do well to care for them now. Veterans face challenging healthcare needs and endure barriers to access. Using resources such as those listed in Table 1 may help clinicians in private practice address some of these challenges and provide more effective care. We must continue to focus efforts on veterans' healthcare needs, both within the VHA and in the private sector; otherwise we risk failing them at a time when so much of the system already has.
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Keywords:Copyright © 2015 American Academy of Physician Assistants
veterans; primary care; suicide; traumatic brain injury; military sexual trauma; posttraumatic stress disorder