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On Veterans Day, remember those living with mental health problems

McManus, Robert N. BSN, RN

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doi: 10.1097/01.NURSE.0000611476.34865.60
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EACH YEAR, AMERICANS observe Veterans Day on November 11. Typical observances tend to focus on the heroism and sacrifice of US Armed Forces members, active and inactive. The enormous cost to service members who return home is difficult to see, but that cost is every bit as devastating as missing limbs, scars, and death.

Combat places a strain on the mind and body unequaled in almost any other situation. Death and dismemberment are acknowledged consequences of war, but developments in medicine and technology have increased survival rates for injuries that were once not survivable. Returning veterans, along with police, firefighters, and survivors of natural disasters, experience nightmares, episodes of explosive violence, loss of memory, and an inability to socialize. They are imprisoned, trapped in their private hells, unable to see a way out.1-3

The US Department of Veterans Affairs (VA) cares for all veterans who served from World War II to the country's ongoing involvement in the Middle East and Afghanistan. Many veterans experience the debilitating effects of posttraumatic stress disorder (PTSD), an array of symptoms that plague their physical, mental, and spiritual lives. Previously known as “shell shock” and “combat fatigue,” PTSD is most closely associated with military veterans. However, police officers, firefighters, and virtually anyone who has experienced violence, catastrophe, loss, or a deeply distressing or disturbing event may be affected.1-3 This article focuses on the burden of PSTD in US military veterans.

TBI: Lasting damage

Traumatic brain injury (TBI) is sometimes found concurrently with PTSD in those who survive injuries from explosions and head wounds suffered in combat. Like people with PTSD, many of these veterans show no outward signs of injury. Exposure to explosions may have subjected them to massive concussive waves that damaged brain tissue. These shockwaves may cause extreme pain, sometimes altering the survivor's personality, mental abilities, and the ability to cope with the stress of everyday life.4

The changes in a veteran's personality or relationship to the world around him or her also have a profound impact on family and friends. Corrosive effects resulting from the unending strain of caring for and loving a person who has suffered such a change in circumstance is only now being understood. The returning veteran with TBI is often not the same person who left for war. Daily life filled with vim and vigor becomes a memory. In its place are mental confusion, anger, and possibly frequent or even daily headaches. These factors combine to create an unsafe environment for the patient attempting to resume daily activities.

Military sexual trauma

Military sexual trauma (MST) encompasses sexual assaults, any sexual activity in which one is unwillingly involved, or repeated and threatening sexual harassment occurring while the veteran served in the military. He or she may have been pressured into sexual activities (for example, with threats of reprisals for refusing to be sexually cooperative or with an expressed or implied promise for faster promotions or better treatment in exchange for sex), may have been unable to consent to sexual activities (for example, when intoxicated), or may have been physically forced into sexual activities. Other experiences include unwanted sexual touching or grabbing; threatening or offensive remarks about a person's body or sexual activities; and/or threatening or unwelcome sexual advances.

The most recent statistics released by the US Department of Defense (DoD) indicate that reporting of sexual assault increased by 10% in fiscal year 2017, even as scientific surveys of the military population in recent years have shown that annual rates of sexual assault are declining. According to the most recent prevalence figures gathered in 2016, annual rates of sexual assault have decreased by half for active-duty women and by two-thirds for military men over the past 10 years.5

MST can occur on or off base, during war or peacetime, and while a service member is on or off duty. Perpetrators can be men or women, military personnel or civilians, and superiors or subordinates in the chain of command. They may have been a stranger to the active duty soldier, a friend, or even an intimate partner.

Veterans from all eras of service have reported experiencing MST. The specter of PTSD hovers over all of this. Veterans who experience MST may exhibit the same personality changes found in veterans who experience a TBI, such as irritability, noise aversion, reacting with violent outbursts, and nightmares.

How nurses can help

In 2017, it was revealed that over 90,000 veterans who had PTSD while on active duty had received a less-than-honorable discharge, which prevented them from receiving full benefits through VA medical centers regardless of mitigating factors. Insult is added to shame for an already damaged human being, who is likely having a tough time adjusting to life after service. Having a less-than-honorable discharge also strongly affects the chances of further education and employment. The DoD has recommended and approved methods to get these less-than-honorable discharges reevaluated so that veterans who have possibly been wrongly denied their earned benefits may have these injustices corrected.6

Researchers in the VA and outside organizations work to understand the changes these veterans have gone through, searching for a coping strategy if not a cure. As with any chronic disease, the patient and family endure and wait for good news. The suicide rate among US veterans is much greater than that of the national nonveteran rate, which is partially attributed to the effects of PTSD/TBI. The top reason cited in veteran suicides is to end emotional suffering and pain.7

The VA has placed appropriate early detection methods within the triage process. All patients are asked if they are considering harming themselves or others. Many times, the veteran recognizes signs and symptoms and states that he or she needs or is seeking help even before being asked. But these efforts are not always successful because they depend on the veteran self-reporting or the family convincing the veteran to seek help and care. Failing to prevent suicide has repercussions for family, friends, and care workers whose lives were touched by the deceased veteran.

To help patients with PTSD feel safe and comfortable, the nurse should make them feel as welcome as possible by speaking in a respectful tone of voice and attempting to meet their needs. Avoid standing too close or standing over them while they are sitting, which can seem threatening. Explain the need to obtain vital signs or lab specimens calmly. An initial reluctance to submit to any testing is normal. The nurse should recognize that these patients already feel threatened, and an invasion of their personal space will feel more alarming. If placing them in a room, the nurse should ask where they would like to sit, giving them the option of choosing for themselves to increase their feeling of having some control.

The nurse should always use motivational interviewing techniques such as asking open-ended questions, which allows veterans to feel like they are engaged in a discussion rather than an interrogation and gives them space to answer. Nods and affirmations let patients know that the nurse is listening to what they are saying, as does recapping what has been said and explaining that this is to ensure a clear understanding.8

Most patients respond well to the focused attention of active listening. For some of them, this may be the first time they have felt acknowledged as a person. This is a great opportunity to ask if they are getting help for their PTSD. These questions are more focused and less open-ended than before. Are they in the care of a mental health professional? Are they involved in a support group of peers? Are they aware of 24-hour hotlines they can use to talk with a professional to help them when they need someone to hear them? If the patient has begun to trust the nurse, these extra questions may provide an opportunity to offer further assistance.

Patients treated for PTSD are taught coping strategies that allow them to manage many of their symptoms as they heal their inner wounds. Patients can also use supplemental tools, such as digital apps, to assist in the coping process.9 (See PTSD coping apps for patients and nurses.)

Veterans who are not enrolled in a treatment plan often are not aware of their options or have a mistrusting attitude toward mental health providers and/or the healthcare system. The backlog of all claims continues to be a problem despite efforts on the part of the US Congress and the VA to fix the problem.10 Meanwhile, these wounded vets continue to deal with their altered realities, doing so mostly in silence.

We continue to honor both our fallen and our living veterans this Veterans Day, but let us make a special effort to recognize the wounded warriors who live with their sacrifice every day.

PTSD coping apps for patients and nurses

Several digital apps are available to help veterans cope with their PTSD symptoms and assist nurses in their care. A few examples are provided below.

  • Mindfulness Coach. Offered by the VA, this self-help app features nine guided exercises and information on mindfulness. Available for iPhones, it is intended to be used in conjunction with professional help.11
  • PTSD Coach. Available for both Android and iPhones, this app offers guided exercises to help veterans and other patients with PTSD recognize and manage stress.12
  • PTSD Toolkit for Nurses. Nurses whose patients are experiencing PTSD can use this tool for assistance in assessment. It is available for Android and iPhone users.13


1. Lamplugh M. I'm a firefighter with PTSD. Now what? 2016.
2. One in five police officers are at risk for PTSD. Here's how we need to respond. The Conversation. 2016.
    3. US Department of Veterans Affairs. Traumatic effects of specific types of disasters.
    4. Brain Injury Institute. Effects of traumatic brain injury.
    5. Ferdinando L. DoD releases annual report on sexual assault in military. US Department of Defense. 2018.
    6. Guina R. Veterans with PTSD or TBI may be eligible for military discharge upgrade. The Military Wallet. 2019.
    7. 35 engrossing PTSD suicide statistics.
    8. Farber T. The effect of a motivational interviewing pretreatment on CBT treatment of PTSD in veterans. 2015.
    9. Cohut M. Five ways to cope with PTSD. Medical News Today. 2017.
    10. Ogrysko N. Shulkin details 13 areas of improvement in his diagnosis of VA. 2017.
    11. US Department of Veterans Affairs. Mindfulness Coach.
    12. US Department of Veterans Affairs. PTSD Coach.
    13. American Nurses Foundation. The PTSD Toolkit for Nurses.
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