Mental Health for Veterans Nursing CE Course

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Mental Health for Veterans

Disclosure Statement

The purpose of this module is to provide an overview of the most common mental illnesses affecting veterans and their families, including post-traumatic stress disorder, depression, grief, and suicide, by reviewing the defining characteristics of each condition, available screening methods, interventions, treatments, and resources.

At the completion of this module, learners should be able to:

• discuss military cultural competence and the epidemiology of mental health in military veterans and their families in the US
• review screening methods used to evaluate the most common mental health conditions affecting veterans and their family members
• describe the diagnosis, symptoms, and treatment of post-traumatic stress disorder, depression, and grief
• review the impact of traumatic brain injury on normal functioning and treatment options
• describe the risk factors and warning signs of those at risk for suicide, the core components of suicide prevention training, safety planning, and evidence-based tools and interventions
• identify available resources for veterans diagnosed with mental illness and their family members

Epidemiology

Statistics indicate there were 16.2 million living veterans in the US in 2022; 1.7 million (10.3%) were female. According to the US Census Bureau (2003, 2023), the veteran population has declined by over one-third since 2000, when there were 26.4 million living veterans. In addition, 1.33 million individuals currently serve on active duty across all military branches (plus 40,000 active duty Coast Guard members), with over 1.5 million immediate family members (US Census Bureau, 2003, 2023; US Department of Defense, 2021). Mental health is as critical as physical health; injury to the mind and spirit can lead to a loss of control and damage essential life functions. Veterans, active military members, and their family members are more likely to suffer from mental health disorders than those who have never served in the armed forces. According to the most recent Substance Abuse and Mental Health Services Administration (SAMHSA, 2023a) National Survey on Drug Use and Health (NSDUH), 3.1 million adult veterans reported a mental illness in the past year, which is a prevalence of 16.1%. This is lower than the non-veteran prevalence of mental illness amongst adults, which is 23%. Mental illness was most common amongst veterans between 18 and 49. 617,000 adult veterans had serious thoughts of suicide, which indicates a prevalence of 3.2% compared to 5% amongst non-veteran adults. Despite the significant consequences and disease burden associated with mental illness, the SAMHSA report indicates tremendous treatment gaps. For example, mental health services were received by only 56.4% of adult veterans with mental illness and only 46.6% of adult non-veterans (National Institute of Mental Health [NIMH], 2023b; SAMHSA, 2023a).

An estimated 1.34 million Americans were deployed worldwide as of June 2022 (Statista, 2022). Between 14 and 16% of service members returning from deployment in Iraq and/or Afghanistan have post-traumatic stress disorder (PTSD) or depression. Others return with traumatic brain injury (TBI) or related comorbid conditions such as substance use disorder (SUD). The impact of deployment, the demands, dangers, and traumas of combat, and the separation of families often provoke deep-rooted and ongoing challenges for veterans and their families (Inoue et al., 2023). According to the VA’s Northeast Program Evaluation Center’s annual data report on PTSD, 11% of the 6 million veterans who received care during fiscal year 2021 were diagnosed with PTSD. Among those who served in Iraq or Afghanistan, this rate was 24% (VA, 2023a). 1.7 million adult veterans received mental health services during 2021, according to the NSDUH (SAMHSA, 2023a). However, the stigma regarding mental health is still evident within the military culture. Research demonstrates that many veterans view seeking mental health care as a weakness or fear that seeking help will interfere with their future military career or potential promotions. Regardless, many veterans seek treatment in civilian environments, including hospitals, clinics, and primary care settings. Nurses of all educational backgrounds and licensures (i.e., licensed practical nurses [LPNs], registered nurses [RNs], and advanced practice registered nurses [APRNs]) serve vital roles in dispelling the stigma and should engage with veterans without inadvertently reinforcing these misconceptions. All nurses must be prepared to care for military members and veterans across primary care, urgent care, emergency, and hospital settings. To care adequately and effectively for veterans and their families, nurses must receive knowledge and training on the unique challenges faced by these populations (SAMHSA, 2023b; US Department of Veterans Affairs [VA], 2019a).

Screening Veterans and Family Members for Mental Health Conditions

Mental illnesses comprise several different conditions that vary in severity and range from mild to moderate to severe. They are often subject to periods of relapse but are treatable, and many veterans recover with symptoms managed and functioning restored. Veterans may not share information regarding their military service with healthcare professionals if they are not prompted. Therefore, a core component of all health history-taking and clinical assessments is to ask, “Have you ever served in the military?” Family members may have also been impacted by military service and should be screened by asking, “Do you have a close family member who has served in the military?” The VA (2019a) suggests that all healthcare professionals adhere to the following guidelines when inquiring about military health history:

• ask questions in a safe and private area
• maintain eye contact
• use a supportive tone of voice
• ask permission before delving into the specifics of the veteran’s experience (e.g.,” May I ask you about stressful experiences that people can have during their military service?”)
• thank veterans for disclosing any stressful or traumatic experiences
• if someone is suspected to be at active risk for suicide, they should not be left alone (VA, 2019a)

Once military service is confirmed, the nurse should ask additional questions about the service period to assess the veteran’s mental health thoroughly. Military service may have included chemical or biological exposures (e.g., pollutants, solvents, chemical weapons, infectious diseases, biological weapons), psychological trauma (e.g., mental or emotional abuse, moral injury, combat casualties), physical injury (e.g., TBI, bullet wound, shell fragment, motor vehicle collision, radiation, noise injury), or unwanted sexual experiences (e.g., military sexual trauma [MST]). According to the VA clinical practice guidelines (CPG), a comprehensive mental health assessment must include screening for PTSD, depression, and suicide risk. Screening for these conditions requires more than asking straightforward questions or completing a checklist. Instead, it encompasses the art of open-ended queries that offer insight into possible symptoms associated with each condition. These assessments can be eye-opening to veterans who may not have formally acknowledged their symptoms as a component of an illness. Table 1 outlines several central aspects of mental health screening assessments (VA, 2019a, 2023e).

Table 1

Mental Health History Screening: Questions to Ask

 (VA, 2019a, 2023e)

Military Cultural Competence

The unique needs and challenges veterans and their families face are well-cited across the literature. The need for a culturally competent approach to mental health services and treatment continues to be of the utmost importance. Nurses should convey to veterans that they recognize the importance of their military background and have taken the time to acquire a foundational understanding of military culture. The ability to tailor clinical practice based on understanding and appreciation for the veteran’s background is imperative to establish rapport and build effective therapeutic working relationships. Resilience, or the ability to regroup and recover, is crucial to military life, especially during and after deployment. Military ethos is the backbone of military culture and is the foundation for resiliency. Conversely, military ethos can be a vulnerability when these beliefs hinder resources, support, and hope. Comprised of 6 traits, Table 2 illustrates each trait’s impact as a strength or weakness (SAMHSA, 2023b; Uniformed Services University [USU], n.d.).

Table 2

Military Ethos: Strengths and Weaknesses

(USU, n.d.)

Combat Stress

Stress is a normal component of everyday life; once the stressor is removed, an individual will typically resume normal behaviors. However, veterans are often impacted by combat stress (also known as battle stress), which is a natural reaction to the mental and emotional strain placed on the mind and body in dangerous and traumatic situations. Combat stress can be challenging to detect since the symptoms can vary, including physical, emotional, and behavioral manifestations. The most common symptoms of combat stress include:

• irritability and angry outbursts, including changes in personality or other behaviors
• excessive worry and anxiety
• withdrawal from others
• headaches and fatigue
• depression and apathy
• loss of appetite
• sleep disturbances (Military OneSource, 2022a, 2022b)

There are several strategies to help veterans cope with combat stress. These include the following:

• care for your personal health
  • consume a healthy, well-balanced diet with regular meals
  • engage in daily exercise
  • focus on sleep hygiene and adequate rest, aiming for 7-9 hours of sleep per night
• employ relaxation techniques such as deep breathing or meditation
• address spirituality and spiritual needs (e.g., prayer, guidance from a chaplain, religious services)
• engage in leisurely activities
• seek help and counseling (e.g., individual counseling, group therapy, or support from friends and loved ones; Military OneSource, 2022a, 2022b)

Combat Stress and Stress Disorders

Combat stress is often confused with stress disorders, such as acute stress disorder (ASD) and PTSD; however, there are key distinctions between these conditions. Combat stress typically occurs for brief periods and is considered a natural reaction to the traumatic events endured during a deployment. Furthermore, these symptoms usually resolve after a service member returns home. In contrast, ASD and PTSD are similar psychiatric conditions characterized by neural functioning changes in response to overwhelming stress, trauma, or horror. Both ASD and PTSD may be preempted by either direct or indirect exposure to the trauma, including bearing witness to or hearing about horrific events. In both conditions, symptoms are not due to medication, substance use, or any other identifiable illness and cause significant distress or functional impairment. In many cases, PTSD may be a continuation of ASD. Table 3 clarifies the main differences between these conditions according to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition, Text Revision (DSM-5-TR; American Psychiatric Association [APA], 2022).

Table 3

Differences Between ASD and PTSD

 (APA, 2022; VA, 2023f)

PTSD

According to the VA (2023a), the percentage of veterans affected by PTSD varies by service era as follows:

• Approximately 15 to 29 of every 100 veterans who served in Operations Iraqi Freedom (OIF) or Enduring Freedom (OEF) are diagnosed with PTSD in a given year.
• About 14 of every 100 Gulf War (Desert Storm) veterans have PTSD in a given year.
• An estimated 5 to 10 out of every 100 Vietnam War veterans develop PTSD in their lifetime.

PTSD may be categorized as either acute or chronic. Acute PTSD lasts at least 1 month but no longer than 3 months, whereas chronic PTSD lasts longer than 3 months. Less commonly, some cases of PTSD may occur years or even decades after the traumatic event(s). According to the DSM-5-TR, the main symptoms of PTSD include concerning intrusions about and avoidance of memories associated with the traumatic event. Table 4 outlines the full criteria required for the diagnosis of PTSD (APA, 2022).

Table 4

DSM-5-TR Diagnostic Criterion for PTSD

(APA, 2022)

Screening for PTSD 

Various screening instruments are used to evaluate for PSTD, such as the PTSD Checklist for DSM-5-TR (PCL-5), which is a 20-item tool. Other examples of validated PTSD screening instruments include:

• Primary Care PTSD Screen for DSM-5-TR (PC-PTSD-5)
• Short Post-Traumatic Stress Disorder Rating Interview (SPRINT)
• Trauma Screening Questionnaire (TSQ; APA, 2022; VA, 2019a)

Regardless of the screening tool used, all positive cases must be followed by a structured clinical interview to confirm the presence of all of the aforementioned criteria, which is the gold standard for diagnosing PTSD (APA, 2022; VA, 2019a).

Treatment for PTSD

The VA last updated their CPGs for PTSD in 2023. They recommend engaging patients in shared decision-making (SDM), including educating patients about effective treatment options and developing a treatment plan based on individual needs and preferences. The VA (2023f) recommends individualized, trauma-focused psychotherapy as a highly recommended treatment for PTSD. Trauma-focused psychotherapy focuses directly on the memory of the traumatic event. Trauma-focused psychotherapy utilizes various techniques, such as visualizing the trauma, analyzing the trauma (i.e., through talk or reflection), and altering unhelpful beliefs about the trauma. Trauma-focused therapies with the most robust evidence include the following (Stein & Norman, 2023; VA, 2022c, 2023f):

• Prolonged exposure (PE) includes relaxation skills, recalling details of the traumatic memory, reframing negative thoughts about the trauma, writing a letter about the traumatic event, or holding a farewell ritual to leave the trauma in the past.
• Cognitive processing therapy (CPT) teaches the veteran to reframe negative thoughts about the trauma by talking with the mental health provider about negative thoughts and completing short writing assignments.
• Eye-movement desensitization and reprocessing (EMDR) helps the veteran process and make sense of the trauma and involves calling the trauma to mind while paying attention to a back-and-forth movement or sound.

When individual trauma-focused psychotherapy is not readily available, not preferred, or ineffective, the VA (2023f) recommends medications to treat PTSD. The following three antidepressant medications are recommended for monotherapy treatment:

• sertraline (Zoloft)
• paroxetine (Paxil)
• venlafaxine (Effexor)

Paroxetine (Paxil) and sertraline (Zoloft) are selective serotonin reuptake inhibitors (SSRIs). SSRIs are usually the safest initial choice for PTSD, as they are associated with the fewest side effects. Venlafaxine (Effexor) is a serotonin-norepinephrine reuptake inhibitor (SNRI). Both SSRIs and SNRIs can increase serotonin levels in the body, posing a risk for serotonin syndrome, which is characterized by agitation, anxiety, confusion, high fever, sweating, tremors, a lack of coordination, dangerous fluctuations in blood pressure, and a rapid heart rate. Serotonin syndrome is a potentially life-threatening condition for which patients must seek immediate medical attention. Nurses should counsel patients on the importance of not abruptly stopping the medication, as withdrawal symptoms may occur with the sudden discontinuation of SSRIs and SNRIs. Withdrawal symptoms are most commonly seen with abrupt discontinuation of paroxetine (Paxil) and venlafaxine (Effexor). All these medications should be started at lower initial doses and titrated as indicated and tolerated. Table 5 outlines the possible side effects of SSRIs and SNRIs. Other antidepressants can be prescribed; however, these are the most effective for patients who have PTSD (VA, 2023f).

Table 5

SSRIs and SNRIs: Side Effects, Warnings, and Monitoring

(Mayo Clinic, 2019a, 2019b; National Alliance on Mental Illness [NAMI], 2017, VA, 2023f)

Caution is advised when prescribing venlafaxine (Effexor) to patients with hypertension. Patients prescribed venlafaxine XR (Effexor) should have their blood pressure checked at baseline, periodically after starting, and following any dose increase to evaluate for hypertension (VA, 2023f).

Traumatic Brain Inquiry (TBI) and Veterans’ Mental Health

The American Association of Neurological Surgeons (AANS, n.d.) defines TBI as a disruption in brain function and/or structure due to external physical force. A mechanical force or trauma external to the body leads to the brain’s rotational acceleration within the skull. The brain moves rapidly back and forth inside the skull, prompting a cascade of events, such as chemical changes, neuronal depolarization, metabolic derangements at a cellular level, and decreased blood flow. The stretching, damage, and/or death of brain cells associated with the injury subsequently provoke a clinical syndrome characterized by an immediate and/or a transient alteration in brain function. The impact of a TBI on brain function can cause varying symptoms and damage to the brain based on the extent of the injury (AANS, n.d.). TBI and PTSD are sometimes called the invisible wounds of war since no obvious physical deformities or injuries are evident. Kulas and Rosenheck (2018) studied more than 160,000 veterans diagnosed with mild TBI, PTSD, or both disorders. They concluded that PTSD serves a dominant role in the development of psychiatric difficulties in veterans. Brenner and colleagues (2023) studied 860,892 active-duty military personnel, examining the prevalence of TBI and mental health disorders in a longitudinal cohort study. 108,785 of the study participants had at least one documented TBI. Their analysis revealed a significantly increased risk of mental health disorders, particularly mood disorders (67% versus 37%) and substance use disorder (100% versus 14%), following a TBI (Brenner et al., 2023). Causes of TBI in veterans may include, but are not limited to, the following:

• blow to the head
• nearby blast or explosion
• sudden abrupt stops or changes in movement (Jak et al., 2019; VA, n.d.d)

Symptoms of TBI can range from mild to severe, and most are acute, resolving with rest. However, the lingering symptoms following the acute phase of TBI can impact functioning and long-term quality of life and contribute to significant disability. Many veterans suffer from the lingering neurological deficits of TBI, but symptoms are often unpredictable and inconsistent. Table 6 lists some of the acute and long-term symptoms of TBI (Jak et al., 2019; VA, 2022d).

Table 6

Symptoms of TBI 

 (VA, n.d.)

Treatment for TBI

PTSD is highly comorbid with mild TBI, a combination observed in military personnel returning from combat. Since depression, PTSD, and suicidal thinking are all associated with TBI and its recovery in veterans, the VA (2022d) recommends treatment with combined psychotherapy for PTSD and TBI. A hybrid psychotherapeutic approach combining cognitive training for TBI with CPT for PTSD was efficacious in a clinical trial among military veterans affected by both disorders. The clinical trial randomly assigned 100 veterans with PTSD and mild to moderate TBI to receive CPT or hybrid CPT-compensatory cognitive training. The combined therapy was delivered individually during 12 weekly 60- to 75-minute sessions. At the end of treatment and then three months later, both groups showed improvements in lingering TBI symptoms, PTSD symptoms, and quality of life. Combined therapy was also associated with improvements in multiple neuropsychological functioning domains (Jak et al., 2019; Stein & Norman, 2023). Rehabilitation is an essential aspect of TBI treatment in veterans. Most treatment plans are comprehensive and multifactorial, addressing the areas of deficit. Some of the most common treatments include one or more of the following:

• physical therapy
• occupational therapy
• speech and language therapy
• recreational therapy
• psychotherapy
• family and group therapies (VA, 2022d)

The VA’s Polytrauma/TBI System of Care is an integrated network of specialized rehabilitation programs dedicated to serving veterans with TBI and/or more severe secondary injuries. The Defense and Veterans Brain Injury Center (DVBIC) is a program that serves veterans and their families who have experienced a TBI by providing medical care, innovative research initiatives, and educational programs (VA, 2022d).

Depression

According to the NIMH (2023a), MDD—frequently referred to as depression—is a serious mental health condition that can cause severe impairment in thinking and daily functioning. Depression is among the most common mental disorders in the US. Symptoms must be present for at least 2 weeks to be diagnosed. Without treatment, depression can have devastating complications. Research suggests that depression is caused by a combination of factors, including genetic, biological, environmental, and psychological. Depression can occur at any age but is most prevalent in adulthood. Some of the most common risk factors include personal or family history of depression, significant life changes, stress, trauma, and certain medications (NIMH, 2023a). In veterans, depression is most commonly triggered by life crises, especially trauma, combat injury, natural disasters, or MST. However, life changes—including the loss of a loved one or fellow soldier, retirement, deployment, financial problems, job change, or divorce—are also linked to veterans’ stress and depression. Exposure to trauma can alter the body’s response to fear and stress, leading to depression. While not every veteran exposed to trauma or life changes will subsequently develop depression, this condition is nearly 3 to 5 times more likely in those with PTSD than those without PTSD (VA, 2022c). Symptoms of a depressive disorder include:

significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed*

• poor or sad mood for the majority of the day most days; may include self-reports of unhappiness, unfulfillment, or despondency or tearfulness observed by others*
• psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms
• reduced mental clarity, focus, or decision-making almost every day
• feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic
• substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month
• the inability to sleep at night or stay awake during the day despite getting an adequate amount of sleep the night before most days

feeling lethargic, weary, or exhausted most days

• a preoccupation with death, consistent suicidal ideations with or without a specific plan, or attempted suicide (APA, 2022; NIMH, 2023a)

Screening for Depression

The VA (2022b) recommends initially screening veterans for depression using the Patient Health Questionnaire-2 (PHQ-2). The PHQ-2 asks the following priority questions:

• Over the past 2 weeks, how often have you been bothered by any of the following problems?
  • little interest or pleasure in doing things
  • feeling down, depressed, or hopeless (APA, 2022; VA, 2022b)

Patients with suspected depression should undergo additional screening with the PHQ-9 tool, which is a multipurpose, 9-item symptom checklist used to screen for, diagnose, monitor, and measure the severity of depression. It incorporates DSM-5-TR diagnostic criteria for depression and a question that screens for the presence and duration of suicidal ideation. The tool is brief and easily used in clinical practice. It is completed by the patient, rapidly scored by the nurse or clinician, and can be used repeatedly to assess for improving or worsening symptoms. In addition to the PHQ-9, nurses must evaluate the acute safety risks (e.g., harm to self or others, psychotic features) and administer an appropriate assessment of the patient’s functional status, medical history, past treatment, and family history. Table 7 reviews the DSM-5-TR diagnostic criteria for depression (VA, 2022b).

Table 7

DSM-5-TR Diagnostic Criteria for a Major Depressive Episode 

 (APA, 2022)

Treatment for Depression

An individualized treatment plan should be developed using SDM and will vary based on the patient’s severity level (mild, moderate, or severe), as outlined below in Table 8. Treatment for depression may include counseling, therapy, and/or antidepressant medication. The most effective treatment for depression is a combination of psychotherapy with antidepressant medication (VA, 2022b).

Table 8

Severity Level of Depression

(APA, 2022; VA, 2022b)

Evidence-Based Psychotherapy for Depression

Acceptance and Commitment Therapy (ACT). ACT is an action-oriented intervention in which patients learn to stop avoiding, denying, and struggling with their inner emotions. Instead, they learn to accept these deeper feelings as appropriate responses to specific situations. ACT emphasizes acceptance of emotional distress and engagement in goal-directed behaviors to reduce symptom severity. To facilitate effective behavior change, ACT emphasizes identifying personal values and learning to help veterans commit to making necessary changes in their behavior (VA, 2022b).

Cognitive Behavioral Therapy (CBT). This combination of cognitive and behavioral therapies is evidence-based and very common. Strong clinical evidence supports the use of CBT as an effective treatment for depression, anxiety (including panic disorder), PTSD, eating disorders, substance use disorder, and obsessive-compulsive disorder. Cognitive therapy focuses on identifying and then improving maladaptive beliefs. Behavioral therapy teaches patients to increase rewarding activities. Patients learn to track their activities and identify the affective and behavioral consequences. Patients then learn techniques to schedule activities to improve their mood. CBT helps patients assess and restructure negative thinking patterns. CBT’s goal is for the patient to recognize negative thoughts and learn positive and effective coping strategies. CBT is time-limited and typically consists of 8–16 sessions. Patients learn to track their thoughts and activities to identify the affective and behavioral consequences. They subsequently learn techniques to change their thinking and activities to improve their mood. CBT has demonstrated efficacy in veterans, active service members, and family members suffering from depression. CBT can also be administered via computer-based programs, which is referred to as computer-based CBT (CCBT; Lebow, 2022; VA, 2022b).

Interpersonal Therapy (IPT). IPT focuses on improving personal relationships as a core component of solving psychological problems such as depression and eating disorders. While an event or a relationship may not always cause depression, depression affects relationships and can create interpersonal problems. IPT is a short-term treatment that teaches patients to evaluate their interactions to understand and improve how they relate to others. IPT is derived from attachment theory and treats depression by focusing on improving interpersonal functioning and exploring relationship-based difficulties. IPT targets four primary areas: interpersonal loss (grief), role conflict (interpersonal disputes), role change/transitions, and interpersonal skills (Lebow, 2022; VA, 2022b).

Mindfulness-Based Cognitive Therapy (MBCT). MBCT integrates traditional CBT interventions with mindfulness-based skills to help patients attend to the present moment in a non-judgmental, accepting manner. Unlike CBT, MBCT does not modify or eliminate dysfunctional thoughts and instead focuses on assisting patients to become more detached and observe their thoughts objectively without necessarily attempting to change them. MBCT employs meditation, imagery, experiential exercises, and relaxation techniques (VA, 2022b).

Problem-Solving Therapy (PST). PST is a structured psychological intervention that helps veterans focus on developing specific coping skills for problem areas. Through a collaborative relationship with the therapist, veterans learn to identify and prioritize key problem areas and break them into manageable tasks to develop appropriate coping behaviors and solutions (VA, 2022b).

Psychodynamic psychotherapy. This form of therapy strives to enhance patient insight. It is based on the theory that a patient’s current concerns are largely influenced by their childhood experiences, previous relationships, and past conflicts, especially if unresolved. This form of therapy attempts to improve function by shedding light on unconscious patterns or behaviors that began in childhood. It may be used in the treatment of depression, eating disorders, and personality disorders (Lebow, 2022).

Pharmacotherapy

Antidepressant medications are the pharmacological treatment of choice for depression to reduce or control symptoms. Nurses should counsel veterans that antidepressants typically take 2-4 weeks to yield an effect and 12 weeks to achieve the maximum benefit. For veterans who demonstrate only a partial or no response to initial monotherapy after a minimum of 4-6 weeks of treatment, the VA recommends switching to another monotherapy (medication or psychotherapy) or augmenting therapy by adding a second agent. After the initiation of therapy or a change in treatment, veterans should be monitored at least monthly until remission is achieved. For those who achieve remission on antidepressants, the medication should be continued at the therapeutic dose for at least six months to reduce the risk of relapse (VA, 2022b). The VA (2022b) recommends the following medications with strong evidence:

• SSRIs (e.g., citalopram [Celexa], escitalopram [Lexapro], fluoxetine, [Prozac], paroxetine [Paxil], and sertraline [Zoloft]; (see Table 5 for side effects and monitoring) 
• SNRIs (e.g., duloxetine [Cymbalta], venlafaxine [Effexor], levomilnacipran [Fetzima], and desvenlafaxine [Pristiq]; (see Table 5 for side effects and monitoring)
• Mirtazapine (Remeron)
  • common side effects include sedation, increased appetite, weight gain, dizziness, and elevated cholesterol levels
  • rare and serious side effects include angle-closure glaucoma (eye pain, changes in vision, swelling or redness in or around the eye), agranulocytosis (low white blood cells), serotonin syndrome, and a black box warning for increased suicidality (NAMI, 2017; VA, 2022b)

The VA (2022b) recommends tailoring the patient’s treatment for uncomplicated mild to moderate depression based on the following factors:

• patient preference
• safety and side effect profile
• history of prior response to a specific medication
• presence of concurrent medical illnesses
• concurrently prescribed medications
• cost of drugs
• provider competence

The current evidence does not support recommending one specific evidence-based psychotherapy or pharmacotherapy over another (VA, 2022b).

Grief and Bereavement

According to Mental Health America (n.d.), grief consists of the physical, psychological, emotional, and behavioral expression of loss or the perceived threat of loss. They define mourning as “the natural process you go through to accept a major loss.” Bereavement means “to be deprived by death” (Mental Health America, n.d.). While these terms are often used interchangeably, bereavement is often the trigger that starts the grieving process. In veterans, many other situations and circumstances incite the grieving process. For veterans, grief may develop from the loss of:

• a military comrade who died in battle
• a sense of closeness with fellow service members
• identity as a member of the armed forces
• physical health and ability (e.g., disability acquired during service, such as amputation of a limb)
• mental health, such as PTSD, loss of sense of safety and control, or lingering effects of a TBI (VA, 2023b, 2023c)

Veterans may also experience survivor guilt, which is a sense of remorse for having survived when others did not. Loss is an incredibly stressful and painful event, and the expression of grief is personal. Grief is a process, and it is common for feelings to waver through periods of exacerbation and relief with varying timelines in the aftershock of loss. Grief reactions can impair physical, behavioral, emotional, and spiritual well-being and are impacted by cultural backgrounds and beliefs. While there is no specific or “normal” way to grieve, there are several common grief reactions that often induce physiological, emotional, mental, and social symptomatology, as listed in Table 9. Thoughts and images of the deceased are common in grief reactions, which may be accompanied by auditory, visual, or tactile illusions (VA, 2023b, 2023c).

Table 9

Common Grief Reactions

(VA, 2023b, 2023c

Complicated grief causes prolonged sadness, guilt, or anger. These emotions often lead to behavior changes, such as:

• withdrawal from all interactions with friends and family members (social isolation)
• lashing out at others
• obsessively ruminating on past events (VA, 2023b)

Distinguishing Grief from Depression

According to the DSM-5-TR, feelings of emptiness and loss are predominant in grief, and symptoms often decrease in intensity over days to weeks. In contrast, depression is characterized by a persistently depressed mood and the inability to anticipate happiness or pleasure. Self-esteem is typically preserved in grief, whereas in depression, feelings of worthlessness and self-loathing are common. If a bereaved individual thinks about death and dying, their thoughts are usually focused on the deceased and possibly “‘joining” the deceased. In depression, these thoughts are focused on ending one’s own life due to intolerable feelings of being worthless, not deserving to live, or being unable to cope with the pain of depression (APA, 2022).

Managing Grief

The VA (2023b, 2023c) recommends the following self-care strategies for grieving veterans:

• allow time to grieve
• talk to others about the grieving experience and seek support from family, friends, and comrades
• stay active and busy
• exercise regularly
• engage in purposeful work that is consistent with personal values
• consume a healthy diet
• postpone making any major life decisions (e.g., moving or changing jobs)
• consider journaling to record thoughts and feelings
• focus on spiritual or religious beliefs or seek guidance from a chaplain or pastor
• consider seeking professional help from a counselor or therapist (VA, 2023b, 2023c)

Suicide and Suicide Prevention

Suicide is a complex, multifactorial phenomenon involving various risk factors and warning signs. Suicide is defined by the Centers for Disease Control and Prevention (CDC, 2023) as “death caused by self-directed injurious behavior with an intent to die as a result of the behavior.” Suicidal behavior encompasses suicide attempts (a non-fatal, self-directed, potentially injurious act intended to result in death that may or may not result in injury) and suicide ideation (thinking about, considering, or planning suicide). Suicide has devastating psychological impacts on family, friends, and loved ones, and it can provoke a consequential ripple effect on others and the community. According to statistics from the National Veteran Suicide Prevention Annual Report (VA, 2022a), the number of veteran suicides was 6,146 in 2020. Between 2001 and 2020, the suicide rate amongst veterans peaked in 2018, followed by a fall of 9.7% from 2018 to 2020. Between 2001 and 2020, the veteran suicide rate exceeded the rate for non-veteran adults each year, with a differential ranging from 12% (in 2002) up to 66% (in 2017). Firearms were the method of suicide in 72.1% of male veteran suicide deaths and 48.2% of female veteran suicide deaths in 2020. Overall, a firearm was the method involved in 71% of veteran suicides versus just 50% of non-veteran suicides (VA, 2022a).

Suicide Myths and Realities 

The NAMI highlights various myths and realities related to suicide (Fuller, 2020):

• Myth: Asking/talking about suicide will plant the idea in a person’s head.
• Reality: Asking about suicide does not create suicidal thoughts. Asking the question allows the patient to talk about their thoughts or feelings and reduces the stigma around suicide.

• Myth: Most suicides are impulsive and occur without warning.
• Reality: Most people who die by suicide have previously communicated some intent and/or exhibited warning signs.

• Myth: If somebody is suicidal, there is nothing anyone can do about it.
• Reality: Most suicidal ideations are short-term and situation-specific. Helping someone find a safe environment for treatment can save a life. The acute risk for suicide is often time-limited. If someone helps the person survive the immediate crisis and overcome the strong intent to die by suicide, a positive outcome is possible. If an underlying mental health condition is diagnosed, treatment can be sought to reduce/ameliorate symptoms.

• Myth: Suicide only impacts patients with a mental illness.
• Reality: Mental illness does not always include suicidal thoughts/intent, and patients who attempt suicide do not always have a history of a mental health condition (54% do not have a diagnosable disorder).

• Myth: People who attempt suicide are selfish and take the easy way out.
• Reality: Most people who attempt suicide are doing so to reduce their pain and suffering, which has led to feeling hopeless and helpless.

Warning Signs and Screening

Although statistical data demonstrates that most people who die by suicide received some form of health care services within the year preceding their death, suicidal ideation is rarely detected. Nurses must develop a keen awareness and understanding of the risk and protective factors associated with suicide to identify individuals at risk for suicide across clinical settings. Nurses must also acquire the skills to evaluate if a veteran is in distress, depressed, in crisis, or at heightened risk, prompting timely intervention. While suicide does not have a single cause, the risk for suicide generally increases as the current number of contributing risk factors rises. The more warning signs present, the greater the risk of suicide becomes, intensifying the need for timely assessment and intervention (American Foundation for Suicide Prevention [AFSP], n.d. CDC, 2022).

 A prior suicide attempt is the most predictive risk factor for suicide. The following additional warning signs are correlated with the highest likelihood of the short-term onset of suicidal behaviors:

• threatening, talking, or thinking about hurting or killing one’s self
• searching for ways to kill oneself, including seeking access to drugs or other lethal means (e.g., stockpiling or obtaining weapons, strong prescription medications, or items associated with self-harm)
• talking, writing, or posting on social media about death, dying, and suicide
• self-destructive behavior such as substance use(AFSP, 2019; CDC, 2022; Veterans Crisis Line, n.d.)

Veterans who are considering suicide may exhibit signs of depression, anxiety, or low self-esteem. The Veterans Crisis Line (n.d.) and the VA (2019b) CPG for suicide have identified the following warning signs that may indicate a veteran is at increased risk of suicide:

• performing poorly at work or school
• acting recklessly or engaging in risky activities that could lead to death (e.g., driving at fast speeds or running red lights)
• showing unusual rage, anger, frustration, or violent behavior (e.g., punching holes in walls or getting into fights)
• giving away prized possessions, putting affairs in order, or tying up loose ends
• anxiety, agitation, sleeplessness, or mood swings
• hopelessness, expressing/feeling that there is no way out or reason to live
• increasing alcohol or substance use
• withdrawing from family and friends (Veterans Crisis Line, n.d.; VA, 2019b)

These higher-level warning signs are medical emergencies, as they warrant immediate attention, evaluation, referral, and hospitalization. Any individual who is displaying these warning signs is considered to be at high risk for suicide and requires immediate intervention to ensure safety. These individuals should be immediately referred for admission to an inpatient facility, as specialty care is urgently needed. If a placement is impossible, refer patients to their local emergency department. Suicide precautions and one-on-one monitoring should be employed until the imminent risk declines (VA, 2019b).

Suicide Risk Assessment

A suicide risk assessment is a process in which clinical information is gathered to determine an individual’s risk for suicide. The risk for suicide is multifactorial, premised on the individual’s suicidal behaviors, warning signs, risk factors, and protective factors. A risk assessment identifies behavioral and psychological characteristics associated with an increased risk for suicide, allowing healthcare professionals to implement effective, evidence-based treatments and interventions to reduce this risk. The risk assessment for suicide is an ongoing process, as suicidal behaviors can fluctuate quickly and unpredictably. A complete risk assessment must include the following vital aspects:

• information about past, recent, and present suicidal ideation and behavior
• details on the patient’s context and history
• synthesis of this information into a prevention-oriented suicide risk formulation anchored in the patient’s life context (AFSP, 2019)

According to the VA (2019a, 2019b), an assessment of risk factors as part of a comprehensive evaluation of suicide risk should include the following components:

• current suicidal ideation
• prior suicide attempt(s)
• current psychiatric conditions (e.g., mood disorders, substance use disorders) or symptoms of any pre-existing psychiatric condition (e.g., hopelessness, insomnia, and agitation)
• prior psychiatric hospitalization
• recent biopsychosocial stressors
• availability of firearms

The VA (2019a, 2019b) has identified the following factors associated with a veteran’s military service, which may contribute to their risk of a suicide attempt. These veteran-specific risks include:

• frequent deployments
• deployments to hostile environments
• exposure to extreme stress
• physical/sexual assault while serving
• length of deployments
• service-related injury

A complete suicide risk assessment must also include a validated, evidence-based screening tool, which encompasses a set of directed questions to assess the risk level. A critical aspect of suicide prevention involves tailoring interventions to the perceived suicide risk level. Nurses and clinicians must understand how to perform a proper risk assessment, ascertain the patient’s risk level, and respond according to evidence-based guidelines. Several tools are available for use across various clinical settings, and the most common are outlined below (National Action Alliance for Suicide Prevention, 2018).

Suicide Severity Rating Scale (C-SSRS)

C-SSRS is one of the most widely used, validated, and evidence-based instruments in suicide risk assessment. The C-SSRS is supported by extensive evidence and existing literature that reinforces the tool’s validity as a screening method for longitudinally predicting future suicidal behaviors. This tool provides a framework to assess suicide risk, determine the risk level, and guide appropriate action according to that risk level. Also, the C-SSRS measures non-suicidal self-injury (NSSI), which is a deliberate self-harm behavior performed without the intent to die (Brodsky et al., 2018).

Suicide Assessment 5-Step Evaluation and Triage (SAFE-T)

SAFE-T is a tool that incorporates the DSM-5-TR guidelines for suicide assessment and is used most commonly in emergency departments by clinicians and nurses. The SAFE-T helps identify risk and protective factors, inquire about suicidal thoughts, behavior, and intent, and determine the patient’s risk level. It provides appropriate interventions directly at the bottom of the tool to enhance safety. According to the SAFE-T screening tool, assessing the risk of suicide involves three levels: low, moderate, and high. Table 10 provides an overview of suicide risk stratification, defining features, and accompanying evidence-based interventions (Columbia Lighthouse Project, 2016).

Table 10

Level of Suicide Risk, Defining Features, and Associated Interventions

 (Columbia Lighthouse Project, 2016; Minnesota Department of Health, 2019, p. 7)

Protective Factors

Protective factors are associated with a lower risk of suicide and have been shown to safeguard individuals from suicidal thoughts and behaviors. According to the CDC (2022), some of the most well-established suicide protective factors include the following:

• presence of adequate social support and family connections (connectedness)
• effective clinical care for mental, physical, and substance use disorders, along with access to a variety of clinical interventions and support for help-seeking
• supportive and effective clinical care from medical and mental health professionals
• skills in coping, problem-solving, conflict resolution, and other nonviolent ways of handling disputes
• cultural and religious beliefs that discourage suicide and support instincts for self-preservation (e.g., intentional participation in religious activities)

Suicide Prevention

For suicide-related issues, prevention offers the most positive impact on veterans and their family members. The VA has focused on the early identification of those experiencing difficulties as the key to suicide prevention. All veterans at any risk level should be provided with information on the Veterans Crisis Line, the 988 Suicide & Crisis Lifeline, as well as local crisis and peer support contacts. The acronym SAVE may help fellow citizens prevent veteran suicide, which stands for:

S- signs of suicidal thinking should be recognized

A- ask the most important question of all: are you thinking of killing yourself?

V- validate the veteran’s experience.

E- encourage treatment and expedite getting help (VA, 2023d)

The VA (2019b, 2023d) recommends using CBT interventions focused on suicide prevention for veterans with a recent history of self-directed violence to reduce incidents of future self-directed violence. Evidence-based clinical approaches that help reduce suicidal thoughts and behaviors include the following:

• Cognitive Behavioral Therapy for Suicide Prevention (CBTSP)
• The Collaborative Assessment and Management of Suicide (CAMS)
• Dialectical Behavior Therapy (DBT)
• Connectedness with caring contacts (social/familial support systems) for post-discharge suicide prevention (NIMH, 2023c; VA, 2019b, 2023d)

For patients in a suicidal crisis, nurses should take immediate action and implement a safety plan through the following steps:

• keep patients in a safe healthcare environment under one-on-one observation
• do not leave suicidal patients alone
• arrange immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis clinic
• screen suicidal patients and their visitors for items that could be used to attempt suicide or harm others
• ensure suicidal patients are kept away from anchor points for hanging and material that can be used for self-injury
  • examples of lethal means that are readily available in hospitals and clinics that have been used in suicides include bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing (NIMH, 2023c)

Safety Planning

Safety planning is critical and should be conducted by collaboratively identifying possible coping strategies and providing resources to reduce risk. A safety plan is not a “no-suicide contract,” which is not recommended by experts in suicide prevention. Safety planning is an intervention for lowering an individual’s imminent suicide risk following a risk assessment. A trained APRN, nurse, or other healthcare professional should perform safety planning in collaboration with the patient. Components of a safety plan include the following:

• identifying warning signs
• utilization of coping strategies
• ability to socialize with others as a means of distracting from suicidal thoughts
• connection to and contact with family or friends to seek help during a suicidal crisis
• contact information for mental health professionals or resources for assistance
• restricting access to means for completing suicide (NIMH, 2023c; VA, 2019b, 2022a, 2023d)

 Table 11 outlines the 6-step process of safety planning using a brief intervention tool. 

Table 11

Brief Safety Planning Intervention (BSPI)

(NIMH, 2023c; VA, 2019b, 2022a, 2023d)

Nurses should review and reiterate the patient’s safety plan at every interaction until the patient is no longer at risk for suicide. A safety plan should always include a discussion on how to restrict access to lethal means. When assessing a patient’s access to firearms or other lethal means, professionals should inquire about prescription medications and chemicals. Next, they should discuss ways of removing or locking up firearms, other weapons, and medicines during crisis periods (NIMH, 2023c; VA, 2019b, 2022a, 2023d).

Resources for Veterans and Families

When caring for veterans, nurses must be equipped to offer realistic, practical, and useful information regarding mental healthcare. Veterans and their family members may be unaware of the available resources and treatment options. In addition to those listed below, nurses should maintain familiarity with local resources and treatment facilities for referring patients as needed.

Veteran Health Benefits and Services

www.myhealth.va.gov

This website can be accessed by veterans, family members, and caregivers, providing information on veteran health benefits and services (My HealtheVet, n.d.).

Veterans Crisis Line

https://www.veteranscrisisline.net

The Veterans Crisis Line is a VA resource that connects veterans and service members in crisis and their families and friends with information and qualified, caring VA responders through a confidential, toll-free hotline, online chat, and text messaging service. Veterans and their families can call 988 (Press 1), chat online at www.VeteransCrisisLine.net, or send a text message to 838255 to receive support from specially trained professionals 24 hours a day, 7 days a week, 365 days a year (Veterans Crisis Line, n.d.).

VA Mental Health Services

https://www.va.gov/health-care/health-needs-conditions/mental-health

According to the VA, veterans are entitled to free mental health care for at least a year after separation, regardless of their discharge status, service history, or eligibility for VA health care.

This resource offers training via online self-help portals geared toward overcoming everyday challenges (e.g., anger management, parenting, and problem-solving skills), smartphone apps, telehealth services, or assistance with referrals to nearby VA health facilities (citation).

Military OneSource

https://www.militaryonesource.mil/

Military OneSource provides a list of confidential resources and support for veterans and their family members based on areas of need, including sexual assault, PTSD, TBI, intimate partner violence, child maltreatment, and beyond (Military OneSource, n.d.).

Suicide and Crisis Lifeline

https://988lifeline.org

Previously the National Suicide Prevention Lifeline, the suicide and crisis lifeline is available 24/7 by simply dialing 988 for free and confidential support for those in crisis (Suicide & Crisis Lifeline, n.d.)

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