UNCOVERING MENTAL HEALTH ISSUES IN THE VETERAN POPULATION
Faculty:
Ellen Feldman, MD
Dr. Ellen Feldman is a graduate of Thomas Jefferson University, Sidney Kimmel Medical College. Dr. Feldman is a child and adolescent psychiatrist with 30 years in healthcare and 8 years in medical writing. She has worked in the Department of Behavioral Health, Altru Health System, Grand Forks, North Dakota, since 1998. Dr. Feldman has chaired the Department of Behavioral Health since 2010.
Becca Resnik, RN
Becca Resnik received her nursing degree from Chattanooga State Community College. She has an MA in Translation Studies from the University of Birmingham, United Kingdom, and a BS in Nuclear Engineering Technology from Excelsior University, Albany, New York. Becca Resnik also has a Medical Writing Certificate from the University of Connecticut School of Pharmacy. Becca Resnik maintains an active Registered Nurse license.
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and currently licensed pharmacist in 3 states. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Topic Overview:
There are over 16 million veterans in the United States. These servicemen and women form a distinct community with unique healthcare needs, particularly concerning mental health. Mental health issues among veterans are not only prevalent but frequently complex due to the nature of military service, which often includes exposure to combat, high-stress environments, and the challenging transition back to civilian life. Healthcare teams will likely interact with veterans in various settings. This course offers an overview of mental health concerns among US veterans, emphasizing the unique role of healthcare teams in recognizing, accurately diagnosing, and effectively treating this often-underserved population.
Accreditation Statement
RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.
Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is
Pharmacist 0669-0000-24-196-H01-P
Pharmacy Technician 0669-0000-24-197-H01-T
Credits: 3 contact hour(s) (0.3 CEU(s)) of continuing education credit
Type of Activity: Knowledge
Media: Internet/Home study Fee Information: $8.99
Estimated time to complete activity: 3 contact hour(s) (0.3 CEU(s)), including Course Test and course evaluation
Release Date: December 31, 2024 Expiration Date: December 31, 2027
Target Audience: This educational activity is for pharmacists and pharmacy technicians.
Secondary Audiences: Other healthcare professionals, such as nurses, physicians, or others who may be part of a healthcare team, may be interested in this educational topic. Healthcare team roles and approaches to patient care are discussed in this activity. No state board, professional organization, or credentialing body has evaluated this activity to determine whether it meets the continuing education requirements of nurses, physicians, or other professions not listed under the “Target Audience” section above. Always verify with individual employers or supervisors whether they will accept this educational activity upon completion.
How to Earn Credit: From December 31, 2024, through December 31, 2027, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “Educational Activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
Credit for this course will be uploaded to CPE Monitor®.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Recognize the most common mental health disorders in veterans
Understand commonly used medications, monitor their side effects, and how co-morbidities may affect treatment plans
Provide screening and referrals for mental health conditions, including recognition of high-risk suicidal patients
Address how an interprofessional approach to care can mitigate the stigma associated with mental health
Disclosures
The following individuals were involved in developing this activity: Ellen Feldman, MD, Becca Resnik, RN, and Pamela Sardo, PharmD, BS. Ellen Feldman, Becca Resnik, and Pamela Sardo have no conflicts of interest or financial relationships regarding the subject matter discussed. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity
Uncovering Mental Health Issues in the Veteran Population Introduction
Veterans in the United States form a distinct community with unique healthcare needs, particularly concerning mental health. Mental health issues among veterans are not only prevalent but frequently complex due to the nature of military service, which often includes exposure to combat, high- stress environments, and the challenging transition back to civilian life. This course offers an overview of mental health concerns among US veterans, emphasizing the unique role of healthcare teams in recognizing, accurately diagnosing, and effectively treating this often-underserved population.
Veterans in the Clinical Setting
There are over 16 million veterans in the United States, representing 6.2% of the adult population.1,2 These servicemen and women form a distinct community with unique healthcare needs, particularly concerning mental health. This means that a broad range of healthcare clinicians regularly interact with veterans. This interaction can occur inside or outside the Veteran’s Administration (VA).
Regardless of the clinical setting, clinicians must consider the unique characteristics found in the veteran population. This includes the unique values, traditions, and norms that characterize a distinct military culture. These include a strong sense of camaraderie, discipline, and a hierarchy-based system of governance. These elements often shape how veterans perceive and engage with their world, including approaches to health and wellness.
Recognizing this cultural framework is key for clinicians, as it influences the symptoms and presentations of health conditions and how veterans communicate their needs and respond to treatment strategies.1-4 This is especially poignant when treating mental health disorders since conditions
such as post-traumatic stress disorder (PTSD), depression, suicidal thoughts, and substance use disorders are disproportionately higher among veterans compared with the civilian population.1-4 These conditions are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM- 5), including revisions in the DSM-5-TR,5,6 and the International Classification of Diseases 11th Revision (ICD-11).7,8
Healthcare teams, consisting of multiple disciplines, can be most effective in recognizing and accurately diagnosing mental health issues in this often-underserved population. Effective treatment plans may then be implemented through collaboration with team members and shared decision- making by the patient.3
Post-traumatic stress disorder (PTSD)
In 1980, PTSD was officially classified as a disorder in the DSM 3, a recognition that expanded our understanding of trauma beyond combat to include any form of traumatic experience.9 Two key studies followed decades later, researching the prevalence of PTSD as a classified disorder. These two studies were the Wave 3 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III) and the 2019-2020 National Health and Resilience in Veterans Study (NHRVS).10,11
NESARC-III was a 2012-2013 general population survey that included veterans.10 The lifetime PTSD prevalence in the general population was 6%, compared to 7% for veterans.10,11 The 2019-2020 NHRVS was a survey of veterans. It reported a 5% prevalence overall.10 These studies leave the impression that civilian and veteran rates of PTSD are not far apart; however, the veteran rate of PTSD rose to 23% of veterans receiving care at VA facilities.10,11 The discrepancy may be due to the VA’s more rigorous screening protocols.10 A reasonable conclusion here is that veteran PTSD is underdiagnosed, and more rigorous screening is needed.
Gender is a factor when evaluating the prevalence of PTSD. The NESARC-III and NHRVS studies both reported higher rates of PTSD for
females, compared to their male counterparts, within the civilian and veteran populations.10 In the military, this may be due to higher levels of sexual discrimination and harassment of women in service.10,11 This is referred to as military sexual trauma (MST).11
LGBTQ+ veterans are at significantly higher risk of developing PTSD.12 Screening and diagnosing PTSD is complicated since symptoms from traumatic experiences often overlap with socially produced stressors, called “minority stressors.”12
Deployment increases the risk of developing PTSD, and the prevalence of PTSD differs depending on the theater of deployment.10,13 For example, veterans of Operations Enduring Freedom and Iraqi Freedom have a higher current PTSD rate of 15%, while Vietnam War veterans are 5% and Persian Gulf War veterans 14%.10 Veterans of World War II and the Korean War were the lowest at 2%.10
Screening for PTSD
Screens in mental health are helpful but are never diagnostic tools. The Primary Care PTSD (PC-PTSD-5) screen for DSM-5 is perhaps the most efficient and specific screen for primary care practices. This is a five-item, binary (yes or no) checklist preceded by a query about exposure to a traumatic event. If there has been no exposure to a traumatic event, the individual is “screened out.” For those patients who continue with the checklist, a score of 3 or higher on the scale is a presumptive positive result.11
The five items on the PC-PTSD-5 ask about the following:14
Nightmares or intrusive thoughts
Avoidant behaviors
Hypervigilance
Feeling numb or detached
Guilt or self-blame about the event or aftermath
Diagnosing PTSD
Diagnostic criteria from DSM-5:5,8
Exposure to traumatic events: Directly experiencing, witnessing, or learning about a traumatic event affecting oneself or someone close.
Intrusive symptoms (at least one required):
Recurrent distressing memories of the event
Distressing dreams related to the event
Flashbacks, often with dissociation, as if reliving the event
Intense psychological distress and/or physiological reactions to reminders of the event
Avoidance (persistent):
Avoiding thoughts, feelings, or conversations related to the trauma
Steering clear of places, people, and activities that are reminders of the traumatic experience
Negative changes in mood and cognition (two or more of the below are required):
Inability to recall key aspects of the event
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
Distorted perceptions about the cause or consequences of the event that led one to blame oneself or others
Persistent negative emotional state
Markedly diminished interest or participation in activities
Feelings of detachment or estrangement
Persistent inability to experience positive emotions
Alterations in arousal and reactivity (two or more of the below required)
Irritable behavior is an angry outburst with minimal provocation
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Concentration problems
Sleep disturbance
Duration: Criteria A-E have lasted more than one month
Functional significance:
The disturbance causes clinically significant distress or impairment in functioning
The disturbance is not attributable to the effects of a substance or another medical condition
ICD-11 criteria for PTSD involve exposure to an event of an extremely threatening or horrific nature.7,8 Symptoms, grouped into re-experiencing, avoidance, and heightened threat perception, last several weeks or more, impair functioning, and typically start within months of the event (but can be delayed). The ICD-11 requires hypervigilance or an exaggerated startle response for a PTSD diagnosis. By comparison, the DSM-5 includes hypervigilance and exaggerated startle on the list of six symptoms that may support a PTSD diagnosis but since any two or more behaviors are required from this list, a person may be diagnosed with PTSD under the DSM-5 without hypervigilance or an exaggerated startle response.8
Post-traumatic stress disorder is diagnosed only when symptoms have persisted for more than one month after exposure to a traumatic event (criteria above) and have caused significant distress or impairment in social, occupational, or other important areas of functioning.5,8,15 In other words, symptoms such as anxiety or sleep disturbance that are present immediately
following a traumatic event but resolve within the first month and do not cause significant distress or impairment are generally considered a normal reaction to a traumatic event.5,8,15
Delayed-onset PTSD is diagnosed if diagnostic criteria are not met within six months of exposure to the traumatic event.5,8,15 Post-traumatic stress disorder can appear as a sole diagnosis or, more commonly, with another co- occurring DSM-5-TR disorder, such as a substance use disorder (SUD), mood disorder, or anxiety disorder. PTSD is strongly associated with functional difficulties, reduced QoL, and adverse physical health outcomes.5,8,15
Current guidelines recommend educating patients about trauma and expected reactions, along with ongoing monitoring in the months following trauma to see if functional impairment resolves.15 Persistent, disabling symptoms may require referral for psychotherapy or psychopharmacologic intervention.15
Treating PTSD
Treating PTSD requires coordination between various professionals, such as social workers, physicians, nurses, and pharmacists. It also incorporates the patient in shared decision-making. Post-traumatic stress disorder may be treated with psychotherapy, medication, or a combination of the two.15 These treatments seek to reduce the symptoms of PTSD and improve patient functioning and quality of life.
Non-pharmacologic Treatments for PTSD
Most guidelines recommend specialized psychotherapy as the first-line treatment for PTSD. In general, evidence shows that trauma-focused psychotherapies such as prolonged exposure therapy, trauma-focused cognitive-behavioral therapy, or cognitive processing therapy are effective in reducing symptoms and achieving remission. These structured talk therapy programs aim to change thinking (cognitions) and behavior, typically involving weekly 60-minute sessions over three to four months.15,16
Eye movement desensitization and reprocessing therapy (EMDR) is another therapy with evidence of efficacy for PTSD. This therapy involves recalling distressing memories related to the trauma while the therapist guides eye movement in an attempt to process the memory with less distress (“desensitize.”)17
However, some patients, especially those with severe PTSD, may find it challenging to tolerate exposure to traumatic memories inherent in trauma- focused therapies. Non-trauma-based therapies, such as cognitive behavioral therapy, can be effective in such cases. Additionally, emerging data suggest that mindfulness-based treatments, such as mindfulness-based stress reduction, an eight-week program focused on emotional regulation and accepting one's internal state, may help address residual PTSD symptoms.18
In some communities, these types of specialized therapy are neither available nor affordable. Recent studies on internet-delivered therapy show suggestions of efficacy for PTSD.19
Pharmacologic Treatments for PTSD
When non-pharmacologic therapy is impractical or undesired, medication is a reasonable alternative.20,21 There is evidence that pharmacotherapy can be effective in reducing symptoms. Guidelines include using specific agents (see below) starting at a low dose with a gradual increase over 4-6 weeks to achieve symptom reduction.22 If remission is reached, these medications should be continued for an entire year before a taper.15,23
Monotherapy for PTSD: While only paroxetine and sertraline have FDA approval for PTSD, other medications are used “off-label, e.g., fluoxetine, venlafaxine, and quetiapine are often prescribed "off-label" for the treatment of PTSD.20,21
Paroxetine, fluoxetine, and sertraline are selective serotonin reuptake inhibitors (SSRIs)
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI)
Quetiapine (a second-generation atypical antipsychotic) – given the potential of significant weight gain and metabolic side effects, only use if the patient does not respond to adequate doses of SSRI or SNRI
There is no evidence that one medication is superior to another.21 Genetics, comorbidities, presenting symptoms, and environment influence a patient’s response to an agent.23,24 Adjunct medication may be used when there is a partial response to monotherapy, but residual symptoms persist. These adjuncts, tested primarily with patients after combat, include the following:25-27
Prazosin – peripheral alpha-adrenergic blocker used for sleep disruption and nightmares (emerging evidence to use this as a first- line agent)
Risperdal – second-generation atypical antipsychotic for paranoia and outbursts (monitor for weight gain and metabolic side effects and carefully review risks and benefits)
Hydroxyzine – antihistamine used for as-needed (prn) treatment of anxiety and insomnia
Clonidine – alpha-2 agonist with some emerging evidence for efficacy in insomnia in PTSD
Benzodiazepines should not be used to treat PTSD. Despite this, 30- 70% of patients with PTSD are prescribed these agents. Studies show benzodiazepines lack efficacy for PTSD symptoms; the risk of their use includes dependence, abuse, and cognitive dulling, far outweighing any potential benefits. Patients should be carefully tapered off these medications to prevent life-threatening withdrawal symptoms.25,27
Deprescribing benzodiazepines is complex and may be most successful when multiple stakeholders are engaged in the deprescribing process.25 Patients are vulnerable during transitions of care, and strategic care coordination can increase system efficiencies, promote quality and safety in care, and improve the patient experience. Failure to implement a
comprehensive deprescribing protocol can lead to a disorganized process. Patient and provider education, a patient-centered culture, and multidisciplinary collaboration promote successful deprescribing.
Comparing Medication to Psychotherapy
Randomized trials comparing medication to psychotherapy suggest slightly better outcomes and marginally better symptom reduction with psychotherapy alone. However, the methodology does not allow for firm conclusions. A 2019 double-randomized study found the highest symptom remission in patients who chose their treatment.29
To personalize PTSD care, it is essential to understand the impact of preferences with shared decision-making and communication among the healthcare team.30 Shared decision-making involves the patient. The patient works with the healthcare team when treatment choices are made. This approach works when the patient is informed about the evidence supporting treatment options and understands the reasonable treatment goals that may be pursued.30 With shared decision-making, patients are given current and accurate information regarding treatment options, outcomes, and side effects.30 The healthcare provider assists the patient in exploring treatment goals and the patient’s comfort level with the goals given the patient’s values. Risks associated with treatment alternatives are also discussed with the patient.30
Takeaways
PTSD begins after direct or indirect exposure to a traumatic event.
Symptom clusters include intrusive thoughts, avoidance, negative emotions, heightened reactivity, and interfere with functioning.
There are both pharmacologic and nonpharmacologic treatments.
Benzodiazepines are not indicated for PTSD but are often prescribed.
Depression
Although depression may feel like a diagnosis of modern times, evidence from tablets and scrolls indicates that symptoms of this disorder were recognized by the early Egyptians. Over time, debates about whether depression stems from biological or environmental and character-based factors have contributed to an ongoing stigma. The introduction of SSRIs in the late 1980s revolutionized treatment, leading to medications being more widely prescribed.31 Today, a comprehensive biopsychosocial model is used, integrating medication, psychological therapies, nutrition, and other lifestyle interventions. However, stigma, particularly within military communities, continues to challenge the management of patients with depression.31,32
The prevalence of depression in veterans varies across studies, likely due to the link between depression and service experience. For instance, a 2014 investigation found no difference in depression rates between veterans and the general population.33 However, subsets such as Vietnam veterans had almost twice the risk compared with those who served in Korea.33 A 2021 meta-analysis revealed a 20% (1 in 5) prevalence of depression in veterans, which was considerably higher than in the general population.33
Screening for Depression
The Patient Health Questionnaire (PHQ) 2 and 9 are free and self- explanatory screens for depression.33 Each questionnaire allows one response per question ranging on a scale from “not at all” to “nearly every day.”33 Scores reflect the likelihood of depression, with a score of 5-27 representing mild to severe depression on the PHQ9 and a score of 3 (out of 6) representing depression on the PHQ2. In general, best practice is to use a screening tool for depression in conjunction with a comprehensive history and physical.33
Diagnosing Depression
The DSM-5 criteria for depression require the presence of five or more symptoms of depression, which must include either a depressed mood, loss
of interest, or loss of energy, persisting for at least two weeks. These symptoms should alter the individual's level of functioning and cannot be explained by another mental disorder, substance use disorder, or another medical condition. There must be no history of manic or hypomanic episodes.8
Coding and billing are an essential and complex reality in healthcare. In the USA, most clinicians diagnose using the DSM-5, but coding manuals and insurance coding may differ.8 This results in distinct processes, so billing for services in the clinic may use slightly different criteria from the ICD-11.8 When professionals bill for services, this dual system can lead to confusion when linking diagnostic codes to a prescription. Where relevant, both criteria are provided.
The ICD-11 criteria for depression require a consistently depressed mood or a noticeable decrease in interest or pleasure and activities nearly every day for at least two weeks. Other symptoms can include feelings of excessive guilt, thoughts of suicide, sleep disturbances, and difficulty concentrating. Similar to the DSM-5, there should be no history of manic, hypomanic, or mixed episodes.8
Both ICD-11 and DSM-5 require specific symptoms, such as depressed mood or loss of interest/energy, lasting at least two weeks and significantly impacting daily functioning. The DSM-5 additionally requires at least four other specific symptoms from a list of nine, while the ICD-11 does not specify the number of additional symptoms but acknowledges their presence.8
Treating Depression
Treating depression seeks to return the patient to normal functioning even though some residual symptoms remain.34,35 A patient is described as recovered if depression symptoms are in remission for two months.35 This is closely associated with improved functioning and quality of life. If recovery is not achieved, the healthcare team should reconsider the goal of the treatment. For example, the team may focus on reducing symptoms or patient improvement, focusing on the patient’s optimism and self-confidence instead
of “recovery.” Persistent symptoms can increase the risk of relapse, impede recovery, and impair functioning and quality of life. Ramanuj, et al. (2019), state that “the reduction of symptoms, either in intensity or in frequency, should be sought when full recovery is not possible.”35
Evidence-based treatment for depression includes the use of specific psychological therapies and/or pharmacological agents.34,35 A meta-analysis in 2013 and again in 2017 comparing these interventions for depression in primary care found efficacy for each, but no clear “winner” in the treatment of depression.35 Most guidelines emphasize that the severity of functional impairment, as measured by the impact of symptoms on everyday life, should be the primary factor in defining the severity of depression, as opposed to the number of symptoms or other factors.34,35
Non-pharmacologic Treatments for Depression
Cognitive behavioral therapy (CBT), a highly structured therapy, has a track record of efficacy.35 Other, less well-studied therapies may have an equal or greater impact (such as problem-solving and interpersonal therapies), but firm conclusions await more research and head-to-head investigations. Home- or office-based treatments, including guided self-help and computerized CBT, have limited efficacy. Generic “psychological counseling” has suggestive evidence of impact similar to CBT.35
Mindfulness-based cognitive therapy (MBCT), an eight-week group- based skill-building program with elements of CBT, has evidence for use specifically in depression prevention.36 Although studies confirming efficacy and mechanism of action continue, the American Psychological Association endorses MBCT as a viable treatment to prevent depression relapse; many guidelines for depression prevention amongst high-risk patients worldwide incorporate this therapy as well.36
Investigations looking at factors influencing the success of therapy have pointed to the relationship between patient and therapist, as well as patient expectation, as highly significant, perhaps even more so than the type of
therapy. Interestingly, patient expectation of response to pharmaceutical intervention in depression also plays a role in predicting response when medication is used for depression.35,37
Pharmacologic Treatments for Depression
Selective serotonin reuptake inhibitor (SSRI), SNRI, NDRI, and TCA are therapeutic medication classes commonly referred to by their acronym that indicate the drug’s mode of action.37,38 It is easy to be lost in this “alphabet soup” that represents more than 30 FDA-approved antidepressants. Although specific neurochemical targets vary, all antidepressants work by initially increasing serotonin and/or norepinephrine availability.35,38
A 2018 large meta-analysis looking at the efficacy of antidepressants in adults in primary care practices found significant effect sizes for antidepressants over placebo.37 The choice of an agent involves obtaining patient input regarding target symptoms (for example, sleep, cognitive functioning, appetite), expected tolerance of specific side effects, interactions with other medications, and affordability or insurance restrictions.37
Tricyclic Antidepressants
Due to adverse cardiovascular side effects, significant anticholinergic effects, and lethality in overdose, tricyclic antidepressants (TCA) or first- generation antidepressants are not as commonly used for depression as the other agents.37 Given significant sedating side effects, agents such as nortriptyline still play a role in the treatment of insomnia associated with depression.37
Serotonin Reuptake Inhibitors
Serotonin reuptake inhibitors include SSRIs such as fluoxetine and citalopram; SNRIs such as duloxetine, venlafaxine, and desvenlafaxine; and serotonin antagonist and reuptake inhibitors (SARI) such as trazodone. SSRIs are the most common antidepressant agents used in the USA and globally
(although the popularity of a specific type of SSRI varies regionally). Common, well-tolerated side effects include gastrointestinal disturbance and headache. Other side effects include sexual dysfunction and weight gain. The risk of abnormal clotting and bleeds is increased with all of these agents and is potentiated when combined with non-steroidal anti-inflammatory agents (NSAIDs) and anticoagulants.37,39
Atypical Antidepressants
Atypical antidepressants include bupropion, a norepinephrine and dopamine reuptake inhibitor (NDRI), and mirtazapine, a noradrenergic and specific serotonergic antidepressant (NaSSA). Newer agents include vilazodone, a serotonin partial agonist reuptake inhibitor (SPARI), and vortioxetine.37,40
Warnings and Precautions
Cytochrome P450 (CYP450): Most antidepressants interact with the CYP450 system, leading to potential clinically significant drug interactions. Antidepressants with the strongest inhibitory impact on the CYP450 enzymes are fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and bupropion (Wellbutrin). Take note of the potential for interaction with other prescribed agents and consider dosage adjustments.41
All antidepressants have a delay in response. A typical scenario is to evaluate the tolerance of the antidepressant at week one to week two and look for a response by week three or four. Remember that some individuals are slow responders, so wait longer for a response if there is any suggestion of impact during this initial period. Given multiple studies showing a high rate of noncompliance with antidepressant treatment, it is also advisable to check medication compliance, as well as the use of other pharmaceuticals influencing mood. Finally, throughout each step, consider and address lifestyle factors that could impede progress.34,35,37
Boxed Warning: The FDA issued a “boxed warning” in 2005 regarding the potential of increased suicidal thoughts in children, adolescents, and
young adults taking any anti-depressant, especially early in treatment. While there is controversy regarding the validity of the findings and the usefulness of the warning, clinicians should discuss the warning with patients, weigh the risks of medication treatment, and monitor carefully.42 Healthcare team members who provide direct care (for example, nurses) should include increased assessment frequency in the care plans of patients who have recently begun antidepressant therapy. Such professionals in in-patient care, particularly in the mental health care setting, should also vary the timing of rounds to limit patients’ ability to plan a suicide attempt based on predicted unsupervised periods.
Serotonin Syndrome: This syndrome is caused by serotonergic drugs (in overdose or due to unforeseen interaction) and is potentially life- threatening. It presents from mild to severe with symptoms including agitation, confusion, and tremors. When severe, it progresses to seizures and coma.43
Studies regarding decreasing social isolation, increasing the quality of sleep, encouraging physical activity, and nutritional interventions show promise in the treatment of depression.34,35,44
Takeaways
Symptoms of depression must interfere with an individual’s level of functioning and be persistent for at least two weeks.
Symptoms must include depressed mood, loss of interest, or loss of energy.
There are pharmacologic and non-pharmacologic interventions for this disorder.
The severity of depression is determined primarily by the impact on functioning.
Substance Use Disorders (SUD)
The early history of humanity is sprinkled with references to the use of substances with psychoactive properties, such as opium and cannabis. As societal attitudes have changed, governmental regulations have followed.45
With the publication of the first DSM in 1952 through subsequent editions until 1980, substance misuse was viewed as arising from a separate disorder of mental health (such as a personality disorder).46 The third edition of the DSM began to move away from this conceptualization. The 2013 edition demonstrated a new perspective on substance use disorders, basing diagnosis on an understanding of a biopsychosocial model, describing functional impairment, and recognizing that SUD presents on a spectrum according to the number of symptoms and degree of impairment.46
It is helpful to note that societal influences continually contribute to a shifting perception of substance misuse. It is unlikely that our current DSM classification and description of SUD is our final or most definitive word. As our understanding of this disorder, its underpinnings, and treatments shift, it may very well be that societal perceptions will also shift.45,46
Substance use disorders are most often seen with alcohol, opioid, and tobacco misuse.47,48 About 11% of first-time users of primary care at VA clinics present with substance use disorder – typically involving alcohol or nicotine. Risk factors include younger ages, non-married and male, and environmental factors such as deployment and combat. Often, the SUD presents after the development of PTSD or depression.47
Misuse of prescription drugs (especially opioids) is increasing among veterans, and illicit street drug use is becoming on par with civilian counterparts.47
Screening for Substance Use Disorders
The ten-question, five-minute self-administered AUDIT-10 may be used when a patient responds with a non-zero answer on a pre-screen question recommended by the National Institute of Alcohol and Alcoholism (NIAA): For men, “How many times in the past year have you had more than 4 drinks in one day?” For women or patients over 65 years old, “How many times in the past year have you had more than 3 drinks in one day?” A score of 14 or above on AUDIT indicates moderate to severe alcohol use disorder (AUD) and the probable need for intensive intervention.49
Diagnosing Substance Use Disorders
The DSM-5-TR gives concrete guidelines for the diagnosis of SUD.6 Substances specified in DSM-5 include alcohol, caffeine, cannabis,
hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, and
tobacco-related disorders.
For most of these categories (apart from caffeine), diagnostic criteria are as follows:
“A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following over 12 months.” Eleven criteria are listed, each falling into one of four domains.
Impaired control:
taking more than intended
experiencing cravings
spending a lot of time obtaining, using, or recovering from use
unsuccessful efforts to stop or cut the use
Social impairment:
continued use despite failure to fulfill major obligations
continued use despite a deterioration in interpersonal or social relations caused by use
giving up important social, occupational, or recreational activities because of the use
Risky use:
Recurrent use in hazardous situations
Continued use despite knowing use will worsen physical or psychological problems
Physiologic adaptation:
Tolerance to effects of substance
Withdrawal when reduce or stop use
The number of criteria determines the severity level. Two to 3 criteria indicate a mild disorder, 4 to 5 criteria indicate a moderate disorder and 6 or more criteria indicate a severe disorder.6
Treating Substance Use Disorders
Medication-Assisted Treatment for Alcohol Use Disorder
The goal of treating AUD has traditionally been abstinence from alcohol; however, treatments that help patients reduce the amount they drink without requiring abstinence can also reduce alcohol-related harm.47 This could be useful because some patients are not ready or prepared to quit drinking altogether.50
There are several FDA-approved medications for alcohol use disorder (AUD).44 These include the following:
Naltrexone (Riva®): This opioid receptor antagonist reduces the craving for alcohol and decreases pleasure from drinking. The daily dose of naltrexone is 50-100 mg/day (also in long-acting-injectable form). Be cautious in patients with liver damage and do not use in patients needing opioids for pain control.51
Acamprosate: Previously marketed under the brand name Campral, this agent acts as a modulator on glutaminergic receptors and may be used in maintaining abstinence.52 The daily dose of acamprosate is 666 mg three times daily. Use with caution in patients with renal disease.53
Disulfiram (Antabuse®): FDA-approved, but evidence from head-to- head trials suggests this is not always the most effective agent. Recommendations are to use this agent second-line. The mechanism of action involves interrupting the metabolism of alcohol, leading to a buildup of acetaldehyde, which causes a series of unpleasant symptoms (such as nausea, vomiting, and dyspnea.) The dose is 250-500 mg daily. This agent is contraindicated in patients with psychosis, liver failure, and severe coronary disease.54
Medications without FDA approval in the treatment of AUD with moderate levels of evidence for efficacy include topiramate and gabapentin.55,56 Notably, most of the trials of these medications included a psychosocial intervention and the specified agent; future studies regarding the benefits of using these alone are needed.57 There is insufficient evidence for the use of antidepressants, antianxiety agents, or antipsychotic agents in the treatment of AUD.57
Medication-Based Opioid Use Disorder Treatment (MOUD)
FDA-approved Medications for Opioid Use Disorder (OUD) include the following:
Buprenorphine – this partial opioid agonist is highly effective for OUD with long-term use.58 It is available in combination form with Naloxone (e.g., Suboxone) in an oral, sublingual form for daily use. The idea of the combination is to prevent diversion, as injecting this combination precipitates acute withdrawal in opioid-dependent individuals. It also may be used as a single agent and come in multiple forms. Extreme caution is indicated when combining buprenorphine with any sedative- hypnotics, as this combination may lead to respiratory suppression.58
Methadone – this opioid agonist is highly effective for the treatment of OUD.59 In many US states, with goals to provide patient-centered, evidence-based care and widen the population served, methadone is now permitted to be used outside of specialized clinics.59
Naltrexone – this opioid blocker in injectable monthly form is highly effective for reducing cravings and relapse. A patient must be opioid- free (for 7-10 days) before starting this medication. It may be a particularly good agent for a patient with OUD and AUD.51
Naloxone – this opioid antagonist rapidly reverses an opioid overdose. This does not treat OUD but can be lifesaving should an overdose occur. Prescriptions for this agent include a “naloxone kit,” intranasal prefilled syringes, and a pre-filled auto-injector.60
Nalmefene is an opioid receptor antagonist nasal spray for use in “adults and pediatric patients aged 12 years and older, as manifested by respiratory and/or central nervous system depression.”61
Tobacco Use Disorder
Globally, tobacco use accounts for over eight million deaths annually, including approximately 1.3 million non-smokers who are exposed to second- hand smoke.62 These numbers exceed deaths from alcohol and illicit drugs combined. While public policy and pharmacologic interventions appear
effective in decreasing smoking, there is increased awareness that individuals with mental illness use tobacco at high rates.63
There are multiple FDA-approved medications for tobacco use disorder.63 Bupropion (Zyban) is an antidepressant that reduces cravings in tobacco users; while FDA-approved, efficacy is slightly lower than varenicline (previously available as Chantix®).63,64 Varenicline is a partial agonist of the nicotinic acetylcholine receptor.63,64 Bupropion and varenicline may be combined.64 Bupropion is contraindicated in persons with seizure disorders, and caution is warranted in individuals with eating disorders or electrolyte abnormalities or who are taking other antidepressants.63 Nicotine replacement therapies are available over the counter in patch, gum, and lozenge forms and by prescription as a nasal spray and inhaler.63 A patient may be more likely to quit tobacco when taking varenicline in combination with nicotine replacement therapy.64
Non-pharmacologic Treatments for SUD
Local resources may include individual and group counseling, family counseling, and mutual-help organizations, including 12-step and non-12-step (such as Alcoholics Anonymous or SMART recovery.)65 Individual and group therapies with suggestive evidence in effectiveness in the treatment of specific SUDs include cognitive behavioral therapy, dialectical behavioral therapy, and motivational enhancement therapy. Contingency management (offering tangible incentives) has shown some evidence of effectiveness in moving towards abstinence, and exposure therapy may be used when SUD is combined with post-traumatic stress disorder.65 Moreover, there is strong evidence that combining psychosocial and pharmacologic therapies is effective in the treatment of substance use disorder.65
Takeaways
Symptoms of SUD include clinically significant impairment or distress.
Symptom clusters include impaired control, social impairment, risky use, and physiologic adaptation.
Combining pharmacologic and non-pharmacologic interventions is most effective.
There is insufficient evidence for the use of antidepressant, antianxiety, and antipsychotic agents in the treatment of AUD.
Suicidal Ideation
The latest data on veteran suicide reveals some alarming trends. According to the 2023 national veteran suicide prevention annual report, there were 6392 veteran suicides in 2021, an increase of 114 compared with 2020.66 Veterans are 1.5 times more likely to die by suicide than non-veteran adults, with an average of 17.5 veteran suicides per day.66 Suicide remains the 13th leading cause of death for veterans overall and the second-leading cause of death for veterans under the age of 45. Notably, while suicide rates among male veterans remain higher than their female counterparts, the age-adjusted suicide rate among female veterans increased by 24.1% from 2020 to 2021, significantly higher than the rate of increase among male veterans.66
Efforts to address this issue include expanding support for veterans in crisis, offering no-cost healthcare for veterans in suicidal crises at both VA and non-VA facilities, and enhancing access to the Veterans Crisis Line by dialing 988 and pressing one.66 Additionally, the VA is working on community-based and clinical strategies to prevent veteran suicides, which includes partnerships with community organizations and advancements in mental health services.66
Evaluating Suicidal Risk
Depression, PTSD, and SUD are major risk factors for completed suicide, suicide attempts, and self-harm.67 An additional factor to consider, especially in veterans, is that traumatic brain injuries are an independent risk factor for suicide and an additive risk factor when combined with a disorder of mental health.67
Patients may be hesitant to express thoughts about suicide directly but often will respond to open-ended queries. Clinicians may feel unprepared to respond to patients who are at risk of suicide. Asking patients with depression or depressive symptoms about suicidal thoughts, plans, or intentions may open a discussion.68
Patient Referral
Refer patients with high-risk factors and suicidal intentions to a specialist.68 This requires that the healthcare team have a well-defined referral pathway.68 Regional variation in mental health specialist availability may ultimately determine referral and consultation patterns.
There is growing evidence that collaborative care models, with a team led by the PCP and containing mental health professionals, with supportive teams including nurses, pharmacists, and case managers, lead to efficient and effective care for more complex, higher-risk patients who have made suicidal statements.69,70
Telemedicine
Telemedicine consultation has also shown evidence of efficacy and can assist in bringing specialty care to previously underserved communities.69,70 Regardless of the manner of delivery, it is helpful for pharmacists to have a strong working relationship with professionals in the mental health community. In addition, providing patients with information about local
support groups and services, such as suicide hotlines, provides an additional safety net for this population.69,70
Takeaways
Suicide rates in veterans are higher than the national average.
Suicide rates increased among women veterans compared to their male counterparts.
Depression, PTSD, SUD, and traumatic brain injuries are risk factors for suicide; the rates of these conditions are higher in veterans than in age-adjusted peers.
Asking open-ended questions is recommended to launch a discussion regarding suicidal thoughts or plans for attempting suicide.
Pharmacists’ roles can transcend dispensing medication, as they often recognize signs of mental distress and provide appropriate screening, referrals, and patient education. These capabilities and roles also apply to nurses with a high degree of patient contact and who are specifically trained to perform ongoing patient assessment.
Case Study
Background: Mica is a 42-year-old Army military intelligence veteran who served several tours overseas. Since his discharge, he has struggled with chronic back pain and symptoms of post-traumatic stress disorder (PTSD), including severe anxiety, sleep problems, and sporadic flashbacks. Recently relocated, Mica has not yet established care with a local healthcare provider. The following presentation reviews a hypothetical case where team members collaborate and the patient is engaged in shared decision-making.
Initial Presentation
Mica visits his local pharmacy to refill an old oxycodone prescription, which he uses to manage his back pain. He appears agitated and mentions in passing to the pharmacy technician that he has not slept well in several nights due to recurring nightmares.
Pharmacy Team: The pharmacy technician offers to relay Mica’s concerns to the pharmacist. While processing his prescription, the pharmacist initiates a conversation to build rapport, engaging Mica with empathy and active listening.
Pharmacist: “I see you served in the military. We have a strong veteran community here. How long has it been since your service?”
Mica: “It's been about eight years. Some buddies recommended this place. It's OK, but my new bed isn't doing my back any favors. And when I don't sleep, everything feels worse – it’s hard to start in a new place.”
Pharmacist: “I’m sorry to hear you are going through this. Moving is tough, and many vets tell me it brings back some of the stress of the past for them. It’s sometimes surprising how much it can help to talk about how you feel. Have you connected with the VA or a local healthcare provider?”
Mica: “No, I haven’t had the time, but I think I should because this is the last refill for the oxy. I would like to get off these – I am just not sure how to take care of the pain without them.”
Pharmacist: “I noticed this is the only refill on file. The VA is the place to go. They have a walk-in clinic, but we can reserve a time slot in advance – would you like me to set you up there? We work closely with them, and the whole team there is top-notch.
Mica hesitates and then nods: “Ok, if you think they won’t look down on me for taking pain pills or just throw more pills at me. I feel like that is what happened with my old doctor.”
Pharmacist: “No – not at all. They may be able to offer you something instead of oxy, and I think they can help you with feeling so overwhelmed and stressed with this move. It’s not just doctors there – they have therapists and counselors also.”
Mica: “I guess that is OK. I am willing to try, but I am not so sure it will be any better than before.”
Pharmacist: “Definitely let me know what you think after you go. We try our best to work as a team, so I expect to have a chance to see you again after the appointment.”
The pharmacist is introducing the idea of a comprehensive approach with a multidisciplinary team.
With Mica’s permission, the pharmacist reaches out to the walk-in clinic at the local VA, explains the situation, and gets Mica an appointment slot within a few days for an evaluation.
Interdisciplinary Approach: At the Clinic
A nurse performs an intake assessment, administering the PC-PTSD-5 and collecting details about Mica’s sleep and mental health challenges.
Nurse: “Your answers suggest PTSD may be contributing to both your pain and sleep issues. The next step is to discuss this with your primary care provider. We all work together to create a care plan that meets your needs.”
The nurse is applying the nursing process to associate Mica’s assessment data (questionnaire and past medical history) with his care needs, including interprofessional collaboration.69
Mica: “Yes, my old doctor said I had PTSD. She told me to take Ativan – which I hated, it made me so foggy – and go to an online group, which was useless as far as I was concerned. And then my pain got worse, and honestly, this move hasn’t helped. I just want to get off the oxy, sleep better, and feel better.”
Nurse: “Understood. The pharmacist who referred you mentioned you had an unsatisfying experience with your old clinic. I hope you give us a chance to do better, and I hope you will let me know if you think of some way we can help!”
The nurse is practicing the therapeutic communication principles of encouraging communication and offering self. These concepts invite Mica to continue sharing information that could lead to a stronger application of the nursing process through enhanced assessment data.71
Primary Care Provider (PCP)
The PCP performs a physical exam, assesses Mica’s pain management needs, and discusses tapering off the opioids in favor of safer alternatives.
PCP: “Mica, it sounds like the nightmares and stress have been adding to your pain. Chronic pain can snowball, especially alongside PTSD. We need to start by addressing both and following you closely until you feel better.” Mica nods: “Sometimes I feel foolish not being able to handle back pain. I know people in worse situations.”
PCP: “There’s no use comparing pain – physical or emotional. I’m just glad you realize you don’t have to deal with this alone. What do you think about gradually reducing the oxycodone and exploring options that should work better in the long run? We can discuss alternatives like medications for nerve pain, such as gabapentin, combined with physical therapy.”
Mica: “I don’t want to start something new and feel worse like I did with my last doctor’s prescription for sleep medication. And, well, I guess I can tell you that if I don’t take the oxy, I'll drink a little to get through the night.”
PCP: “Thanks for letting me know that – it’s understandable to be worried. Please know we all work together here and want your feedback. Typically, I coordinate with the pharmacist to monitor how you are doing and adjust or change medication if needed. We also have a health coach that will be calling you weekly. And finally, I think connecting you with our behavioral health specialist will help to address the nightmares, sleep, and drinking.”
Mica: “It is a lot to take in – but maybe, if it helps, it will be worth a
shot.”
Pharmacist and PCP Collaboration
After the appointment, the PCP and pharmacist discuss Mica’s care plan.
PCP: “I am tapering the oxycodone and starting gabapentin. Can you counsel Mica on what to expect and monitor his progress when he comes for refills?”
Pharmacist: “Absolutely. I can answer any questions about gabapentin and explain how it works, review potential side effects, and reinforce the tapering schedule. I see he is on-board with limited quantities of medication – that helps. I will also emphasize avoiding alcohol during this transition.” Follow-up at the Pharmacy (One Week Later)
Pharmacist: “Hi, Mica. How are you feeling about the new plan?” Mica: “A little nervous. I don’t want to feel worse.”
Pharmacist: “That’s completely normal. Gabapentin works differently from oxycodone; it will take more time but has less risk. Let’s also talk about avoiding alcohol – mixing it with these medications can be dangerous.”
Mica: “I know. I plan to stick to the plan. Checking in here surprisingly helps – makes me feel less alone.”
Pharmacist: “Great. We’ll keep it up. If anything feels off, let me know right away.”
Behavioral Health (Two Weeks Later)
Behavioral health specialist: “Mica, PTSD, and sleep disturbances can often be treated with specialized cognitive behavioral therapy, or CBT as we call it. We offer this in group form.”
Mica: “No, I already tried a group. It was worse than useless because I came away feeling like nothing would ever change.”
Behavioral health specialist: “OK, maybe individual therapy would be a better fit for you.”
Mica: “If that’s an option, I’m game to try, but I don’t want to get into my childhood and stuff.”
Behavioral health therapist: “No, CBT is more about recognizing non- productive thought patterns and changing unwanted behaviors linked to the thoughts. Also, I think your doctor told you about the health coaches. They can check in with you for a brief phone call or visit weekly to make sure the medicine and therapy are helpful to you.
Mica: “Ok, I can try. And I believe I am due to start physical therapy, but I haven’t heard.”
Behavioral health therapist: “Let's check with the social worker. He coordinates your care through the team and should be able to tell you where that stands.”
Patient Follow-up
Two months later, Mica has tapered off the oxycodone, is stable on a low dose of gabapentin, has started physical therapy, and has begun CBT with an individual therapist. He still has some nightmares and occasional sleep problems, but he reports less drinking and a more even mood.
This case highlights the importance of collaboration and effective communication among all members of the healthcare team, emphasizing the patient’s central role in achieving health and wellness.
Summary and Key Learning Points
Regardless of the clinical setting, clinicians must consider the unique characteristics found in the veteran population, including the values, traditions, and norms that characterize military culture. Recognizing this cultural framework is key for clinicians when developing treatment strategies for PTSD, depression, suicidal thoughts, and substance use disorders for the veteran population. Healthcare teams made up of multiple disciplines can be more effective in recognizing, accurately diagnosing, and effectively treating this often-underserved population. Key Learning Points include the following:
Recognition: Review recognition and common treatments for the most common conditions of mental health impacting veterans: PTSD, depression, substance use disorder, and suicidal behavior.
Medication management for these conditions: Understand commonly used medication side effects and consider comorbidities.
Non-pharmacologic interventions: Be aware of types of non- pharmacologic interventions.
Address stigma: Overcoming the stigma associated with mental health is a central step in encouraging veterans to seek help.
Screening and referrals: Identify high-risk patients and know community resources.
Psychoeducation: Educate veterans about their conditions and treatments.
Course Test
Regarding veterans and PTSD,
PTSD impacts over half of veterans.
PTSD impacts fewer veterans receiving care at VA facilities.
PTSD risk decreases with years of service.
PTSD risk increases with deployment.
Which of the following is true regarding PTSD treatment?
No medication is effective for PTSD symptoms after combat; veterans need specialized therapy.
Paroxetine and sertraline are FDA-approved for treating PTSD symptoms.
Medications are better than talk therapy for symptoms of PTSD because they work almost immediately.
Benzodiazepines are particularly effective as an adjunct medication for PTSD symptoms.
A veteran who presents with disrupted sleep and poor concentration that resolves within two weeks after a traumatic event
is exhibiting an expected response to a traumatic event.
is experiencing delay-onset PTSD.
has a need to develop better coping skills.
needs to develop improved social connections.
Which option below, discovered during a clinic visit, reveals the patient should be considered for further evaluation for depression according to ICD-11 criteria?
intermittently depressed mood for 2 weeks because the veteran’s child is leaving for college soon
a decreased interest in sports one week after a favored team lost a championship playoff
feelings of excessive guilt and thoughts of suicide without pinpointing a specific reason
sleep disturbance due to a recent change in work schedule
Common side effects of SSRIs include
GI disturbance, headache, weight gain, and sexual dysfunction.
joint swelling, dizziness, weight loss, and confusion.
GI disturbance, headache, weight loss, and confusion.
joint swelling, dizziness, weight gain, and sexual dysfunction.
Which of the following statements is true regarding SUD?
The most common types of substance use in the veteran population involve prescription drugs and methamphetamine.
About 45% of first-time patients in primary care at VA clinics present with SUD.
SUD is unrelated to and rarely comorbid with PTSD or depression.
The most common types of substance use seen in the veteran population involve alcohol and tobacco.
Which of the following is true regarding SUD?
There is rarely a need to combine pharmacotherapy with talk therapy.
Anti-anxiety agents are almost always indicated in AUD.
Risk factors include younger age, male, and history of combat.
Naloxone should never be prescribed to someone with SUD.
is a partial agonist of the nicotinic acetylcholine receptor that may be used to treat tobacco use disorder.
Bupropion
Acamprosate
Varenicline
Naloxone
When assessing a patient for suicide risk,
never ask if the patient has felt suicidal, as this may give the patient suicidal ideas.
open-ended questions, a non-judgmental stance, and knowledge of local resources are all indicated.
understand that suicide is a rare cause of death for veterans under the age of 45.
do not use open-ended questions when evaluating suicide risk, as these make patients uncomfortable.
Which of the following is an effective practice for overcoming stigma within healthcare teams?
Try not to discuss the history of military service or any connection to current symptoms.
Distract the patient with talk of weather or other superficial topics.
Take a sincere interest, build rapport, provide relevant medical information, and provide targeted referrals.
Do not comment on any nonpharmacologic interventions, as this could be seen as trivializing the symptoms.
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The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.
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Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.
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