Care of the Military Veteran: Selected Health Issues

 

Am Fam Physician. 2019 Nov 1;100(9):544-551.

  Patient information: See related handout on military veterans, written by the authors of this article

Related editorial: Military Health History: Resources for Use at the Point of Care.

Author disclosure: No relevant financial affiliations.

According to the U.S. Census Bureau, 18.2 million veterans were living in the United States in 2017, of whom 1.6 million were female. Less than one-half of all veterans receive care at a Veterans Health Administration or military treatment facility, leaving most to receive services from primary care physicians. Injuries and illnesses common among this patient population include musculoskeletal injuries and chronic pain, mental health issues such as posttraumatic stress disorder (PTSD) and moral injury, traumatic brain injury, chemical and noise exposures, and infectious disease concerns. Family physicians should ask about military service and be well informed about the range of veterans' health concerns, particularly PTSD, depression, and suicidality. Physicians should screen veterans for depression using the Patient Health Questionnaire-9 and for PTSD using the PTSD Checklist for DSM-5. Veterans with traumatic brain injury should be screened specifically for comorbid PTSD and chronic pain because the diagnosis informs treatment. Exposures to loud noise, chemicals, and infectious diseases are prevalent and can cause disability. Family physicians can use available resources and clinical practice guidelines such as those from the U.S. Department of Veterans Affairs and Department of Defense to inform care and to assist veterans.

A veteran is someone who has served in the military (following completion of basic training) as a member of the Army, Navy, Air Force, Marine Corps, or Coast Guard or as a commissioned officer in the Public Health Service, Environmental Science Services Administration, or National Oceanic and Atmospheric Administration. An estimated 18.2 million veterans (1.6 million females) were living in the United States in 2017 according to the U.S. Census Bureau.1 Most veterans receive care exclusively from family physicians or cooperatively with the Veterans Health Administration or military treatment facility, although more than one-half receive care only from the civilian sector.2  Eligibility for benefits is based on acceptable discharge classification and is outlined by the Veterans Benefit Administration on its website (Table 1).

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Family physicians should assess patients' history of military service.3

C

Expert opinion in the absence of clinical trials

Patients with chronic musculoskeletal pain and multisystem illness should have symptoms evaluated based on clinical judgment and be treated with a collaborative, team-based approach, including a behavioral health specialist.12

C

Expert opinion and a systematic review of clinical and epidemiological evidence

Patients with suspected posttraumatic stress disorder should undergo diagnostic evaluation that includes determination of Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria and acute risk of harm to self or others.16

C

Expert opinion and a review of clinical evidence

Risk-based management, clinical interventions, comprehensive and regularly updated safety planning, and reliable continuity of care may reduce the risk of suicide.29

C

Consensus expert opinion in the absence of clear validated, predictive models


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Family physicians should assess patients' history of military service.3

C

Expert opinion in the absence of clinical trials

Patients with chronic musculoskeletal pain and multisystem illness should have symptoms evaluated based on clinical judgment and be treated with a collaborative, team-based approach, including a behavioral health specialist.12

C

Expert opinion and a systematic review of clinical and epidemiological evidence

Patients with suspected posttraumatic stress disorder should undergo diagnostic evaluation that includes determination of Diagnostic and Statistical Manual of Mental Disorders, 5th ed., criteria and acute risk of harm to self or others.16

C

Expert opinion and a review of clinical evidence

Risk-based management, clinical interventions, comprehensive and regularly updated safety planning, and reliable continuity of care may reduce the risk of suicide.29

C

Consensus expert opinion in the absence of clear validated, predictive models


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

NICOLE T. YEDLINSKY, MD, CAQSM, FAAFP, RMSK, is a faculty member of the University of Kansas Family Medicine Residency Program and an assistant professor in the Department of Family Medicine at the University of Kansas Medical Center, Kansas City....

LAUREL A. NEFF, DO, MBA, FAAFP, is the Deputy for the Medical Corps Chief at the Defense Health Headquarters, Falls Church, Va.

KEVIN M. JORDAN, MD, is a third-year resident in the Department of Family Medicine at Madigan Army Medical Center, Tacoma, Wash.

Address correspondence to Nicole T. Yedlinsky, MD, CAQSM, FAAFP, RMSK, University of Kansas School of Medicine, 3901 Rainbow Blvd., Mailstop 4010, Kansas City, KS 66160 (email: nyedlinsky@kumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. United States Census Bureau. Selected social characteristics in the United States 2013-2017 American Community Survey 5-year estimates. Accessed July 30, 2019. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_GCT2101.US01PR&prodType=table...

2. U.S. Department of Veterans Affairs. National Center for Veterans Analysis and Statistics: utilization. Updated June 11, 2019. Accessed July 30, 2019. https://www.va.gov/vetdata/Utilization.asp

3. Vest BM, Kulak J, Hall VM, et al. Addressing patients' veteran status: primary care providers' knowledge, comfort, and educational needs. Fam Med. 2018;50(6):455–459.

4. Bowman MA, Sanders KM, Sharpe JW. Military health history: resources for use at the point of care. Am Fam Physician. 2019;100(9):523–524. Accessed November 1, 2019. https://www.aafp.org/afp/2019/1101/p523.html

5. Hauret KG, Jones BH, Bullock SH, et al. Musculoskeletal injuries description of an under-recognized injury problem among military personnel. Am J Prev Med. 2010;38(1 suppl):S61–S70.

6. Konitzer LN, Fargo MV, Brininger TL, et al. Association between back, neck, and upper extremity musculoskeletal pain and the individual body armor. J Hand Ther. 2008;21(2):143–148.

7. Cameron KL, Hsiao MS, Owens BD, et al. Incidence of physician-diagnosed osteoarthritis among active duty United States military service members. Arthritis Rheum. 2011;63(10):2974–2982.

8. Gatchel RJ, McGeary DD, Peterson A, et al. Preliminary findings of a randomized controlled trial of an interdisciplinary military pain program. Mil Med. 2009;174(3):270–277.

9. Haskell SG, Ning Y, Krebs E, et al. Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom. Clin J Pain. 2012;28(2):163–167.

10. Bryant RA, O'Donnell ML, Creamer M, et al. The psychiatric sequelae of traumatic injury. Am J Psychiatry. 2010;167(3):312–320.

11. Higgins DM, Kerns RD, Brandt CA, et al. Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans. Pain Med. 2014;15(5):782–790.

12. McAndrew LM, Helmer DA, Phillips LA, et al. Iraq and Afghanistan veterans report symptoms consistent with chronic multisymptom illness one year after deployment. J Rehabil Res Dev. 2016;53(1):59–70.

13. Steenkamp MM, Litz BT, Hoge CW, et al. Psychotherapy for military-related PTSD: a review of randomized clinical trials. JAMA. 2015;314(5):489–500.

14. Weathers FW, Litz BT, Keane TM, et al. PTSD checklist for DSM-5 (PCL-5); April 11, 2018. Accessed June 28, 2019. https://www.ptsd.va.gov/professional/assessment/documents/PCL5_Standard_form.PDF

15. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013.

16. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder; 2017. Accessed June 28, 2019. https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf

17. Kulka RA, Schlenger WE, Fairbank JA, et al. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. Routledge; 1990.

18. Kang HK, Natelson BH, Mahan CM, et al. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141–148.

19. Tanielian T, Jaycox L, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. RAND Center for Military Health Policy Research; 2008.

20. Hoge CW, Grossman SH, Auchterlonie JL, et al. PTSD treatment for soldiers after combat deployment: low utilization of mental health care and reasons for dropout. Psychiatr Serv. 2014;65(8):997–1004.

21. Saguil A. Psychological and pharmacologic treatments for adults with PTSD. Am Fam Physician. 2019;99(9):577–583. Accessed July 2, 2019. https://www.aafp.org/afp/2019/0501/p577.html

22. U.S. Department of Veterans Affairs. PTSD: National Center for PTSD: PTSD treatment basics. Accessed January 22, 2019. https://www.ptsd.va.gov/understand_tx/tx_basics.asp

23. Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695–706.

24. Held P, Klassen BJ, Brennan MB, et al. Using prolonged exposure and cognitive processing therapy to treat veterans with moral injury-based PTSD: two case examples. Cogn Behav Pract. 2018;25(3):377–390.

25. Farnsworth JK, Drescher KD, Evans W, et al. A functional approach to understanding and treating military-related moral injury. J Contextual Behav Sci. 2017;6(4):391–397.

26. Johnson NL, Robinett S, Smith LM, et al. Establishing a new military sexual trauma treatment program: issues and recommendations for design and implementation. Psychol Serv. 2015;12(4):435–442.

27. U.S. Department of Veterans Affairs. Mental health: military sexual trauma. Updated May 17, 2019. Accessed July 29, 2019. https://www.mentalhealth.va.gov/msthome/index.asp

28. Boakye EA, Buchanan P, Wang J, et al. Self-reported lifetime depression and current mental distress among veterans across service eras. Mil Med. 2017;182(3):e1691–e1696.

29. Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide; June 2013. Accessed June 28, 2019. https://www.healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf

30. Chandra N, Sundaramurthy A. Acute pathophysiology of blast injury—from biomechanics to experiments and computations: implications on head and polytrauma. In: Kobeissy FH, ed. Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects. CRC Press; 2015:195-253.

31. Mehalick ML, Glueck AC. Examining the relationship and clinical management between traumatic brain injury and pain in military and civilian populations. Brain Inj. 2018;32(11):1307–1314.

32. Tanev KS, Pentel KZ, Kredlow MA, et al. PTSD and TBI co-morbidity: scope, clinical presentation and treatment options. Brain Inj. 2014;28(3):261–270.

33. Theodoroff SM, Lewis MS, Folmer RL, et al. Hearing impairment and tinnitus: prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars. Epidemiol Rev. 2015;37:71–85.

34. Schram B, Orr R, Rigby T, et al. An analysis of reported dangerous incidents, exposures, and near misses amongst Army soldiers. Int J Environ Res Public Health. 2018;15(8):1605–1618.

35. McDonald JR, Liang SY, Li P, et al.; Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group. Infectious complications after deployment trauma: following wounded US military personnel into veterans affairs care. Clin Infect Dis. 2018;67(8):1205–1212.

36. U.S. Department of Veterans Affairs. Infectious diseases and Gulf War veterans. Accessed June 28, 2019. https://www.publichealth.va.gov/exposures/gulfwar/infectious_diseases.asp

37. McAndrew LM, Teichman RF, Osinubi OY, et al. Environmental exposure and health of Operation Enduring Freedom/Operation Iraqi Freedom veterans. J Occup Environ Med. 2012;54(6):665–669.

38. U.S. Department of Veterans Affairs. Agent Orange. Accessed June 28, 2019. https://www.publichealth.va.gov/exposures/agentorange/index.asp

39. Quinlan JD, Gauron MR, Deschere BR, et al. Care of the returning veteran. Am Fam Physician. 2010;82(1):43–39. Accessed July 17, 2019. https://www.aafp.org/afp/2010/0701/p43.html

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article