Veterans returning from service overseas often continue to experience the war long after they have left the front lines. They may not have a physical injury, but trauma from war can be hidden and far more serious long-term. As the wars in the Middle East continue into a second decade, the numbers of veterans experiencing mental health issues continues to rise. It is imperative that we understand their challenges so we can offer effective treatment and support for the soldiers (and their families) who give so much.

One of the first issues to address when veterans return home is chronic pain that is being treated by overprescription of opioids. A study published in the June 2014 issue of JAMA Internal Medicine found that not only were more soldiers taking opioids for chronic pain, but some soldiers also admitted to taking opioids daily when no pain was present. Just under half of the 2,600 soldiers in the study admitted to no pain or only mild pain in the previous month.

Of the remaining soldiers:

  • 48% reported pain lasting more than a year
  • 56% suffer daily pain
  • 51% classify their pain as moderate or severe

Taking prescription opioids when no pain is present is a clear indication that veterans may be masking another condition or using opioids to sleep. This is not to say that veterans do not experience chronic pain but rather that there may be a correlation between what is happening as a result of post-traumatic stress disorder (PTSD) and their physical symptoms. Their minds may still be reliving dangerous nighttime combat missions, not allowing their bodies to relax and regenerate with a full night of sleep.

Sleep deprivation can seriously hinder treatment for those soldiers diagnosed with PTSD. Researchers at the University of California, San Diego School of Medicine and Veterans Affairs San Diego Healthcare System found that signatures of PTSD – flashbacks, anxiety, nightmares, and uncontrollable thoughts – may decrease the quality of the sleep, thereby strengthening PTSD symptoms. Sean P.A. Drummond, PhD, professor of psychiatry and director of the Behavioral Sleep Medicine Program at the VA San Diego Healthcare System believes that:

[T]he implication is that we should try treating sleep before treating the daytime symptoms of PTSD and see if those who are sleeping better when they start exposure therapy derive more benefit.”

The mental health issue becomes even more complex for those veterans who spent any time as a prisoner of war (POW). The psychological trauma suffered by a veteran who is captured and imprisoned cannot be underestimated. According to professor Zahava Solomon, an Israel Prize laureate, professor of social work and psychiatric epidemiology at Tel Aviv University’s School of Social Work, and head of the newly founded Center of Excellence for Mass Trauma Research established by the Israel Science Foundation, mental trauma is not a fixed target:

“The effect of psychological trauma is like cancer — it metastasizes. You cannot treat a person only according to PTSD, an anxiety disorder, or depression, an effective disorder, because then the treatment itself becomes ineffective. Sometimes they overlap, but they are also quite different. This is a major challenge for clinicians, who must not be blinded or restricted by their textbook categories.”

The key to addressing the issue of mental health for veterans is to holistically address all parts of the problem, including physical (poor sleep and potential opioid dependence), psychological (mental reactions as if still in combat), and emotional (inability to connect with family or friends). Selecting which treatment path to head down is often most effective when the veterans themselves get to choose, both in terms of healing the mental wounds inflicted and the actual cost of treatment.

In evaluating how well a treatment works, we seldom pay attention to the role of a patient’s preference, although it could be particularly important in mental health treatments. Lori Zoellner, co-author of one such study and director of the University of Washington’s Center for Anxiety and Traumatic Stress believes that this has big implications for future treatment options. She notes:

“Trauma survivors with PTSD often have strong opinions about wanting to talk about the trauma or not in therapy, some believing they really need to talk about it to heal and others really wanting to avoid talking about it. They may experience greater relief when they receive the treatment that they prefer.”

The 200 study participants were placed into two groups, one of which could choose between prolonged exposure therapy or a medication called sertraline (commonly called Zoloft or Lustral) and one which was assigned a treatment plan. Zoellner and her colleagues found that patients saved an average of just over $1,600 a year when they chose their own treatment protocols. The study did not comment extensively on the effectiveness of each treatment option but did say that if a choice was given, prolonged exposure treatment was most effective for both groups.

In terms of effective treatment, as the POW study points out, there is no one “silver bullet” when it comes to assessing and addressing the mental health challenges of returning veterans. Some research indicates that virtual reality war games may be effectively used even during combat operations to evaluate and begin treatment for PTSD, a practice which can continue when veterans return home.

It is also crucial to properly treat veterans for any chronic pain they may be experiencing, whether it is from a major injury or simply their body’s reaction to stress. This can include pharmacological treatment but should also include:

  • Physical therapy
  • Relaxation, such as mindfulness meditation
  • Exercise
  • Healthy diet

Some veterans who lost limbs during or after deployment may also experience the very real sensations of phantom limb pain. This could include not only pain but also itching, tingling, and burning sensations. This neurological condition may occur when the brain attempts to process why signals are no longer coming from the missing limb. These sensations can be addressed through a variety of methods both traditional and non-traditional, including minimally-invasive spinal blocks, acupuncture, and medications.

No matter if our veterans return with wounds that are visible or hidden, it is important to do whatever we can to help them come back all the way. For the 1.64 million soldiers deployed since 2001, we need to provide equal access to high-quality, holistic healthcare that supports them through their transition home. Visit Charity Navigator for a list of organizations that help do just that.

Image by DVIDSHUB via Flickr