To ensure the early identification and effective treatment of mental health disorders in the veteran population, general practitioners (GPs) need to be aware that the traditional profile of an Australian veteran has changed, and that more than combat service can give rise to mental health issues.
This article uses findings that have emerged from research undertaken with participants from three veteran cohorts to highlight mental health issues that should be considered in general practice.
GPs have a key role to play in the diagnosis and treatment of mental health issues among the veteran population for several reasons. First, mental health issues may emerge at any point during a veteran’s lifespan and among any veteran cohort. Second, mental health issues may have a significant trans-generational impact on a veteran’s family. Third, GPs are uniquely positioned to break down barriers to help-seeking, such as stigma. Importantly, there is a comprehensive system of support available to assist GPs in providing effective and culturally appropriate care for veterans.
Today, an Australian veteran may be any age or gender, and may have served in a wide variety of military environments. Military tasks may include border protection at sea, searching for bodies after bushfires, or war-like services in places such as Afghanistan. Research and clinical experience has found that military personnel will be changed as a result of exposure to high-risk environments, and that a significant number will experience sub-syndromal symptoms of fatigue, sleeplessness, impaired concentration, nightmares, intrusive thoughts, hyper-arousal or anger.1–3 For many veterans, these symptoms will resolve, and they will view their experiences positively and potentially as a source of personal growth.4,5 However, a minority will be negatively affected and will go on to have mental health disorders. General practitioners (GPs) have a key role to play in the early identification of veterans needing assistance.
The Department of Veterans’ Affairs (DVA) recognises the unique nature of military service by providing a dedicated system of compensation, income support and health treatment for members of the Australian Defence Force (ADF). DVA supports some 316,000 clients, of whom approximately 40,000 are World War II veterans and 44,000 are Vietnam War veterans. Contemporary veterans from conflicts in places such as Timor Leste, Iraq and Afghanistan have emerged as the largest and most recent cohort requiring support (approximately 66,800 veterans in total, including those from peacekeeping missions).6 Research conducted with each of these cohorts has highlighted the need for mental health support and associated clinical care.7–9
Veterans of the Vietnam War era
The mental health consequences of the Vietnam War have been extensively documented over the past three decades and have informed our current understanding of war-related mental health disorders, especially post-traumatic stress disorder (PTSD). An important emerging issue for Vietnam War veterans is their increased risk of dementia, as well as comorbidities such as alcohol or substance misuse, cardiovascular disease and autoimmune disease.10 All of these conditions have since been linked to PTSD,10–12 which is especially significant as there were approximately 25,000 Vietnam War veterans with an accepted claim for disability from PTSD as at September 2015.6
Families are fundamental in the support system for serving and ex-serving military personnel who have a mental health disorder. Similarly, families living with a veteran with mental health issues need support and understanding. While the majority of children of military personnel from the Vietnam War era are living healthy and productive lives, research has revealed that the children of veterans who were deployed to Vietnam have poorer health outcomes (particularly for mental health) than the children of veterans from the Vietnam War era who were not deployed.13 This research also revealed that the health outcomes of children of Vietnam War veterans with a diagnosis of PTSD can be especially poor. This finding emphasises the importance of the Veteran and Veterans Families Counselling Service (www.vvcs.gov.au), which provides services to families as well as veterans, and highlights the opportunity that GPs have in addressing the trans-generational impact of military service.13
Veterans of peacekeeping missions
While media attention focuses on the risks associated with combat exposure, research has also examined the impact of peacekeeping missions on military personnel.9 This research is important because of Australia’s ongoing commitment to such missions, and the fact that this cohort will continue to grow. The 2013 Australian peacekeepers: Long-term mental health status, health service use, and quality of life report,14 which examined the impact of peacekeeping on the mental health of military personnel 10–15 years after deployment, found that veterans on peacekeeping missions experienced a level of mental health illness comparable to that of Australia’s Vietnam War–era veterans.
The study included personnel who were deployed on seven peacekeeping missions sanctioned by the United Nations (UN) between 1989 and 2002, and had left full-time service with the ADF. The deployments included Namibia, Western Sahara, Cambodia, Rwanda, Somalia and two missions to Timor Leste. Of those personnel, around 60% of participants appeared to be coping well, with little or no evidence of psychological dysfunction. However, 20% of participants showed moderate levels of mental health issues and the remaining 20% reported more severe mental health problems.14 Deployments to regions such as Rwanda, where there was considerable exposure to atrocities and human suffering, were linked to a particularly high risk of mental health disorder.9,14
Despite the significant time lapse since deployment, the study found that peacekeepers were twice as likely to meet the criteria for a mental health diagnosis in the previous 12 months, compared with the general community. This high rate may be the result of ongoing life stress, delayed onset of mental health disorders or episodic symptoms. Furthermore, while 83% of participants with a mental health disorder had seen a clinician or therapist in the past three months, 41% were not satisfied with their healthcare. Both these findings highlight the need for GPs to continue to engage with veterans and to ensure optimal treatment across the lifespan.
Veterans with contemporary service
As of 2011, 43% of military personnel in the ADF had been deployed multiple times, 19% had been deployed once and the remaining 38% had never been deployed. The 2010 ADF Mental Health and Wellbeing Prevalence Study indicated that there was very little difference in the prevalence of mental disorders between personnel who had been on deployment and those who had never been deployed. This lack of difference was explained by the unexpected rates of trauma among non-deployed personnel – for example, as a result of dealing with human misery or life-threatening situations while carrying out border protection patrols, or associated with Australian natural disasters, motor vehicle and training accidents, and interpersonal violence. There was a significant association between the level of trauma exposure and levels of PTSD and depression, independent of whether those conditions were deployment-related.7,15 This highlights how important it is for GPs to enquire about domestic military experiences as well as international military experience when treating veteran patients.
The cohort of contemporary veterans is increasingly diverse, with the number of women in the ADF having grown from 4% in 1973 to 15% in 2015.16 In the past two decades, women’s roles in the military have expanded significantly, and doors that were once closed to women are now opening (eg the deployment of mothers). Research among serving women in the ADF found that they reported similar rates of affective and anxiety disorders as women in the general Australian community.7 However, while the overall rate is the same, servicewomen are significantly more likely to be diagnosed with major depression. This research also found an association between good social support and lower psychological distress. Of particular relevance to GPs is the fact that serving women reported feeling less supported following deployment and reported greater psychological distress than their male counterparts.7
Reassuringly, research that specifically compared mothers who have been deployed with women without children who have also been deployed indicated no particular difference in terms of psychological distress, PTSD symptomology, alcohol use or somatic symptoms.17 This suggests that mental health issues that arise are common to the experience of being a servicewoman rather than to whether they have children. This research also indicates that most mothers have positive deployment experiences, despite the challenges of combining family and work life. Upon returning from deployment, mothers may experience feelings of disconnection (which should be monitored) and may need support in balancing family priorities with time spent with military peers. GPs have opportunities to play an important role in aiding the transition of military mothers, as well as supporting the partners and children of deployed mothers who may also experience adjustment issues.
Barriers to mental health treatment
Veterans seeking help for mental health disorders may be undermined by a fear of stigma and other perceived barriers. Fulltime ADF personnel have reported that help-seeking is associated with a fear of reduced deployability (36.9%), being treated differently (27.6%) and reduced career prospects (26.9%).7 A challenge across all veteran cohorts is overcoming these hurdles. The ability to facilitate early access to treatment for mental health disorders may result in a greater number of military personnel being able to remain in the workforce and lead meaningful lives, and minimises the development of chronic issues. GPs have a role to play in identifying potential barriers to care, as well as recognising the somatic manifestations of mental health issues, such as musculoskeletal pain and gastrointestinal symptoms.18
It is also important for GPs to address the maladaptive strategies that some veterans may use to avoid acceptance of their mental health issues, such as alcohol or substance misuse.19 Consequently, GPs may wish to investigate alcohol-related injuries and unexplained symptoms. They may also use the ADF Post-discharge GP Health Assessment (highlighted in this issue of Australian Family Physician) if there is a clinical suspicion of a mental or physical health disorder. A rebate is available under the health assessment items on the Medicare Benefits Schedule.
It is important to note that, on the diagnosis by a GP, the DVA will fund treatment of PTSD, anxiety, depression, and alcohol or substance misuse disorders for veterans with operational service and many with more than three years of peacetime service.20 This is even if these conditions are not service-related and even if no injury claim has been lodged. Such arrangements are known as ‘non-liability health care’ (NHLC; information on eligibility is available at http://dva.gov.au/health-and-wellbeing and in the article ‘Supporting new Australian veterans’ in this issue of AFP).
To help GPs engage with veteran patients and overcome barriers to care, a number of training resources are available on the At Ease website (http://at-ease.dva.gov.au/professionals) and via the gplearning program (http://gplearning.racgp.org.au) offered by The Royal Australian College of General Practitioners (RACGP). These training resources include advice on addressing specific cultural issues, and delivering evidence-based treatments among the veteran population. The At Ease website also contains a range of educational and self-management tools that GPs can recommend to veterans to help improve their mental health literacy.
Wendy, 38 years of age, is an ex-army warrant officer who worked as a medical assistant with deployments to Rwanda and Timor Leste.
- Presenting symptoms – stomach cramps, headaches, nightmares, chronic depressive symptoms
- Precipitating event – working with refugees to find housing solutions, resulting in intrusive memories
- Psycho-social issues – increasingly socially withdrawn but has a supportive partner
- Explore Wendy’s potentially traumatic experiences throughout her career, including nature and frequency of her trauma exposure.
- Assess for psychophysiological basis for her physical symptoms and the interaction between signs of depression and post-traumatic stress disorder (PTSD).
- Ask Wendy who she is responsible for and explore if they are being impacted.
- Complete the ADF Post-discharge GP Health Assessment.
- Recommend the At Ease website so Wendy can learn more about PTSD and depression.
- Refer for cognitive behavioral therapy and trauma-focused treatment if not provided by the general practice clinic.
- Provide Wendy with details of the Veterans and Veterans Families Counselling Service to support her and her family.
Veterans can be of any age and gender, and are often unrecognised in general practice. A veteran might present as a retiree, an individual in their first job outside the military, or a young mother. There are many traumatic stressors in the military environment that may lead to mental health disorders, and these exposures can occur in Australia and on deployment overseas (peacetime and combat). The veteran patient may be a young adult from a recent operation or an older individual from World War II or the Vietnam War. No matter the source of the exposure, mental health disorders will have an impact on a patient’s family, and both the patient and their support network may need care. GPs have a key role to play in breaking down stigma and other barriers to care through early diagnosis and treatment.
Stephanie Hodson CSC, PhD, BPsych (Hons), MAPS, Mental Health Adviser, Department of Veterans’ Affairs, Canberra, ACT. Stephanie.Hodson@dva.gov.au
Alexander McFarlane AO, MBBS (Hons), MD, FRANZCP, Dip Psychotherapy, Director of the Centre for Traumatic Stress Studies, University of Adelaide, SA; and Psychiatric Advisor, Department of Veterans’ Affairs, Canberra, ACT
Competing interests: The authors declare that they were paid by the Department of Veterans’ Affairs for writing this manuscript.
Provenance and peer review: Commissioned, externally peer reviewed.
The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of Department of Veterans’ Affairs.
- Pietrzak RH, Goldstein MB, Malley JC, Johnson DC, Southwick SM. Subsyndromal posttraumatic stress disorder is associated with health and psychosocial difficulties in veterans of Operations Enduring Freedom and Iraqi Freedom. Depress Anxiety 2009;26(8):739–44.
- Tsai J, Sippel LM, Mota N, Southwick SM, Pietrzak RH. Longitudinal course of posttraumatic growth among US military veterans: Results from the National Health and Resilience in Veterans Study. Depress Anxiety 2016;33(1):9–18.
- Davy C, Dobson A, Lawrence‐Wood E, et al. 2012. The Middle East Area of Operations (MEAO) Health Study: Prospective study summary report. Adelaide: University of Adelaide Centre for Military and Veterans Health, 2012. Available at www.defence.gov.au/Health/Home/Docs/130318-MEAOProspectiveStudyExecutiveSummary.pdf [Accessed 11 November 2015].
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- Thomas S, Dandeker C, Greenberg N, Kelly V, Wessely S. Serving in Bosnia made me appreciate living in Bristol: Stressful experiences, attitudes, and psychological needs of members of the United Kingdom Armed Forces. J Military Med 2006;171(5):376–80.
- Department of Veterans’ Affairs. Annual report 2014–2015, Department of Veterans’ Affairs. Canberra: DVA, 2015. Available at www.dva.gov.au/sites/default/files/files/about%20dva/annual_report/2014-2015/annrep2014-15.pdf [Accessed 20 November 2015].
- McFarlane A, Hodson SE, Van Hoof M, Davies C. Mental health in the Australian Defence Force: 2010 ADF Mental Health and Prevalence and Wellbeing Study: Full report. Canberra: Department of Defence, 2011.
- O’Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. Am J Epidemiol 2009;170: 318–30.
- Forbes D, O’Donnell M, Brand RM, et al. The long-term mental health impact of peacekeeping: Prevalence and predictors of psychiatric disorder. Br J Psychiatr Open 2016;2(1):32–37.
- McFarlane AC. The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry 2010;9(1):3–10.
- Qureshi SU, Kimbrell T, Pyne JM, et al. Greater prevalence and incidence of dementia in older veterans with posttraumatic stress disorder. J Am Geriatr Soc 2010;58(9):1627–33.
- Yaffe K, Vittinghoff E, Lindquist K, et al. Posttraumatic stress disorder and risk of dementia among US veterans. Arch Gen Psychiatry 2010;67(6):608–13.
- Department of Veterans’ Affairs. Vietnam veterans health study: Volume 1, Introduction and summary of the studies of Vietnam veteran families. Canberra: DVA, 2014. Available at www.dva.gov.au/sites/default/files/files/consultation%20and%20grants/healthstudies/vvfs/vvfs_vol1.pdf [Accessed 14 January 2016].
- Hawthorne G, Korn S, Creamer M. Mental health of Australian peacekeepers: Long-term mental health status, health service use, and quality of life. Parkville, Vic: University of Melbourne, 2013. Available at www.dva.gov.au/sites/default/files/files/consultation%20and%20grants/healthstudies/peacekeepers/pktechnical.pdf [Accessed 20 November 2015].
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- Lawrence-Wood E, Jones L, Hodson S, Crompvoets S, McFarlane A, Neuhaus S. Mothers in the Middle East Area of Operations (MEAO): The health impacts of maternal deployment to an area of operations. Canberra: Department of Veterans’ Affairs, 2014. Available at www.dva.gov.au/sites/default/files/files/consultation%20and%20grants/healthstudies/Mothers_in_MEAO.pdf [Accessed 14 January 2016].
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- Zamorski M. Towards a broader conceptualization of need, stigma, and barriers to mental health care in military organizations: Recent research findings from the Canadian forces. Ottawa: North Atlantic Treaty Organization, 2011. Available at www.dtic.mil/get-tr-doc/pdf?AD=ADA582781 [Accessed November 2015].
- Department of Veterans’ Affairs. Factsheet HSV109 – Non-liability health care. Canberra: DVA, 2015. Available at http://factsheets.dva.gov. au/factsheets/documents/HSV109%20Non-Liability%20Health%20Care.pdf [Accessed 14 January 2016].