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Veterans and Co-Occurring Disorders

Despondent male soldier covering his face with hands.The United States is home to about 23.4 million veterans of the US Armed Forces, including the Army, Navy, and Air Force. There are also around 2.2 million active members of the US Armed Forces, and about 3.1 million family members with loved ones serving their country. This is a distinguished career, and many veterans are rightfully proud of the time spent in the military; however, with more service members seeing active combat situations, more veterans return home struggling with mental health problems, disability, or traumatic brain injury. Post-traumatic stress disorder (PTSD), depression, anxiety disorders, substance abuse, and suicide are prevalent among veterans, and these conditions often overlap.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), about 18.5 percent of service members returning from Iraq and Afghanistan struggle with PTSD and depression, as these conditions frequently co-occur. In addition, 19.5 percent report experiencing a traumatic brain injury (TBI) during deployment, which can lead to mood and behavioral changes that contribute to the risk of developing PTSD, depression, insomnia, and substance use disorders.

About half of the returning veterans of just the wars in Iraq and Afghanistan have been treated by the Veterans Administration (VA) for symptoms of mental illness, according to the Drug Policy Alliance; 30 percent of those veterans report PTSD symptoms specifically, and 19 percent of veterans of current conflicts have received diagnoses of substance use disorders. It is extremely important to understand how mental health struggles and substance abuse overlap among military veterans, so symptoms can be noticed as soon as possible, and veterans can get the treatment they need.

Substance Abuse, Mental Health Struggles, and Veterans

Co-occurring disorders are defined as two or more types of mental or behavioral conditions that appear together in one person. Generally, discussion of co-occurring disorders means a mood disorder like depression or bipolar disorder, an anxiety disorder like panic disorder or PTSD, or schizophrenia, with a substance use disorder like alcohol use disorder (AUD), opioid addiction, prescription drug abuse, or stimulant abuse (either prescription stimulants like Adderall and Ritalin, or illicit drugs like meth). Marijuana, nicotine, alcohol, narcotics, and cocaine are among the most abused substances associated with mental health problems. Veterans are at risk for specific co-occurring disorders.

Specific Mental and Substance Abuse Disorders That Co-Occur in Veterans

PTSD and Substance Abuse

The most prevalent mental health condition diagnosed in veterans is post-traumatic stress disorder (PTSD). This stress condition is triggered by a specific traumatic event, such as a natural disaster, serious accident, abuse, or combat. People who develop PTSD typically have intrusive thoughts like nightmares or flashbacks, feel consistently on edge, are easily startled, have angry outbursts, or struggle to sleep. They have difficulty remembering key parts of the event, experience distorted or negative thoughts about themselves or the world around them, lose interest in once enjoyable activities, and avoid places, people, or objects associated with the event.

They have difficulty remembering key parts of the event, experience distorted or negative thoughts about themselves or the world around them, lose interest in once enjoyable activities, and avoid places, people, or objects associated with the event.

Unfortunately, many veterans begin abusing substances as a method of self-medicating the physical and emotional stress brought about through untreated PTSD. A nationwide epidemiological study found that 46.4 percent of people with PTSD also had at least one substance use disorder. Alcohol, narcotics, and marijuana are the most frequently reported drugs associated with PTSD, including among veterans.

Alcohol Abuse

Alcohol use disorder (AUD), heavy drinking, and binge drinking are the most frequently reported types of substance abuse among veterans in general. Alcohol abuse is often diagnosed alongside PTSD. According to VA administrative data, 63 percent of veterans returning from combat in Iraq and Afghanistan struggled with AUD or another type of substance abuse also had a diagnosis of PTSD. Among veterans with a diagnosis of AUD and another type of substance abuse, 76 percent received a diagnosis of PTSD. A survey of 88,205 returning Iraq and Afghanistan veterans found that between 12 percent and 15 percent screened positive for drinking problems.

Marijuana and Illicit Drugs

Although some sources link marijuana abuse with PTSD among veterans, statistics on the co-occurrence are hard to find, because service members who abuse illicit drugs like marijuana or heroin are dishonorably discharged and are no longer considered veterans of the armed services. According to the Department of Defense (DoD) in 2008, about 2.3 percent of military personnel abused illicit drugs in the month before the survey, compared to 12 percent of civilians. However, as marijuana becomes a socially acceptable drug and is legalized in some states, the VA is tracking abuse rates more closely: between 2002 and 2014, the number of veterans diagnosed with PTSD and marijuana abuse rose from 13 percent to 22.7 percent, with an average of 40,000 veterans diagnosed with co-occurring marijuana addiction and PTSD.

Depression and Alcohol Abuse

PTSD and depression were found to frequently co-occur in veterans. In fact, a 2010 report showed that 48-60 percent of veterans with PTSD also struggled with depression, especially female service members; however, in general, only about 5 percent of veterans presented with symptoms of depression without PTSD. Veterans with PTSD and/or depression reported higher rates of suicidal ideation and attempts.

Alcohol abuse is already known to be high among veterans with PTSD, so this may contribute to increased rates of depression as alcohol changes brain chemistry. Depression and alcohol use disorder are closely associated in general, not just among veterans.

Heavy alcohol consumption among active-duty service members declined from the 1980s to 1990s, but began rising again in the early 2000s. Binge drinking in this group rose from 35 percent in 1998 to 47 percent in 2008. These forms of drinking were closely associated with co-occurring mental illnesses, especially depression and PTSD.

Other Anxiety Disorders, Insomnia, and Opioids

Abuse of opioid drugs, especially prescription painkillers, is rising among veterans as it rises in the general population. One study reported that 2 percent of veterans who received opioid therapy for a chronic pain condition developed an addiction to these drugs. Further research found that 16.3 percent of veterans misused opioid prescriptions by sharing them with friends or taking drugs that had not been prescribed to them. In another study of 343 veterans, 35.3 percent reported aberrant pain management behavior, which included abusing prescription drugs, illicit drugs, and alcohol.

Two-thirds of returning Iraq and Afghanistan veterans with elevated pain screening scores, indicating serious injury, chronic pain, and associated emotional trauma, abused opioids in the past year. PTSD increased the risk of abusing opioids even when the veteran already abused alcohol. Pain was also closely associated with chronic insomnia and anxiety disorders, which co-occurred with PTSD, and abuse of opioids was associated with higher rates of anxiety disorders that were not PTSD among veterans.

Treatment for Veterans with Co-Occurring Disorders

Soldier sitting on the sofa during psychological therapy

The Veterans Affairs Administration is clear that the foundation of treatment for any mental or behavioral problem in veterans is psychotherapy. While some medical interventions, like antidepressant prescriptions or brief treatment with anti-anxiety medications, may be beneficial, pharmacological treatments work best when combined with counseling.

The VA and other professional organizations recommend Cognitive Behavioral Therapy (CBT) as the leading approach to treating co-occurring disorders, mental illnesses, and behavioral conditions among the general population as well as among veterans. For veterans with PTSD, trauma-focused treatment like Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE) appear to work the best.

Counseling that does not specifically deal with trauma is also beneficial in conjunction with therapy directed at PTSD. At the VA, this includes a program called Seeking Safety, which is an approach to psychotherapy that has been integrated with improved coping skills. It is often applied to treating co-occurring disorders among veterans.

Currently, about 40 percent of veterans who have screened positive for emotional problems like mood or panic disorders and co-occurring substance abuse receive some kind of treatment for these struggles. Stigma among current and retired service members is a major barrier to seeking treatment, but reduced access to evidence-based psychological and pharmacological therapies also hinders many veterans from getting the care they need. Failure to get appropriate treatment increases veterans’ risk of chronic health problems, financial instability, loss of community and close relationships, divorce, and homelessness. Fortunately, it is never too late to get help for these conditions.