Substance use disorders (especially alcohol(Drug information on alcohol) abuse) are the most common comorbid psychiatric condition in returning veterans with PTSD. The Alcohol Use Disorders Identification Test (AUDIT–C) has shown utility as a screening for alcohol use disorders and at-risk drinking in veterans,31 which includes OIF soldiers. The short-form shows promise for use in the ED.32
The Seeking Safety program, a cognitive-behavioral treatment for comorbid substance abuse and PTSD, has shown impressive results in veterans—especially women.33,34
Depression and suicide
Anger, substance abuse, and depression are all risk factors for suicidal and (in some cases) homicidal behavior. Their presence warrants risk assessment of self-harm and other harm in any veteran seeking emergency care, even if the chief complaint is a mundane medical problem. (See “Young Veteran With Polytrauma” case vignette.) All returning veterans should be screened for depression and suicidality. The Patient Health Questionnaire (PHQ)-2 is a brief depression screen consisting of 2 questions pertaining to depressed or hopeless mood and anhedonia over the past month. The PHQ-9 also assesses suicidal ideation.35 Both forms have shown validity and utility in primary care settings with veterans and can be used in a medical or psychiatric ED setting.36
The year 2007 saw an alarming increase in suicide among active duty Army soldiers. There were 117 completed suicides and 934 nonfatal attempts in 2007.37 In January 2009, the Army announced that the suicide rate had risen for the fourth year in 2008 and surpassed that of civilians for the first time since the Vietnam war.38
Analysis of the demographics of soldiers who completed or attempted suicide reveals a number of risk factors that ED clinicians may keep in mind when assessing returning veterans. Soldiers who killed themselves were more likely to be young, white, and in the lower enlisted ranks; 95% of suicide completers were men and 27% of suicide attempters were women. Firearms (in 60% of completed suicides), cutting, and overdose were the primary methods of self-harm. A recent failed intimate relationship was the most common contributing factor in both completions and attempts. Forty-four percent of those who killed themselves and 55% of those who tried to do so had a history that included at least 1 psychiatric diagnosis—chiefly mood, anxiety, or substance use disorders. Sixty-one percent of veterans who killed themselves had served in either Iraq or Afghanistan.39 Veterans’ access to and skill with firearms mandates that questions about weapons be included in any suicide risk assessment.40
A diagnosis of TBI—particularly frontal lobe injury—has been documented to increase risk of suicide mediated through both neurobiological and psychosocial mechanisms. Those with such an injury may require more rigorous assessment and intervention.41
Given the prevalence of medical and substance abuse comorbidities in returning veterans, appropriate medical history and physical examination and clinically indicated laboratory testing—including a toxicology screen for alcohol and drugs—should be routinely performed before psychiatric evaluation. These data provide information regarding possible contraindications, drug interactions, or allergies that will inform the choice of psychopharmacological agents.
Veterans who present with bona fide psychiatric emergencies, such as acute psychosis, complicated withdrawal from alcohol, or active suicidal or homicidal intent or plan, must be managed through extant protocols for medical stabilization and psychiatric hospitalization operative in respective EDs.42 Established pharmacological regimens, such as benzodiazepines for acute withdrawal and anxiety and haloperidol(Drug information on haloperidol) or atypical antipsychotics for psychosis and agitation, are also the standard of care for veterans with these classic ED presentations.43 (See “Veteran in an Acute Dissociative State” case vignette.)
The treatment of ASD, including emerging research on interventions to prevent or minimize the risk for PTSD, will not be covered here. Such protocols are most suitable for use in military or VA psychiatry settings and require specialized competency. The evidence base for PTSD pharmacotherapy is reviewed in several clinical practice guidelines. The most pertinent to the current population comes from the VA/DOD.44 A précis of these recommendations is offered in Table 2.
There is general consensus that SSRIs are the first line of treatment for PTSD. Paroxetine(Drug information on paroxetine) and sertraline(Drug information on sertraline) are both FDA-approved for the condition. These agents also have established efficacy for the panic and depression that are often comorbid with PTSD. Their benign side-effect profile also makes these agents ideal for initiation in the ED.
Clinicians should be aware of the 2007 FDA “black box” warning on all antidepressant medications indicating an increased risk of suicidality in young adults between 18 and 24 years old45—the age range of many returnees. Research supports the benefit of SSRIs for reducing symptoms in the re-experiencing, avoidance/numbing, and hyperarousal clusters in men and women, as well as contributing to global improvement in symptoms.42
Hyperarousal is one of the most distressing and dangerous PTSD symptoms. The literature reflects the role of anxiety and agitation in heightened suicidality and the efficacy of benzodiazepines in providing short-term risk-reduction.46 However, the expert consensus argues against the long-term (longer than 2 weeks) use of benzodiazepines because of risks of addiction and lack of efficacy in reducing core PTSD symptoms.47