Meeting the Needs of Veteran Patients

According to the Veterans Administration, the posttraumatic stress disorder (PTSD) rate among Vietnam veterans was 30.9% for men and 26.9% for women; for Gulf War veterans, the rate was 12.1%; for Operation Enduring Freedom, it was 13.8%.¹ Veterans with PTSD are twice as likely to die from suicide, accidental injury, and viral hepatitis than other Americans. Veterans with PTSD are also more likely to die from diabetes and chronic liver disease and are 5% more likely to die from any cause. Moreover, veterans with PTSD may engage in unhealthy or risky lifestyle behaviors that raise the risk of death.

Meeting the needs of veteran patients is more complex than an approval of any one medication or combination of medications. The suicide rate in veterans with PTSD is 10% to 20%. It has been found that the immediate period after being discharged, up to 1 year, is a crucial time factor for suicidal ideation among veterans. Different PTSD symptoms affect quality of life in men and women.² Women veterans with PTSD whose symptoms of depression were reduced are more likely to see improvements in their quality of life. For men, however, reducing symptoms of anger has a greater effect on improving the quality of their lives.²

Treatment Insights and Challenges

To better care for veterans, the US Department of Veterans Affairs (VA) established the National Center for PTSD in 1989. Today, they lead the world in PTSD research, treatment, and education to help veterans overcome their trauma through individualized care.³ Of those treatment options, evidence-based therapies (EBTs) have proven to be the most effective in treating PTSD.⁴ The 2023 VA/DoD clinical practice guideline recommended the following individual, manualized, trauma-focused psychotherapies for the treatment of PTSD: cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), or prolonged exposure (PE). CPT teaches patients to examine and change negative thoughts. EMDR is a psychotherapy which can help patients process upsetting memories, thoughts, and feelings related to the trauma. PE is an individual therapy for PTSD in which patients gradually approach trauma-related memories, feelings, and situations that they have been avoiding since their trauma.³

The implementation of these treatments in health systems including the US Military Health System (MHS) has been limited.⁴ Efforts to increase the use of evidence-based practice (EBP) have included policies supporting EBP use and provider EBP training via didactic workshops with optional case consultation. Despite these efforts, a majority of US DoD behavioral health providers do not use EBPs when treating patients with PTSD.⁴

Access interventions—strategies designed to lower barriers to entry—for veterans with PTSD demonstrate varied success across interventions and outcomes.⁴ The national initiatives—particularly primary care mental health integration—are successful across several outcomes; telemental health demonstrates promise in improving access; and the success of direct outreach varies across interventions.²

As recently as 2024, the VA practice guidelines recommended against the use of combination therapy (medication and psychotherapy) for PTSD.⁵ Atypical antipsychotic medications—risperidone, aripiprazole, and olanzapine—have been evaluated for augmenting medication treatment in PTSD in the past. For these and other atypical antipsychotic medications there are known serious risks, including weight gain, hyperlipidemia, diabetes mellitus, QTc prolongation, and extrapyramidal adverse effects.⁵ The current recommendation for using brexpiprazole as an adjunct to an SSRI is a break from previous practice and represents an opportunity to improve the lives of veterans experiencing prolonged or previously unresponsive symptoms. The consistency of the results of the clinician-reported and the patient-reported PTSD scales indicates that brexpiprazole plus sertraline treatment leads to noticeably larger clinical and functional improvement than treatment with sertraline alone.²

Although the risks for adverse effects or negative reactions vary across individual patients, they are generally more likely to occur with pharmacologic treatments than with psychotherapy.⁵ Second, the positive effects of medication treatment often diminish over time and are lost when medications are withdrawn. Studies have found personal preference also guides the choices of medication versus therapy interventions for the individual.

The success of evidence-based practice has been less than 50% over time.⁶ The issue has more to do with accessibility of veteran patients concerning the VA medical system. The majority of veterans are being treated in the civilian healthcare system.⁵ Providers within the civilian system are not familiar with treatment of PTSD especially for those individuals exposed to combat situations. The ability to positively screen individuals with PTSD is hampered by civilian healthcare providers who are inexperienced in identifying veteran patients and appropriately diagnosing PTSD. Psychotherapy is a critical part of evidence-based care necessary to provide to people with PTSD.⁵ The ability to provide weekly psychotherapy, a prerequisite for implementing PE, or any EBP, is limited.⁴ Providers are often unable to schedule weekly sessions, and there are average appointment wait times of 2 to 6 weeks across sites. The inability to schedule weekly appointments appeared driven, in part, by a high ratio of patients to providers.

Inconsistent patient education about PTSD treatment options and not connecting patients to EBP providers also limit PE use. VA primary care physicians often do not match patients with PTSD to providers who deliver EBPs for PTSD. Instead, new intakes get assigned to the next available provider, regardless of provider training.⁴

Concluding Thoughts

In conclusion, there are several positive and negative aspects concerning treatment of PTSD in veterans. The risk of suicide and suicidal thoughts are much greater in this population. New treatments and continuing research will have an impact on the issue. Present resources can address diagnosis and treatment of PTSD in a limited number. Expanding education and provider networks show promise. Providing PTSD education to both providers and the public in recognizing the signs and symptoms of PTSD would be a step in the right direction. PTSD is a serious health risk for veterans and sufficient resources should be made available in public and VA health systems to properly assess, diagnose and properly treat the condition. Research into best practice should continue and have appropriate funding by governmental agencies.

Dr Lucas is an associate professor and coordinator of the distance education Psychiatric/Mental Health Nurse Practitioner program at Wilkes University.

References

1. US Department of Veterans Affairs. VA, DoD study a major breakthrough for understanding PTSD. VA News. Published March 24, 2017. Accessed November 11, 2025. https://news.va.gov/36351/va-dod-study-major-breakthrough-understanding-ptsd/
2. US Department of Veterans Affairs, Office of Research & Development. VA research on posttraumatic stress disorder (PTSD) [fact sheet]. Updated August 2020. Accessed November 111, 2025. https://www.research.va.gov/pubs/docs/va_factsheets/ptsd.pdf
3. US Department of Veterans Affairs. VA leads the way in PTSD research and treatment. VA Washington DC Health Care. June 27, 2023. Accessed November 11, 2025. https://www.va.gov/washington-dc-health-care/stories/va-leads-the-way-in-ptsd-research-and-treatment/
4. McLean CP, Cook J, Riggs DS, et al. Barriers and potential solutions to implementing evidence-based PTSD treatment in military treatment facilities. Mil Med. 2024;189(3-4):721-731.
5. Management of Posttraumatic Stress Disorder and Acute Stress Disorder Work Group. VA/DoD clinical practice guideline for management of posttraumatic stress disorder and acute stress disorder. Version 4.0. Department of Veterans Affairs; Department of Defense; 2023. Accessed November 11, 2025. https://www.healthquality.va.gov/guidelines/mh/ptsd/
6. Held P, Splaine CC, Smith DL, Kaysen D. Examining trauma cognition change trajectories among initial PTSD treatment non-optimal responders: a potential avenue to guide subsequent treatment selection. Eur J Psychotraumatol. 2023;14(2):2237361.