From War to Home: Psychiatric Emergencies of Returning Veterans

October 3, 2009

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The soldier’s heartache of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Since the time of Homer, warriors have returned from battle with wounds both physical and psychological, and healers from priests to physicians have tried to relieve the pain of injured bodies and tormented minds.1 The "soldier’s heart" of the American Civil War and the shell shock of World War I both describe the human toll of combat that since Vietnam has been clinically recognized as posttraumatic stress disorder (PTSD).2 The veterans of Operation Iraqi Freedom (OIF) and of Operation Enduring Freedom (OEF) share with their brothers and sisters in arms the high cost of war. As of August 2009, there have been 4333 confirmed deaths of US service men and women and 31,156 wounded in Iraq. As of this writing, 796 US soldiers have died in the fighting in Afghanistan.3

Yet, there are also unique aspects of the combat experience of these veterans that influence their psychiatric presentations in acute settings.

First, far more of the troops (up to 45%) are reserve or National Guard rather than active duty compared with earlier wars.4 Their combat exposure, severity of PTSD, and impairments in interpersonal functioning are more similar to those experienced by career military.5 These individuals are most likely to appear in crises in community emergency departments (EDs); they may present with problems that may be different from veterans of previous wars or from soldiers in active military duty.

Typical presenting symptoms are marital stress from unexpectedly long deployments of 15 months (rather than the standard 12), employment concerns, financial stresses, and overall difficulty in reintegrating into civilian life. The absence of a strong military identity and cohesion, geographical separation from comrades, greater stigma, and misunderstanding from communities without exposure to the military or combat trauma serve as formidable barriers to care for these citizen-soldiers.

Second, multiple deployments have become the expectation. Many soldiers serve 2, 3, or even 4 tours of duty-a phenomenon unparalleled in other conflicts. Data from the Mental Health Advisory Team V report show that 11% of soldiers on their first deployment experienced mental health problems; that figure rose to 27% for those on their third tour.6

Third, it is estimated that up to 15% of all soldiers deployed to Iraq are women7; they have assumed an unprecedented combat support role in the war, resulting in greater risk for trauma. (See “Female Veteran Who Had Been Sexually Assaulted” case vignette.)Sadly, these women are also all too frequently victims of sexual harassment and assault. Although estimates from this conflict are not yet available, a study of female outpatients from Veterans Affairs hospitals found 23% had experienced sexual assault and 44% sexual harassment.8

Fourth, the enormous progress of battlefield medicine has created an unprecedented situation in which warriors who would have died in all previous wars from their injuries now survive. They must struggle with multiple devastating wounds-most commonly traumatic brain injuries (TBIs)9 often with co-occurring PTSD.10 Emergency physicians and mental health consultants who work in the ED often encounter returning veterans with subtle forms of cognitive impairment and medical conditions that have gone undiagnosed or untreated.

The goal of this review is to assist ED clinicians and psychiatrists who are faced with the challenges of caring for increasing numbers of returning veterans with combat-related physical and mental trauma. An overview of the epidemiology of mental health conditions identified in OIF/OEF veterans will serve as background for subsequent sections in which evidence-based assessment of PTSD, suicidality, and substance abuse in returning soldiers are the focus.11,12 Management approaches-including crises stabilization, initiation of psychotherapeutic and psychopharmacological treatments when clinically indicated, and (most important) education and counseling of patient and family regarding their mental health issues, safety, and arrangement of proper referral-will then be presented. Case vignettes will also be presented to illustrate these concepts.

It is hoped that the information, clinical guidance, and referral resources offered here will raise the comfort and competence level of ED clinicians so that they may see visits from our returning soldiers as a rewarding opportunity to serve those who have served.

EPIDEMIOLOGICAL BACKGROUND

One of the most comprehensive and authoritative sources for information about the mental health problems of returning soldiers is a 2007 longitudinal assessment of active duty and reserve soldiers returning from Iraq.13 In response to earlier methodological concerns about underestimation of the extent of mental health problems in OIF soldiers, the Department of Defense (DOD) conducted a Post-Deployment Health Re-Assessment (PDHRA) screening of 88,235 soldiers. Screening was administered immediately after return from deployment and then 3 to 6 months later. When compared with the prior study that utilized the Post-Deployment Health Assessment (PDHA), the population-based study that used the PDHRA documented significantly higher rates of mental health issues.14 Clinicians who administered the screening found that 20.3% of active duty and 42.4% of reserve soldiers required treatment for mental health issues. These findings highlight the need for effective outreach to reservists.

The incidence of interpersonal conflict had quadrupled from the earlier survey. This finding, which is particularly relevant for civilian ED staff, underscores the need for treatment not just of the soldier, but of the military family as well. Alcohol problems were frequently identified; nevertheless, few soldiers were referred for treatment. The authors of a JAMA article that compared the results of the PDHRA to the earlier PDHA suggest that this may be related to concerns about stigma and confidentiality that could affect the military careers of reservists and National Guard troops.13 Indeed, the study found that most of the soldiers who received mental health treatment were self-referred-a result echoing the earlier report by Hoge and colleagues.14

Drilling down into this and other literature identifies important diagnostic information for ED clinicians who treat returning soldiers. National Guard and Army Reserve veterans had much higher rates of PTSD, interpersonal conflicts, depression, and overall mental health risk than active duty soldiers (35.5% to 27.1%, respectively), as well as increased rates of referral for mental and physical health concerns.13 Rates of PTSD identified in returning veterans range from 12% to 19%; the most frequently quoted average is 15% to 16%, and rates are higher in OIF than in OEF veterans.15-17

The high prevalence of PTSD in service personnel involved in the wars in Iraq and Afghanistan has been much publicized in the public and professional press, but the elevated rates of other serious mental health disorders-in particular the comorbidity of substance abuse and PTSD-has been underappreciated. Up to 35% of soldiers meet criteria for major depressive disorder, and figures for problem alcohol use range from 11% to 40%, depending on definitions employed, methods of screening, and cohort examined.12,15,16 Respondents with lower education and lower income were more likely to have problematic alcohol use. Several studies have shown that returnees who engage in hazardous drinking are less likely to seek and receive appropriate diagnosis and treatment.12,15

There is a general trend across the research on returning veterans for young cohorts to have more serious mental health problems, including substance abuse and suicidal behavior. Soldiers with mental health issues consistently endorse an overall lower quality of health and life,15,18 higher distress, and functional impairment.16 A PTSD diagnosis alone is associated with more sick calls, missed worked days, worse general health, and a greater number and severity of somatic symptoms.19,20 All of this suggests that many OIF/OEF veterans may present to community EDs with physical symptoms that have a substantial psychosomatic component.20,21 A disturbing finding of emerging research is that returnees, especially OIF veterans with PTSD, have high levels of anger, hostility, and aggression22 and manifest more violent behavior than Vietnam veterans.23

ASSESSMENT OF PTSD

As the above-mentioned demographics indicate, PTSD-often co-occurring with other physical and mental health disorders-will probably be the most common presentation among veterans in community EDs. Thus, it is important for ED mental health professionals, especially emergency psychiatrists, to develop familiarity with the signs and symptoms that characterize the diagnosis as well as with validated screening instruments that can improve the accuracy of a clinical diagnosis. PTSD, acute stress disorder (ASD) and adjustment disorder-all of which can be seen in returning veterans-are unique in the DSM-IV-TR because their etiology in trauma and stress is specified.

PTSD is classified as an anxiety disorder in which there must be exposure to a traumatic event. Criterion A requires that:

1. The individual experiences directly or indirectly, by witnessing or confronting, an event or events that involved the actual or perceived threat of death or serious injury or disruption of physical integrity to the self or another human being.

2. The individual responds to the traumatic exposure with a sense of intense fear, helplessness, or horror.

In addition, a specified number of symptoms from criteria B through D are required and are listed in Table 1. Grouping of the symptoms in 4 core clusters (re-experiencing, avoidance, numbing, and hyperarousal) helps to both understand and recognize the primary dimensions of the disorder.

To distinguish PTSD from ASD, criterion D requires that the symptoms must last longer than 1 month and must cause clinically significant distress or impairment in social, occupational, or other areas of functioning to meet criterion E. PTSD can be classified as either acute, if the symptoms last for less than 3 months, or chronic if they persist longer. There is also a delayed-onset qualifier when criteria are only met for the disorder 6 months after the traumatic event, which several studies suggest may be the pattern in OIF veterans with comorbid depression and battle injuries.24-26

There are several specific assessments that can help the ED clinician identify PTSD. Among the most widely used is the Clinician-Administered PTSD Scale (CAPS),27 a 30-question evaluation corresponding to DSM-IV criteria that assesses severity, frequency, and intensity of current and past PTSD symptoms, as well as multiple areas of psychosocial functioning.28 Many of the more structured interviews have strong psychometric reliability and validity but require more training and time than can be expected in an ED setting. Fortunately, there are also a number of self-report measures that can easily be used in the ED, such as the National Center for PTSD Checklist for veterans.

A scale that has proved useful in the primary care area-the Primary Care PTSD Screen (PTSD-PC)-is also a good fit for the ED.29 It consists of 4 yes/no questions, takes about 2 minutes to administer, and requires no specialized training.

Obviously, positive screens on these briefer self-report measures warrant a comprehensive evaluation. Given the protean nature of the effects of PTSD on all aspects of life and the epidemiology reviewed above, the ED assessment should briefly touch on interpersonal and work functioning, recreation and self-care, physical health, and overall psychological state-including pre-deployment functioning and traumatic events. Note that soldiers experience traumatic experiences other than in combat situations, such as training accidents, exposure to chemical and biological weapons, and family stressors, and that women as well as many men all too frequently are victims of sexual harassment and trauma.30

Substance abuse

Substance use disorders (especially 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

PHARMACOLOGICAL TREATMENT

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 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 prcis of these recommendations is offered in Table 2.

There is general consensus that SSRIs are the first line of treatment for PTSD. Paroxetine and 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

Prazosin, an alpha1-antiadrenergic agent, decreases norepinephrine hyperactivity, which is posited to be a central mechanism in the nightmares and other sleep disturbances that are among the most troubling symptoms in combat veterans. A 2005 clinical case series reported on the use of prazosin in 28 OIF soldiers with combat-related nightmares. The medication, administered at bedtime, resulted in elimination of nightmares in 20 patients and a reduced frequency or intensity of sleep disturbance in 2 patients.48 A 2008 review of 2 case reports, 2 chart reviews, 3 open-labeled trials, and 2 placebo-controlled trials published supports the efficacy and safety of this drug for nightmares in both combat- and noncombat-related trauma. Precise dosing regimens have not yet been established but generally begin with 2 mg at bedtime, with titration to 10 to 15 mg. Orthostatic hypotension and dizziness are the most frequent adverse effects to consider when prescribing.49

The clinical experience of many psychiatrists and PTSD patients is that trazodone is effective for insomnia and nightmares in combat veterans. However, there is a paucity of research to support this finding; the drug is generally well tolerated. However, priapism is a concerning adverse effect, particularly in the younger OIF/OEF cohort.50 Finally, atypical antipsychotics also have an emerging place in PTSD pharmacology, particularly for symptoms of paranoia, intense hypervigilance, arousal, extreme agitation, dissociation, psychotic-type flashbacks, and brief psychotic reactions. Clinicians should keep the metabolic effects of these agents in mind and assess risk factors for obesity, diabetes, and hyperlipidemia if therapy with these agents is begun in the ED.51

PSYCHOTHERAPY

The primary interventions for PTSD and associated trauma spectrum disorders are psychotherapeutic. This is even true in the ED, where time and resources are limited, a sustained therapeutic relationship is absent, and safety considerations frame the exigencies of treatment. Emergency psychiatrists should have a working knowledge of the most strongly recommended psychotherapeutic interventions for PTSD (Table 3) so they can counsel patients about the range of available and effective treatment options. Several of these therapies are available “virtually”52 or online,53 which may be particularly useful for veterans who live in rural areas or small communities with limited mental health resources.

While ED clinicians obviously cannot conduct a course of psychotherapy within the acute setting, fundamentals from these evidence-based approaches can be fruitfully incorporated into the clinical interview. Thus assessment can be transformed into a true therapeutic intervention. These essential elements can be summed up in the acronym C-A-R-E: C-Counseling, A-Assurance, R-Referral, and E-Education.

Counseling focuses less on potentially stigmatizing ascribing of a diagnosis and more on a patient-centered view of presenting distress-whether insomnia, irritability at home, or problems concentrating at work-and shared decision-making regarding treatment approaches.

Assurance offers returnees normalization of the symptoms within a broad trauma-spectrum model. While it does not minimize the difficult struggle facing the returnee, it inspires realistic confidence in the veteran’s innate resilience and hope for recovery.54-58

For the ED clinician, referral may be the most significant action taken on behalf of the returning soldier who may not be aware of the wealth of in-person and Internet resources accessible within and outside the DOD and the VA (Table 4).

Education involves oral and written information on the trauma resulting from the 2 wars and the availability of safe and effective treatments. ED staff may wish to obtain information on the subject from these national organizations as well as from local outreach programs and make it readily available to patients and families.

The greater involvement of Army Reserve and National Guard soldiers underscores the importance of couples and family therapy, which are crucial for successful reintegration.59 Indeed, the spouse often motivates the veteran to seek care and couples therapy, which for OIF/OEF veterans shows promise.60

CONCLUSION

The Pentagon estimates that 1.6 million military personnel have served in either Iraq or Afghanistan since the global war on terror began in 2001. The Rand study completed in January 2008 estimates that 300,000 OIF/OEF soldiers suffer from some mental health problem.61 These daunting statistics argue that nearly every ED in the country will at some time be responsible for the care of the psychiatric needs of returning veterans. Emergency psychiatrists and other mental health professionals have a unique opportunity to provide early diagnosis, and acute treatment, education, and referral for these patients and, in so doing, ease the road from war to home.

References:

References

1.

Shay J.

Achilles in Vietnam: Combat Trauma and the Undoing of Character

. New York: Scribner; 1994.

2.

Healy D.

Images of Trauma: From Hysteria to Post-Traumatic Stress Disorder

. London: Faber and Faber; 1993.

3.

Iraq Coalition Casualty Count.

http://iCasualties.org/

. Copyright 2008. Accessed August 24, 2009.

4.

Coalition for Iraq and Afghanistan Veterans. Veterans issue area: National Guard and Reserves. 2009.

http://coalitionforveterans.org/2008/05/national-guard-and-reserves/

. Accessed July 25, 2009.

5.

Renshaw KD, Rodrigues CS, Jones DH. Combat exposure, psychological symptoms, and marital satisfaction in National Guard soldiers who served in Operation Iraqi Freedom from 2005 to 2006.

Anxiety Stress Coping.

2009;22:101-115.

6.

Office of the Surgeon Multi-National Force Iraq, Office of the Command Surgeon, Office for the Surgeon General US Army Medical Command.

Mental Health Advisory Team (MHAT) V. Operation Iraqi Freedom 06-08: Iraq. Operation Enduring Freedom 8: Afghanistan.

February 14, 2008.

http://www.armymedicine.army.mil/reports/mhat/mhat_v/Redacted1-MHATV-4-FEB-2008-Overview.pdf

. Accessed August 21, 2009.

7.

Wertheimer L. Wounded in war: the women serving in Iraq.

All Things Considered.

National Public Radio. March 14, 2008.

http://www.npr.org/templates/story/story.php?storyId=4534450

. Accessed July 25, 2009.

8.

Skinner KM, Kressin N, Frayne S, et al. The prevalence of military sexual assault among female Veteran Administration outpatients.

J Interpersonal Violence.

2000;15:289-304.

9.

Warden D. Military TBI during the Iraq and Afghanistan wars.

J Head Trauma Rehabil.

2006;21:398-402.

10.

Schneiderman AI, Braver ER, Kang HK. Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: persistent postconcussive symptoms and posttraumatic stress disorder.

Am J Epidemiol.

2008;167:1446-1452.

11.

Kang HK, Bullman TA. Risk of suicide among US veterans after returning from the Iraq or Afghanistan war zones.

JAMA.

2008;300:652-653.

12.

Calhoun PS, Elter JR, Jones ER, et al. Hazardous alcohol use and receipt of risk-reduction counseling among US veterans of the wars in Iraq and Afghanistan.

J Clin Psychiatry.

2008;69:1686-1693.

13.

Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.

JAMA.

2007;298:2141-2148.

14.

Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan.

JAMA.

2006;295:1023-1032.

15.

Erbes C, Westermeyer J, Engdahl B, Johnsen E. Post-traumatic stress disorder and service utilization in a sample of service members from Iraq and Afghanistan.

Mil Med.

2007;172:359-363.

16.

Felker B, Hawkins E, Dobie D, et al. Characteristics of deployed Operation Iraqi Freedom military personnel who seek mental health care.

Mil Med.

2008;173:155-158.

17.

Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.

N Engl J Med.

2004;351:13-22.

18.

Jakupcak M, Luterek J, Hunt S, et al. Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care.

J Nerv Ment Dis.

2008;196:425-428.

19.

Vasterling JJ, Schumm J, Proctor SP, et al. Posttraumatic stress disorder and health functioning in a non-treatment-seeking sample of Iraq war veterans: a prospective analysis.

J Rehabil Res Dev.

2008;45:347-358.

20.

Hoge CW, Terhakopian A, Castro CA, et al. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Am J Psychiatry.

2007;164:150-153.

21.

Rundell JR. Somatoform-spectrum diagnoses among medically evacuated “Operation Enduring Freedom” and “Operation Iraqi Freedom” personnel.

Psychosomatics.

2007;48:149-153.

22.

Jakupcak M, Conybeare D, Phelps L, et al. Anger, hostility, and aggression among Iraq and Afghanistan War veterans reporting PTSD and subthreshold PTSD.

J Trauma Stress.

2007;20:945-954.

23.

Fontana A, Rosenheck R. Treatment-seeking veterans of Iraq and Afghanistan: comparison with veterans of previous wars.

J Nerv Ment Dis.

2008;196:513-521.

24.

American Psychiatric Association.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Text Revision

. Washington, DC: American Psychiatric Press; 2000.

25.

National Center for PTSD. Fact Sheet:

DSM-IV-TR

criteria for PTSD.

www.ptsd.va.gov/professional/pages/dsm-iv-tr-ptsd.asp

. Accessed August 21, 2009.

26.

Grieger TA, Cozza SJ, Ursano RJ, et al. Posttraumatic stress disorder and depression in battle-injured soldiers.

Am J Psychiatry.

2006;163:1777-1783.

27.

Blake DD, Weathers FW, Nagy LM, et al. The development of a Clinician-Administered PTSD Scale.

J Trauma Stress.

1995;8:75-90.

28.

Weathers FW, Keane TM, Davidson JR. Clinician-administered PTSD scale: a review of the first ten years of research.

Depress Anxiety.

2001;13:132-156.

29.

Ouimette P, Wade M, Prins A, Schohn M. Identifying PTSD in primary care: comparison of the Primary Care–PTSD screen (PC-PTSD) and the General Health Questionnaire-12 (GHQ).

J Anxiety Disord.

2008;22:337-343.

30.

Litz B, Orsillio SM. The returning veteran of the Iraq war: background issues and assessment guidelines.

Iraq War Clinician Guide

. 2nd ed. White River Station, VT: National Center for PTSD, Department of Veterans Affairs; 2004:21-32.

31.

Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population.

Alcohol Clin Exp Res.

2005;29:844-854.

32.

Rodríguez-Martos A, Santamariña E. Does the short form of the Alcohol Use Disorders Identification Test (AUDIT-C) work at a trauma emergency department?

Subst Use Misuse.

2007;42:923-932.

33.

Cook JM, Walser RD, Kane V, et al. Dissemination and feasibility of a cognitive-behavioral treatment for substance use disorders and posttraumatic stress disorder in the Veterans Administration.

J Psychoactive Drugs.

2006;38:89-92.

34.

Najavits LM, Weiss RD, Shaw SR, Muenz LR. “Seeking safety”: outcome of a new cognitive-behavioral psychotherapy for women with posttraumatic stress disorder and substance dependence.

J Trauma Stress.

1998;11:437-456.

35.

Corson K, Gerrity MS, Dobscha SK. Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item.

Am J Manag Care.

2004;10:839-845.

36.

Gerrity MS, Corson K, Dobscha SK. Screening for posttraumatic stress disorder in VA primary care patients with depression symptoms.

J Gen Intern Med.

2007;22:1321-1324.

37.

Levin A. Suicide among soldiers still rising as stress piles up.

Am Psychiatr News.

June 20, 2008:12.

38.

Alvarez L. Suicides of soldiers reach high of nearly 3 decades.

New York Times.

January 29, 2009:A19.

39.

Suicide Risk Management and Surveillance Office.

Army Suicide Event Report Calendar Year 2007.

Tacoma, WA: Army Behavioral Health Technology Office.

40.

Desai RA, Dausey D, Rosenheck RA. Suicide among discharged psychiatric inpatients in the Department of Veterans Affairs.

Mil Med.

2008;173:721-728.

41.

Gutierrez PM, Brenner LA, Huggins JA. A preliminary investigation of suicidality in psychiatrically hospitalized veterans with traumatic brain injury.

Arch Suicide Res.

2008;12:336-343.

42.

National Center for PTSD. Pharmacological Treatment of Acute Stress Reactions and PTSD: A Fact Sheet for Providers.

http://www.ptsd.va.gov/professional/pages/pharmacological-treatment-acute-stress.asp

. Accessed August 24, 2009.

43.

Yildiz A, Sachs GS, Turgay A. Pharmacological management of agitation in emergency settings.

Emerg Med J.

2003;20:339-346.

44.

Veterans Health Administration, Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. Version 1.0. Washington, DC: Veterans Health Administration, Department of Defense; 2004.

45.

US Food and Drug Administration. FDA proposes new warnings about suicidal thinking, behavior in young adults who take antidepressant medications

.

May 2, 2007.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108905.htm

. Accessed August 21, 2009.

46.

Fawcett J. The detection and consequences of anxiety in clinical depression.

J Clin Psychiatry.

1997;58(suppl 8):35-40.

47.

Ruzek JI, Curran E, Friedman MJ, et al. Treatment of the returning Iraq war veteran. In:

Iraq War Clinician Guide.

White River Station, VT: Department of Veterans Affairs, National Center for PTSD; 2004.

48.

Daly CM, Doyle ME, Radkind M, et al. Clinical case series: the use of prazosin for combat-related recurrent nightmares among Operation Iraqi Freedom combat veterans.

Mil Med.

2005;170:513-515.

49.

Taylor HR, Freeman MK, Cates ME. Prazosin for treatment of nightmares related to posttraumatic stress disorder.

Am J Health Syst Pharm.

2008;65:716-722.

50.

Warner MD, Dorn MR, Peabody CA. Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares.

Pharmacopsychiatry.

2001;34:128-131.

51.

Ahearn EP, Krohn A, Connor KM, Davidson JR. Pharmacologic treatment of posttraumatic stress disorder: a focus on antipsychotic use.

Ann Clin Psychiatry.

2003;15:193-201.

52.

Rizzo AA, Graap K, Perlman K, et al. Virtual Iraq: initial results from a VR [Virtual Reality] exposure therapy application for combat-related PTSD.

Stud Health Technol Inform.

2008;132:420-425.

53.

Litz BT, Engel CC, Bryant RA, Papa A. A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder.

Am J Psychiatry.

2007;164:1676-1683.

54.

Foa EB. Psychosocial therapy for posttraumatic stress disorder.

J Clin Psychiatry.

2006;67(suppl 2):40-45.

55.

Monson CM, Fredman SJ, Adair KC. Cognitive-behavioral conjoint therapy for posttraumatic stress disorder: application to operation enduring and Iraqi Freedom veterans.

J Clin Psychol.

Aug 2008;64:958-971.

56.

Foa EB, Dancu CV, Hembree EA, et al. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims.

J Consult Clin Psychol.

1999;67:194-200.

57.

Silver SM, Rogers S, Russell M. Eye movement desensitization and reprocessing (EMDR) in the treatment of war veterans.

J Clin Psychol.

2008;64:947-957.

58.

Sammons MT, Batten SV. Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences.

J Clin Psychol.

2008;64:921-927.

59.

Kudler H. The need for psychodynamic principles in outreach to new combat veterans and their families.

J Am Acad Psychoanal Dyn Psychiatry.

2007;35:39-50.

60.

Erbes CR, Polusny MA, Macdermid S, Compton JS. Couple therapy with combat veterans and their partners.

J Clin Psychol.

2008;64:972-983.

61.

Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries.

Santa Monica, CA: Rand Center for Military Health Policy Research; 2008.