Veterans at are an increased risk of trauma, especially female veterans, leading to higher rates of PTSD, anxiety, and depression. How have these impacts changed amid the COVID-19 pandemic?
Written by Hector O. Chapa, M.D., F.A.C.O.G.
It’s well established that the COVID-19 pandemic has had a toll on many Americans’ mental health. However, for one special population, the crisis afflicting mental wellbeing is even more pronounced, yet often overlooked. That population includes the men and women who have served their country: our brave veterans.
Defining the Risk of PTSD Among Our Veterans
Most of general society historically has stereotypically assumed a veteran may suffer from post-traumatic stress disorder (PTSD) due to witnessing the horrors and loss of life during an overseas conflict. However, PTSD may result from a variety of major life conflicts or stressors even without a foreign or prolonged deployment.
Trauma is experienced throughout the lifespan, and traumatic experiences may be remote events or current and ongoing. Traumatic events can include a variety of experiences ranging from sexual abuse to natural disasters to even medical interventions.
Among our veterans, females are at particularly high risk. In a 2009-2011 survey, 41 percent of female veterans reported a history of military sexual trauma, which is a major contributor to PTSD, anxiety, and depression.
Veterans may be more prone to mistrust of medical professionals and may not seek care due to feelings of powerlessness, fear, and hopelessness. Additionally, this reluctance to ask for help may have roots in the military’s traditional culture of “grin and bear it.”
Nonetheless, the data show our veterans are hurting, which should prompt all clinicians to ask patients about any prior military service.
Identifying the Symptoms of PTSD
Once we’re aware of a patient’s military history, what patterns of PTSD should we look for? Helpguide.org lists some signs and symptoms of PTSD that all healthcare providers should be on the lookout for and ask of their patients. While PTSD develops differently in each veteran, there are four symptom clusters:
Recurrent, intrusive reminders of the traumatic event, including distressing thoughts, nightmares, and flashbacks. This may manifest as panic attacks, uncontrollable shaking, and heart palpitations.
Extreme avoidance of things that remind the person of the traumatic event, including people, places, thoughts, or situations associated with trauma. This might cause someone to withdraw from friends and family and lose interest in everyday activities.
Negative changes in thoughts and mood, such as exaggerated negative beliefs about oneself or the world and persistent feelings of fear, guilt, or shame.
Being on guard all the time, jumpy, and emotionally reactive, as indicated by irritability, anger, reckless behavior, difficulty sleeping, trouble concentrating, and hypervigilance (increased alertness).
Enhancing Our Approach to PTSD
Now that we know the symptoms we need to be on the lookout for, what can physicians and all health professionals do to help? There are four key strategies.
First, Realize That “Mental Health” Is Not Just “Mental.”
Trauma history from any etiology has been associated with premature mortality through a variety of mechanisms, some of which are better understood than others. Trauma's effects on the brain and body may include impaired neurobehavioral, social, emotional, and cognitive adverse changes.
Additionally, higher posttraumatic stress severity is associated with altered lipid profiles (e.g., lower high-density lipoprotein levels and higher triglycerides), higher blood pressure, and greater body mass index, all of which lead to a greater total number of cardiovascular risk factors.
Lastly, it’s well known that trauma survivors also are at risk for unhealthy behaviors, such as eating disorders, substance use, and self-harm.
Screening for specific types of trauma is either required or recommended by multiple agencies and organizations, including the Joint Commission, the Women's Preventive Services Initiative, the National Academy of Medicine (formerly the Institute of Medicine), the American Medical Association, and the U.S. Preventive Services Task Force (USPSTF).
A framing statement should be used to preface trauma screening since this helps prepare the patient for potentially difficult questions and conveys the universality of the screening. For example, as stated by the American College of Obstetricians and Gynecologists, it may facilitate dialogue to state the following: “Traumatic events are very common and can have detrimental effects on both physical and mental health. So, I've begun asking all of my patients about any prior difficult experiences they've had and whether or not they feel comfortable discussing them.”
Remember, the purpose of this is to identify and understand the patient’s background, not to judge or condemn.
Third, Healthcare Workers Must Learn the “Trauma-Informed” Care Model.
A trauma-informed approach to care has been defined as “a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological, and emotional safety for both practitioners and survivors and that creates opportunities for survivors to rebuild a sense of control and empowerment.”
Many patients with trauma have difficulty maintaining healthy, open relationships with a healthcare provider. Fortunately, trauma-informed care offers patients the opportunity to engage more fully in their healthcare, develop a trusting relationship with their provider, and improve long-term health outcomes. Trauma-informed care can also help reduce burnout among healthcare providers, potentially reducing staff turnover.
Lastly, Connect Patients with Resources.
All healthcare workers should understand the unique needs that veterans need, both physical and emotional, regardless of their prior deployment history or even in its absence.
That’s why it would be helpful to keep the following list of available resources printed and on hand in case any post-traumatic survivor is identified but not yet willing to accept medical or psychological assistance. Any veteran or military personnel may find support at Military One Source.
Combating a Mental Health Crisis Within a Pandemic
During the COVID-19 pandemic, all Americans have been impacted in some form or another. But those who have bravely and selflessly served our country in the armed forces may be paying a higher price than most. And as healthcare specialists, we owe it to all our patients, and especially our veterans, - to ask, recognize, and above all, understand that PTSD is also running rampant as a parallel pandemic. We must do our part to combat that silent enemy fearlessly.