Mission Critical: Getting Vets With PTSD Back to Work

Barbara J. Meade, MD, DVM, MPH, PhD; Margaret K. Glenn, EdD; Oliver Wirth, PhD


March 29, 2013

Editorial Collaboration

Medscape &

In This Article

Role of Healthcare Providers in Return to Work

By recognizing the unique challenges faced by veterans with PTSD while transitioning from military to civilian life, healthcare providers can play an important role in facilitating their reintegration. Providers have 2 major roles in assisting veterans in return to work. They offer traditional healthcare by identifying and mitigating risk factors; providing preventive care; and treating acute and chronic disease, including mental health conditions.

Providers also have a valuable opportunity to participate in interdisciplinary vocational rehabilitation teams. These services are well integrated within the Veterans Health Administration system; however, because only approximately 50% of OIF/OEF veterans receive their healthcare through the Veterans Health Administration,[8] healthcare providers in the private sector should be aware of the importance of this activity.

Traditional healthcare. Primary care providers in the community must be vigilant in identifying men and women who have served in the military, establishing rapport, taking a through military history, and recognizing the unique healthcare needs of veterans. Providers must be purposeful in asking about military service, because veterans may not readily offer this information and the face of military personnel is changing.

Since 2002, 1.44 million personnel with a history of deployment to Iraq and Afghanistan have separated from the military, and approximately 45% of these individuals are veterans of the Reserves and National Guard.[12] Furthermore, the proportion of the veteran population who are women is increasing and is projected to reach 10% by 2020.[13] With the changing roles of women in the military and subsequent exposure to combat, understanding the challenges that female veterans face may be critical in taking an informative history.[14]

Health in veterans. The following facts should heighten awareness on the part of healthcare professionals when providing care to veterans, particularly those with PTSD:

Up to 80% of military women have experienced sexual harassment, and 25% have been sexually assaulted.[14]

Younger veterans (those < 25 years of age) are at higher risk for alcohol abuse (adjusted relative risk [ARR], 2.21; 95% confidence interval [CI], 1.89-2.59) and other drug use disorders (ARR, 4.92; 95% CI, 3.36-6.66) than are older veterans.[15]

Younger active-duty veterans (those 18-24 years of age) were found to be at a higher risk for receiving 1 or more mental health diagnoses (relative risk [RR], 3.32; 95% CI, 3.12-3.54) and developing PTSD (RR, 5.04; 95% CI, 4.52-5.62) compared with older veterans (those > 40 years of age).[16]

Veterans with PTSD may be at increased risk for metabolic syndrome. One study found that 66.7% of veterans with high-intensity PTSD met the criteria for metabolic syndrome, compared with 23.3% of those with low-intensity PTSD.[17] Comorbid depression may increase the risk.[18]

Veterans, who represent only 0.4% of the population, account for nearly 20% of the estimated 30,000 suicides annually in the United States, with 18 veteran suicides per day.[19]

Veterans who screen positive for PTSD are 4 times more likely to express suicidal ideation than those without PTSD symptoms, and the risk increases with 2 or more comorbid factors.[20] Other suicide risk factors include problems with alcohol use, perceived barriers to care, and family concerns.[21,22]

Veterans may be reluctant to seek mental health treatment, citing concerns that they may lose the trust of coworkers, damage career opportunities, and be prevented from gaining security clearances for postservice employment.[9,23]

Within the Veterans Heath Administration system, where the index of suspicion is high, 60% of mental health disorders are diagnosed in non-mental health settings; 42% are found during primary care visits,[16] underscoring the importance of screening in the primary care setting.

Key resources. A recent article by Spelman and colleagues,[8] "Post Deployment Care for Returning Combat Veterans," reviews key elements of providing primary care for returning veterans, including common risk factors, recommended approaches to care, screening tools, and other useful resources. "Posttraumatic Stress Disorder, Depression, and Suicide in Veterans," by Sher and colleagues,[24] provides insight into unique aspects of suicidal behavior among veterans and potential intervention strategies. "Women and War. What Physicians Should Know," by Murdoch and colleagues,[14] discusses medical and psychiatric conditions among female veterans. These articles are valuable resources for any primary care provider in the private sector.

The Interdisciplinary Return-to-Work Team

Return-to-work assistance is available to all people, including veterans who were in a job and sustained an injury or other medical condition as a result of that job or work environment, and then attempt to return to employment. The process requires a team that assists veterans to understand themselves and their disabling conditions, the role that work plays in recovery, and the resources available to be successful in meeting their goals. These team members include the veteran, the primary care provider, the mental health professional, and the vocational rehabilitation counselor, along with other healthcare professionals if comorbid conditions are present. The vocational rehabilitation counselor may play the most vital role in understanding the relationship between work and recovery.

The primary care provider's role on the team is to recognize the importance of work to a veteran's recovery and how the process of vocational rehabilitation works. The provider can then furnish the team with an employment-focused understanding of the patient's diagnoses, treatment options and prognosis, existing functional limitations, and updates if the patient's condition changes over time.