Mark B. Stephens, MD

Adolescents are an increasingly diverse population reflecting changes in the racial, ethnic, and geopolitical milieus of the United States. The World Health Organization classifies adolescence as ages 10 to 19 years.¹ However, given the complexity of adolescent development physically, behaviorally, emotionally, and socially, others propose that adolescence may extend to age 24.²

Recognizing the specific challenges adolescents face is key to providing comprehensive longitudinal health care. Moreover, creating an environment of trust helps to ensure open 2-way communication that can facilitate anticipatory guidance.

Our review focuses on common adolescent issues, including injury from vehicles and firearms, tobacco and substance misuse, obesity, behavioral health, sexual health, and social media use. We discuss current trends and recommend strategies to maximize health and wellness.

Start by framing the visit

Confidentiality

Laws governing confidentiality in adolescent health care vary by state. Be aware of the laws pertaining to your practice setting. In addition, health care facilities may have their own policies regarding consent and confidentiality in adolescent care. Discuss confidentiality with both an adolescent and the parent/guardian at the initial visit. And, to help avoid potential misunderstandings, let them know in advance what will (and will not) be divulged.

The American Academy of Pediatrics has developed a useful tip sheet regarding confidentiality laws (www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Confidentiality_Laws.pdf). Examples of required (conditional) disclosure include abuse and suicidal or homicidal ideations. Patients should understand that sexually transmitted infections (STIs) are reportable to public health authorities and that potentially injurious behaviors to self or others (eg, excessive drinking prior to driving) may also warrant disclosure(TABLE 1³).

Privacy and general visit structure

Create a safe atmosphere where adolescents can discuss personal issues without fear of repercussion or judgment. While parents may prefer to be present during the visit, allowing for time to visit independently with an adolescent offers the opportunity to reinforce issues of privacy and confidentiality. Also discuss your office policies regarding electronic communication, phone communication, and relaying test results.

A useful paradigm for organizing a visit for routine adolescent care is to use an expanded version of the HEADSS mnemonic (TABLE 2^4,5), which includes questions about an adolescent’s Home, Education, Activities, Drug and alcohol use, Sexual behavior, Suicidality and depression, and other topics. Other validated screening tools include RAAPS (Rapid Adolescent Prevention Screening)⁶ (www.possibilitiesforchange.com/raaps/); the Guidelines for Adolescent Preventive Services⁷; and the Bright Futures recommendations for preventive care from the American Academy of Pediatrics.⁸ Below, we consider important topics addressed with the HEADSS approach.

Continue to: Injury from vehicles and firearms

Motor vehicle accidents and firearm wounds are the 2 leading causes of adolescent injury. In 2016, of the more than 20,000 deaths in children and adolescents (ages 1-19 years), 20% were due to motor vehicle accidents (4074) and 15% were a result of firearm-­related injuries (3143). Among firearm-­related deaths, 60% were homicides, 35% were suicides, and 4% were due to accidental discharge.⁹ The rate of firearm-related deaths among American teens is 36 times greater than that of any other developed nation.⁹ Currently, 1 of every 3 US households with children younger than 18 has a firearm. Data suggest that in 43% of these households, the firearm is loaded and kept in an unlocked location.¹⁰

To aid anticipatory guidance, ask adolescents about firearm and seat belt use, drinking and driving, and suicidal thoughts (TABLE 2^4,5). Advise them to always wear seat belts whether driving or riding as a passenger. They should never drink and drive (or get in a car with someone who has been drinking). Advise parents that if firearms are present in the household, they should be kept in a secure, locked location. Weapons should be separated from ammunition and safety mechanisms should be engaged on all devices.

Tobacco and substance misuse

Tobacco use, the leading preventable cause of death in the United States,¹¹ is responsible for more deaths than alcohol, motor vehicle accidents, suicides, homicides, and HIV disease combined.¹² Most tobacco-associated mortality occurs in individuals who began smoking before the age of 18.¹² Individuals who start smoking early are also more likely to continue smoking through adulthood.

Encouragingly, tobacco use has declined significantly among adolescents over the past several decades. Roughly 1 in 25 high school seniors reports daily tobacco use.¹³ Adolescent smoking behaviors are also changing dramatically with the increasing popularity of electronic cigarettes (“vaping”). Currently, more adolescents vape than smoke cigarettes.¹³ Vaping has additional health risks including toxic lung injury.

Multiple resources can help combat tobacco and nicotine use in adolescents. The US Preventive Services Task Force recommends that primary care clinicians intervene through education or brief counselling to prevent initiation of tobacco use in school-aged children and adolescents.¹⁴ Ask teens about tobacco and electronic cigarette use and encourage them to quit when use is acknowledged. Other helpful office-based tools are the “Quit Line” 800-QUIT-NOW and texting “Quit” to 47848. Smokefree teen (https://teen.smokefree.gov/) is a website that reviews the risks of tobacco and nicotine use and provides age-appropriate cessation tools and tips (including a smartphone app and a live-chat feature). Other useful information is available in a report from the Surgeon General on preventing tobacco use among young adults.¹⁵

Continue to: Alcohol use

Alcohol use. Three in 5 high school students report ever having used alcohol.¹³ As with tobacco, adolescent alcohol use has declined over the past decade. However, binge drinking (≥ 5 drinks on 1 occasion for males; ≥ 4 drinks on 1 occasion for females) remains a common high-risk behavior among adolescents (particularly college students). Based on the Monitoring the Future Survey, 1 in 6 high school seniors reported binge drinking in the past 2 weeks.¹³ While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.¹³

While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.

The National Institute on Alcohol Abuse and Alcoholism has a screening and intervention guide specifically for adolescents.¹⁶A 2-question screening tool asking about personal use of alcohol and use of alcohol by friends is followed by a risk assessment with recommendations to advise young patients not to drink and to assist them with appropriate intervention and follow-up (https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf).

Illicit drug use. Half of adolescents report using an illicit drug by their senior year in high school.¹³ Marijuana is the most commonly used substance, and laws governing its use are rapidly changing across the United States. Marijuana is illegal in 10 states and legal in 10 states (and the District of Columbia). The remaining states have varying policies on the medical use of marijuana and the decriminalization of marijuana. In addition, cannabinoid (CBD) products are increasingly available. Frequent cannabis use in adolescence has an adverse impact on general executive function (compared with adult users) and learning.¹⁷ Marijuana may serve as a gateway drug in the abuse of other substances,¹⁸ and its use should be strongly discouraged in adolescents.

Of note, there has been a sharp rise in the illicit use of prescription drugs, particularly opioids, creating a public health emergency across the United States.¹⁹ In 2015, more than 4000 young people, ages 15 to 24, died from a drug-related overdose (> 50% of these attributable to opioids).²⁰ Adolescents with a history of substance abuse and behavioral illness are at particular risk. Many adolescents who misuse opioids and other prescription drugs obtain them from friends and relatives.²¹

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends universal screening of adolescents for substance abuse. This screening should be accompanied by a brief intervention to prevent, mitigate, or eliminate substance use, or a referral to appropriate treatment sources. This process of screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care.²²

Continue to: Obesity and physical activity

Obesity and physical activity

The percentage of overweight and obese adolescents in the United States has more than tripled over the past 40 years,²³ and 1 in 5 US adolescents is obese.²³ Obese teens are at higher risk for multiple chronic diseases, including type 2 diabetes, sleep apnea, and heart disease.²⁴ They are also more likely to be bullied and to have poor self-esteem.²⁵ Only 1 in 5 American high school students engages in 60 or more minutes of moderate-to-­vigorous physical activity on 5 or more days per week.²⁶

Regular physical activity is, of course, beneficial for cardiorespiratory fitness, bone health, weight control, and improved indices of behavioral health.²⁶ Adolescents who are physically active consistently demonstrate better school attendance and grades.¹⁷ Higher levels of physical fitness are also associated with improved overall cognitive performance.²⁴

General recommendations. The Department of Health and Human Services recommends that adolescents get at least 60 minutes of mostly moderate physical activity every day.²⁶ Encourage adolescents to engage in vigorous physical activity (heavy breathing, sweating) at least 3 days a week. As part of their physical activity patterns, adolescents should also engage in muscle-­strengthening and bone-strengthening activities on at least 3 days per week.

Behavioral health

As young people develop their sense of personal identity, they also strive for independence. It can be difficult, at times, to differentiate normal adolescent rebellion from true mental illness. An estimated 17% to 19% of adolescents meet criteria for mental illness, and about 7% have a severe psychiatric disorder.²⁷ Only one-third of adolescents with mental illness receive any mental health services.²⁸

Depression. The 1-year incidence of major depression in adolescents is 3% to 4%, and the lifetime prevalence of depressive symptoms is 25% in all high school students.²⁷ Risk factors include ethnic minority status, poor self-esteem, poor health, recent personal crisis, insomnia, and alcohol/­substance abuse. Depression in adolescent girls is correlated with becoming sexually active at a younger age, failure to use contraception, having an STI, and suicide attempts. Depressed boys are more likely to have unprotected intercourse and participate in physical fights.²⁹ Depressed teens have a 2- to 3-fold greater risk for behavioral disorders, anxiety, and attention-deficit/hyperactivity disorder (ADHD).³⁰

Continue to: Suicide

Suicide. Among individuals 15 to 29 years of age, suicide is the second leading cause of death globally, with an annual incidence of 11 to 15 per 100,000.³¹ Suicide attempts are 10 to 20 times more common than completed suicide.³¹ Males are more likely than females to die by suicide,³² and boys with a history of attempted suicide have a 30-fold increased risk of subsequent successful suicide.³¹ Hanging, drug poisoning, and firearms (particularly for males) are the most common means of suicide in adolescents. More than half of adolescents dying by suicide have coexisting depression.³¹

Adolescents prefer that providers address sexual health and are more likely to respond if asked directly about sexual behaviors.

Characteristics associated with suicidal behaviors in adolescents include impulsivity, poor problem-solving skills, and dichotomous thinking.³¹ There may be a genetic component as well. In 1 of 5 teenage suicides, a precipitating life event such as the break-up of a relationship, cyber-bullying, or peer rejection is felt to contribute.³¹

ADHD. The prevalence of ADHD is 7% to 9% in US school-aged children.³³ Boys more commonly exhibit hyperactive behaviors, while girls have more inattention. Hyperactivity often diminishes in teens, but inattention and impulsivity persist. Sequelae of ADHD include high-risk sexual behaviors, motor vehicle accidents, incarceration, and substance abuse.³⁴ Poor self-esteem, suicidal ideation, smoking, and obesity are also increased.³⁴ ADHD often persists into adulthood, with implications for social relationships and job performance.³⁴

Eating disorders. The distribution of eating disorders is now known to increasingly include more minorities and males, the latter representing 5% to 10% of cases.³⁵ Eating disorders show a strong genetic tendency and appear to be accelerated by puberty. The most common eating disorder (diagnosed in 0.8%-14% of teens) is eating disorder not otherwise specified (NOS).³⁵ Anorexia nervosa is diagnosed in 0.5% of adolescent girls, and bulimia nervosa in 1% to 2%—particularly among athletes and performers.³⁵ Unanticipated loss of weight, amenorrhea, excessive concern about weight, and deceleration in height/weight curves are potential indicators of an eating disorder. When identified, eating disorders are best managed by a trusted family physician, acting as a coordinator of a multidisciplinary team.

Sexual health

Girls begin to menstruate at an average age of 12, and it takes about 4 years for them to reach reproductive maturity.³⁶ Puberty has been documented to start at younger ages over the past 30 years, likely due to an increase in average body mass index and a decrease in levels of physical activity.³⁷ Girls with early maturation are often insecure and self-conscious, with higher levels of psychological distress.³⁸ In boys, the average age for spermarche (first ejaculation) is 13.³⁹ Boys who mature early tend to be taller, be more confident, and express a good body image.⁴⁰ Those who have early puberty are more likely to be sexually active or participate in high-risk behaviors.⁴¹

Continue to: Pregnancy and contraception

Over the past several decades, more US teens have been abstaining from sexual intercourse or have been using effective forms of birth control, particularly condoms and long-acting reversible contraceptives (LARCs).⁴² Teenage birth rates in girls ages 15 to 19 have declined significantly since the 1980s.⁴² Despite this, the teenage birth rate in the United States remains higher than in other industrialized nations, and most teen pregnancies are unintended.⁴³ Disparities in teenage birth rates also persist across racial and socioeconomic lines.⁴⁴

Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.

There are numerous interventions to reduce teen pregnancy, including sex education, contraceptive counseling, the use of mobile apps that track a user’s monthly fertility cycle or issue reminders to take oral contraceptives,⁴⁵ and the liberal distribution of contraceptives and condoms. The Contraceptive CHOICE Project shows that providing free (or low-cost) LARCs influences young women to choose these as their preferred contraceptive method.⁴⁶ Other programs specifically empower girls to convince partners to use condoms and to resist unwanted sexual advances or intimate partner violence.

Adolescents prefer to have their health care providers address the topic of sexual health. Teens are more likely to share information with providers if asked directly about sexual behaviors.⁴⁷TABLE 2^4,5 offers tips for anticipatory guidance and potential ways to frame questions with adolescents in this context. State laws vary with regard to the ability of minors to seek contraception, pregnancy testing, or care/screening for STIs without parental consent. Contraceptive counseling combined with effective screening decrease the incidence of STIs and pelvic inflammatory disease for sexually active teens.⁴⁸

Sexually transmitted infections

Young adolescents often have a limited ability to imagine consequences related to specific actions. In general, there is also an increased desire to engage in experimental behaviors as an expression of developing autonomy, which may expose them to STIs. About half of all STIs contracted in the United States occur in individuals 15 to 24 years of age.⁴⁹ Girls are at particular risk for the sequelae of these infections, including cervical dysplasia and infertility. Many teens erroneously believe that sexual activities other than intercourse decrease their risk of contracting an STI.⁵⁰

Human papillomavirus (HPV) infection is the most common STI in adolescence.⁵¹ In most cases, HPV is transient and asymptomatic. Oncogenic strains may cause cervical cancer or cancers of the anogenital or oropharyngeal systems. Due to viral latency, it is not recommended to perform HPV typing in men or in women younger than 30 years of age; however, Pap tests are recommended every 3 years for women ages 21 to 29. Primary care providers are pivotal in the public health struggle to prevent HPV infection.

Continue to: Universal immunization of all children...

Universal immunization of all children older than 11 years of age against HPV is strongly advised as part of routine well-child care. Emphasize the proven role of HPV vaccination in preventing cervical⁵² and oropharyngeal⁵³ cancers. And be prepared to address concerns raised by parents in the context of vaccine safety and the initiation of sexual behaviors (www.cdc.gov/hpv/hcp/answering-questions.html).

Chlamydia is the second most common STI in the United States, usually occurring in individuals younger than 24.⁵⁴ The CDC estimates that more than 3 million new chlamydial infections occur yearly. These infections are often asymptomatic, particularly in females, but may cause urethritis, cervicitis, epididymitis, proctitis, or pelvic inflammatory disease. Indolent chlamydial infection is the leading cause of tubal infertility in women.⁵⁴ Routine annual screening for chlamydia is recommended for all sexually active females ≤ 25 years (and for older women with specific risks).⁵⁵ Annual screening is also recommended for men who have sex with men (MSM).⁵⁵

Chlamydial infection may be diagnosed with first-catch urine sampling (men or women), urethral swab (men), endocervical swab (women), or self-collected vaginal swab. Nucleic acid amplification testing is the most sensitive test that is widely available.⁵⁶ First-line treatment includes either azithromycin (1 g orally, single dose) or doxycycline (100 mg orally, twice daily for 7 days).⁵⁶

Gonorrhea. In 2018, there were more than 500,000 annual cases of gonorrhea, with the majority occurring in those between 15 and 24 years of age.⁵⁷ Gonorrhea may increase rates of HIV infection transmission up to 5-fold.⁵⁷ As more adolescents practice oral sex, cases of pharyngeal gonorrhea (and oropharyngeal HPV) have increased. Symptoms of urethritis occur more frequently in men. Screening is recommended for all sexually active women younger than 25.⁵⁶ Importantly, the organism Neisseria gonorrhoeae has developed significant antibiotic resistance over the past decade. The CDC currently recommends dual therapy for the treatment of gonorrhea using 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin.⁵⁶

Syphilis. Rates of syphilis are increasing among individuals ages 15 to 24.⁵¹ Screening is particularly recommended for MSM and individuals infected with HIV. Benzathine penicillin G, 50,000 U/kg IM, remains the treatment of choice.⁵⁶

Continue to: HIV

HIV. Globally, HIV impacts young people disproportionately. HIV infection also facilitates infection with other STIs. In the United States, the highest burden of HIV infection is borne by young MSM, with prevalence among those 18 to 24 years old varying between 26% to 30% (black) and 3% to 5.5% (non-Hispanic white).⁵¹ The use of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) has recently been approved for the prevention of HIV. PrEP reduces risk by up to 92% for MSM and transgender women.⁵⁸

Sexual identity

One in 10 high school students self-identifies as “nonheterosexual,” and 1 in 15 reports same-sex sexual contact.⁵⁹ The term LGBTQ+ includes the communities of lesbian, gay, bisexual, transgender, transsexual, queer, questioning, intersex, and asexual individuals. Developing a safe sense of sexual identity is fundamental to adolescent psychological development, and many adolescents struggle to develop a positive sexual identity. Suicide rates and self-harm behaviors among ­LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.⁶⁰ Rates of mood disorders, substance abuse, and high-risk sexual behaviors are also increased in the LGBTQ+ population.⁶¹

Suicide rates and self-harm behaviors among LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.

The LGBTQ+ community often seeks health care advice and affirmation from primary care providers. Resources to enhance this care are available at www.lgbthealtheducation.org.

Social media

Adolescents today have more media exposure than any prior generation, with smartphone and computer use increasing exponentially. Most (95%) teens have access to a smartphone,⁶² 45% describe themselves as constantly connected to the Internet, and 14% feel that social media is “addictive.”⁶² Most manage their social media portfolio on multiple sites. Patterns of adolescents' online activities show that boys prefer online gaming, while girls tend to spend more time on social networking.⁶²

Whether extensive media use is psychologically beneficial or deleterious has been widely debated. Increased time online correlates with decreased levels of physical activity.⁶³ And sleep disturbances have been associated with excessive screen time and the presence of mobile devices in the bedroom.⁶⁴ The use of social media prior to bedtime also has an adverse impact on academic performance—particularly for girls. This adverse impact on academics persists after correcting for daytime sleepiness, body mass index, and number of hours spent on homework.⁶⁴

Continue to: Due to growing concerns...

Due to growing concerns about the risks of social media in children and adolescents, the American Academy of Pediatrics has developed the Family Media Plan (www.healthychildren.org/English/media/Pages/default.aspx). Some specific questions that providers may ask are outlined in TABLE 3.⁶⁴ The Family Media Plan can provide age-specific guidelines to assist parents or caregivers in answering these questions.

Cyber-bullying. One in 3 adolescents (primarily female) has been a victim of cyber-bullying.⁶⁵ Sadly, 1 in 5 teens has received some form of electronic sexual solicitation.⁶⁶ The likelihood of unsolicited stranger contact correlates with teens’ online habits and the amount of information disclosed. Predictors include female sex, visiting chat rooms, posting photos, and disclosing personal information. Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.⁶⁵ While 63% of cyber-bullying victims feel upset, embarrassed, or stressed by these contacts,⁶⁶ few events are actually reported. To address this, some states have adopted laws adding cyber-bullying to school disciplinary codes.

Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.

Negative health impacts associated with cyber-bullying include anxiety, sadness, and greater difficulty in concentrating on school work.⁶⁵ Victims of bullying are more likely to have school disciplinary actions and depression and to be truant or to carry weapons to school.⁶⁶ Cyber-bullying is uniquely destructive due to its ubiquitous presence. A sense of relative anonymity online may encourage perpetrators to act more cruelly, with less concern for punishment.

Young people are also more likely to share passwords as a sign of friendship. This may result in others assuming their identity online. Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.⁶⁶

CORRESPONDENCE
Mark B. Stephens, MD, Penn State Health Medical Group, 1850 East Park Avenue, State College, PA 16803; [email protected].

Adolescents are an increasingly diverse population reflecting changes in the racial, ethnic, and geopolitical milieus of the United States. The World Health Organization classifies adolescence as ages 10 to 19 years.¹ However, given the complexity of adolescent development physically, behaviorally, emotionally, and socially, others propose that adolescence may extend to age 24.²

Recognizing the specific challenges adolescents face is key to providing comprehensive longitudinal health care. Moreover, creating an environment of trust helps to ensure open 2-way communication that can facilitate anticipatory guidance.

Our review focuses on common adolescent issues, including injury from vehicles and firearms, tobacco and substance misuse, obesity, behavioral health, sexual health, and social media use. We discuss current trends and recommend strategies to maximize health and wellness.

Start by framing the visit

Confidentiality

Laws governing confidentiality in adolescent health care vary by state. Be aware of the laws pertaining to your practice setting. In addition, health care facilities may have their own policies regarding consent and confidentiality in adolescent care. Discuss confidentiality with both an adolescent and the parent/guardian at the initial visit. And, to help avoid potential misunderstandings, let them know in advance what will (and will not) be divulged.

The American Academy of Pediatrics has developed a useful tip sheet regarding confidentiality laws (www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Confidentiality_Laws.pdf). Examples of required (conditional) disclosure include abuse and suicidal or homicidal ideations. Patients should understand that sexually transmitted infections (STIs) are reportable to public health authorities and that potentially injurious behaviors to self or others (eg, excessive drinking prior to driving) may also warrant disclosure(TABLE 1³).

Privacy and general visit structure

Create a safe atmosphere where adolescents can discuss personal issues without fear of repercussion or judgment. While parents may prefer to be present during the visit, allowing for time to visit independently with an adolescent offers the opportunity to reinforce issues of privacy and confidentiality. Also discuss your office policies regarding electronic communication, phone communication, and relaying test results.

A useful paradigm for organizing a visit for routine adolescent care is to use an expanded version of the HEADSS mnemonic (TABLE 2^4,5), which includes questions about an adolescent’s Home, Education, Activities, Drug and alcohol use, Sexual behavior, Suicidality and depression, and other topics. Other validated screening tools include RAAPS (Rapid Adolescent Prevention Screening)⁶ (www.possibilitiesforchange.com/raaps/); the Guidelines for Adolescent Preventive Services⁷; and the Bright Futures recommendations for preventive care from the American Academy of Pediatrics.⁸ Below, we consider important topics addressed with the HEADSS approach.

Continue to: Injury from vehicles and firearms

Motor vehicle accidents and firearm wounds are the 2 leading causes of adolescent injury. In 2016, of the more than 20,000 deaths in children and adolescents (ages 1-19 years), 20% were due to motor vehicle accidents (4074) and 15% were a result of firearm-­related injuries (3143). Among firearm-­related deaths, 60% were homicides, 35% were suicides, and 4% were due to accidental discharge.⁹ The rate of firearm-related deaths among American teens is 36 times greater than that of any other developed nation.⁹ Currently, 1 of every 3 US households with children younger than 18 has a firearm. Data suggest that in 43% of these households, the firearm is loaded and kept in an unlocked location.¹⁰

To aid anticipatory guidance, ask adolescents about firearm and seat belt use, drinking and driving, and suicidal thoughts (TABLE 2^4,5). Advise them to always wear seat belts whether driving or riding as a passenger. They should never drink and drive (or get in a car with someone who has been drinking). Advise parents that if firearms are present in the household, they should be kept in a secure, locked location. Weapons should be separated from ammunition and safety mechanisms should be engaged on all devices.

Tobacco and substance misuse

Tobacco use, the leading preventable cause of death in the United States,¹¹ is responsible for more deaths than alcohol, motor vehicle accidents, suicides, homicides, and HIV disease combined.¹² Most tobacco-associated mortality occurs in individuals who began smoking before the age of 18.¹² Individuals who start smoking early are also more likely to continue smoking through adulthood.

Encouragingly, tobacco use has declined significantly among adolescents over the past several decades. Roughly 1 in 25 high school seniors reports daily tobacco use.¹³ Adolescent smoking behaviors are also changing dramatically with the increasing popularity of electronic cigarettes (“vaping”). Currently, more adolescents vape than smoke cigarettes.¹³ Vaping has additional health risks including toxic lung injury.

Multiple resources can help combat tobacco and nicotine use in adolescents. The US Preventive Services Task Force recommends that primary care clinicians intervene through education or brief counselling to prevent initiation of tobacco use in school-aged children and adolescents.¹⁴ Ask teens about tobacco and electronic cigarette use and encourage them to quit when use is acknowledged. Other helpful office-based tools are the “Quit Line” 800-QUIT-NOW and texting “Quit” to 47848. Smokefree teen (https://teen.smokefree.gov/) is a website that reviews the risks of tobacco and nicotine use and provides age-appropriate cessation tools and tips (including a smartphone app and a live-chat feature). Other useful information is available in a report from the Surgeon General on preventing tobacco use among young adults.¹⁵

Continue to: Alcohol use

Alcohol use. Three in 5 high school students report ever having used alcohol.¹³ As with tobacco, adolescent alcohol use has declined over the past decade. However, binge drinking (≥ 5 drinks on 1 occasion for males; ≥ 4 drinks on 1 occasion for females) remains a common high-risk behavior among adolescents (particularly college students). Based on the Monitoring the Future Survey, 1 in 6 high school seniors reported binge drinking in the past 2 weeks.¹³ While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.¹³

While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.

The National Institute on Alcohol Abuse and Alcoholism has a screening and intervention guide specifically for adolescents.¹⁶A 2-question screening tool asking about personal use of alcohol and use of alcohol by friends is followed by a risk assessment with recommendations to advise young patients not to drink and to assist them with appropriate intervention and follow-up (https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf).

Illicit drug use. Half of adolescents report using an illicit drug by their senior year in high school.¹³ Marijuana is the most commonly used substance, and laws governing its use are rapidly changing across the United States. Marijuana is illegal in 10 states and legal in 10 states (and the District of Columbia). The remaining states have varying policies on the medical use of marijuana and the decriminalization of marijuana. In addition, cannabinoid (CBD) products are increasingly available. Frequent cannabis use in adolescence has an adverse impact on general executive function (compared with adult users) and learning.¹⁷ Marijuana may serve as a gateway drug in the abuse of other substances,¹⁸ and its use should be strongly discouraged in adolescents.

Of note, there has been a sharp rise in the illicit use of prescription drugs, particularly opioids, creating a public health emergency across the United States.¹⁹ In 2015, more than 4000 young people, ages 15 to 24, died from a drug-related overdose (> 50% of these attributable to opioids).²⁰ Adolescents with a history of substance abuse and behavioral illness are at particular risk. Many adolescents who misuse opioids and other prescription drugs obtain them from friends and relatives.²¹

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends universal screening of adolescents for substance abuse. This screening should be accompanied by a brief intervention to prevent, mitigate, or eliminate substance use, or a referral to appropriate treatment sources. This process of screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care.²²

Continue to: Obesity and physical activity

Obesity and physical activity

The percentage of overweight and obese adolescents in the United States has more than tripled over the past 40 years,²³ and 1 in 5 US adolescents is obese.²³ Obese teens are at higher risk for multiple chronic diseases, including type 2 diabetes, sleep apnea, and heart disease.²⁴ They are also more likely to be bullied and to have poor self-esteem.²⁵ Only 1 in 5 American high school students engages in 60 or more minutes of moderate-to-­vigorous physical activity on 5 or more days per week.²⁶

Regular physical activity is, of course, beneficial for cardiorespiratory fitness, bone health, weight control, and improved indices of behavioral health.²⁶ Adolescents who are physically active consistently demonstrate better school attendance and grades.¹⁷ Higher levels of physical fitness are also associated with improved overall cognitive performance.²⁴

General recommendations. The Department of Health and Human Services recommends that adolescents get at least 60 minutes of mostly moderate physical activity every day.²⁶ Encourage adolescents to engage in vigorous physical activity (heavy breathing, sweating) at least 3 days a week. As part of their physical activity patterns, adolescents should also engage in muscle-­strengthening and bone-strengthening activities on at least 3 days per week.

Behavioral health

As young people develop their sense of personal identity, they also strive for independence. It can be difficult, at times, to differentiate normal adolescent rebellion from true mental illness. An estimated 17% to 19% of adolescents meet criteria for mental illness, and about 7% have a severe psychiatric disorder.²⁷ Only one-third of adolescents with mental illness receive any mental health services.²⁸

Depression. The 1-year incidence of major depression in adolescents is 3% to 4%, and the lifetime prevalence of depressive symptoms is 25% in all high school students.²⁷ Risk factors include ethnic minority status, poor self-esteem, poor health, recent personal crisis, insomnia, and alcohol/­substance abuse. Depression in adolescent girls is correlated with becoming sexually active at a younger age, failure to use contraception, having an STI, and suicide attempts. Depressed boys are more likely to have unprotected intercourse and participate in physical fights.²⁹ Depressed teens have a 2- to 3-fold greater risk for behavioral disorders, anxiety, and attention-deficit/hyperactivity disorder (ADHD).³⁰

Continue to: Suicide

Suicide. Among individuals 15 to 29 years of age, suicide is the second leading cause of death globally, with an annual incidence of 11 to 15 per 100,000.³¹ Suicide attempts are 10 to 20 times more common than completed suicide.³¹ Males are more likely than females to die by suicide,³² and boys with a history of attempted suicide have a 30-fold increased risk of subsequent successful suicide.³¹ Hanging, drug poisoning, and firearms (particularly for males) are the most common means of suicide in adolescents. More than half of adolescents dying by suicide have coexisting depression.³¹

Adolescents prefer that providers address sexual health and are more likely to respond if asked directly about sexual behaviors.

Characteristics associated with suicidal behaviors in adolescents include impulsivity, poor problem-solving skills, and dichotomous thinking.³¹ There may be a genetic component as well. In 1 of 5 teenage suicides, a precipitating life event such as the break-up of a relationship, cyber-bullying, or peer rejection is felt to contribute.³¹

ADHD. The prevalence of ADHD is 7% to 9% in US school-aged children.³³ Boys more commonly exhibit hyperactive behaviors, while girls have more inattention. Hyperactivity often diminishes in teens, but inattention and impulsivity persist. Sequelae of ADHD include high-risk sexual behaviors, motor vehicle accidents, incarceration, and substance abuse.³⁴ Poor self-esteem, suicidal ideation, smoking, and obesity are also increased.³⁴ ADHD often persists into adulthood, with implications for social relationships and job performance.³⁴

Eating disorders. The distribution of eating disorders is now known to increasingly include more minorities and males, the latter representing 5% to 10% of cases.³⁵ Eating disorders show a strong genetic tendency and appear to be accelerated by puberty. The most common eating disorder (diagnosed in 0.8%-14% of teens) is eating disorder not otherwise specified (NOS).³⁵ Anorexia nervosa is diagnosed in 0.5% of adolescent girls, and bulimia nervosa in 1% to 2%—particularly among athletes and performers.³⁵ Unanticipated loss of weight, amenorrhea, excessive concern about weight, and deceleration in height/weight curves are potential indicators of an eating disorder. When identified, eating disorders are best managed by a trusted family physician, acting as a coordinator of a multidisciplinary team.

Sexual health

Girls begin to menstruate at an average age of 12, and it takes about 4 years for them to reach reproductive maturity.³⁶ Puberty has been documented to start at younger ages over the past 30 years, likely due to an increase in average body mass index and a decrease in levels of physical activity.³⁷ Girls with early maturation are often insecure and self-conscious, with higher levels of psychological distress.³⁸ In boys, the average age for spermarche (first ejaculation) is 13.³⁹ Boys who mature early tend to be taller, be more confident, and express a good body image.⁴⁰ Those who have early puberty are more likely to be sexually active or participate in high-risk behaviors.⁴¹

Continue to: Pregnancy and contraception

Over the past several decades, more US teens have been abstaining from sexual intercourse or have been using effective forms of birth control, particularly condoms and long-acting reversible contraceptives (LARCs).⁴² Teenage birth rates in girls ages 15 to 19 have declined significantly since the 1980s.⁴² Despite this, the teenage birth rate in the United States remains higher than in other industrialized nations, and most teen pregnancies are unintended.⁴³ Disparities in teenage birth rates also persist across racial and socioeconomic lines.⁴⁴

Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.

There are numerous interventions to reduce teen pregnancy, including sex education, contraceptive counseling, the use of mobile apps that track a user’s monthly fertility cycle or issue reminders to take oral contraceptives,⁴⁵ and the liberal distribution of contraceptives and condoms. The Contraceptive CHOICE Project shows that providing free (or low-cost) LARCs influences young women to choose these as their preferred contraceptive method.⁴⁶ Other programs specifically empower girls to convince partners to use condoms and to resist unwanted sexual advances or intimate partner violence.

Adolescents prefer to have their health care providers address the topic of sexual health. Teens are more likely to share information with providers if asked directly about sexual behaviors.⁴⁷TABLE 2^4,5 offers tips for anticipatory guidance and potential ways to frame questions with adolescents in this context. State laws vary with regard to the ability of minors to seek contraception, pregnancy testing, or care/screening for STIs without parental consent. Contraceptive counseling combined with effective screening decrease the incidence of STIs and pelvic inflammatory disease for sexually active teens.⁴⁸

Sexually transmitted infections

Young adolescents often have a limited ability to imagine consequences related to specific actions. In general, there is also an increased desire to engage in experimental behaviors as an expression of developing autonomy, which may expose them to STIs. About half of all STIs contracted in the United States occur in individuals 15 to 24 years of age.⁴⁹ Girls are at particular risk for the sequelae of these infections, including cervical dysplasia and infertility. Many teens erroneously believe that sexual activities other than intercourse decrease their risk of contracting an STI.⁵⁰

Human papillomavirus (HPV) infection is the most common STI in adolescence.⁵¹ In most cases, HPV is transient and asymptomatic. Oncogenic strains may cause cervical cancer or cancers of the anogenital or oropharyngeal systems. Due to viral latency, it is not recommended to perform HPV typing in men or in women younger than 30 years of age; however, Pap tests are recommended every 3 years for women ages 21 to 29. Primary care providers are pivotal in the public health struggle to prevent HPV infection.

Continue to: Universal immunization of all children...

Universal immunization of all children older than 11 years of age against HPV is strongly advised as part of routine well-child care. Emphasize the proven role of HPV vaccination in preventing cervical⁵² and oropharyngeal⁵³ cancers. And be prepared to address concerns raised by parents in the context of vaccine safety and the initiation of sexual behaviors (www.cdc.gov/hpv/hcp/answering-questions.html).

Chlamydia is the second most common STI in the United States, usually occurring in individuals younger than 24.⁵⁴ The CDC estimates that more than 3 million new chlamydial infections occur yearly. These infections are often asymptomatic, particularly in females, but may cause urethritis, cervicitis, epididymitis, proctitis, or pelvic inflammatory disease. Indolent chlamydial infection is the leading cause of tubal infertility in women.⁵⁴ Routine annual screening for chlamydia is recommended for all sexually active females ≤ 25 years (and for older women with specific risks).⁵⁵ Annual screening is also recommended for men who have sex with men (MSM).⁵⁵

Chlamydial infection may be diagnosed with first-catch urine sampling (men or women), urethral swab (men), endocervical swab (women), or self-collected vaginal swab. Nucleic acid amplification testing is the most sensitive test that is widely available.⁵⁶ First-line treatment includes either azithromycin (1 g orally, single dose) or doxycycline (100 mg orally, twice daily for 7 days).⁵⁶

Gonorrhea. In 2018, there were more than 500,000 annual cases of gonorrhea, with the majority occurring in those between 15 and 24 years of age.⁵⁷ Gonorrhea may increase rates of HIV infection transmission up to 5-fold.⁵⁷ As more adolescents practice oral sex, cases of pharyngeal gonorrhea (and oropharyngeal HPV) have increased. Symptoms of urethritis occur more frequently in men. Screening is recommended for all sexually active women younger than 25.⁵⁶ Importantly, the organism Neisseria gonorrhoeae has developed significant antibiotic resistance over the past decade. The CDC currently recommends dual therapy for the treatment of gonorrhea using 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin.⁵⁶

Syphilis. Rates of syphilis are increasing among individuals ages 15 to 24.⁵¹ Screening is particularly recommended for MSM and individuals infected with HIV. Benzathine penicillin G, 50,000 U/kg IM, remains the treatment of choice.⁵⁶

Continue to: HIV

HIV. Globally, HIV impacts young people disproportionately. HIV infection also facilitates infection with other STIs. In the United States, the highest burden of HIV infection is borne by young MSM, with prevalence among those 18 to 24 years old varying between 26% to 30% (black) and 3% to 5.5% (non-Hispanic white).⁵¹ The use of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) has recently been approved for the prevention of HIV. PrEP reduces risk by up to 92% for MSM and transgender women.⁵⁸

Sexual identity

One in 10 high school students self-identifies as “nonheterosexual,” and 1 in 15 reports same-sex sexual contact.⁵⁹ The term LGBTQ+ includes the communities of lesbian, gay, bisexual, transgender, transsexual, queer, questioning, intersex, and asexual individuals. Developing a safe sense of sexual identity is fundamental to adolescent psychological development, and many adolescents struggle to develop a positive sexual identity. Suicide rates and self-harm behaviors among ­LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.⁶⁰ Rates of mood disorders, substance abuse, and high-risk sexual behaviors are also increased in the LGBTQ+ population.⁶¹

Suicide rates and self-harm behaviors among LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.

The LGBTQ+ community often seeks health care advice and affirmation from primary care providers. Resources to enhance this care are available at www.lgbthealtheducation.org.

Social media

Adolescents today have more media exposure than any prior generation, with smartphone and computer use increasing exponentially. Most (95%) teens have access to a smartphone,⁶² 45% describe themselves as constantly connected to the Internet, and 14% feel that social media is “addictive.”⁶² Most manage their social media portfolio on multiple sites. Patterns of adolescents' online activities show that boys prefer online gaming, while girls tend to spend more time on social networking.⁶²

Whether extensive media use is psychologically beneficial or deleterious has been widely debated. Increased time online correlates with decreased levels of physical activity.⁶³ And sleep disturbances have been associated with excessive screen time and the presence of mobile devices in the bedroom.⁶⁴ The use of social media prior to bedtime also has an adverse impact on academic performance—particularly for girls. This adverse impact on academics persists after correcting for daytime sleepiness, body mass index, and number of hours spent on homework.⁶⁴

Continue to: Due to growing concerns...

Due to growing concerns about the risks of social media in children and adolescents, the American Academy of Pediatrics has developed the Family Media Plan (www.healthychildren.org/English/media/Pages/default.aspx). Some specific questions that providers may ask are outlined in TABLE 3.⁶⁴ The Family Media Plan can provide age-specific guidelines to assist parents or caregivers in answering these questions.

Cyber-bullying. One in 3 adolescents (primarily female) has been a victim of cyber-bullying.⁶⁵ Sadly, 1 in 5 teens has received some form of electronic sexual solicitation.⁶⁶ The likelihood of unsolicited stranger contact correlates with teens’ online habits and the amount of information disclosed. Predictors include female sex, visiting chat rooms, posting photos, and disclosing personal information. Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.⁶⁵ While 63% of cyber-bullying victims feel upset, embarrassed, or stressed by these contacts,⁶⁶ few events are actually reported. To address this, some states have adopted laws adding cyber-bullying to school disciplinary codes.

Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.

Negative health impacts associated with cyber-bullying include anxiety, sadness, and greater difficulty in concentrating on school work.⁶⁵ Victims of bullying are more likely to have school disciplinary actions and depression and to be truant or to carry weapons to school.⁶⁶ Cyber-bullying is uniquely destructive due to its ubiquitous presence. A sense of relative anonymity online may encourage perpetrators to act more cruelly, with less concern for punishment.

Young people are also more likely to share passwords as a sign of friendship. This may result in others assuming their identity online. Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.⁶⁶

CORRESPONDENCE
Mark B. Stephens, MD, Penn State Health Medical Group, 1850 East Park Avenue, State College, PA 16803; [email protected].

Adolescents are an increasingly diverse population reflecting changes in the racial, ethnic, and geopolitical milieus of the United States. The World Health Organization classifies adolescence as ages 10 to 19 years.¹ However, given the complexity of adolescent development physically, behaviorally, emotionally, and socially, others propose that adolescence may extend to age 24.²

Recognizing the specific challenges adolescents face is key to providing comprehensive longitudinal health care. Moreover, creating an environment of trust helps to ensure open 2-way communication that can facilitate anticipatory guidance.

Our review focuses on common adolescent issues, including injury from vehicles and firearms, tobacco and substance misuse, obesity, behavioral health, sexual health, and social media use. We discuss current trends and recommend strategies to maximize health and wellness.

Start by framing the visit

Confidentiality

Laws governing confidentiality in adolescent health care vary by state. Be aware of the laws pertaining to your practice setting. In addition, health care facilities may have their own policies regarding consent and confidentiality in adolescent care. Discuss confidentiality with both an adolescent and the parent/guardian at the initial visit. And, to help avoid potential misunderstandings, let them know in advance what will (and will not) be divulged.

The American Academy of Pediatrics has developed a useful tip sheet regarding confidentiality laws (www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Confidentiality_Laws.pdf). Examples of required (conditional) disclosure include abuse and suicidal or homicidal ideations. Patients should understand that sexually transmitted infections (STIs) are reportable to public health authorities and that potentially injurious behaviors to self or others (eg, excessive drinking prior to driving) may also warrant disclosure(TABLE 1³).

Privacy and general visit structure

Create a safe atmosphere where adolescents can discuss personal issues without fear of repercussion or judgment. While parents may prefer to be present during the visit, allowing for time to visit independently with an adolescent offers the opportunity to reinforce issues of privacy and confidentiality. Also discuss your office policies regarding electronic communication, phone communication, and relaying test results.

A useful paradigm for organizing a visit for routine adolescent care is to use an expanded version of the HEADSS mnemonic (TABLE 2^4,5), which includes questions about an adolescent’s Home, Education, Activities, Drug and alcohol use, Sexual behavior, Suicidality and depression, and other topics. Other validated screening tools include RAAPS (Rapid Adolescent Prevention Screening)⁶ (www.possibilitiesforchange.com/raaps/); the Guidelines for Adolescent Preventive Services⁷; and the Bright Futures recommendations for preventive care from the American Academy of Pediatrics.⁸ Below, we consider important topics addressed with the HEADSS approach.

Continue to: Injury from vehicles and firearms

Motor vehicle accidents and firearm wounds are the 2 leading causes of adolescent injury. In 2016, of the more than 20,000 deaths in children and adolescents (ages 1-19 years), 20% were due to motor vehicle accidents (4074) and 15% were a result of firearm-­related injuries (3143). Among firearm-­related deaths, 60% were homicides, 35% were suicides, and 4% were due to accidental discharge.⁹ The rate of firearm-related deaths among American teens is 36 times greater than that of any other developed nation.⁹ Currently, 1 of every 3 US households with children younger than 18 has a firearm. Data suggest that in 43% of these households, the firearm is loaded and kept in an unlocked location.¹⁰

To aid anticipatory guidance, ask adolescents about firearm and seat belt use, drinking and driving, and suicidal thoughts (TABLE 2^4,5). Advise them to always wear seat belts whether driving or riding as a passenger. They should never drink and drive (or get in a car with someone who has been drinking). Advise parents that if firearms are present in the household, they should be kept in a secure, locked location. Weapons should be separated from ammunition and safety mechanisms should be engaged on all devices.

Tobacco and substance misuse

Tobacco use, the leading preventable cause of death in the United States,¹¹ is responsible for more deaths than alcohol, motor vehicle accidents, suicides, homicides, and HIV disease combined.¹² Most tobacco-associated mortality occurs in individuals who began smoking before the age of 18.¹² Individuals who start smoking early are also more likely to continue smoking through adulthood.

Encouragingly, tobacco use has declined significantly among adolescents over the past several decades. Roughly 1 in 25 high school seniors reports daily tobacco use.¹³ Adolescent smoking behaviors are also changing dramatically with the increasing popularity of electronic cigarettes (“vaping”). Currently, more adolescents vape than smoke cigarettes.¹³ Vaping has additional health risks including toxic lung injury.

Multiple resources can help combat tobacco and nicotine use in adolescents. The US Preventive Services Task Force recommends that primary care clinicians intervene through education or brief counselling to prevent initiation of tobacco use in school-aged children and adolescents.¹⁴ Ask teens about tobacco and electronic cigarette use and encourage them to quit when use is acknowledged. Other helpful office-based tools are the “Quit Line” 800-QUIT-NOW and texting “Quit” to 47848. Smokefree teen (https://teen.smokefree.gov/) is a website that reviews the risks of tobacco and nicotine use and provides age-appropriate cessation tools and tips (including a smartphone app and a live-chat feature). Other useful information is available in a report from the Surgeon General on preventing tobacco use among young adults.¹⁵

Continue to: Alcohol use

Alcohol use. Three in 5 high school students report ever having used alcohol.¹³ As with tobacco, adolescent alcohol use has declined over the past decade. However, binge drinking (≥ 5 drinks on 1 occasion for males; ≥ 4 drinks on 1 occasion for females) remains a common high-risk behavior among adolescents (particularly college students). Based on the Monitoring the Future Survey, 1 in 6 high school seniors reported binge drinking in the past 2 weeks.¹³ While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.¹³

While historically more common among males, rates of binge drinking are now basically similar between male and female adolescents.

The National Institute on Alcohol Abuse and Alcoholism has a screening and intervention guide specifically for adolescents.¹⁶A 2-question screening tool asking about personal use of alcohol and use of alcohol by friends is followed by a risk assessment with recommendations to advise young patients not to drink and to assist them with appropriate intervention and follow-up (https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuidePocket.pdf).

Illicit drug use. Half of adolescents report using an illicit drug by their senior year in high school.¹³ Marijuana is the most commonly used substance, and laws governing its use are rapidly changing across the United States. Marijuana is illegal in 10 states and legal in 10 states (and the District of Columbia). The remaining states have varying policies on the medical use of marijuana and the decriminalization of marijuana. In addition, cannabinoid (CBD) products are increasingly available. Frequent cannabis use in adolescence has an adverse impact on general executive function (compared with adult users) and learning.¹⁷ Marijuana may serve as a gateway drug in the abuse of other substances,¹⁸ and its use should be strongly discouraged in adolescents.

Of note, there has been a sharp rise in the illicit use of prescription drugs, particularly opioids, creating a public health emergency across the United States.¹⁹ In 2015, more than 4000 young people, ages 15 to 24, died from a drug-related overdose (> 50% of these attributable to opioids).²⁰ Adolescents with a history of substance abuse and behavioral illness are at particular risk. Many adolescents who misuse opioids and other prescription drugs obtain them from friends and relatives.²¹

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends universal screening of adolescents for substance abuse. This screening should be accompanied by a brief intervention to prevent, mitigate, or eliminate substance use, or a referral to appropriate treatment sources. This process of screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care.²²

Continue to: Obesity and physical activity

Obesity and physical activity

The percentage of overweight and obese adolescents in the United States has more than tripled over the past 40 years,²³ and 1 in 5 US adolescents is obese.²³ Obese teens are at higher risk for multiple chronic diseases, including type 2 diabetes, sleep apnea, and heart disease.²⁴ They are also more likely to be bullied and to have poor self-esteem.²⁵ Only 1 in 5 American high school students engages in 60 or more minutes of moderate-to-­vigorous physical activity on 5 or more days per week.²⁶

Regular physical activity is, of course, beneficial for cardiorespiratory fitness, bone health, weight control, and improved indices of behavioral health.²⁶ Adolescents who are physically active consistently demonstrate better school attendance and grades.¹⁷ Higher levels of physical fitness are also associated with improved overall cognitive performance.²⁴

General recommendations. The Department of Health and Human Services recommends that adolescents get at least 60 minutes of mostly moderate physical activity every day.²⁶ Encourage adolescents to engage in vigorous physical activity (heavy breathing, sweating) at least 3 days a week. As part of their physical activity patterns, adolescents should also engage in muscle-­strengthening and bone-strengthening activities on at least 3 days per week.

Behavioral health

As young people develop their sense of personal identity, they also strive for independence. It can be difficult, at times, to differentiate normal adolescent rebellion from true mental illness. An estimated 17% to 19% of adolescents meet criteria for mental illness, and about 7% have a severe psychiatric disorder.²⁷ Only one-third of adolescents with mental illness receive any mental health services.²⁸

Depression. The 1-year incidence of major depression in adolescents is 3% to 4%, and the lifetime prevalence of depressive symptoms is 25% in all high school students.²⁷ Risk factors include ethnic minority status, poor self-esteem, poor health, recent personal crisis, insomnia, and alcohol/­substance abuse. Depression in adolescent girls is correlated with becoming sexually active at a younger age, failure to use contraception, having an STI, and suicide attempts. Depressed boys are more likely to have unprotected intercourse and participate in physical fights.²⁹ Depressed teens have a 2- to 3-fold greater risk for behavioral disorders, anxiety, and attention-deficit/hyperactivity disorder (ADHD).³⁰

Continue to: Suicide

Suicide. Among individuals 15 to 29 years of age, suicide is the second leading cause of death globally, with an annual incidence of 11 to 15 per 100,000.³¹ Suicide attempts are 10 to 20 times more common than completed suicide.³¹ Males are more likely than females to die by suicide,³² and boys with a history of attempted suicide have a 30-fold increased risk of subsequent successful suicide.³¹ Hanging, drug poisoning, and firearms (particularly for males) are the most common means of suicide in adolescents. More than half of adolescents dying by suicide have coexisting depression.³¹

Adolescents prefer that providers address sexual health and are more likely to respond if asked directly about sexual behaviors.

Characteristics associated with suicidal behaviors in adolescents include impulsivity, poor problem-solving skills, and dichotomous thinking.³¹ There may be a genetic component as well. In 1 of 5 teenage suicides, a precipitating life event such as the break-up of a relationship, cyber-bullying, or peer rejection is felt to contribute.³¹

ADHD. The prevalence of ADHD is 7% to 9% in US school-aged children.³³ Boys more commonly exhibit hyperactive behaviors, while girls have more inattention. Hyperactivity often diminishes in teens, but inattention and impulsivity persist. Sequelae of ADHD include high-risk sexual behaviors, motor vehicle accidents, incarceration, and substance abuse.³⁴ Poor self-esteem, suicidal ideation, smoking, and obesity are also increased.³⁴ ADHD often persists into adulthood, with implications for social relationships and job performance.³⁴

Eating disorders. The distribution of eating disorders is now known to increasingly include more minorities and males, the latter representing 5% to 10% of cases.³⁵ Eating disorders show a strong genetic tendency and appear to be accelerated by puberty. The most common eating disorder (diagnosed in 0.8%-14% of teens) is eating disorder not otherwise specified (NOS).³⁵ Anorexia nervosa is diagnosed in 0.5% of adolescent girls, and bulimia nervosa in 1% to 2%—particularly among athletes and performers.³⁵ Unanticipated loss of weight, amenorrhea, excessive concern about weight, and deceleration in height/weight curves are potential indicators of an eating disorder. When identified, eating disorders are best managed by a trusted family physician, acting as a coordinator of a multidisciplinary team.

Sexual health

Girls begin to menstruate at an average age of 12, and it takes about 4 years for them to reach reproductive maturity.³⁶ Puberty has been documented to start at younger ages over the past 30 years, likely due to an increase in average body mass index and a decrease in levels of physical activity.³⁷ Girls with early maturation are often insecure and self-conscious, with higher levels of psychological distress.³⁸ In boys, the average age for spermarche (first ejaculation) is 13.³⁹ Boys who mature early tend to be taller, be more confident, and express a good body image.⁴⁰ Those who have early puberty are more likely to be sexually active or participate in high-risk behaviors.⁴¹

Continue to: Pregnancy and contraception

Over the past several decades, more US teens have been abstaining from sexual intercourse or have been using effective forms of birth control, particularly condoms and long-acting reversible contraceptives (LARCs).⁴² Teenage birth rates in girls ages 15 to 19 have declined significantly since the 1980s.⁴² Despite this, the teenage birth rate in the United States remains higher than in other industrialized nations, and most teen pregnancies are unintended.⁴³ Disparities in teenage birth rates also persist across racial and socioeconomic lines.⁴⁴

Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.

There are numerous interventions to reduce teen pregnancy, including sex education, contraceptive counseling, the use of mobile apps that track a user’s monthly fertility cycle or issue reminders to take oral contraceptives,⁴⁵ and the liberal distribution of contraceptives and condoms. The Contraceptive CHOICE Project shows that providing free (or low-cost) LARCs influences young women to choose these as their preferred contraceptive method.⁴⁶ Other programs specifically empower girls to convince partners to use condoms and to resist unwanted sexual advances or intimate partner violence.

Adolescents prefer to have their health care providers address the topic of sexual health. Teens are more likely to share information with providers if asked directly about sexual behaviors.⁴⁷TABLE 2^4,5 offers tips for anticipatory guidance and potential ways to frame questions with adolescents in this context. State laws vary with regard to the ability of minors to seek contraception, pregnancy testing, or care/screening for STIs without parental consent. Contraceptive counseling combined with effective screening decrease the incidence of STIs and pelvic inflammatory disease for sexually active teens.⁴⁸

Sexually transmitted infections

Young adolescents often have a limited ability to imagine consequences related to specific actions. In general, there is also an increased desire to engage in experimental behaviors as an expression of developing autonomy, which may expose them to STIs. About half of all STIs contracted in the United States occur in individuals 15 to 24 years of age.⁴⁹ Girls are at particular risk for the sequelae of these infections, including cervical dysplasia and infertility. Many teens erroneously believe that sexual activities other than intercourse decrease their risk of contracting an STI.⁵⁰

Human papillomavirus (HPV) infection is the most common STI in adolescence.⁵¹ In most cases, HPV is transient and asymptomatic. Oncogenic strains may cause cervical cancer or cancers of the anogenital or oropharyngeal systems. Due to viral latency, it is not recommended to perform HPV typing in men or in women younger than 30 years of age; however, Pap tests are recommended every 3 years for women ages 21 to 29. Primary care providers are pivotal in the public health struggle to prevent HPV infection.

Continue to: Universal immunization of all children...

Universal immunization of all children older than 11 years of age against HPV is strongly advised as part of routine well-child care. Emphasize the proven role of HPV vaccination in preventing cervical⁵² and oropharyngeal⁵³ cancers. And be prepared to address concerns raised by parents in the context of vaccine safety and the initiation of sexual behaviors (www.cdc.gov/hpv/hcp/answering-questions.html).

Chlamydia is the second most common STI in the United States, usually occurring in individuals younger than 24.⁵⁴ The CDC estimates that more than 3 million new chlamydial infections occur yearly. These infections are often asymptomatic, particularly in females, but may cause urethritis, cervicitis, epididymitis, proctitis, or pelvic inflammatory disease. Indolent chlamydial infection is the leading cause of tubal infertility in women.⁵⁴ Routine annual screening for chlamydia is recommended for all sexually active females ≤ 25 years (and for older women with specific risks).⁵⁵ Annual screening is also recommended for men who have sex with men (MSM).⁵⁵

Chlamydial infection may be diagnosed with first-catch urine sampling (men or women), urethral swab (men), endocervical swab (women), or self-collected vaginal swab. Nucleic acid amplification testing is the most sensitive test that is widely available.⁵⁶ First-line treatment includes either azithromycin (1 g orally, single dose) or doxycycline (100 mg orally, twice daily for 7 days).⁵⁶

Gonorrhea. In 2018, there were more than 500,000 annual cases of gonorrhea, with the majority occurring in those between 15 and 24 years of age.⁵⁷ Gonorrhea may increase rates of HIV infection transmission up to 5-fold.⁵⁷ As more adolescents practice oral sex, cases of pharyngeal gonorrhea (and oropharyngeal HPV) have increased. Symptoms of urethritis occur more frequently in men. Screening is recommended for all sexually active women younger than 25.⁵⁶ Importantly, the organism Neisseria gonorrhoeae has developed significant antibiotic resistance over the past decade. The CDC currently recommends dual therapy for the treatment of gonorrhea using 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin.⁵⁶

Syphilis. Rates of syphilis are increasing among individuals ages 15 to 24.⁵¹ Screening is particularly recommended for MSM and individuals infected with HIV. Benzathine penicillin G, 50,000 U/kg IM, remains the treatment of choice.⁵⁶

Continue to: HIV

HIV. Globally, HIV impacts young people disproportionately. HIV infection also facilitates infection with other STIs. In the United States, the highest burden of HIV infection is borne by young MSM, with prevalence among those 18 to 24 years old varying between 26% to 30% (black) and 3% to 5.5% (non-Hispanic white).⁵¹ The use of emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis (PrEP) has recently been approved for the prevention of HIV. PrEP reduces risk by up to 92% for MSM and transgender women.⁵⁸

Sexual identity

One in 10 high school students self-identifies as “nonheterosexual,” and 1 in 15 reports same-sex sexual contact.⁵⁹ The term LGBTQ+ includes the communities of lesbian, gay, bisexual, transgender, transsexual, queer, questioning, intersex, and asexual individuals. Developing a safe sense of sexual identity is fundamental to adolescent psychological development, and many adolescents struggle to develop a positive sexual identity. Suicide rates and self-harm behaviors among ­LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.⁶⁰ Rates of mood disorders, substance abuse, and high-risk sexual behaviors are also increased in the LGBTQ+ population.⁶¹

Suicide rates and self-harm behaviors among LGBTQ+ adolescents can be 4 times higher than among their heterosexual peers.

The LGBTQ+ community often seeks health care advice and affirmation from primary care providers. Resources to enhance this care are available at www.lgbthealtheducation.org.

Social media

Adolescents today have more media exposure than any prior generation, with smartphone and computer use increasing exponentially. Most (95%) teens have access to a smartphone,⁶² 45% describe themselves as constantly connected to the Internet, and 14% feel that social media is “addictive.”⁶² Most manage their social media portfolio on multiple sites. Patterns of adolescents' online activities show that boys prefer online gaming, while girls tend to spend more time on social networking.⁶²

Whether extensive media use is psychologically beneficial or deleterious has been widely debated. Increased time online correlates with decreased levels of physical activity.⁶³ And sleep disturbances have been associated with excessive screen time and the presence of mobile devices in the bedroom.⁶⁴ The use of social media prior to bedtime also has an adverse impact on academic performance—particularly for girls. This adverse impact on academics persists after correcting for daytime sleepiness, body mass index, and number of hours spent on homework.⁶⁴

Continue to: Due to growing concerns...

Due to growing concerns about the risks of social media in children and adolescents, the American Academy of Pediatrics has developed the Family Media Plan (www.healthychildren.org/English/media/Pages/default.aspx). Some specific questions that providers may ask are outlined in TABLE 3.⁶⁴ The Family Media Plan can provide age-specific guidelines to assist parents or caregivers in answering these questions.

Cyber-bullying. One in 3 adolescents (primarily female) has been a victim of cyber-bullying.⁶⁵ Sadly, 1 in 5 teens has received some form of electronic sexual solicitation.⁶⁶ The likelihood of unsolicited stranger contact correlates with teens’ online habits and the amount of information disclosed. Predictors include female sex, visiting chat rooms, posting photos, and disclosing personal information. Restricting computer use to an area with parental supervision or installing monitoring programs does not seem to exert any protective influence on cyber-bullying or unsolicited stranger contact.⁶⁵ While 63% of cyber-bullying victims feel upset, embarrassed, or stressed by these contacts,⁶⁶ few events are actually reported. To address this, some states have adopted laws adding cyber-bullying to school disciplinary codes.

Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.

Negative health impacts associated with cyber-bullying include anxiety, sadness, and greater difficulty in concentrating on school work.⁶⁵ Victims of bullying are more likely to have school disciplinary actions and depression and to be truant or to carry weapons to school.⁶⁶ Cyber-bullying is uniquely destructive due to its ubiquitous presence. A sense of relative anonymity online may encourage perpetrators to act more cruelly, with less concern for punishment.

Young people are also more likely to share passwords as a sign of friendship. This may result in others assuming their identity online. Adolescents rarely disclose bullying to parents or other adults, fearing restriction of Internet access, and many of them think that adults may downplay the seriousness of the events.⁶⁶

CORRESPONDENCE
Mark B. Stephens, MD, Penn State Health Medical Group, 1850 East Park Avenue, State College, PA 16803; [email protected].

CASE A 37-year-old white woman presents for an employment physical. Your nurse reports that she also has a complaint of headaches, that she scored an 8 on the Alcohol Use Disorders identification Test-consumption (AUDiT-c), and that the result on her patient health Questionnaire (phQ-2) suggests a depressive disorder. You ask the patient whether she has served in the military and discover that, in the last 4 years, she served 2 year-long tours in Afghanistan with her Army reserve unit, returning home 6 months ago.  Since her return, she has lost her job due to chronic tardiness (sleeping through her alarm, she says) and admits she has “started drinking again.” Her visit with you this day is only to undergo the physical exam required by her new employer. What are your next steps with this patient? What resources can you use to help her?

As long as human beings have engaged in combat, there have often been extraordinarily damaging psychiatric1  injuries among those who survive. Combat survivability today is 84% to 90%, the highest in the history of armed conflict,^2,3 thanks to improvements in personal protective gear, vehicle armor, rapid casualty evacuation, and surgical resuscitation and stabilization that is “far forward” on the battlefield. These survivors are subsequently at high risk for a host of other medical conditions, which commonly include traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), depression, suicide, and substance abuse.^4-8 

Family physicians—both civilian and uniformed—may be the first to encounter these individuals. Of the more than 2.4 million US service members who have been deployed to Afghanistan or Iraq in support of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF), nearly 60% are no longer on active duty.

Among this group, only half receive care from the US Department of Veterans Affairs (VA).⁹ Despite a concerted effort on the part of the Department of Defense (DoD) and the VA to develop and distribute effective, evidenced-based treatment protocols for veterans with combat-related conditions, major gaps remain in the care provided to combat veterans.¹⁰

This article seeks to help fill that gap by providing the information you need to recognize and treat common combat-related illness, as well as resources to help improve the quality of life for veterans and their families (TABLE 1).

Initial roadblocks to care

One of the biggest challenges in treating veterans with behavioral health issues is the fact that only 23% to 40% of those with mental illness seek care.¹¹ Among the reasons veterans have offered for avoiding behavioral health care are a fear of the stigma associated with mental illness, concern that treatment will negatively affect their career, lack of comfort with mental health professionals, and the perception that mental health treatment is a “last resort.”¹² Unfortunately, efforts by the DoD leadership to overcome these inherent biases have been largely unsuccessful¹³ and much work is still required to see that service members get the care they need.

Due to low rates of self-reporting, effective screening is essential. With this in mind, the DoD has implemented the deployment health assessment program (DHAP), which requires service members to be screened for common conditions within 60 days of deployment, within 30 days of returning, and again at 90 to 180 days after their return.

While the long-term effects of this program are yet to be determined, results to date are promising. Since the DHAP was implemented, there has been a significant decrease in occupationally impairing mental health problems and suicidal ideation requiring medical evacuation from a combat theater.¹⁴

FPs should begin with a simple question. Many of the 20+ million veterans living in the United States will not be wearing a uniform when they enter your office. Simply asking all of your patients, “Have you or a loved one ever served in the military?” may help you discover service-related questions or concerns.^15,16 Underscoring the importance of such screening is the recent decision by the American Academy of Family Physicians to partner with First Lady Michelle Obama and Dr. Jill Biden in a new campaign called “Joining Forces,” which aims to support veterans and their families.¹⁶

Mild traumatic brain injury: Common—though overlooked

A TBI is any temporary or permanent neurologic dysfunction after a blow to the head.^10,17 TBI is classified based on severity and mechanism (direct blow to the head or exposure to blast waves). Mild TBI (mTBI) is commonly referred to as a concussion and usually is not associated with loss of consciousness or altered mental status. Brain imaging results are also normal with mTBI. Severe TBI, on the other hand, is associated with prolonged loss of consciousness, altered mental status, and abnormal brain imaging results (TABLE 2).¹⁷

A unique obstacle to accurate evaluation in the field. It is important to emphasize that mTBI is a clinical diagnosis, and its detection requires honest patient communication. This can be problematic with motivated soldiers who are anxious to continue the mission and fear that any admission of symptoms might delay a return to their unit. As with a concussed athlete eager to return to the field of play, the clinical diagnosis of mTBI requires a high index of clinical suspicion and constant vigilance by the health care provider. Despite being the most common combat- related injury, mTBI is often overlooked due to the absence of obvious physical injuries.⁴ Recent data suggest that 28% to 60% of ser- vice members evacuated from combat have a TBI. Most of these injuries (77%) are mTBI.^18-20 Improved personal protective equipment (including Kevlar helmets and body armor) and the high number of blast-related injuries are likely responsible for the high incidence of mTBI among OEF/OIF veterans.^8,21,22 The prevalence of mTBI among service members not evacuated is estimated to be 20% to 30%.²⁰ Veterans with non–cancer-related pain who are treated with opioid analgesics have an increased risk of adverse clinical outcomes compared with those not treated with opioids.

Symptoms can persist. Most patients with mTBI completely recover within 30 days of the injury. Unfortunately, 10% to 15% of mTBI patients develop chronic problems lasting months to years.⁴ Residual symptoms most commonly include headache, irritability, depression, sleep disturbance, impaired reasoning, memory problems, and difficulty concentrating. These symptoms are not unique to mTBI and overlap with comorbid combat diagnoses like PTSD, depression, and sleep deprivation.¹⁰ The following tools can help physicians determine whether mTBI is present.

Checking for possible mtBi. In the field, patients with possible mTBI can be screened rapidly using the Military Acute Concussion Evaluation (MACE, found at www.dvbic.org), a modification of the validated and widely used Sideline Assessment of Concussion (SAC) tool. More challenging is evaluating potential mTBI patients who present weeks or months after a traumatic event, for which there are no simple confirmatory tests. In this event, conduct a thorough neurological evaluation that includes vestibular, vision, postural, and neurocognitive assessments. For patients with persistent symptoms or possible anatomic brain abnormalities, magnetic resonance imaging (MRI) is the imaging modality of choice. Patients with complications or a questionable diagnosis are best managed in consultation with a neurologist.

Initial treatment of mtBi is symptom-based. When practical, try nonpharmacologic interventions first (TABLE 3).¹⁰ In particular, have the patient avoid further high-risk exposures that could lead to second impact syndrome (an issue increasingly recognized in contact sports). Also critical are physical and cognitive rest and the restoration of sleep until the patient is completely asymptomatic.

If the patient exhibits irritability and depression, selective serotonin reuptake inhibitors (SSRIs) are first-line treatment. Avoid narcotics and sedative-hypnotic sleep medications if treating comorbidities such as pain and sleep deprivation. The VA/DoD guideline on managing concussion and mTBI provides additional detailed, evidence-based treatment recommendations.¹⁷

Reliving the horror again and again: PTSD

PTSD is a persistent and, at times, debilitating clinical syndrome that develops after exposure to a psychologically traumatic event. It’s the second most common illness among OEF/OIF combat veterans, with an estimated prevalence of 3% to 20%, a finding consistent with prior wars.^6,23-25 In the case of combat veterans, the inciting event usually involves an actual or perceived risk of death or serious injury. The individual’s response to the event involves intense fear, helplessness, or horror. The traumatic event is persistently re-experienced through intrusive and disturbing recollections or dreams that cause intense psychological distress. This, in turn, leads to a state of persistent sympathetic arousal. As symptoms are often triggered by specific cues, individuals with PTSD actively seek to avoid thoughts, situations, or stimuli associated with the event.^23,26

Symptoms commonly associated with PTSD include difficulty falling or staying asleep, recurrent nightmares, hypervigilance, and an exaggerated startle response. Individuals with PTSD also have a poorer sense of well-being, a higher rate of work absenteeism, and significantly more somatic complaints than age-matched peers.²⁷ For symptoms to be attributable to PTSD, their onset must follow a recent inciting event and must also cause clinically significant distress or impairment in social, occupational, or other areas of daily living. Common comorbid illnesses include mTBI, depression, and substance abuse. As with mTBI, the presence of multiple comorbidities in patients with PTSD can complicate evaluation, diagnosis, and treatment.

Diagnosis. PTSD is subdivided into acute (symptoms lasting more than one month but less than 3 months after the traumatic event) and chronic (symptoms lasting longer than 3 months after the traumatic event).²⁸ The distinction of acute or chronic does not affect treatment, but it is useful information for the patient to have regarding prognosis and eventual outcome. Like mTBI, PTSD is a clinical diagnosis made only after a thorough, structured diagnostic interview. The use of a validated, self-administered checklist, such as the Post-Traumatic Checklist-Military (PCL-M), allows for an efficient review of a patient’s symptoms and a reliable way to track treatment progress (http://www.ptsd.va.gov/professional/ pages/assessments/ptsd-checklist.asp).

Treatment Options. Effective evidence-based treatments for PTSD are cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), and pharmacotherapy. SSRIs and serotonin- norepinephrine reuptake inhibitors (SNRIs) have the strongest evidence for pharmacologic benefit in the treatment of PTSD.^28,29 Other helpful medications are prazosin for nightmares and trazodone for sleep. Family physicians can use these medications as part of a patient-centered collaboration with the rest of the integrated care team, to offer the best chance for treatment success.^10,28,30

Depression: Vets are reluctant to self-report

Combat experience is a significant risk factor for major depression. Estimates of the lifetime prevalence of depression in the general US population vary from 9% to 25% in women and 5% to 12% in men. By contrast, the prevalence of depression in OIF/OEF veterans ranges from 2% to 37%.^24,31,32

Screening can yield false negatives. Many combat veterans are reluctant to self-report behavioral conditions, including depression. Screening, therefore, is important to identify potential depression and allow for intervention. Validated screening tools for depression include the PHQ-2 and PHQ-9, which are easy to use in the office setting. (See http://www.cqaimh.org/pdf/ tool_phq2.pdf [PHQ-2] and http://www. integration.samhsa.gov/images/res/ PHQ%20-%20Questions.pdf [PHQ-9]). Importantly, some veterans will have a negative depression screen on return from deployment, and then test positive 6 to 12 months later.²⁴ The complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a multidisciplinary approach to treatment.Explanations for the early false-negative results include the excitement of being home and patients intentionally answering questions inaccurately to avoid excessive screening at their home base.¹¹

Treatment is most effective with a combination approach. As with most cases of depression, combining psychotherapy and psychopharmacology appears to be most effective for treating depression related to combat experience.^33,34 While SSRIs and SNRIs are typical first-line pharmacologic agents, combat veterans often have comorbid mTBI, PTSD, or substance abuse issues that may influence the initial choice of therapy³⁵ (TABLE 3).¹⁰

Suicide is on the rise in the military

Historically, the incidence of suicide has been 25% lower in military personnel than in civilian peers.³⁶ However, between 2005 and 2009, the incidence of suicide in the Marine Corps and Army almost doubled.³⁷ While the exact reasons remain unknown, it is likely due to prolonged and repeated deployments to a combat environment.¹² While the incidence of suicide has been particularly high in the Army (22 per 100,000 active-duty and reserve personnel per year), all services have been affected. In fact, since 2009, the number of suicides among active duty service members exceeds those killed in action.³⁷

Consider all veterans to be at risk for suicide, and screen accordingly. An effective screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is able to predict those most at risk for an impending suicide attempt.³⁴ Service members identified as high risk for suicide require unhindered access to care. The VA has worked to improve access to care and provide evidence-based point-of-care treatment strategies.³⁸ Available resources can be found in TABLE 1.

Unfortunately, even with effective screening and treatment, not all suicides can be prevented. Studies have demonstrated that approximately 65% of service members who commit suicide had no known history of communicating their suicidal intent. Since 2009, the number of suicides among active duty service members exceeds those killed in action.Sadly, 25% of service members who committed suicide had seen a mental health provider within the previous 30 days.³⁹

Alcohol abuse is common; opioids present a unique risk

Excessive use of alcohol and recreational and prescription drugs is common among OEF/ OIF veterans, especially those with comorbid mental health disorders. Retrospective cross-sectional studies show that 11% to 20% of OEF/OIF veterans met DSM-IV-TR diagnostic criteria for substance use disorders.^40-42 At highest risk are single enlisted men under the age of 24 in the Army or Marine Corps who serve in a combat-specific capacity. Interestingly, the prevalence of substance use disorders among OEF/OIF veterans closely mirrors that reported in epidemiologic studies of Vietnam veterans (11%-14%).⁴¹ This similarity, combined with the 39% lifetime prevalence of substance use disorders among Vietnam veterans, may foreshadow a similar lifetime prevalence of substance use disorders among OEF/OIF veterans.⁴¹

Most-abused substances. Alcohol is the most commonly abused substance among OEF/OIF veterans (10%-20%).^40,41,43-45 Other abused substances include opioids (prescribed or illicitly obtained), synthetic marijuana (“Spice” and “K2”), and “bath salts” (synthetic stimulants) (W.M. Sauve, MD, personal communication, August 27, 2012).

OEF/OIF veterans seem to be at particular risk for developing problems related to opioid use. A 2012 retrospective cohort study showed that veterans with non–cancer- related pain diagnoses treated with opioid analgesics had an increased risk for adverse clinical outcomes compared with those not treated with opioid analgesics (9.5% vs 4.1%; relative risk [RR]=2.33; 95% confidence interval [CI], 2.20-2.46). These outcomes included traumatic accidents, overdoses, self-inflicted injuries, and injuries related to violence. This study also demonstrated that, compared with veterans without mental illness, veterans with mental illness (particularly PTSD) and non–cancer-related pain were significantly more likely to receive opioids to treat their pain and had a higher risk of adverse clinical outcomes, including overdose.^46,47

Recreational use of synthetic marijuana and “bath salts” has increased in recent years. These substances are commonly labeled “not for human consumption,” which allows them to remain outside US Food and Drug Administration (FDA) regulation and be sold legally in the United States. Efforts to prohibit the sale or possession of these drugs, including the Federal Synthetic Bath Salt Ban in 2012, have fallen short, often due to creative product ”re-engineering.”³³ Synthetic marijuana and stimulants are inexpensive, readily available, and perceived by users to be safe. Health care providers are often unaware that their patients are using these products. Adverse health outcomes associated with the use of these synthetic drugs include memory loss, depression, and psychosis.

These alcohol and drug screens can help
One efficient screening tool to identify veterans at risk for alcohol abuse is the AUDIT-C, developed by the World Health Organization. This brief 3-question test identifies past-year hazardous drinking and alcohol abuse or dependence with >79% sensitivity and >56% specificity in male veterans, and >66% sensitivity and >87% specificity in female veterans. These numbers are similar to those provided by the full 10-question AUDIT.^48,49 The Drug Abuse Screen Test-10 (DAST-10) provides a similar screening instrument for other substances. Condensed from the original DAST-28 instrument, the DAST-10 identifies high-risk substance abuse with 74% to 94% sensitivity and 68% to 88% specificity.³

Screen for comorbidities. When you see veterans with a diagnosis of substance abuse, also evaluate for comorbid disease. Most veterans with substance use disorders (82%-93%) have at least one other mental health diagnosis (a 45% greater risk than that of civilians with substance abuse disorders),⁵⁰ most commonly PTSD, depression, anxiety, and adjustment disorders.^41,44,45 A number of hypotheses exist to explain the association between substance use disorders and other mental health diagnoses (“dual diagnoses”). The prevailing theory, in both veteran and civilian populations, is that substance abuse is an attempt to self-treat mental illness. Other evidence suggests that substance abuse promotes the development of mental illness, either by leading to a higher risk for traumatic experiences (increasing the chance of developing PTSD) or through a direct biochemical mechanism. Finally, con- current substance use disorder and mental illness may be due to an undefined genetic or biological vulnerability.^38,44 This complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a comprehensive, multidisciplinary approach to treatment.

Treatment options. Office-based treatment options for narcotic and alcohol abuse and dependency are available to family physicians. Methadone has been used since the 1950s to treat opioid addiction and remains one of the mainstays of outpatient treatment.^47,51 Originally, methadone was restricted to detoxification and maintenance treatment in narcotic addiction treatment programs approved by the FDA. In 1976, this restriction was lifted, and all physicians registered with the Drug Enforcement Agency (DEA) were permitted to prescribe methadone for analgesia.

In 2002, the FDA approved buprenorphine monotherapy and the combination product buprenorphine/naloxone for the treatment of opioid addiction. The prescribing of buprenorphine products requires physicians to undergo extra training, declare to the DEA their intent to prescribe buprenorphine, and obtain a special DEA identification number.^52,53 Physicians interested in finding out more about buprenorphine treatment and prescribing requirements can go to the Substance Abuse and Mental Health Services Administration (SAMHSA) Web page at http://samhsa.gov.

Naltrexone is an opioid receptor agonist that is used primarily to treat alcohol dependency, and is thought to work by reducing the craving for alcohol. Multiple studies have proven the efficacy of naltrexone in an outpatient setting when used alone or in combination with psychotherapy.^54,55 If you are uncomfortable or unfamiliar with the use or prescribing of these medications, referral to a substance abuse clinic specializing in dual-diagnosis treatment (TABLE 1) may offer optimal outcomes for patients with substance abuse disorders and other mental illness.

Cognitive behavioral therapy—including coping skills training, relapse prevention, contingency management, and behavioral couples’ therapy—and 12-step treatment programs are evidence-based options for the treatment of substance abuse disorders. Behavioral counseling interventions in the primary care setting (typically lasting 5-15 minutes) result in decreases in alcohol consumption, heavy drinking episodes, drinking above recommended amounts, and the number of days spent in the hospital, but have not been demonstrated to affect mortality, alcohol-related liver problems, outpatient visits, legal problems, or quality of life.⁵⁶ Resources can be found at www.niaaa.nih.gov. For patients with dual diagnoses, it is not yet known whether sequential therapy (in which substance abuse is treated first, followed by treatment of the comorbid mental illness) or concurrent therapy results in better outcomes.⁵⁷

CASE Your patient’s history of recent combat service, acknowledgement of employment and behavioral difficulties, and initial screening results lead you to diagnose alcoholism and depression. Additionally, she denies any suicidal ideation, but admits to experimenting with synthetic marijuana. After some discussion, she agrees to see your clinic’s social worker, and you start her on an SSri with scheduled follow-up.

CORRESPONDENCE
Shawn Kane, MD, USASoc, Attn: Surgeon (AomD), 2929 Desert Storm Drive, Ft. Bragg, NC 28310, or PO Box 3639 Pinehurst, NC 28374; [email protected]

CASE A 37-year-old white woman presents for an employment physical. Your nurse reports that she also has a complaint of headaches, that she scored an 8 on the Alcohol Use Disorders identification Test-consumption (AUDiT-c), and that the result on her patient health Questionnaire (phQ-2) suggests a depressive disorder. You ask the patient whether she has served in the military and discover that, in the last 4 years, she served 2 year-long tours in Afghanistan with her Army reserve unit, returning home 6 months ago.  Since her return, she has lost her job due to chronic tardiness (sleeping through her alarm, she says) and admits she has “started drinking again.” Her visit with you this day is only to undergo the physical exam required by her new employer. What are your next steps with this patient? What resources can you use to help her?

As long as human beings have engaged in combat, there have often been extraordinarily damaging psychiatric1  injuries among those who survive. Combat survivability today is 84% to 90%, the highest in the history of armed conflict,^2,3 thanks to improvements in personal protective gear, vehicle armor, rapid casualty evacuation, and surgical resuscitation and stabilization that is “far forward” on the battlefield. These survivors are subsequently at high risk for a host of other medical conditions, which commonly include traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), depression, suicide, and substance abuse.^4-8 

Family physicians—both civilian and uniformed—may be the first to encounter these individuals. Of the more than 2.4 million US service members who have been deployed to Afghanistan or Iraq in support of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF), nearly 60% are no longer on active duty.

Among this group, only half receive care from the US Department of Veterans Affairs (VA).⁹ Despite a concerted effort on the part of the Department of Defense (DoD) and the VA to develop and distribute effective, evidenced-based treatment protocols for veterans with combat-related conditions, major gaps remain in the care provided to combat veterans.¹⁰

This article seeks to help fill that gap by providing the information you need to recognize and treat common combat-related illness, as well as resources to help improve the quality of life for veterans and their families (TABLE 1).

Initial roadblocks to care

One of the biggest challenges in treating veterans with behavioral health issues is the fact that only 23% to 40% of those with mental illness seek care.¹¹ Among the reasons veterans have offered for avoiding behavioral health care are a fear of the stigma associated with mental illness, concern that treatment will negatively affect their career, lack of comfort with mental health professionals, and the perception that mental health treatment is a “last resort.”¹² Unfortunately, efforts by the DoD leadership to overcome these inherent biases have been largely unsuccessful¹³ and much work is still required to see that service members get the care they need.

Due to low rates of self-reporting, effective screening is essential. With this in mind, the DoD has implemented the deployment health assessment program (DHAP), which requires service members to be screened for common conditions within 60 days of deployment, within 30 days of returning, and again at 90 to 180 days after their return.

While the long-term effects of this program are yet to be determined, results to date are promising. Since the DHAP was implemented, there has been a significant decrease in occupationally impairing mental health problems and suicidal ideation requiring medical evacuation from a combat theater.¹⁴

FPs should begin with a simple question. Many of the 20+ million veterans living in the United States will not be wearing a uniform when they enter your office. Simply asking all of your patients, “Have you or a loved one ever served in the military?” may help you discover service-related questions or concerns.^15,16 Underscoring the importance of such screening is the recent decision by the American Academy of Family Physicians to partner with First Lady Michelle Obama and Dr. Jill Biden in a new campaign called “Joining Forces,” which aims to support veterans and their families.¹⁶

Mild traumatic brain injury: Common—though overlooked

A TBI is any temporary or permanent neurologic dysfunction after a blow to the head.^10,17 TBI is classified based on severity and mechanism (direct blow to the head or exposure to blast waves). Mild TBI (mTBI) is commonly referred to as a concussion and usually is not associated with loss of consciousness or altered mental status. Brain imaging results are also normal with mTBI. Severe TBI, on the other hand, is associated with prolonged loss of consciousness, altered mental status, and abnormal brain imaging results (TABLE 2).¹⁷

A unique obstacle to accurate evaluation in the field. It is important to emphasize that mTBI is a clinical diagnosis, and its detection requires honest patient communication. This can be problematic with motivated soldiers who are anxious to continue the mission and fear that any admission of symptoms might delay a return to their unit. As with a concussed athlete eager to return to the field of play, the clinical diagnosis of mTBI requires a high index of clinical suspicion and constant vigilance by the health care provider. Despite being the most common combat- related injury, mTBI is often overlooked due to the absence of obvious physical injuries.⁴ Recent data suggest that 28% to 60% of ser- vice members evacuated from combat have a TBI. Most of these injuries (77%) are mTBI.^18-20 Improved personal protective equipment (including Kevlar helmets and body armor) and the high number of blast-related injuries are likely responsible for the high incidence of mTBI among OEF/OIF veterans.^8,21,22 The prevalence of mTBI among service members not evacuated is estimated to be 20% to 30%.²⁰ Veterans with non–cancer-related pain who are treated with opioid analgesics have an increased risk of adverse clinical outcomes compared with those not treated with opioids.

Symptoms can persist. Most patients with mTBI completely recover within 30 days of the injury. Unfortunately, 10% to 15% of mTBI patients develop chronic problems lasting months to years.⁴ Residual symptoms most commonly include headache, irritability, depression, sleep disturbance, impaired reasoning, memory problems, and difficulty concentrating. These symptoms are not unique to mTBI and overlap with comorbid combat diagnoses like PTSD, depression, and sleep deprivation.¹⁰ The following tools can help physicians determine whether mTBI is present.

Checking for possible mtBi. In the field, patients with possible mTBI can be screened rapidly using the Military Acute Concussion Evaluation (MACE, found at www.dvbic.org), a modification of the validated and widely used Sideline Assessment of Concussion (SAC) tool. More challenging is evaluating potential mTBI patients who present weeks or months after a traumatic event, for which there are no simple confirmatory tests. In this event, conduct a thorough neurological evaluation that includes vestibular, vision, postural, and neurocognitive assessments. For patients with persistent symptoms or possible anatomic brain abnormalities, magnetic resonance imaging (MRI) is the imaging modality of choice. Patients with complications or a questionable diagnosis are best managed in consultation with a neurologist.

Initial treatment of mtBi is symptom-based. When practical, try nonpharmacologic interventions first (TABLE 3).¹⁰ In particular, have the patient avoid further high-risk exposures that could lead to second impact syndrome (an issue increasingly recognized in contact sports). Also critical are physical and cognitive rest and the restoration of sleep until the patient is completely asymptomatic.

If the patient exhibits irritability and depression, selective serotonin reuptake inhibitors (SSRIs) are first-line treatment. Avoid narcotics and sedative-hypnotic sleep medications if treating comorbidities such as pain and sleep deprivation. The VA/DoD guideline on managing concussion and mTBI provides additional detailed, evidence-based treatment recommendations.¹⁷

Reliving the horror again and again: PTSD

PTSD is a persistent and, at times, debilitating clinical syndrome that develops after exposure to a psychologically traumatic event. It’s the second most common illness among OEF/OIF combat veterans, with an estimated prevalence of 3% to 20%, a finding consistent with prior wars.^6,23-25 In the case of combat veterans, the inciting event usually involves an actual or perceived risk of death or serious injury. The individual’s response to the event involves intense fear, helplessness, or horror. The traumatic event is persistently re-experienced through intrusive and disturbing recollections or dreams that cause intense psychological distress. This, in turn, leads to a state of persistent sympathetic arousal. As symptoms are often triggered by specific cues, individuals with PTSD actively seek to avoid thoughts, situations, or stimuli associated with the event.^23,26

Symptoms commonly associated with PTSD include difficulty falling or staying asleep, recurrent nightmares, hypervigilance, and an exaggerated startle response. Individuals with PTSD also have a poorer sense of well-being, a higher rate of work absenteeism, and significantly more somatic complaints than age-matched peers.²⁷ For symptoms to be attributable to PTSD, their onset must follow a recent inciting event and must also cause clinically significant distress or impairment in social, occupational, or other areas of daily living. Common comorbid illnesses include mTBI, depression, and substance abuse. As with mTBI, the presence of multiple comorbidities in patients with PTSD can complicate evaluation, diagnosis, and treatment.

Diagnosis. PTSD is subdivided into acute (symptoms lasting more than one month but less than 3 months after the traumatic event) and chronic (symptoms lasting longer than 3 months after the traumatic event).²⁸ The distinction of acute or chronic does not affect treatment, but it is useful information for the patient to have regarding prognosis and eventual outcome. Like mTBI, PTSD is a clinical diagnosis made only after a thorough, structured diagnostic interview. The use of a validated, self-administered checklist, such as the Post-Traumatic Checklist-Military (PCL-M), allows for an efficient review of a patient’s symptoms and a reliable way to track treatment progress (http://www.ptsd.va.gov/professional/ pages/assessments/ptsd-checklist.asp).

Treatment Options. Effective evidence-based treatments for PTSD are cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), and pharmacotherapy. SSRIs and serotonin- norepinephrine reuptake inhibitors (SNRIs) have the strongest evidence for pharmacologic benefit in the treatment of PTSD.^28,29 Other helpful medications are prazosin for nightmares and trazodone for sleep. Family physicians can use these medications as part of a patient-centered collaboration with the rest of the integrated care team, to offer the best chance for treatment success.^10,28,30

Depression: Vets are reluctant to self-report

Combat experience is a significant risk factor for major depression. Estimates of the lifetime prevalence of depression in the general US population vary from 9% to 25% in women and 5% to 12% in men. By contrast, the prevalence of depression in OIF/OEF veterans ranges from 2% to 37%.^24,31,32

Screening can yield false negatives. Many combat veterans are reluctant to self-report behavioral conditions, including depression. Screening, therefore, is important to identify potential depression and allow for intervention. Validated screening tools for depression include the PHQ-2 and PHQ-9, which are easy to use in the office setting. (See http://www.cqaimh.org/pdf/ tool_phq2.pdf [PHQ-2] and http://www. integration.samhsa.gov/images/res/ PHQ%20-%20Questions.pdf [PHQ-9]). Importantly, some veterans will have a negative depression screen on return from deployment, and then test positive 6 to 12 months later.²⁴ The complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a multidisciplinary approach to treatment.Explanations for the early false-negative results include the excitement of being home and patients intentionally answering questions inaccurately to avoid excessive screening at their home base.¹¹

Treatment is most effective with a combination approach. As with most cases of depression, combining psychotherapy and psychopharmacology appears to be most effective for treating depression related to combat experience.^33,34 While SSRIs and SNRIs are typical first-line pharmacologic agents, combat veterans often have comorbid mTBI, PTSD, or substance abuse issues that may influence the initial choice of therapy³⁵ (TABLE 3).¹⁰

Suicide is on the rise in the military

Historically, the incidence of suicide has been 25% lower in military personnel than in civilian peers.³⁶ However, between 2005 and 2009, the incidence of suicide in the Marine Corps and Army almost doubled.³⁷ While the exact reasons remain unknown, it is likely due to prolonged and repeated deployments to a combat environment.¹² While the incidence of suicide has been particularly high in the Army (22 per 100,000 active-duty and reserve personnel per year), all services have been affected. In fact, since 2009, the number of suicides among active duty service members exceeds those killed in action.³⁷

Consider all veterans to be at risk for suicide, and screen accordingly. An effective screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is able to predict those most at risk for an impending suicide attempt.³⁴ Service members identified as high risk for suicide require unhindered access to care. The VA has worked to improve access to care and provide evidence-based point-of-care treatment strategies.³⁸ Available resources can be found in TABLE 1.

Unfortunately, even with effective screening and treatment, not all suicides can be prevented. Studies have demonstrated that approximately 65% of service members who commit suicide had no known history of communicating their suicidal intent. Since 2009, the number of suicides among active duty service members exceeds those killed in action.Sadly, 25% of service members who committed suicide had seen a mental health provider within the previous 30 days.³⁹

Alcohol abuse is common; opioids present a unique risk

Excessive use of alcohol and recreational and prescription drugs is common among OEF/ OIF veterans, especially those with comorbid mental health disorders. Retrospective cross-sectional studies show that 11% to 20% of OEF/OIF veterans met DSM-IV-TR diagnostic criteria for substance use disorders.^40-42 At highest risk are single enlisted men under the age of 24 in the Army or Marine Corps who serve in a combat-specific capacity. Interestingly, the prevalence of substance use disorders among OEF/OIF veterans closely mirrors that reported in epidemiologic studies of Vietnam veterans (11%-14%).⁴¹ This similarity, combined with the 39% lifetime prevalence of substance use disorders among Vietnam veterans, may foreshadow a similar lifetime prevalence of substance use disorders among OEF/OIF veterans.⁴¹

Most-abused substances. Alcohol is the most commonly abused substance among OEF/OIF veterans (10%-20%).^40,41,43-45 Other abused substances include opioids (prescribed or illicitly obtained), synthetic marijuana (“Spice” and “K2”), and “bath salts” (synthetic stimulants) (W.M. Sauve, MD, personal communication, August 27, 2012).

OEF/OIF veterans seem to be at particular risk for developing problems related to opioid use. A 2012 retrospective cohort study showed that veterans with non–cancer- related pain diagnoses treated with opioid analgesics had an increased risk for adverse clinical outcomes compared with those not treated with opioid analgesics (9.5% vs 4.1%; relative risk [RR]=2.33; 95% confidence interval [CI], 2.20-2.46). These outcomes included traumatic accidents, overdoses, self-inflicted injuries, and injuries related to violence. This study also demonstrated that, compared with veterans without mental illness, veterans with mental illness (particularly PTSD) and non–cancer-related pain were significantly more likely to receive opioids to treat their pain and had a higher risk of adverse clinical outcomes, including overdose.^46,47

Recreational use of synthetic marijuana and “bath salts” has increased in recent years. These substances are commonly labeled “not for human consumption,” which allows them to remain outside US Food and Drug Administration (FDA) regulation and be sold legally in the United States. Efforts to prohibit the sale or possession of these drugs, including the Federal Synthetic Bath Salt Ban in 2012, have fallen short, often due to creative product ”re-engineering.”³³ Synthetic marijuana and stimulants are inexpensive, readily available, and perceived by users to be safe. Health care providers are often unaware that their patients are using these products. Adverse health outcomes associated with the use of these synthetic drugs include memory loss, depression, and psychosis.

These alcohol and drug screens can help
One efficient screening tool to identify veterans at risk for alcohol abuse is the AUDIT-C, developed by the World Health Organization. This brief 3-question test identifies past-year hazardous drinking and alcohol abuse or dependence with >79% sensitivity and >56% specificity in male veterans, and >66% sensitivity and >87% specificity in female veterans. These numbers are similar to those provided by the full 10-question AUDIT.^48,49 The Drug Abuse Screen Test-10 (DAST-10) provides a similar screening instrument for other substances. Condensed from the original DAST-28 instrument, the DAST-10 identifies high-risk substance abuse with 74% to 94% sensitivity and 68% to 88% specificity.³

Screen for comorbidities. When you see veterans with a diagnosis of substance abuse, also evaluate for comorbid disease. Most veterans with substance use disorders (82%-93%) have at least one other mental health diagnosis (a 45% greater risk than that of civilians with substance abuse disorders),⁵⁰ most commonly PTSD, depression, anxiety, and adjustment disorders.^41,44,45 A number of hypotheses exist to explain the association between substance use disorders and other mental health diagnoses (“dual diagnoses”). The prevailing theory, in both veteran and civilian populations, is that substance abuse is an attempt to self-treat mental illness. Other evidence suggests that substance abuse promotes the development of mental illness, either by leading to a higher risk for traumatic experiences (increasing the chance of developing PTSD) or through a direct biochemical mechanism. Finally, con- current substance use disorder and mental illness may be due to an undefined genetic or biological vulnerability.^38,44 This complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a comprehensive, multidisciplinary approach to treatment.

Treatment options. Office-based treatment options for narcotic and alcohol abuse and dependency are available to family physicians. Methadone has been used since the 1950s to treat opioid addiction and remains one of the mainstays of outpatient treatment.^47,51 Originally, methadone was restricted to detoxification and maintenance treatment in narcotic addiction treatment programs approved by the FDA. In 1976, this restriction was lifted, and all physicians registered with the Drug Enforcement Agency (DEA) were permitted to prescribe methadone for analgesia.

In 2002, the FDA approved buprenorphine monotherapy and the combination product buprenorphine/naloxone for the treatment of opioid addiction. The prescribing of buprenorphine products requires physicians to undergo extra training, declare to the DEA their intent to prescribe buprenorphine, and obtain a special DEA identification number.^52,53 Physicians interested in finding out more about buprenorphine treatment and prescribing requirements can go to the Substance Abuse and Mental Health Services Administration (SAMHSA) Web page at http://samhsa.gov.

Naltrexone is an opioid receptor agonist that is used primarily to treat alcohol dependency, and is thought to work by reducing the craving for alcohol. Multiple studies have proven the efficacy of naltrexone in an outpatient setting when used alone or in combination with psychotherapy.^54,55 If you are uncomfortable or unfamiliar with the use or prescribing of these medications, referral to a substance abuse clinic specializing in dual-diagnosis treatment (TABLE 1) may offer optimal outcomes for patients with substance abuse disorders and other mental illness.

Cognitive behavioral therapy—including coping skills training, relapse prevention, contingency management, and behavioral couples’ therapy—and 12-step treatment programs are evidence-based options for the treatment of substance abuse disorders. Behavioral counseling interventions in the primary care setting (typically lasting 5-15 minutes) result in decreases in alcohol consumption, heavy drinking episodes, drinking above recommended amounts, and the number of days spent in the hospital, but have not been demonstrated to affect mortality, alcohol-related liver problems, outpatient visits, legal problems, or quality of life.⁵⁶ Resources can be found at www.niaaa.nih.gov. For patients with dual diagnoses, it is not yet known whether sequential therapy (in which substance abuse is treated first, followed by treatment of the comorbid mental illness) or concurrent therapy results in better outcomes.⁵⁷

CASE Your patient’s history of recent combat service, acknowledgement of employment and behavioral difficulties, and initial screening results lead you to diagnose alcoholism and depression. Additionally, she denies any suicidal ideation, but admits to experimenting with synthetic marijuana. After some discussion, she agrees to see your clinic’s social worker, and you start her on an SSri with scheduled follow-up.

CORRESPONDENCE
Shawn Kane, MD, USASoc, Attn: Surgeon (AomD), 2929 Desert Storm Drive, Ft. Bragg, NC 28310, or PO Box 3639 Pinehurst, NC 28374; [email protected]

CASE A 37-year-old white woman presents for an employment physical. Your nurse reports that she also has a complaint of headaches, that she scored an 8 on the Alcohol Use Disorders identification Test-consumption (AUDiT-c), and that the result on her patient health Questionnaire (phQ-2) suggests a depressive disorder. You ask the patient whether she has served in the military and discover that, in the last 4 years, she served 2 year-long tours in Afghanistan with her Army reserve unit, returning home 6 months ago.  Since her return, she has lost her job due to chronic tardiness (sleeping through her alarm, she says) and admits she has “started drinking again.” Her visit with you this day is only to undergo the physical exam required by her new employer. What are your next steps with this patient? What resources can you use to help her?

As long as human beings have engaged in combat, there have often been extraordinarily damaging psychiatric1  injuries among those who survive. Combat survivability today is 84% to 90%, the highest in the history of armed conflict,^2,3 thanks to improvements in personal protective gear, vehicle armor, rapid casualty evacuation, and surgical resuscitation and stabilization that is “far forward” on the battlefield. These survivors are subsequently at high risk for a host of other medical conditions, which commonly include traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), depression, suicide, and substance abuse.^4-8 

Family physicians—both civilian and uniformed—may be the first to encounter these individuals. Of the more than 2.4 million US service members who have been deployed to Afghanistan or Iraq in support of Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF), nearly 60% are no longer on active duty.

Among this group, only half receive care from the US Department of Veterans Affairs (VA).⁹ Despite a concerted effort on the part of the Department of Defense (DoD) and the VA to develop and distribute effective, evidenced-based treatment protocols for veterans with combat-related conditions, major gaps remain in the care provided to combat veterans.¹⁰

This article seeks to help fill that gap by providing the information you need to recognize and treat common combat-related illness, as well as resources to help improve the quality of life for veterans and their families (TABLE 1).

Initial roadblocks to care

One of the biggest challenges in treating veterans with behavioral health issues is the fact that only 23% to 40% of those with mental illness seek care.¹¹ Among the reasons veterans have offered for avoiding behavioral health care are a fear of the stigma associated with mental illness, concern that treatment will negatively affect their career, lack of comfort with mental health professionals, and the perception that mental health treatment is a “last resort.”¹² Unfortunately, efforts by the DoD leadership to overcome these inherent biases have been largely unsuccessful¹³ and much work is still required to see that service members get the care they need.

Due to low rates of self-reporting, effective screening is essential. With this in mind, the DoD has implemented the deployment health assessment program (DHAP), which requires service members to be screened for common conditions within 60 days of deployment, within 30 days of returning, and again at 90 to 180 days after their return.

While the long-term effects of this program are yet to be determined, results to date are promising. Since the DHAP was implemented, there has been a significant decrease in occupationally impairing mental health problems and suicidal ideation requiring medical evacuation from a combat theater.¹⁴

FPs should begin with a simple question. Many of the 20+ million veterans living in the United States will not be wearing a uniform when they enter your office. Simply asking all of your patients, “Have you or a loved one ever served in the military?” may help you discover service-related questions or concerns.^15,16 Underscoring the importance of such screening is the recent decision by the American Academy of Family Physicians to partner with First Lady Michelle Obama and Dr. Jill Biden in a new campaign called “Joining Forces,” which aims to support veterans and their families.¹⁶

Mild traumatic brain injury: Common—though overlooked

A TBI is any temporary or permanent neurologic dysfunction after a blow to the head.^10,17 TBI is classified based on severity and mechanism (direct blow to the head or exposure to blast waves). Mild TBI (mTBI) is commonly referred to as a concussion and usually is not associated with loss of consciousness or altered mental status. Brain imaging results are also normal with mTBI. Severe TBI, on the other hand, is associated with prolonged loss of consciousness, altered mental status, and abnormal brain imaging results (TABLE 2).¹⁷

A unique obstacle to accurate evaluation in the field. It is important to emphasize that mTBI is a clinical diagnosis, and its detection requires honest patient communication. This can be problematic with motivated soldiers who are anxious to continue the mission and fear that any admission of symptoms might delay a return to their unit. As with a concussed athlete eager to return to the field of play, the clinical diagnosis of mTBI requires a high index of clinical suspicion and constant vigilance by the health care provider. Despite being the most common combat- related injury, mTBI is often overlooked due to the absence of obvious physical injuries.⁴ Recent data suggest that 28% to 60% of ser- vice members evacuated from combat have a TBI. Most of these injuries (77%) are mTBI.^18-20 Improved personal protective equipment (including Kevlar helmets and body armor) and the high number of blast-related injuries are likely responsible for the high incidence of mTBI among OEF/OIF veterans.^8,21,22 The prevalence of mTBI among service members not evacuated is estimated to be 20% to 30%.²⁰ Veterans with non–cancer-related pain who are treated with opioid analgesics have an increased risk of adverse clinical outcomes compared with those not treated with opioids.

Symptoms can persist. Most patients with mTBI completely recover within 30 days of the injury. Unfortunately, 10% to 15% of mTBI patients develop chronic problems lasting months to years.⁴ Residual symptoms most commonly include headache, irritability, depression, sleep disturbance, impaired reasoning, memory problems, and difficulty concentrating. These symptoms are not unique to mTBI and overlap with comorbid combat diagnoses like PTSD, depression, and sleep deprivation.¹⁰ The following tools can help physicians determine whether mTBI is present.

Checking for possible mtBi. In the field, patients with possible mTBI can be screened rapidly using the Military Acute Concussion Evaluation (MACE, found at www.dvbic.org), a modification of the validated and widely used Sideline Assessment of Concussion (SAC) tool. More challenging is evaluating potential mTBI patients who present weeks or months after a traumatic event, for which there are no simple confirmatory tests. In this event, conduct a thorough neurological evaluation that includes vestibular, vision, postural, and neurocognitive assessments. For patients with persistent symptoms or possible anatomic brain abnormalities, magnetic resonance imaging (MRI) is the imaging modality of choice. Patients with complications or a questionable diagnosis are best managed in consultation with a neurologist.

Initial treatment of mtBi is symptom-based. When practical, try nonpharmacologic interventions first (TABLE 3).¹⁰ In particular, have the patient avoid further high-risk exposures that could lead to second impact syndrome (an issue increasingly recognized in contact sports). Also critical are physical and cognitive rest and the restoration of sleep until the patient is completely asymptomatic.

If the patient exhibits irritability and depression, selective serotonin reuptake inhibitors (SSRIs) are first-line treatment. Avoid narcotics and sedative-hypnotic sleep medications if treating comorbidities such as pain and sleep deprivation. The VA/DoD guideline on managing concussion and mTBI provides additional detailed, evidence-based treatment recommendations.¹⁷

Reliving the horror again and again: PTSD

PTSD is a persistent and, at times, debilitating clinical syndrome that develops after exposure to a psychologically traumatic event. It’s the second most common illness among OEF/OIF combat veterans, with an estimated prevalence of 3% to 20%, a finding consistent with prior wars.^6,23-25 In the case of combat veterans, the inciting event usually involves an actual or perceived risk of death or serious injury. The individual’s response to the event involves intense fear, helplessness, or horror. The traumatic event is persistently re-experienced through intrusive and disturbing recollections or dreams that cause intense psychological distress. This, in turn, leads to a state of persistent sympathetic arousal. As symptoms are often triggered by specific cues, individuals with PTSD actively seek to avoid thoughts, situations, or stimuli associated with the event.^23,26

Symptoms commonly associated with PTSD include difficulty falling or staying asleep, recurrent nightmares, hypervigilance, and an exaggerated startle response. Individuals with PTSD also have a poorer sense of well-being, a higher rate of work absenteeism, and significantly more somatic complaints than age-matched peers.²⁷ For symptoms to be attributable to PTSD, their onset must follow a recent inciting event and must also cause clinically significant distress or impairment in social, occupational, or other areas of daily living. Common comorbid illnesses include mTBI, depression, and substance abuse. As with mTBI, the presence of multiple comorbidities in patients with PTSD can complicate evaluation, diagnosis, and treatment.

Diagnosis. PTSD is subdivided into acute (symptoms lasting more than one month but less than 3 months after the traumatic event) and chronic (symptoms lasting longer than 3 months after the traumatic event).²⁸ The distinction of acute or chronic does not affect treatment, but it is useful information for the patient to have regarding prognosis and eventual outcome. Like mTBI, PTSD is a clinical diagnosis made only after a thorough, structured diagnostic interview. The use of a validated, self-administered checklist, such as the Post-Traumatic Checklist-Military (PCL-M), allows for an efficient review of a patient’s symptoms and a reliable way to track treatment progress (http://www.ptsd.va.gov/professional/ pages/assessments/ptsd-checklist.asp).

Treatment Options. Effective evidence-based treatments for PTSD are cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR), and pharmacotherapy. SSRIs and serotonin- norepinephrine reuptake inhibitors (SNRIs) have the strongest evidence for pharmacologic benefit in the treatment of PTSD.^28,29 Other helpful medications are prazosin for nightmares and trazodone for sleep. Family physicians can use these medications as part of a patient-centered collaboration with the rest of the integrated care team, to offer the best chance for treatment success.^10,28,30

Depression: Vets are reluctant to self-report

Combat experience is a significant risk factor for major depression. Estimates of the lifetime prevalence of depression in the general US population vary from 9% to 25% in women and 5% to 12% in men. By contrast, the prevalence of depression in OIF/OEF veterans ranges from 2% to 37%.^24,31,32

Screening can yield false negatives. Many combat veterans are reluctant to self-report behavioral conditions, including depression. Screening, therefore, is important to identify potential depression and allow for intervention. Validated screening tools for depression include the PHQ-2 and PHQ-9, which are easy to use in the office setting. (See http://www.cqaimh.org/pdf/ tool_phq2.pdf [PHQ-2] and http://www. integration.samhsa.gov/images/res/ PHQ%20-%20Questions.pdf [PHQ-9]). Importantly, some veterans will have a negative depression screen on return from deployment, and then test positive 6 to 12 months later.²⁴ The complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a multidisciplinary approach to treatment.Explanations for the early false-negative results include the excitement of being home and patients intentionally answering questions inaccurately to avoid excessive screening at their home base.¹¹

Treatment is most effective with a combination approach. As with most cases of depression, combining psychotherapy and psychopharmacology appears to be most effective for treating depression related to combat experience.^33,34 While SSRIs and SNRIs are typical first-line pharmacologic agents, combat veterans often have comorbid mTBI, PTSD, or substance abuse issues that may influence the initial choice of therapy³⁵ (TABLE 3).¹⁰

Suicide is on the rise in the military

Historically, the incidence of suicide has been 25% lower in military personnel than in civilian peers.³⁶ However, between 2005 and 2009, the incidence of suicide in the Marine Corps and Army almost doubled.³⁷ While the exact reasons remain unknown, it is likely due to prolonged and repeated deployments to a combat environment.¹² While the incidence of suicide has been particularly high in the Army (22 per 100,000 active-duty and reserve personnel per year), all services have been affected. In fact, since 2009, the number of suicides among active duty service members exceeds those killed in action.³⁷

Consider all veterans to be at risk for suicide, and screen accordingly. An effective screening tool is the Columbia-Suicide Severity Rating Scale (C-SSRS), which is able to predict those most at risk for an impending suicide attempt.³⁴ Service members identified as high risk for suicide require unhindered access to care. The VA has worked to improve access to care and provide evidence-based point-of-care treatment strategies.³⁸ Available resources can be found in TABLE 1.

Unfortunately, even with effective screening and treatment, not all suicides can be prevented. Studies have demonstrated that approximately 65% of service members who commit suicide had no known history of communicating their suicidal intent. Since 2009, the number of suicides among active duty service members exceeds those killed in action.Sadly, 25% of service members who committed suicide had seen a mental health provider within the previous 30 days.³⁹

Alcohol abuse is common; opioids present a unique risk

Excessive use of alcohol and recreational and prescription drugs is common among OEF/ OIF veterans, especially those with comorbid mental health disorders. Retrospective cross-sectional studies show that 11% to 20% of OEF/OIF veterans met DSM-IV-TR diagnostic criteria for substance use disorders.^40-42 At highest risk are single enlisted men under the age of 24 in the Army or Marine Corps who serve in a combat-specific capacity. Interestingly, the prevalence of substance use disorders among OEF/OIF veterans closely mirrors that reported in epidemiologic studies of Vietnam veterans (11%-14%).⁴¹ This similarity, combined with the 39% lifetime prevalence of substance use disorders among Vietnam veterans, may foreshadow a similar lifetime prevalence of substance use disorders among OEF/OIF veterans.⁴¹

Most-abused substances. Alcohol is the most commonly abused substance among OEF/OIF veterans (10%-20%).^40,41,43-45 Other abused substances include opioids (prescribed or illicitly obtained), synthetic marijuana (“Spice” and “K2”), and “bath salts” (synthetic stimulants) (W.M. Sauve, MD, personal communication, August 27, 2012).

OEF/OIF veterans seem to be at particular risk for developing problems related to opioid use. A 2012 retrospective cohort study showed that veterans with non–cancer- related pain diagnoses treated with opioid analgesics had an increased risk for adverse clinical outcomes compared with those not treated with opioid analgesics (9.5% vs 4.1%; relative risk [RR]=2.33; 95% confidence interval [CI], 2.20-2.46). These outcomes included traumatic accidents, overdoses, self-inflicted injuries, and injuries related to violence. This study also demonstrated that, compared with veterans without mental illness, veterans with mental illness (particularly PTSD) and non–cancer-related pain were significantly more likely to receive opioids to treat their pain and had a higher risk of adverse clinical outcomes, including overdose.^46,47

Recreational use of synthetic marijuana and “bath salts” has increased in recent years. These substances are commonly labeled “not for human consumption,” which allows them to remain outside US Food and Drug Administration (FDA) regulation and be sold legally in the United States. Efforts to prohibit the sale or possession of these drugs, including the Federal Synthetic Bath Salt Ban in 2012, have fallen short, often due to creative product ”re-engineering.”³³ Synthetic marijuana and stimulants are inexpensive, readily available, and perceived by users to be safe. Health care providers are often unaware that their patients are using these products. Adverse health outcomes associated with the use of these synthetic drugs include memory loss, depression, and psychosis.

These alcohol and drug screens can help
One efficient screening tool to identify veterans at risk for alcohol abuse is the AUDIT-C, developed by the World Health Organization. This brief 3-question test identifies past-year hazardous drinking and alcohol abuse or dependence with >79% sensitivity and >56% specificity in male veterans, and >66% sensitivity and >87% specificity in female veterans. These numbers are similar to those provided by the full 10-question AUDIT.^48,49 The Drug Abuse Screen Test-10 (DAST-10) provides a similar screening instrument for other substances. Condensed from the original DAST-28 instrument, the DAST-10 identifies high-risk substance abuse with 74% to 94% sensitivity and 68% to 88% specificity.³

Screen for comorbidities. When you see veterans with a diagnosis of substance abuse, also evaluate for comorbid disease. Most veterans with substance use disorders (82%-93%) have at least one other mental health diagnosis (a 45% greater risk than that of civilians with substance abuse disorders),⁵⁰ most commonly PTSD, depression, anxiety, and adjustment disorders.^41,44,45 A number of hypotheses exist to explain the association between substance use disorders and other mental health diagnoses (“dual diagnoses”). The prevailing theory, in both veteran and civilian populations, is that substance abuse is an attempt to self-treat mental illness. Other evidence suggests that substance abuse promotes the development of mental illness, either by leading to a higher risk for traumatic experiences (increasing the chance of developing PTSD) or through a direct biochemical mechanism. Finally, con- current substance use disorder and mental illness may be due to an undefined genetic or biological vulnerability.^38,44 This complicated relationship between substance abuse and behavioral health reinforces the need for screening, early diagnosis, and a comprehensive, multidisciplinary approach to treatment.

Treatment options. Office-based treatment options for narcotic and alcohol abuse and dependency are available to family physicians. Methadone has been used since the 1950s to treat opioid addiction and remains one of the mainstays of outpatient treatment.^47,51 Originally, methadone was restricted to detoxification and maintenance treatment in narcotic addiction treatment programs approved by the FDA. In 1976, this restriction was lifted, and all physicians registered with the Drug Enforcement Agency (DEA) were permitted to prescribe methadone for analgesia.

In 2002, the FDA approved buprenorphine monotherapy and the combination product buprenorphine/naloxone for the treatment of opioid addiction. The prescribing of buprenorphine products requires physicians to undergo extra training, declare to the DEA their intent to prescribe buprenorphine, and obtain a special DEA identification number.^52,53 Physicians interested in finding out more about buprenorphine treatment and prescribing requirements can go to the Substance Abuse and Mental Health Services Administration (SAMHSA) Web page at http://samhsa.gov.

Naltrexone is an opioid receptor agonist that is used primarily to treat alcohol dependency, and is thought to work by reducing the craving for alcohol. Multiple studies have proven the efficacy of naltrexone in an outpatient setting when used alone or in combination with psychotherapy.^54,55 If you are uncomfortable or unfamiliar with the use or prescribing of these medications, referral to a substance abuse clinic specializing in dual-diagnosis treatment (TABLE 1) may offer optimal outcomes for patients with substance abuse disorders and other mental illness.

Cognitive behavioral therapy—including coping skills training, relapse prevention, contingency management, and behavioral couples’ therapy—and 12-step treatment programs are evidence-based options for the treatment of substance abuse disorders. Behavioral counseling interventions in the primary care setting (typically lasting 5-15 minutes) result in decreases in alcohol consumption, heavy drinking episodes, drinking above recommended amounts, and the number of days spent in the hospital, but have not been demonstrated to affect mortality, alcohol-related liver problems, outpatient visits, legal problems, or quality of life.⁵⁶ Resources can be found at www.niaaa.nih.gov. For patients with dual diagnoses, it is not yet known whether sequential therapy (in which substance abuse is treated first, followed by treatment of the comorbid mental illness) or concurrent therapy results in better outcomes.⁵⁷

CASE Your patient’s history of recent combat service, acknowledgement of employment and behavioral difficulties, and initial screening results lead you to diagnose alcoholism and depression. Additionally, she denies any suicidal ideation, but admits to experimenting with synthetic marijuana. After some discussion, she agrees to see your clinic’s social worker, and you start her on an SSri with scheduled follow-up.

CORRESPONDENCE
Shawn Kane, MD, USASoc, Attn: Surgeon (AomD), 2929 Desert Storm Drive, Ft. Bragg, NC 28310, or PO Box 3639 Pinehurst, NC 28374; [email protected]