Clinical Review

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.

To most Americans, the sight of a soldier returning from Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and being reunited with his or her family epitomizes a happy ending. After all, parents, spouses, and children, having sent their loved ones to serve in Afghanistan or Iraq, now have their heroes returned safely to them. Not every family has been so fortunate, and each reunion is a small victory, a moment to reflect on what has been lost since 2001—and to be grateful for what has not.

But sometimes the battle continues when the troops come home. It may be a very different battle—but then again, the conflicts in Iraq and Afghanistan represent a very different kind of war. What our soldiers have experienced in theatre, through extended and multiple deployments, often leaves them with lingering, not-so-obvious injuries. The effects of these psychological and emotional wounds, if they are not properly healed, impact not only the soldiers but also their families.

The Department of Veterans Affairs (VA) has been developing programs and services to meet soldiers’ physical and mental health needs, but not every OEF/OIF veteran is going to have ready access to a top-notch VA facility. Health care providers in non-VA settings may represent the only contact some soldiers and their families will have with the health care system.

“I think providers have the burden here, because they’re the ones that are going to be on the front lines, seeing these families,” says Peggy Anne Fisher McNulty, DrPH, CPNP, CFNP, RN, an Assistant Professor in the University of Hawaii at Manoa School of Nursing and Dental Hygiene, who served with the US Navy Nurse Corps for more than 30 years. “I think it’s going to be their mission to open that door and get families the help they need.”

Invisible Wounds
Last year, the RAND Corporation’s Center for Military Health Policy Research issued a report outlining the effects the current conflicts have had on soldiers. A confidential survey of almost 2,000 returned veterans indicated that nearly 19% met criteria for either posttraumatic stress disorder (PTSD) or depression, and nearly 20% reported experiencing a probable traumatic brain injury during deployment. An earlier report from the VA’s Special Committee on PTSD suggested that up to 20% of OEF/OIF veterans are “at risk for significant symptoms short of full diagnosis but severe enough to cause significant functional impairment.”

Beyond potential clinical diagnoses, soldiers’ lives in theatre are just much different from civilian life. Deployment has been described as a year-long adrenaline rush, filled with stressors, and soldiers are trained to have a battle mindset and focus on the mission.

“That frame of mind is hard to transition back from,” says Master Sergeant Christopher Pugh of the Community-Based Warrior Transition Unit of Massachusetts, an Iraq veteran who was preparing to redeploy when Clinician Reviews spoke with him. “For most soldiers who come off the plane, they’re not focused on battle mind or potential problems. They just want to get through the process and go home to their loved ones if possible. And that’s usually when the problems start arising.”

Readjustment issues can include difficulty dealing with crowds, loss of patience with certain individuals, and a lingering sense of urgency that others don’t feel. “You feel like if you need to get something done, it has to be done right away,” Pugh explains, “whereas it’s not as important to anyone else.”

But if left unaddressed, any of these underlying stressors could eventually manifest in the form of domestic, substance abuse, or gambling problems. According to a study published in JAMA last year, nearly 12% of soldiers report problems with alcohol on their postdeployment health assessment forms. Unpublished data from a study of OEF/OIF veterans referred for behavioral health assessment (as cited in a -report by the Iraq and Afghanistan Veterans of America) indicated that more than half of those who were currently or recently separated from their partner reported “conflicts involving shouting, pushing, or shoving.” Another 22% of those surveyed reported concerns that their children “did not act warmly” toward them or “were afraid” of them.

Even more distressing is the possibility of suicide; the rate among active-duty veterans is on track to surpass the demographically adjusted civilian rate, but statistics on veterans who have completed their service are more difficult to obtain. These issues negatively impact not only the soldier but also his or her family. 

“Soldiers aren’t getting the help they need, so the families are suffering,” says McNulty, who is conducting research on the effects of reunification. Her data, which she is preparing for publication, indicate that spouses were most likely to take steps toward divorce within three months of their soldier’s return home. Other high-risk factors, such as contemplation of suicide or use of prescription medications for stress, remained high throughout the study, which ended 12 months after the soldier’s return.

“Spouses seem to be groping for help,” McNulty observes, “whereas the soldiers aren’t, yet. And you can’t heal the whole family without both people getting the proper help.”

Opening the Door in Primary Care
Whether primary care providers are in a position to help families heal may depend on their training and available resources. But they can play a very important role in identifying at-risk soldiers and families and encouraging them to seek help.

“Primary care is a great place to catch people, because I notice veterans will come in if they need to get their hearing or their back checked out,” says Elizabeth Price, LICSW, a social worker at the ENRM-VA Hospital in Bedford, Massachusetts. “Those are very concrete issues that people need to get addressed. But while they’re there, we also have the opportunity to ask, ‘How are you doing? That must have been a really stressful year you just had; how are things going?’”

Price, McNulty, and Pugh all emphasize the importance of normalizing the transition process. “We very much try to pre-sent it as, ‘This can be a really hard process for a lot of people. We just want to see how you’re doing with it. A lot of people do fine; have you noticed anything challenging or different since you’ve been back?’” Price explains. “Leave it pretty open-ended. 

“I think if families knew that it wasn’t a stigma for them to be hurting,” McNulty says, “that’s a good message that I don’t know that they get.”

Performing a thorough assessment and asking the right questions, such as those related to sleep, may help to identify a soldier or family member whose needs run deeper than their presenting complaint. “The basic questions are [often] enough to alert providers that maybe there’s something else going on that a soldier might need to talk to somebody about,” Pugh says.

Price points out, too, that “there is no set timeline” on how long it will take soldiers and families to readjust. With that in mind, she says it might be helpful to arrange for more frequent follow-up visits rather than waiting for the next annual physical to roll around. “If we can engage folks that way,” she says, “that might be another opportunity to keep an eye on things.”

Preventing a New “Don’t Ask, Don’t Tell”
Clinicians may need to ask the sensitive questions related to stress, depression, and suicidal thoughts. “If we don’t ask, we miss that person,” McNulty says. “If you just ask, they can deny it—but maybe the second time they come to see you, they’ll say, ‘You know what? I am depressed. And what you said last time, I’ve thought about it and yes, I’ve thought of suicide.’ You have to open that door or you won’t get them to trust you enough. It’s a fine line when you’re a provider, but if you develop a rapport and trust, you can save families.”

The VA has established a Web site for returning veterans (www.oefoif.va.gov) that provides information about available services and benefits. Soldiers who are not ready to pursue mental health care or counseling may be more willing to connect with peers; Pugh says community-based organizations such as the American Legion and the Veterans of Foreign Wars may be good additional resources for them. But everyone has an opportunity to make a difference.

“I had a pretty good doc—I say he was pretty good, because he actually caught something that I wasn’t fully aware of myself,” Pugh says. “So, even when you’re presented with complaints, they may not seem what they really are until you do a little more digging. I know you say everyone should do that, but not everyone does.”

“A lot of times, patients come in wanting that help, but they’re going to say they have a stomachache,” McNulty adds. “Sure, you can treat their stomachache, but why are they having a stomachache?

“You have to play detective with these families and find out what’s triggering these symptoms. Maybe it’s not the stomachache. Maybe we don’t have to run all these tests a million times. Maybe we just have to find out what’s really going on emotionally.”

The views expressed in this article are those of the individuals and do not necessarily reflect those of the US government or any of its agencies.