Veterans and Co-Occurring Mental Health Disorders

Last Updated: June 25, 2024

Editorial Policy | Research Policy

Key Takeaways

  • Co-occurring disorders in veterans refer to the simultaneous presence of a mental health disorder and a substance use disorder (SUD).
  • Veterans have a higher prevalence of co-occurring disorders, with unique manifestations due to military service experiences.
  • Common co-occurring disorders among veterans include PTSD, depression, anxiety disorders, and TBI.
  • Risk factors for veterans include combat exposure, demographic variables, prior trauma, and military culture.
  • Co-occurring disorders can lead to increased hospitalization, suicide risk, and impact on quality of life and family dynamics.
  • Employment and financial well-being of veterans are adversely affected by co-occurring disorders.
  • Integrated treatment models combining psychotherapy and SUD interventions are essential for treating veterans.
  • Psychotherapy and effective medication management are key components of treatment for co-occurring disorders.
  • Challenges in treating co-occurring disorders in veterans include treatment uptake, stigma, and access to quality care.
  • Support systems, including family, friends, and professional services, are crucial for veterans’ recovery from co-occurring disorders.

Co-occurring disorders, also known as dual diagnoses or concurrent disorders, refer to the simultaneous presence of both a mental health disorder and a substance use disorder (SUD) within an individual. According to the National Institute of Mental Health (NIMH), a substance use disorder is a mental disorder that significantly affects a person’s behavior and brain, leading to an inability to control the use of substances such as legal or illegal drugs, alcohol, or medications. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR), as noted by the Substance Abuse and Mental Health Services Administration (SAMHSA), does not specify particular combinations of mental and substance use disorders as co-occurring disorders, indicating that any combination of two or more disorders can qualify.

These disorders can manifest in various combinations, such as an anxiety disorder coupled with an alcohol problem, schizophrenia with cannabis dependence, or bipolar disorder with problem gambling. The complexity of co-occurring disorders lies in the interplay between the disorders, where one may exacerbate the symptoms of the other, or a substance use disorder could mask or mimic psychiatric symptoms, making diagnosis and treatment more challenging. Veterans may experience unique forms of co-occurring disorders due to their specific life experiences and exposures during military service, which can increase the risk of developing these complex conditions.

Understanding the Prevalence of Co-occurring Disorders Among Veterans

Co-occurring disorders, which refer to the simultaneous presence of mental health and substance use disorders, are a significant concern among veteran populations. Studies indicate that veterans face a higher prevalence of multiple chronic conditions (MCC) compared to nonveterans, with notable differences in age-adjusted prevalence across genders and age groups. 

Key Statistics of Co-occurring Disorders

  • 22.2% of male veterans aged 25-64 MCC
  • 66.9% of male veterans over 65 have MCC
  • 17.0% of nonveterans aged 25-64 have MCC
  • 61.9% of nonveteran males over 65 have MCC

Mental Health Challenges and Co-occurring Disorders

Furthermore, mental health challenges such as anxiety have been linked to increased rates of psychiatric and functional difficulties, suicidal thoughts, and behaviors in veterans. Anxiety symptoms, even when mild, can be indicative of broader psychological issues, emphasizing the need for effective screening measures. The Yale study highlights the complex interplay of sociodemographic and military factors contributing to anxiety among veterans, including trauma and substance use.

Substance Use Disorder and Mental Illness in Veterans

Data from the Substance Abuse and Mental Health Services Administration (SAMHSA) reveals that approximately 1.1 million veterans aged 18 or older have co-occurring substance use disorder (SUD) and any mental health condition (AMI), with a notably high prevalence of 38.7% among veterans aged 18 to 25. These statistics underscore the urgent need for tailored mental health services and interventions for veterans, particularly those who are younger.

Addressing the prevalence and complexity of co-occurring disorders in the veteran community requires a multifaceted approach, including improved access to mental health care, integrated treatment programs, and robust support systems.

Prevalent Co-occurring Disorders Among Veterans

Veterans often face unique challenges that can lead to the development of co-occurring disorders, which are conditions where an individual simultaneously suffers from a substance use disorder (SUD) and one or more mental health disorders. The most common co-occurring disorders in veterans include Posttraumatic Stress Disorder (PTSD), depression, anxiety disorders, and Traumatic Brain Injury (TBI). PTSD is particularly prevalent among veterans due to their exposure to combat and other traumatic events. It frequently occurs alongside depression, substance abuse, and TBI, which can also result in mood and behavioral changes.

  • PTSD and Substance Use Disorders: Veterans with PTSD may turn to substances like alcohol or drugs as a coping mechanism, leading to a higher risk of developing SUDs.
  • Depression and Alcohol Use: Studies show that depression and alcohol use are closely linked, with a significant number of veterans engaging in binge drinking as a response to depressive symptoms.
  • Anxiety Disorders and Insomnia: Anxiety can cause sleep disturbances such as insomnia, and some veterans may misuse substances like opioids to self-medicate.
  • Traumatic Brain Injury (TBI): TBI is often associated with cognitive deficits, mood disorders, and increased risk for PTSD, which can complicate treatment and recovery.

Understanding these common co-occurring disorders is crucial for providing effective treatment and support for veterans. Integrated treatment approaches that address both the mental health condition and the substance use disorder concurrently have been shown to yield better outcomes.

Understanding Risk Factors for Co-occurring Disorders Among Veterans

Co-occurring disorders (COD), which involve the simultaneous presence of a substance use disorder and a mental health condition, are particularly prevalent among veterans. Several risk factors contribute to the heightened susceptibility of veterans to COD.

1. Combat and Traumatic Experiences

A significant factor is the exposure to combat and related traumatic experiences, which can lead to post-traumatic stress disorder (PTSD) and other mental health issues. Studies show that up to 68% of veterans with PTSD also exhibit signs of alcohol use disorder (AUD).

2. Demographic Variables

Demographic variables such as younger age and female gender have been associated with increased distress during the COVID-19 pandemic, indicative of the role stressors like school closures, work disruptions, and relationship challenges play in exacerbating mental health issues. The JAMA Network Open study highlights that while some veterans demonstrate resilience, a considerable minority experience persistent or exacerbated distress.

3. History of Prior Trauma

Other risk factors include a history of prior trauma, such as physical or sexual abuse, which may precede military service. The National Center for PTSD reports that most individuals with PTSD have at least one additional mental health diagnosis, further compounding the risk for COD. 

4. Military Culture and High-Risk Behavior

Military culture and high-risk behaviors, such as binge drinking, are also contributing factors, with service members often experiencing heightened levels of stress and a lack of social support upon returning home.

5. Traumatic Brain Injuries

It is also crucial to recognize the impact of traumatic brain injury (TBI), which can lead to mood and behavioral changes that increase the risk of mental health conditions and substance use disorders. The interrelation between TBI, PTSD, depression, and substance misuse forms a complex web of challenges for veterans, necessitating comprehensive and integrated treatment approaches.

The Detrimental Effects of Co-occurring Disorders on Veterans’ Lives

The lives of veterans are profoundly affected by co-occurring disorders, which encompass a range of mental health issues compounded by substance use disorders (SUDs). These conditions can lead to a heightened risk of hospitalization, suicide, and even death. 

  • Increased Risk of Suicide: Statistics reveal that veterans are at a 50% higher risk of suicide compared to the civilian population, with an alarming average of 21 veterans dying by suicide each day. The presence of SUDs alongside other mental health conditions, such as depression and post-traumatic stress disorder (PTSD), can significantly exacerbate these risks.
  • Decreased Quality of Life: Co-occurring disorders can also have a substantial impact on a veteran’s quality of life, affecting their physical health, personal relationships, and financial stability. For instance, veterans with PTSD often experience chronic pain, which is associated with an increased likelihood of developing alcohol use disorders (AUDs).
  • Sleep Disruption: Mental health issues like mood and anxiety disorders, particularly PTSD and major depressive disorder (MDD), are strongly correlated with conditions like obstructive sleep apnea among veterans.

The challenges posed by co-occurring disorders are further compounded by factors such as lower education levels, multiple deployments, and pre-existing psychological issues. These factors not only increase the risk of developing PTSD but also hinder the transition from military to civilian life, making it difficult for veterans to secure employment and achieve financial stability. The complex interplay between mental health, substance misuse, and societal reintegration demands a comprehensive approach to treatment and support for our veterans.

The Effects of Co-occurring Disorders on Veterans’ Family Dynamics

Co-occurring disorders in veterans can have profound impacts on family and personal relationships. The presence of disorders such as PTSD and substance use disorders (SUDs) can strain partnerships, leading to increased distress and challenges in family life. Research indicates that veterans with PTSD and a co-occurring SUD experience lower relationship satisfaction, which can manifest as:

  • Emotional violence
  • Physical violence
  • Grief from loss of safety
  • A shift in worldview that affects the entire family unit

Partners of veterans with these conditions often face difficulties in confronting and managing symptoms of PTSD and substance misuse. The stress of combat, traumatic brain injuries (TBI), and chronic pain are factors that contribute to the high risk of alcohol and drug misuse among veterans, further complicating family readjustment post-deployment. Studies have shown that veterans returning from combat with depression or PTSD are significantly more likely to face challenges in family readjustment than those without such diagnoses.

Supporting a Veteran With Co-occurring Disorders

Family members are encouraged to support their veteran loved ones by understanding the complexities of these disorders and seeking professional help. The VA recommends steps to foster a supportive environment, such as educating oneself about the disorders, encouraging open communication, and guiding veterans towards appropriate treatment options. The impact of co-occurring disorders extends beyond the individual, affecting the family’s stability, emotional well-being, and overall quality of life.

Effects of Co-occurring Disorders on Veterans’ Employment and Financial Well-being

Co-occurring disorders, which involve the simultaneous presence of a mental health condition and a substance use disorder, can have profound impacts on the employment and financial stability of veterans. Studies indicate that veterans with CODs face significant challenges in maintaining employment, which in turn affects their financial well-being. 

The prevalence of unemployment among homeless veterans with CODs increased from 47% to 66% between 2005 and 2008, highlighting the correlation between CODs, unemployment, and housing instability.

Financial Strain as a Result of Co-occurring Disorders

Financial strain is a critical concern as it not only increases the risk of homelessness but also exacerbates chronic health conditions, including mental and substance use disorders. 

Assistance for Veterans with Co-occurring Disorders

Temporary financial assistance (TFA) has been shown to improve housing outcomes among veterans experiencing housing instability, suggesting that financial support can be a pivotal factor in managing the adverse effects of CODs.

Furthermore, the integration of vocational supports aimed at obtaining competitive employment is crucial for veterans with CODs. Programs like the Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking – Veterans Edition (MISSION-Vet) are designed to increase engagement in care and prevent future housing loss, thus addressing the intersection of employment, financial stability, and health outcomes.

Given these challenges, it is essential to provide comprehensive treatment and support systems that address both the mental health and vocational needs of veterans with CODs to enhance their chances of achieving stable employment and financial independence.

Comprehensive Treatment Approaches for Veterans with Co-occurring Disorders

Veterans facing co-occurring disorders such as substance use disorders (SUD) and post-traumatic stress disorder (PTSD) require specialized treatment strategies that address both conditions simultaneously. 

Integrated treatment models that combine evidence-based psychotherapies for mental health conditions with SUD interventions are critical for improving outcomes. Research from RAND Corporation highlights the importance of standardized, patient-centered care that avoids the pitfalls of treating SUD and mental health disorders in isolation.

Top Treatment Options for Co-occurring Disorders in Veterans

Key treatment options include cognitive behavioral therapy (CBT), which has been shown to reduce substance cravings and related problems, as well as decrease PTSD symptoms when tailored for co-occurring disorders. 

The VA’s adoption of a “no wrong door policy” ensures that veterans can access PTSD and SUD treatment across various care settings without the barrier of required abstinence from substance use prior to mental health care. This approach is bolstered by the Uniform Mental Health Services Handbook, which mandates the availability of evidence-based pharmacotherapy and psychosocial interventions.

Next Steps for Treatment of Veterans with Co-occurring Disorders

Expanding treatment availability and accessibility is another crucial step, as recommended by the RAND study. This includes enhancing the capacity of treatment facilities to offer integrated care and ensuring that veterans have comprehensive insurance coverage under acts like the Affordable Care Act and the Mental Health Parity and Addiction Equity Act. Cognitive behavioral therapy, alongside other modalities like dialectical behavior therapy (DBT), peer support, and medication management, forms the cornerstone of a multi-faceted treatment approach for veterans with co-occurring disorders.

Psychotherapy for Co-occurring Disorders in Veterans

Psychotherapy is a cornerstone in the treatment of co-occurring disorders, particularly among veterans who may face unique challenges related to their service. Integrated treatment, which addresses both substance use disorders (SUDs) and mental health conditions simultaneously, is consistently found to be more effective than treating each diagnosis separately. Cognitive Behavioral Therapy (CBT) strategies are commonly employed to enhance interpersonal and coping skills while fostering motivation and functional recovery. The approach is tailored to help patients navigate the complex interplay between psychiatric symptoms and substance abuse, aiming to improve treatment engagement and reduce relapse rates.

Despite the challenges, including higher rates of treatment dropout, research continues to evolve, offering new insights into effective psychotherapeutic interventions for this population. Collaboration between clinical providers and support services is crucial to address broader issues such as homelessness and physical health, which are often intertwined with co-occurring disorders. Effective psychotherapy for veterans with co-occurring disorders also involves: 

  • Strengthening protective factors
  • Providing tools for emotional regulation
  • Preventing behaviors with negative consequences 

For comprehensive care, it is imperative that SUD programs for veterans also screen for and treat comorbid mental disorders, considering the use of medications where appropriate to support the psychotherapeutic process.

Effective Medication Management for Veterans with Co-occurring Disorders

Medication management is a critical component in treating veterans with co-occurring disorders, which include a combination of mental health and substance use issues. 

Medication for Opioid Use Disorder

The integration of Medication for Opioid Use Disorder (MOUD) in mental health settings is essential for addressing co-occurring opioid use and mental health disorders. Guides have been developed to assist clinicians in the initiation of MOUD, aiming to improve outcomes for clients with these complex needs.

Standards and Best Practices for Medication Management

The American Society of Addiction Medicine has updated its care standards to reflect the latest research and clinical best practices. The latest standards:

  • Emphasize the importance of a chronic care model
  • Reinforce the need for patient-centered approaches

This involves ongoing engagement in the treatment system and seamless transitions between levels of care, as detailed in The ASAM Criteria.

Role of Medications in Co-occurring Disorders

Medications play a pivotal role in both withdrawal management and relapse prevention, with some studies exploring the efficacy of newer treatments such as topiramate, ketamine, noninvasive brain stimulation, and deep brain stimulation. However, it is crucial to combine these medications with psychosocial interventions for a comprehensive treatment approach, as recommended by research findings.

Pharmacist-delivered comprehensive medication management has also been recognized as a valuable strategy in substance use treatment agencies. This approach addresses the higher risks of hospitalization and health care costs associated with co-occurring disorders, underscoring the need for specialized care in this population as supported by studies.

Navigating the Challenges of Treating Co-occurring Disorders in Veterans

Treating co-occurring disorders in veterans presents unique challenges, often stemming from the complex interplay between mental health and substance use disorders. 

Integrated Treatment Approaches

According to RAND Corporation research, veterans with co-occurring mental health and substance use disorders require integrated treatment approaches tailored to address both conditions simultaneously. Despite the proximity of most veterans to treatment facilities, a significant gap persists in treatment uptake, with many not receiving the necessary care.

Barriers to Treatment

One of the primary barriers is the traditional treatment model, which frequently requires veterans to abstain from substance use before receiving mental health care. This precondition can deter veterans from seeking help, as highlighted in RAND’s research brief. The separation of services for substance use and mental health issues can lead to a cycle of incomplete treatment and relapse.

Rates of Co-occurring Disorders in Veterans

Furthermore, the prevalence of co-occurring disorders is high among veterans, with as many as 88 percent of those with PTSD also grappling with a substance use disorder. This comorbidity necessitates a patient-centered approach that is evidence-based and integrated, yet many facilities and providers specialize in only one type of treatment. Expanding the availability and accessibility of integrated treatments is crucial, requiring a coordinated effort across the treatment community.

Addressing the Stigma of Mental Health in the Military

The stigma associated with mental health within the military is a significant barrier that can prevent service members from seeking necessary treatment. Despite ongoing efforts to normalize mental health care, concerns about personal and professional repercussions continue to hinder open discussions and access to care. 

The Brandon Act

The Department of Defense has implemented policies like the Brandon Act, which aims to create a confidential self-referral process for mental health care, as an effort to mitigate this stigma. 

Further Research 

Research from RAND Corporation further emphasizes the need for stigma-reduction strategies that align with best practices, suggesting that such efforts may be contributing to a decline in self-reported stigma among military personnel.

Military Programs

Programs like Military Pathways and the Real Warriors Campaign are examples of initiatives designed to improve mental health through self-directed activities, education, and referrals. These programs also work to shift the military culture from one that values self-reliance and toughness to one that recognizes mental well-being as a continuum of preparedness for service. 

Embedded Behavioral Health Teams

Furthermore, embedding Behavioral Health teams and Combat Operational Stress Control programs within units aims to foster a supportive culture and encourage service members to seek help for mental health and substance abuse issues.

Future Efforts

Despite these initiatives, stigma persists, and many veterans still avoid seeking treatment due to misconceptions and fears of being judged or deemed unfit for service. Addressing this stigma requires continued education of military leadership, cultural change towards mental health care, and the promotion of veteran-specific programs that decrease stigma and engage veterans in care. The Recovery Village highlights the importance of comprehensive efforts to combat stigma, including widespread sharing of educational materials that reassure service members that seeking help is a sign of strength, not weakness.

Challenges in Accessing Quality Mental Health Care for Veterans

Veterans often face significant hurdles in accessing quality mental health care, a critical component for managing co-occurring disorders. Despite increased budgets and efforts to ramp up capacity, veterans encounter multiple barriers:

  • Mistrust of the VA healthcare system
  • Logistical difficulties
  • Stigma associated with seeking mental health services

RAND Corporation research highlights the need for a comprehensive evaluation of the VA mental health system and suggests that private providers, when integrated properly, could enhance access to care.

Veteran-Centered Barriers

Challenges also stem from veteran-centered barriers, such as:

  • Worries about what others may think
  • Personal challenges
  • Financial obstacles
  • Navigating VA benefits

A study published in BMC Health Services Research identified five dimensions of barriers to care, including concerns about privacy and the complexity of accessing VA services. The National Academies of Sciences, Engineering, and Medicine have also addressed the need to improve access through innovations like telehealth and partnerships that leverage VA’s status as a national healthcare system.

Future Solutions

Amidst the crisis in veterans’ mental health, new solutions are being sought to protect access to care. The National Alliance on Mental Illness (NAMI) emphasizes the importance of enhancing the VHA’s role, especially in areas with severe workforce shortages. Legislative efforts, such as the Veterans Mental Health and Addiction Therapy Quality of Care Act, propose studies to assess the quality of care veterans receive, aiming to ensure that standards are met and services are improved.

The Importance of Support Systems for Veterans with Co-occurring Disorders

For veterans grappling with co-occurring disorders, the presence of robust support systems is vital for effective management and recovery. Co-occurring disorders, which include a combination of mental health and substance use disorders, present complex challenges that require comprehensive, integrated treatment approaches. Research indicates that integrated skills and practice supports are essential for programs and providers addressing these disorders. Recommendations for integrated systems and services underscore the need for collaboration between mental health and substance use treatment systems.

Effects of Social Support Systems in Treatment

Support systems play a crucial role in the treatment engagement and the prevention of housing loss, as seen in specialized interventions like MISSION-Vet. 

  • The RAND Corporation also emphasizes the importance of support for behavioral health needs, highlighting treatment, provider, and system factors crucial for veterans’ recovery. 
  • Family, friends, and community networks provide emotional support, encouragement, and practical assistance, contributing to a more stable environment conducive to treatment. 
  • Professional support systems, including healthcare providers, peer support groups, and veteran services, offer specialized care and resources tailored to the unique experiences of veterans.

Ultimately, the integration of support systems into treatment plans for veterans with co-occurring disorders is a critical component of a successful recovery strategy, enabling veterans to navigate the complexities of their conditions with a network of support that addresses both their mental health and substance use challenges.

The Crucial Role of Family and Friends in Supporting Veterans with Co-occurring Disorders

For veterans grappling with co-occurring disorders, the support of family and friends is invaluable. These informal caregivers provide emotional, practical, and sometimes even financial assistance that can significantly impact the veteran’s recovery journey. Research has shown that social support, particularly from close family and friends, can greatly enhance a veteran’s engagement in mental health care, including therapies for conditions such as PTSD.

Family members and friends often play a critical role in encouraging veterans to seek and continue treatment. They can provide a compassionate environment that fosters open communication, helps in recognizing early signs of distress, and supports adherence to treatment plans. The U.S. Department of Veterans Affairs acknowledges the importance of family and friends, offering resources to help them understand the veteran’s challenges and become effective allies in the recovery process.

Support Groups and Resources

Support groups and educational resources are also available to assist family members and friends in coping with the stress of caregiving and to better understand the complexities of co-occurring disorders. These resources can offer guidance on maintaining healthy relationships and managing the emotional toll that caregiving can exact. It’s clear that the involvement of family and friends is not just beneficial but often essential in helping veterans with co-occurring disorders navigate the path to wellness.

The Role of Community and Professional Support in Veteran Co-Occurring Disorder Management

Effective management of co-occurring disorders in veterans requires a multi-faceted approach, leveraging both community and professional support systems. 

The Wounded Warrior Project

The Wounded Warrior Project (WWP), a nonprofit organization, exemplifies community support by assisting post-9/11 veterans and their families in addressing mental health needs. These outreach programs are vital for veterans to recognize and confront behavioral health issues outside conventional care settings.

Evidence-Based Pharmacotherapy and Social Interventions

Professional support, as detailed by the U.S. Department of Veterans Affairs, includes evidence-based pharmacotherapy and psychosocial interventions, ensuring that substance use disorders (SUDs) do not hinder access to treatment for conditions like PTSD. The VA advocates for a “no wrong door policy,” welcoming veterans into treatment programs irrespective of their entry point into the system. This inclusive approach is crucial for veterans who might otherwise face barriers to care.

Combining Psychotherapy and Medication for Veterans with Co-occurring Disorders

Furthermore, the VA’s treatment strategy for co-occurring disorders emphasizes the combination of psychotherapy with medication management when appropriate, facilitating a more comprehensive treatment experience. Specialized interventions, such as the MISSION-Vet program, focus on integrating systems and networking to enhance engagement in care for homeless veterans with co-occurring disorders. By aligning community outreach with professional treatment options, veterans with co-occurring disorders can receive the holistic support necessary for effective management and recovery.

Find Excellent Treatment at The Recovery Village Cherry Hill

If you’re a military veteran seeking addiction treatment, The Recovery Village Cherry Hill at Cooper is here to help. We are a part of the VA Community Care Network, and we offer a trauma-informed program designed for veterans and first responders. Contact a Veteran Advocate today to learn more or to get started with treatment. 

Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

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