Recently transitioned combat veteran with nightmares, alcohol use, and passive death wishes (MEQ)

(i) Formulation. Service is context, not diagnosis. Map combat Criterion A exposures to DSM-5-TR PTSD clusters (intrusion, avoidance, negative cognitions/mood, arousal) lasting more than 1 month with impairment. Alcohol may self-medicate hyperarousal and sleep loss. Moral injury (Litz) may add guilt/shame/betrayal themes that are formulation, not a separate DSM code. Transition stressors (identity, relationships, civilian role) maintain morbidity. Stigma ("I am not weak") is a barrier mechanism delaying care (Hoge framing).[1][3][10]

(ii) Assessment today. Explicit suicide assessment: ideation, intent, plan, means — firearm access and storage. Safety plan and means restriction. Screen violence/IPV and child protection if dependents. Trauma-informed service history (deployments, roles) without forcing graphic first-session retelling; private MST enquiry principle. Substance quantity and withdrawal risk. MSE and capacity. Measures: PCL-5 for severity monitoring; CAPS-5 when diagnostic precision needed. Collateral with consent.[10][1]

(iii) Epidemiology anchors. Hoge 2004: combat-related mental health burden and barriers to care. Fear 2010: UK armed forces deployment mental health consequences including PTSD symptoms and alcohol patterns. Seal 2007: high rates of mental health diagnoses among OEF/OIF veterans using VA care. Fulton 2015 meta-analysis estimates substantial OEF/OIF PTSD prevalence with heterogeneity — avoid false precision.[1][2][9]

(iv) Management. Safety and alcohol plan first. First-line trauma-focused psychotherapy: CPT (Monson veteran RCT) and PE with military psychotherapy synthesis (Steenkamp 2015) noting residual symptoms are common. If medication chosen: sertraline 25–50 mg orally daily, titrate toward 50–200 mg; monitor sexual dysfunction, GI effects, activation/suicidality. Prazosin for nightmares: counsel equipoise — 2013 active-duty positive trial versus 2018 multi-site veteran NEJM null; individualised trial if BP allows. Avoid benzodiazepine default for core trauma. Link veteran-competent services and family support.[4][5][6][7][8]

(v) Pitfalls and disposition. Pitfalls: assuming all veterans have PTSD; skipping weapons; ignoring moral injury; over-selling prazosin; inventing compensation statutes; treating alcohol as optional. Disposition: same-day senior review if high intent or unsafe firearm storage; crisis follow-up; trauma psychology for PE/CPT; primary care liaison; step-up for psychosis, severe withdrawal, or ongoing high risk.[7][10][5]