Military and veteran psychiatry

Meet the patient

A 34-year-old infantry veteran, eight months out of the army, is referred by his partner's GP. He has not slept a full night since he left. He scans the rooftops on the walk to the shops, will not sit with his back to a cafe door, and drinks most evenings to get to sleep. His partner says he is "not the same person". He tells you, flatly, that he was supposed to bring them all home.[1][6]

Three questions travel with this patient: is this PTSD, something else, or both?, what is keeping him unwell now — combat, alcohol, or the loss of identity after discharge?, and are there firearms in the house? A pass-grade answer addresses all three before it names a single drug.[1][5][20]

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1. [1]Hoge CW, Castro CA, Messer SC, McGurk D, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care N Engl J Med, 2004.PMID 15229303
2. [2]Fear NT, Jones M, Murphy D, Hull L, et al. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study Lancet, 2010.PMID 20471076
3. [3]Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities Arch Intern Med, 2007.PMID 17353495
4. [4]Fulton JJ, Calhoun PS, Wagner HR, Schry AR, et al. The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: a meta-analysis J Anxiety Disord, 2015.PMID 25768399
5. [5]Litz BT, Stein N, Delaney E, Lebowitz L, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy Clin Psychol Rev, 2009.PMID 19683376
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7. [7]Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, et al. The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans Psychol Assess, 2018.PMID 28493729
8. [8]Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation J Trauma Stress, 2015.PMID 26606250
9. [9]Monson CM, Schnurr PP, Resick PA, Friedman MJ, et al. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder J Consult Clin Psychol, 2006.PMID 17032094
10. [10]Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, et al. Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial JAMA, 2007.PMID 17327524
11. [11]Steenkamp MM, Litz BT, Hoge CW, Marmar CR Psychotherapy for Military-Related PTSD: A Review of Randomized Clinical Trials JAMA, 2015.PMID 26241600
12. [12]Foa EB, Hembree EA, Cahill SP, Rauch SA, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics J Consult Clin Psychol, 2005.PMID 16287395
13. [13]Powers MB, Halpern JM, Ferenschak MP, Gillihan SJ, Foa EB A meta-analytic review of prolonged exposure for posttraumatic stress disorder Clin Psychol Rev, 2010.PMID 20546985
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15. [15]Brady K, Pearlstein T, Asnis GM, Baker D, et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled trial JAMA, 2000.PMID 10770145
16. [16]Marshall RD, Beebe KL, Oldham M, Zaninelli R Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study Am J Psychiatry, 2001.PMID 11729013
17. [17]Davidson J, Baldwin D, Stein DJ, Kuper E, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial Arch Gen Psychiatry, 2006.PMID 17015818
18. [18]Raskind MA, Peterson K, Williams T, Hoff DJ, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan Am J Psychiatry, 2013.PMID 23846759
19. [19]Raskind MA, Peskind ER, Chow B, Harris C, et al. Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans N Engl J Med, 2018.PMID 29414272
20. [20]Pompili M, Sher L, Serafini G, Forte A, et al. Posttraumatic stress disorder and suicide risk among veterans: a literature review J Nerv Ment Dis, 2013.PMID 23995037