In the United States, there are more than 22.3 million veterans1 and more than 2.2 million active military service members (including the National Guard and Reserve).2 Military personnel and veterans willingly risk their lives to protect our society. These individuals and their families may have both rewarding and troubling experiences while doing so. Among the challenges these men and women face is the risk of developing or exacerbating behavioral health conditions, which include mental and/or substance use disorders.
Among the general population, these conditions are a growing national public health concern – in 2010, an estimated 22.6 million Americans aged 12 or older used illicit drugs in the past month,3 and 45.9 million adults experienced any mental health illness in the past year.4 While active military, veterans, and military families are at risk for experiencing the impact of behavioral health conditions, they can also serve as positive models of recovery for the millions of Americans struggling with similar issues.
The 23rd annual National Recovery Month (Recovery Month) observance this September celebrates the effectiveness of treatment services and the reality of recovery. Recovery Month is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), within the U.S. Department of Health and Human Services (HHS). This year’s theme, “Join the Voices for Recovery: It’s Worth It,” emphasizes that while the road to recovery may be difficult, the benefits of overcoming mental and/or substance use disorders are far-reaching and affect individuals, families, and communities. People in recovery achieve healthy lifestyles, both physically and emotionally, while contributing in positive ways to their communities. They also prove to relatives, friends, coworkers, and others that prevention works, treatment is effective, and people recover.
SAMHSA’s efforts to curb behavioral health issues in soldiers, veterans, and their families are guided by its Military Families Strategic Initiative, which aims to ensure access to needed behavioral health services to achieve positive outcomes in this population.5 In addition, this Strategic Initiative provides support and leadership through a collaborative and comprehensive approach to increase access to appropriate services, promote emotional health, prevent suicide, and reduce homelessness.6
This document outlines the impact of mental and/or substance use disorders on individuals in the military, as well as the prevention, treatment, and recovery resources available to provide support to these individuals and their families. Refer to the “Join the Voices for Recovery” document in this toolkit to learn about real-life recovery journeys from a mental and/or substance use disorder.
Prevalence of Mental and/or Substance Use Disorders
Active military, veterans, and military families are all at risk for developing mental and/or substance use disorders. Mental illness can encompass a variety of conditions, including mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder (PTSD); attention disorders; and personality disorders. Substance use disorders include misuse, dependence on, or addiction to alcohol, tobacco, and/or illicit or prescription drugs. Studies have shown that substance use disorders include both physical and mental dependences7 and have characteristics similar to other chronic diseases, such as asthma, hypertension, and diabetes. Treatment of both chronic diseases and behavioral health conditions requires changes in deeply ingrained behaviors, and a relapse does not necessarily indicate failure, but a need to adjust treatment methods.8
Mental illness and substance use disorders can lead to hardships that render a person’s recovery journey more challenging. Homelessness is one of the adversities plaguing military veterans at a high rate. Between October 2009 and September 2010, as many as 144,842 veterans spent at least one night of the year in a homeless shelter.9 Additionally, 76 percent of homeless veterans experience alcohol, drug, or mental health problems.10
Combat deployments for military members – who are away from family and in risky or dangerous situations – may cause the onset of behavioral health conditions or exacerbate existing problems. The rate of behavioral health conditions among military personnel is significant, with serious consequences:
- Mental and/or substance use disorders caused more hospitalizations among U.S. troops in 2009 than any other cause.11
- More than 1,100 members of the armed forces died by suicide from 2005 to 2009 – an average of 1 suicide by a member of the armed forces occurred every 36 hours during that time.12
Understanding Mental Health Problems in the Military
While serving our Nation, hundreds of thousands of soldiers face exposure to combat. These traumatic war experiences can have a direct effect on mental health. The most common mental health problems among active duty service members include post-traumatic stress disorder (PTSD) and depression.13 These disorders tend to be chronic or long-lasting in duration, increasing the likelihood of adversely affecting military service.14
PTSD is an anxiety disorder associated with traumatic experiences, and can be linked with military deployment. Approximately 14 percent of service members returning from Iraq or Afghanistan meet the criteria for PTSD.15 Post-traumatic stress disorder is a normal reaction for individuals who experience or witness a traumatic event. However, when these stress symptoms are severe and persistent, they can begin to interfere with daily and family life and have other more serious, negative consequences. Recognizing the key symptoms listed below can help people identify PTSD and promote early intervention and improvement of symptoms among military service members. They include:16
Reliving the event: Repeated and upsetting memories of the event, repeated nightmares, flashbacks, and/or intense and upsetting reactions to “reminders” of the traumatic event.
Avoidance: Attempts to avoid places, people, things, or thoughts that are associated with or serve as reminders of the trauma; inability to remember important aspects of the trauma; reduced interest or participation in normal activities; feeling detached; emotional “numbing”; feeling like one has no future.
Arousal: Trouble sleeping; irritability or anger outbursts; difficulty concentrating; feeling more aware (hypervigilance); having an exaggerated response to things that may startle someone.
Depression, a condition that involves feelings of sadness or low mood that last more than just a few days, is a common problem that can occur following trauma. For veterans, depression can be caused by painful memories and feelings about their war experiences.17 It is estimated that 9.3 percent of veterans aged 21 to 39 have experienced at least one major depressive episode (MDE) in the past year.18 An MDE, as defined in The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is a period of at least two weeks when a person experiences a depressed mood or loss of interest or pleasure in daily activities, and has at least four of seven additional symptoms as described in DSM-IV.19 Among veterans aged 21 to 39 who experienced an MDE in the past year, more than half (51.7 percent) reported severe impairment in at least one of the following areas: home management, work, close relationships with others, or social life.20 Additionally, the Veterans Affairs’ National Registry for Depression estimates that 11 percent of veterans aged 65 and older suffer from MDE, a rate that is double that of the general population in that age range.21
According to the National Institute of Mental Health, symptoms of depression can include:22
- Persistent sad, anxious, or “empty” feelings;
- Feelings of hopelessness or pessimism;
- Feelings of guilt, worthlessness, or helplessness;
- Irritability, restlessness;
- Loss of interest in activities or hobbies that once were pleasurable;
- Fatigue and decreased energy;
- Difficulty concentrating, remembering details, and making decisions;
- Insomnia, early-morning wakefulness, or excessive sleeping;
- Overeating or appetite loss;
- Thoughts of suicide; and
- Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.
Understanding Substance Use Disorders in the Military
While substance use disorders are not as pervasive as mental health problems among military populations, they are still a major health concern.23 Alcohol misuse is the most prevalent problem. According to a recent publication, 27 percent of Army soldiers met criteria for alcohol misuse three to four months after returning from deployment to Iraq.24 Additionally, there is a significant need to monitor and reduce prescription drug abuse in the military. From 2005 to 2008, prescription drug abuse nearly tripled among U.S. military personnel.25
It’s important to monitor for signs and symptoms of substance use disorders and to prevent the misuse of alcohol and/or drugs. Individuals, families, and members of the military community should be aware of the following signs and consequences associated with substance use:
- Failure to fulfill major personal and professional obligations;26
- Recurrent use of substances in situations in which they are physically hazardous;27
- Recurrent alcohol or substance-related legal problems;28
- Persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol or substance use, while this use often continues without stopping;29
- Mood and behavior problems;30
- Financial difficulties;31 and
- Hurt social relationships.32
In 2008, the suicide rate in the Army exceeded the suicide rate among the civilian population for the first time (20.2 out of every 100,000 suicides, vs. 19. 2 out of every 100,000 for civilians).33 Additionally, drug or alcohol use was involved in 30 percent of suicide deaths of Army members from 2003 to 2009 and in more than 45 percent of non-fatal suicide attempts from 2005 to 2009. The Department of Veterans Affairs offers many resources for those at risk of suicide, or those having suicidal thoughts. The Veterans Crisis Line (800-273-8255) provides veterans, their families, and their friends with an anonymous chat service with trained counselors who can provide further counseling and referral services for those who need it.
To further address these conditions, government agencies, researchers, public health agencies, and others are working to adapt and test proven alcohol and substance-use prevention and treatment interventions for use with military and veteran populations and their families.3
It is important to note that mental and/or substance use disorders can happen at the same time, which is called a co-occurring disorder.36 These disorders affect the military in large numbers.37 Also, two or more mental health problems can occur at the same time. Among the 25 percent of military personnel discharged between September 2001 and September 2005 who received a mental health diagnosis, approximately 56 percent were diagnosed with two or more mental disorders.38 To effectively treat co-occurring disorders, an integrated treatment program is needed. This helps coordinate mental health and substance use interventions, allowing health professionals to treat the whole person and address all issues at the same time.39
The Extended Impact on Families
In the United States, there are approximately 700,000 military spouses, and more than 700,000 children have experienced the deployment of a parent.40 Military families play an active role in the recovery of a relative’s disorder, while at the same time they may also experience difficulties dealing with situations that can arise due to a family member’s deployment, injury, or death.
Families of military personnel can directly experience both the emotional and physical effects of behavioral health conditions, particularly during their loved one’s long absence(s). Studies show that parental combat deployment has a cumulative effect on children, while prolonged deployment is associated with more mental health diagnosis among U.S. Army wives.41, 42 The effects of deployment are significant, as evidenced by the following findings:
- Children of deployed military personnel have more school, family, and peer-related emotional difficulties, compared with the civilian public;43
- Women whose husbands have been deployed for 1 to 11 months are diagnosed with more depressive disorders, sleep disorders, anxiety, and acute stress reaction and adjustment disorders than those whose husbands are not deployed;44
- For children who were between ages 3 and 8 when a parent was deployed, 19 percent showed an increase in behavioral issues while their parent was gone;45 and
- In 1 year, 34 percent of caregivers in military families reported that their children experienced moderate to high levels of emotional and behavioral problems, compared with 19 percent of all youth nationally.46
To prevent the onset of these issues, families need to identify the signs of mental and/or substance use disorders among loved ones – and monitor for symptoms even after a parent or spouse returns home. Reintegration challenges exist for children, including increased attachment behavior when parents return, compared with children whose parents have not recently been deployed.47 Like recovery, reintegration for both the military personnel and the family members is a journey that takes time and effort.
Address Prejudice to Help Military Members on the Road to Recovery
Social prejudice, or fear of being exploited or judged for mental and/or substance use disorders, can interfere with the desire of individuals with behavioral health conditions to seek treatment and support. Despite the growing need for treatment, this problem is more pronounced among military populations, who often fear they may be construed as “weak” or “cowardly” if they seek help for a mental and/or substance use disorder, and many fear the disapproval of peers.48, 49
For example, in 2008, approximately 12.9 percent of all military personnel – including Army, Navy, Marine Corps, Air Force, and Coast Guard personnel – believed that if they were to seek mental health counseling through the military, their careers would be damaged.50 Considering these sensitivities, command and medical interventions are alternative ways the Army can identify those in need of help or treatment.51
Perception about behavioral health issues can change, however, and research shows that the most effective way of countering prejudice and discrimination is by sharing one’s personal experiences with others.52 Military personnel, as well as their families, can take comfort in the fact that 84 percent of Americans believe individuals with mental illnesses are not to blame for their conditions.53 Additionally, more than 80 percent say that they wouldn’t think less of a friend or relative if they discovered that person is in recovery from a mental and/or substance use disorder.54 It is important to increase access to and understanding of treatment and behavioral health interventions among military communities, and to encourage people who are concerned about mental and/or substance use disorders to seek the help they need.
Over the years, SAMHSA has been active in its efforts to lead conferences and policy academies that have strengthened State-level behavioral health systems and ensured that needed behavioral health services are accessible to the Nation’s service men and women and their families. These policy academies have been done in conjunction with the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors.
In addition, a U.S. Department of Labor project, entitled “America’s Heroes at Work,” addresses employment challenges of returning service members living with traumatic brain injury (TBI) and/or PTSD. Designed for employers and the workforce development system, this service provides information and tools to help returning service members affected by TBI and/or PTSD succeed in the workplace, particularly service members returning from Iraq and Afghanistan.
Opportunities for Prevention, Treatment, Recovery, and Support
Although soldiers may be reticent to seek behavioral health care, they are required to be assessed annually by a primary care provider.55 The primary care setting provides a recognized opportunity for early identification and treatment of physical symptoms associated with behavioral health conditions among active duty soldiers. The same is true for veterans: returning Iraq and Afghanistan veterans with a mental health diagnosis, particularly PTSD, use significantly more non-mental health medical services than do veterans without a mental health diagnosis. This points to the need to ensure outpatient, inpatient, and emergency care services for veterans.56
Proper prevention and intervention techniques offered in primary care settings can have long-lasting benefits. In fact, appropriate prevention, intervention, treatment, and recovery support services decrease the incidence of both mental and/or substance use disorders and help active duty and reservist military personnel and veterans lead healthy lives.
With this in mind, many States have policies in place to respond to the needs of veterans, and in 31 States, substance use disorder treatment providers are required to screen for veterans’ mental health status. Additionally, in 40 States, health care providers screen patients to determine if they need mental health assessments.57
The Department of Defense (DOD) and U.S. Department of Veterans Affairs (VA) promote the integration of behavioral health and primary care. For example, the Army instituted a model of care called RESPECT-MIL (Re-Engineering Systems of Primary Care Treatment in the Military), which requires primary care screening for all service members and offers treatment in that setting. This helps reduce prejudice, improves access to high-quality behavioral health services, and provides a proven “best practice” for treating depression and PTSD.58
The VA has devoted $37.7 million to placing psychiatrists, psychologists, and social workers within primary care clinics.59 This enables these health professionals to observe and intervene on any mental or substance use disorder issues and allows for brief treatment for those who may not require specialty care.60 The VA has also recruited nearly 3,800 new mental health employees, including 800 psychologists.61
With the help of treatment and the support of family and friends, those in the military can and do overcome mental and/or substance use disorders and sustain happy, healthy, and productive lives. Of the millions of individuals in pursuit of recovery, military members form a significant portion of this population.
Many military personnel, veterans, and their families take advantage of the multiple pathways to recovery. They are not alone on their journey. Recovery support services are an integral part of sustaining recovery post-treatment. For more information on recovery support services, refer to the “Treatment and Recovery” document in this toolkit. For more information on SAMHSA resources that make a difference in military communities, refer to the below resources:
Peer support resources are social support services designed to fill the needs of people in or seeking recovery.62 There are additional resources for veterans that show the value of peer support, including:
- Vets4Vets – a national, nonprofit veteran organization that organizes peer support groups for Iraq- and Afghanistan-era veterans to help them feel good about themselves and heal from any negative aspects of service and war.
Vet-to-Vet – an alliance of family members, professionals, and other mental health consumers who work together to improve and increase mental health services through community education and service.
Iraq & Afghanistan Veterans of America - an organization that addresses critical issues facing new veterans and their families.
Make a Difference During Recovery Month and Throughout the Year
This September and throughout the year, SAMHSA encourages all friends and family members to become involved in Recovery Month and help people with behavioral health conditions. You can:
Educate others about behavioral health conditions. If you are an active member of the military, a reservist, a veteran, or a family member, it is important to spread your knowledge about mental and/or substance use disorders. Educating others will help reduce the prejudice and misconceptions surrounding these conditions and promote the effectiveness of prevention and treatment, reminding people that recovery is possible.
Learn the signs of mental and/or substance use disorders, listed in this document. Encourage individuals who are in need of services to seek the appropriate help.
Celebrate Recovery Month. Plan an event and encourage others to participate. If you live on a military base, a Recovery Month event is a great way to provide mental and/or substance use disorder information to others, and can serve as the first step to help someone acknowledge their problem.
It’s Worth It
Millions of military officials, veterans, and their families have demonstrated their ability to overcome behavioral health conditions and lead healthy, productive lives in recovery. This year’s Recovery Month observance highlights why recovery is worth it for all individuals, and educates communities, especially those in the military at home and abroad, that prevention works, treatment is effective, and people recover.
Additional Recovery Resources
A variety of resources provide additional information on Recovery Month, mental and/or substance use disorders, and prevention, treatment, and recovery support services. Use the toll-free numbers and websites below to share your experiences, learn from others, and seek help from professionals. Through these resources, individuals, including family members, can interact with others and find support on an as-needed, confidential basis.
SAMHSA’s Website – Leads efforts to reduce the impact of substance use and mental disorders on communities nationwide.
SAMHSA’s National Helpline, 1-800-662-HELP (4357) or 1-800-487-4889 (TDD) – Provides 24-hour, free and confidential treatment referral and information about mental and/or substance use disorders, prevention, treatment, and recovery in English or Spanish.
SAMHSA’s “Find Substance Abuse and Mental Health Treatment” Website – Contains information about treatment options and special services located in your area.
SAMHSA’s “Considerations for the Provision of E-Therapy” Report – Shares extensive information on the benefits, issues, and success of e-therapy.
SAMHSA’s ADS Center – Provides information and assistance to develop successful efforts to counteract prejudice and discrimination and promote social inclusion.
National Suicide Prevention Lifeline, 1-800-273-TALK (8255)
, 1-800-273-TALK (8255) , 1-800-273-TALK (8255) , 1-800-273-TALK (8255) – Provides a free, 24-hour hotline available to anyone in suicidal crisis or emotional distress.
Veterans Crisis Line, 1-800-273-TALK (8255) – Connects veterans in crises and their family and friends with VA responders through a confidential, toll-free helpline and online chat.
United States Department of Veterans Affairs – Mental Health – Maintains and improves the health and well-being of veterans through health care, social services, education, and research.
Army Substance Abuse Program (ASAP) – Provides guidance and leadership on alcohol and drug abuse prevention, education, and training programs for soldiers and their commanders.
Inclusion of websites and resources in this document and on the Recovery Month website does not constitute official endorsement by the U.S. Department of Health and Human Services or the Substance Abuse and Mental Health Services Administration.