Medical care of the military veteran

INTRODUCTION — Although medical care of the military veteran may be similar in many respects to that of the general population, certain clinical concerns are unique or of particular relevance to veterans. These include both general conditions more commonly seen in veterans (eg, depression, posttraumatic stress disorder [PTSD]) and veteran-specific conditions (eg, combat-related injuries, certain environmental exposures). Non-combat injuries (eg, infections, gastrointestinal illness, and musculoskeletal problems not related to battle) tend to outnumber combat-related injuries [1], and the psychological effects of war are greater in number and duration than the physical effects over the long term.

This topic will provide an overview of medical conditions commonly encountered in military veterans, with a particular emphasis on United States veterans returning from Afghanistan and Iraq. Specific medical conditions associated with combat are discussed in further detail elsewhere:

●(See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

●(See "Traumatic brain injury: Epidemiology, classification, and pathophysiology".)

FRAMEWORK FOR EVALUATION — The initial evaluation should identify key features of military service to provide a framework for evaluating current symptoms and known or potential risks related to service. In addition, patients should be offered screening for conditions commonly seen in veterans, as well as routine acute, chronic, and preventive care.

Deployment history — When taking a military history, the following are essential components:

●Basic information – Ascertain in which military branch the person served, what operations they were involved in, to what degree they were involved in combat, and what specific tasks they performed.

●Location – Identify what countries/global areas the person served in (especially relevant to environmental and infectious disease exposures).

●Timing and duration – Calculate the total time of deployment, and ascertain when it took place (relevant to cumulative risk of sequalae, risks associated with operations/eras).

Screening for conditions common to veterans — Certain conditions, while not unique to the veteran population, occur more commonly in this population and thus warrant heightened awareness and/or screening. (See 'Screening for all patients' below.)

Evaluating conditions related to service — Identify any known combat-related injuries (and prior treatments), psychological or social sequalae, infections during or after deployment, and environmental exposures. (See 'Evaluation for selected patients' below.)

Addressing current concerns — Discuss current symptoms or concerns, and evaluate the potential for a relationship to military service. (See 'Disability and functional assessment' below.)

SCREENING FOR ALL PATIENTS — Veterans are at higher risk than the general population for certain conditions. Principal among these are psychological sequalae related to service. While these sequelae are important by themselves, they are also associated with increased rates of cardiovascular risk factors such as obesity, dyslipidemia, tobacco use, and hypertension [2,3].

An initial screening soon after returning from deployment will miss most cases of mental health problems, and repeated screening is necessary, especially between 3 and 12 months after return. Veterans who screen positive for posttraumatic stress disorder (PTSD), depression, an anxiety disorder, or alcohol or substance use disorder should also be asked about suicidal ideation and intent. (See 'Suicide' below.)

Posttraumatic stress disorder — PTSD is characterized by intrusive thoughts, nightmares, and flashbacks of past traumatic events; avoidance of reminders of trauma; hypervigilance; and sleep disturbance. Battle experiences nearly always fulfill the first criterion for the definition of PTSD (exposure to a severe, traumatic event). The clinical manifestations and diagnostic criteria for PTSD are discussed in detail separately. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Clinical manifestations'.)

●Prevalence – The prevalence of PTSD and other mental health disorders varies based on the particular war, the veteran population being studied (eg, sex, branch of military), and when PTSD assessment is being performed (soon after return compared with years later). In a cohort study of 289,328 United States veterans of the Iraq and Afghanistan Wars who received health care through the Veterans Administration (VA) between 2002 and 2008, the overall prevalence of newly diagnosed PTSD was 21.8 percent, with the rate increasing over time [4]. PTSD and other psychological sequelae are being identified at higher rates than has historically been the case, and they frequently do not fully manifest until months or years after return [5-7]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Combat'.)

●Evaluation – The PTSD checklist (PCL5) may be helpful in screening patients for PTSD and monitoring the progress of treatment over time [8]. The PCL5 (table 1) was developed based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria [9]. It features 20 questions, with each item scored from 0 to 4, with a total score range from 0 to 80. Scoring and indications for diagnostic evaluation are discussed separately. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Diagnosis'.)

Veterans who screen positive for PTSD should be asked about suicidal ideation and intent. (See 'Suicide' below.)

●Treatment – Pharmacotherapy (eg, selective serotonin reuptake inhibitors) and trauma-focused cognitive behavioral therapy are effective for patients with PTSD. However, PTSD in combat veterans may be more resistant to both pharmacologic and nonpharmacologic approaches than non-combat PTSD. Thus, combination therapy and/or a longer duration of therapy may be warranted. Pharmacotherapy and psychotherapy for PTSD are discussed separately. (See "Posttraumatic stress disorder in adults: Treatment overview" and "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions".)

Depression

●Prevalence – Depression and anxiety disorders are significantly associated with war and combat [10-12]. In a cohort study of 289,328 United States veterans of the Iraq and Afghanistan Wars who received health care through the VA between 2002 and 2008, the overall prevalence of newly diagnosed depression was 17 percent, with the rate increasing over time [4]. The clinical manifestations of depression are discussed in detail separately (algorithm 1). (See "Unipolar depression in adults: Assessment and diagnosis".)

●Evaluation – The nine-item Patient Health Questionnaire (PHQ-9) has been the most studied and widely used screening tool for detection of depression. It is brief and easy to use. It consists of nine items that correspond to the nine DSM-5 criteria for unipolar major depression and one additional item assessing psychosocial impairment (table 2). (See "Screening for depression in adults", section on 'Patient Health Questionnaire-9'.)

Veterans who screen positive for depression should be asked about suicidal ideation and intent. (See 'Suicide' below.)

●Treatment – Major depression is a treatable illness that responds to a variety of therapeutic interventions, including psychotherapy and pharmacotherapy. Other modalities (eg, electroconvulsive therapy, deep brain stimulation) may be needed in patients who do not respond to initial therapies. (See "Major depressive disorder in adults: Approach to initial management" and "Unipolar depression in adults: Choosing treatment for resistant depression".)

Suicide

●Prevalence – Suicide rates among veterans in the United States are higher than nonveterans (34 versus 17 per 100,000 in 2021) and have increased since the early 2000s [13]. Rates are highest for male veterans 18 to 34 years of age [13]. Additional risk factors include White race, depression, bipolar disorder, recent psychiatric hospitalization, alcohol-related problems, nonheterosexual status, traumatic brain injury (TBI), dishonorable discharge, recent demotion, early deployment, and early military separation (separation from the military with <4 years of military service) [14-20].

●Evaluation – Veterans who screen positive for PTSD, depression, or anxiety should also be asked about suicidal ideation and intent; if present, the lethality of the plan should be evaluated. Assessing for suicidal ideation is discussed separately (see "Suicidal ideation and behavior in adults", section on 'Patient evaluation'). Veterans may be reluctant to provide information on suicidal ideation. Possible ways to improve suicide risk detection include: removing stigma to seeking help for depression or PTSD, enhancing understanding of mental health issues, recognizing warning signs, and social outreach, including reintegration of the veteran into society [21]. (See 'Readjustment to society' below.)

●Treatment – Veterans determined to be at imminent risk for suicide require immediate psychiatric services and must be monitored continuously until they are no longer an immediate suicide risk. After immediate safety has been ensured, underlying factors of psychiatric disorders, precipitating events, and ongoing life circumstances should be addressed with medications, counseling, and involvement of friends, family, and religious/community groups as appropriate [22]. Confidentiality must be ensured, as veterans may be less inclined than civilians to seek help from mental health professionals because of potential career implications [23,24].

The Department of Defense, the VA, and other organizations in the United States have established several programs to prevent suicide in military service members [25], including clinical practice guidelines for assessing and managing those at risk for suicide [26]. Multidisciplinary suicide prevention programs designed for injured returning veterans may reduce the number of suicides related to combat-related injury [21,27].

Generalized anxiety disorder — Generalized anxiety disorder (GAD) is characterized by excessive worry that is difficult to control and causes significant distress and impairment.

●Prevalence – GAD is more than twice as prevalent in United States military veterans than in the general population, with 7.9 percent meeting criteria for probable GAD, and another 22.1 percent have mild anxiety symptoms (also more common than in the general population) [28]. Anxiety is often accompanied by other mental health problems among veterans, including depression, panic disorder, and substance use disorder, and is a risk factor for multiple medical conditions, including myocardial infarction [29,30].

●Evaluation – A seven-item anxiety questionnaire to help detect GAD (GAD-7) has been developed and validated in a primary care setting that includes a large military and veteran component (table 3). A diagnostic algorithm to help distinguish GAD from major depression and other disorders can be found in an algorithm (algorithm 2). (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

Veterans who screen positive for GAD should be asked about suicidal ideation and intent. (See 'Suicide' above.)

●Treatment – Both pharmacotherapy and cognitive behavioral therapy are efficacious as first-line treatment for GAD. (See "Generalized anxiety disorder in adults: Management".)

Alcohol and substance use

●Prevalence – The stress of deployment leads to adverse health behaviors for some military service members, including heavy alcohol and illicit drug use [31]. Furthermore, prescriptions for psychotropic medications and abuse of prescription medications have increased in the military [31-33]. One in 10 United States military veterans have probable alcohol use disorder (AUD) [34]; in active duty service members, the highest incidence rates are among young (ages 20 to 24) male persons who are White, single, and of lower-enlisted (E1 to E4) rank [35]. AUD is highest in the Marine Corps and lowest in the Air Force [36].

In a study using data from the VA health care system for veterans of Iraq and Afghanistan seen for an initial visit between 2001 and 2009, AUD was diagnosed in 10 percent, drug use disorder in 5 percent, and both diagnoses in 3 percent [37].

Veterans diagnosed with substance use disorder are more likely than other veterans to have either PTSD, depression, or chronic pain resulting in opioid treatment [37,38]. A 2018 survey of a nationally representative population of United States military veterans found that 20.3 percent of those with AUD met criteria for comorbid PTSD, while 16.8 percent with PTSD met criteria for AUD; those with both conditions were more likely to also have depression, GAD, suicidal ideation, and suicide attempts [39].

Alcohol misuse (including drinking and driving, and being late for or missing work due to a hangover) may be more common after deployment, with 27 percent of veterans reporting this [40]. Alcohol misuse is associated with combat exposures involving threat of death or injury, as well as current functional impairment [41].

●Evaluation – Veterans (especially those with a history of combat) should be screened for alcohol and substance use. Their use of prescription and nonprescription medications should be carefully reviewed, with attention to unauthorized or illicit drug use as well. (See "Screening for unhealthy use of alcohol and other drugs in primary care".)

Veterans who screen positive for alcohol or substance use disorder should be asked about suicidal ideation and intent. (See 'Suicide' above.)

●Treatment – Treatment is discussed separately. (See "Brief intervention for unhealthy alcohol and other drug use: Efficacy, adverse effects, and administration".)

Tobacco use

●Prevalence – The frequency and intensity of tobacco use, particularly smokeless tobacco [42], increase after deployment [31]. Smoking rates are particularly high in those with combat-related PTSD.

●Evaluation – Evaluation for tobacco use is discussed separately. (See "Overview of smoking cessation management in adults", section on 'Ask about tobacco use and exposure'.)

●Treatment – In advocating for smoking cessation in the veteran population, any concomitant psychological sequelae should also be addressed. Tobacco cessation efforts that are integrated with PTSD treatment have been found to be more effective than referral to standard smoking cessation programs [43,44]. Smoking cessation treatment is discussed separately. (See "Overview of smoking cessation management in adults".)

Sexual trauma — Military sexual trauma (MST) is defined as "sexual harassment that is threatening in character or physical assault that is sexual in nature that occurred while the victim was in the military" [45].

●Prevalence – The prevalence of MST varies depending upon the definition used. A meta-analysis of 69 studies identified that 1.9 percent of males and 23.6 percent of females reported MST when the definition was limited to assault, whereas when it also included harassment, the rates rose to 3.9 percent of males and 38.4 percent of females [46]. Compared with other types of trauma (eg, combat trauma, illnesses, accidents, traumatic deaths), MST in female veterans is associated with a higher risk of developing PTSD, depression, and suicidal ideation [47,48]. (See 'Posttraumatic stress disorder' above.)

●Evaluation – MST should be considered in those with symptoms of PTSD, anxiety, depression, sleep difficulties, or disordered eating. It is most likely to be identified by screening for PTSD and, in many cases, will only be acknowledged after significant trust and rapport have been established between patient and provider. Males may be even more reluctant than females to acknowledge MST.

●Treatment – Nonpharmacologic and pharmacologic therapies that are effective for PTSD are also likely to be effective for MST, due to the significant overlap between them, but there is no specific evidence for MST alone. Treatment for females with a history of sexual trauma is discussed separately. (See "Health care for female trauma survivors (with posttraumatic stress disorder or similarly severe symptoms)".)

EVALUATION FOR SELECTED PATIENTS — Certain conditions are uniquely related to military service. While veterans may be aware of some of these conditions (eg, combat-related injuries), they may be less aware of others (eg, toxic exposures). Thus, patient symptoms should be evaluated with knowledge of their deployment risks. (See 'Deployment history' above.)

Combat-related injuries

Changing epidemiology — The nature of war-related injuries has changed considerably over time with a reduction in combat-related fatalities. Preventive measures, ranging from improved infection control to protective gear, have been effective in reducing military morbidity and mortality [49,50]. Improvements include the use of tourniquets, modern body armor, early limb salvage, and improved hemostatic resuscitation practices [50-52]. In addition, the rapidity of evacuation and access to higher-quality care have markedly improved survival rates for battle injuries.

Clinicians caring for the new generation of combat veterans need to be prepared for a different distribution of injuries. As an example, it is more common to see survivors of traumatic brain injury (TBI) and amputees who have lost multiple limbs (as the torso is often spared by body armor). Penetrating injuries are common and include high-velocity gunshot wounds; injuries from high-energy explosive munitions including improvised explosive devices, mortars, and rockets; concussive blasts; and thermal injuries [53]. Ocular trauma also occurs at a higher rate than in previous conflicts [54]. By contrast, spinal cord, penetrating abdominal, and chest injuries are less common than in prior wars, likely due to body armor protecting the trunk and back [55].

Persons injured in combat are at increased risk for the development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease [56].

Amputations — Amputee care and the quality of prostheses have improved dramatically as a result of efforts to provide combat amputees with maximum function and mobility. This is especially true for upper extremity amputations as a result of advances made to address injuries resulting from the conflicts in Iraq and Afghanistan [57]. (See "Lower extremity amputation" and "Upper extremity amputation".)

Amputees are able to remain on active duty in the military after injuries that they may not have survived in prior wars. Functional capacity assessment can be helpful in determining whether an amputee is able to return to their usual home and work environment [58]. This is usually performed in conjunction with physical and/or occupational therapy. (See "Disability assessment and determination in the United States".)

Phantom limb pain is a common symptom following amputations [59]. This may require chronic pain management, including referral to a pain specialist. (See "Lower extremity amputation", section on 'Phantom limb pain' and "Upper extremity amputation", section on 'Phantom limb pain'.)

Amputation increases the risk of psychological sequelae, above and beyond the risk simply associated with having been in a warzone [60]. Loss of a limb can profoundly influence one's self-image. One study found high rates of depression and anxiety up to two years postamputation, which appear to decline thereafter to rates of the general population [61].

Concerns about independence and physical prowess may be more important than bodily image in military service members and veterans. Technological advances in prosthetics and rehabilitation enable a greater approximation to prior functional status and psychological recovery. There is limited literature addressing treatment of psychological factors associated with limb amputation. Based on evidence that more adaptive coping styles are associated with improved psychosocial adjustment and well-being, cognitive behavioral therapy should be incorporated into the management plan for veteran amputees [62,63].

Traumatic brain injury — TBI is an important cause of disability among returning veterans. We typically perform a detailed assessment of lifetime TBI history, such as that obtained using the Ohio State University TBI Identification Method [64]. Traumatic brain injuries may exert a cumulative effect on the risk of posttraumatic stress disorder (PTSD) and alterations in cognitive function, and many military service members and veterans have experienced multiple lifetime TBIs [65]. Although these commonly result from sports injuries and accidents, military service members can additionally sustain subconcussive and concussive injuries resulting from blast exposure occurring during training and combat deployment.

TBI encompasses a broad range of pathologic injuries to the brain of varying clinical severity that result from head trauma (see "Traumatic brain injury: Epidemiology, classification, and pathophysiology"). While there is not complete agreement regarding classification, TBI may be best characterized by a combination of the Glasgow Coma Scale score (table 4), duration of loss of consciousness, and clearly abnormal computed tomography (CT) or magnetic resonance imaging (MRI) of the brain. Based on these criteria, as many as 99 percent of service members diagnosed with TBI have mild TBI, including transient or no loss of consciousness [66], and an absence of findings on CT or MRI of the brain. Mild TBI is difficult to distinguish from other conditions [67], as symptoms of mild TBI (eg, concentration impairment, irritability, and headaches) overlap with symptoms of PTSD and depression. Furthermore, veterans with TBI may be at higher risk for PTSD [68], and the combination of the two is associated with cognitive impairment [65]. (See "Acute mild traumatic brain injury (concussion) in adults".)

Moderate to severe TBI represents only a small fraction of those returning from war. Moderate to severe TBI usually requires aggressive management and may lead to long-term disability and cognitive dysfunction. A multicenter trial identified that the N-methyl-d-aspartate antagonist amantadine produced more rapid recovery of neurologic function during the four-week treatment period [69]. However, the placebo group did show improvement during an ensuing two-week follow-up period, so that the two groups had similar functional status after six weeks. (See "Management of acute moderate and severe traumatic brain injury".)

Chronic postconcussive symptoms — TBI is a diagnosis given at the time of injury, based upon the circumstances of the inciting event, whereas persistent symptoms that may follow mild TBI may be more complicated to try to distinguish from other conditions, such as PTSD, that may have similar symptoms. The most common complaints after a concussion include headache, dizziness, cognitive impairment, and sleep difficulties. Most patients recover quickly from a concussion (within two to four weeks); a substantial minority have prolonged disability, including cognitive function [70], that has an onset associated with the TBI [71]. A brain MRI should be performed to exclude other causes if there are persistent and disabling complaints. In the absence of a defined specific treatment for postconcussion syndrome, symptomatic treatment should be offered, which may include migraine medications, analgesics, cognitive behavioral therapy or psychological counseling, and/or psychotropic medications. (See "Postconcussion syndrome".)

The relationship between TBI and psychological sequelae is complex. At least one-quarter to one-half of those with a history of TBI have major depression [72-75]. The overwhelming majority of those who experience a TBI during deployment to Afghanistan or Iraq are categorized as mild TBI, and there is a significant association between mild TBI and psychiatric symptoms [76,77]. One study found that more than 40 percent of those who had loss of consciousness met criteria for PTSD [76]. In this study, high rates of physical symptoms reported by soldiers could be attributed to PTSD and depression; when these conditions were accounted for in the analyses, there was no direct relationship between mild TBI and physical health problems (with the exception of headaches). Another study found that more than half of those in the Veteran’s Administration (VA) system with a TBI diagnosis also had PTSD [78]. In a mail survey of 2235 United States military personnel returning from Afghanistan and Iraq, the PTSD score was more closely associated with residual TBI symptoms than any other factor [76].

Concern has been raised about long-term neurologic sequelae of military service members who have been exposed to repetitive subconcussive blast exposure, in part because of the identification of chronic traumatic encephalopathy (CTE) in athletes who have experienced repetitive subconcussive head injuries. Blast exposures in military personnel can result from exposure to explosives during war or preparatory activities prior to deployment, including heavy weapons training, bomb demolition, and breacher training. However, CTE has only rarely been identified in military service members or veterans, and, when it has, it has almost invariably been identified in those who also have significant histories of repetitive head injuries from football or other contact sports [79]. The characteristic neuropathology associated with blast exposure is astrogliosis at white-gray matter interface regions [80].

Moral injury — Military service members and veterans frequently experience feelings of intense guilt, shame, anger, and self-condemnation that have come to be encompassed by the term "moral injury." Moral injury is defined as symptoms "resulting from perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs” [81] and can be related to combat incidents such as friendly fire and civilian casualties [82]. Moral injury is strongly associated with, and can be a significant contributor to, PTSD [83]. It can be identified and monitored with either the Moral Injury Symptom Scale [84] or the Moral Injury Questionnaire-Military Version [85].

Combat and operational stress reaction — Combat and operational stress reaction is a term used by the United States Army to describe the wide range of maladaptive mental and behavioral symptoms that can emerge in response to combat. This is discussed separately. (See "Combat and operational stress reaction".)

Chronic multisymptom illness — Chronic multisymptom illness (CMI) is a term used to describe a syndrome of multiple persistent symptoms in more than one body system [86]. This condition was termed “Gulf war illness” in veterans from the Gulf War but is not limited to that cohort [87]. Veterans have symptoms such as fatigue, muscle and joint pain, and neurocognitive dysfunction that are not readily attributable to any disease. Parallels have been drawn between CMI and other postwar syndromes (eg, soldier's heart after the Civil War, effort syndrome in World War I, and acute combat stress reaction after the Korean Conflict) [87]. (See "Combat and operational stress reaction", section on 'Definition'.)

Estimates of the number of Gulf War veterans who suffer from CMI range from 175,000 to 250,000 [88]. CMI-related diagnoses including chronic fatigue, fibromyalgia, and irritable bowel syndrome are increasingly recognized in veterans of the Iraq and Afghanistan conflicts [89,90].

There is little evidence to support particular therapies [88,91]. In 2019, the United States Department of Veterans Affairs and the United States Department of Defense commissioned the update of a clinical practice guideline for managing chronic multisymptom illness [86]. Key recommendations include use of nonpharmacologic interventions such as cognitive-behavioral therapy, mindfulness-based therapies and exercise, and the avoidance of opioids for related pain. (See "Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions", section on 'Introduction'.)

Infectious diseases — Deployment may increase the risk of acquiring infectious diseases. This risk may be decreased by the use of protective measures, such as special clothing, insect repellant, and prophylactic medications. The risk of specific infections is dependent upon the geographic area of deployment. The timing of infection with respect to exposure can vary from weeks to years depending on the organism. Clinicians should be aware of deployment history and associated potential exposures.

In general, the assessment and management of infectious diseases are the same for nonmilitary persons who have had similar exposures through work or travel to particular regions.

Infections to consider in veterans with chronic symptoms — Specific examples of chronic infectious agents that are endemic to Afghanistan or Iraq include malaria, leishmaniasis, and tuberculosis.

●Malaria – Malaria is a cause of fever that can present after acute exposure or many months after the initial infection. Plasmodium vivax and Plasmodium falciparum are endemic in many countries, including Afghanistan [92]. P. falciparum is generally apparent within two weeks of exposure and thus does not have a late presentation following return from deployment. However, P. vivax can present with late-onset or relapsing disease many months after initial infection and should be considered in the differential diagnosis of any veteran with fevers returning from Afghanistan. All soldiers from the United States deployed to areas where malaria is endemic are treated with chemoprophylaxis (mostly with doxycycline) [93]. Soldiers deploying to high-risk areas receive primaquine terminal prophylaxis upon return. (See "Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children" and "Non-falciparum malaria: P. vivax, P. ovale, and P. malariae".)

●Visceral leishmaniasis – Visceral leishmaniasis should be considered in the differential diagnosis of veterans with chronic fever and weight loss without any obvious cause. Visceral leishmaniasis has occurred in soldiers returning from Afghanistan and Iraq [94]. Clinical features include chronic fever, weight loss, fatigue, abdominal discomfort that may localize to the left upper quadrant, and hepatosplenomegaly. Laboratory abnormalities include anemia, leukopenia, and elevated liver-associated enzymes. The clinical manifestations and diagnosis of visceral leishmaniasis are discussed separately. (See "Visceral leishmaniasis: Clinical manifestations and diagnosis".)

●Cutaneous leishmaniasis – Cutaneous leishmaniasis should be considered in veterans who present with chronic, painless ulcerations within the first year of returning from Afghanistan or Iraq. Cutaneous leishmaniasis is a parasitic infection that causes chronic, painless ulcerations on areas of skin exposure, most commonly the arms and legs [95]. While lesions from cutaneous leishmaniasis can present within 7 to 10 days of exposure, patients often do not seek medical care until they become chronic (assuming ulcers will heal spontaneously). (See "Cutaneous leishmaniasis: Clinical manifestations and diagnosis" and "Skin lesions in the returning traveler".)

●Tuberculosis – Reactivation tuberculosis (TB) can cause subacute or chronic fevers, weight loss, and cough. TB is endemic in many parts of the world, and deployment-associated conversion rates are approximately 2.5 percent in soldiers returning from Afghanistan and Iraq [96]. For unexplained constitutional symptoms, clinicians should ask returning veterans about whether they were screened for TB and screen for TB if status is unknown. The United States military screens those at high risk of exposure for TB prior to deployment and within 10 weeks of return from deployment. Although most soldiers identified with latent TB infection through military screening receive appropriate treatment, it is conceivable that the occasional returning veteran, especially in the Reserve or National Guard, could bypass screening processes in place by the military. (See "Treatment of tuberculosis infection (latent tuberculosis) in nonpregnant adults without HIV infection" and "Treatment of drug-susceptible pulmonary tuberculosis in nonpregnant adults without HIV infection" and "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

Transfusion-related infections — United States Department of Defense policy requires that recipients of non-FDA-compliant blood products (specifically fresh whole blood or apheresis platelets collected on site) be screened for HIV, HBV, HCV, human T-lymphotropic virus, and rapid plasma reagin at 3, 6, and 12 months following the transfusion [97]. Soldiers are given notification when they have received an emergency blood transfusion and are provided with a letter containing an explanation of required screening tests. Soldiers are advised to keep the letter and provide a copy to their clinicians who are providing follow-up care.

Hemorrhage is the leading preventable cause of mortality in combat casualties [98], and death from hemorrhage usually occurs within 6 to 24 hours of injury [99,100]. Although stored red blood cells, frozen plasma, and cryoprecipitate products used in battle are fully compliant with FDA regulations and have been prescreened for transfusion-transmitted infectious pathogens, transfusion requirements may exceed the supplies of stored blood components [101]. In these situations, non-FDA-compliant, voluntarily donated, and freshly collected blood products (whole blood and apheresis platelets) may be needed [102,103]. Donors of emergency blood products are usually United States service members located near the receiving medical unit. (See "Blood donor screening: Overview of recipient and donor protections".)

Countermeasures to reduce the risk of transfusion-transmitted infections have been implemented to include human immunodeficiency virus (HIV) screening of personnel prior to deployment, compulsory hepatitis B virus (HBV) vaccination, donor questionnaire forms to screen for high-risk exposure history, and rapid diagnostic testing for HIV, HBV, and hepatitis C virus (HCV). As apheresis platelets can be donated relatively frequently, pedigree donors who have previously been screened are used preferentially. However, there remains residual risk for transfusion-transmitted infections [97,104].

Environmental hazards

Noise exposure — Noise-related hearing loss and tinnitus are two of the most prevalent service-connected disabilities among United States veterans [105,106]. United States soldiers have mandatory audiology screening prior to deployment to provide a baseline hearing assessment, and audiology testing is performed if returning veterans report hearing loss or tinnitus. It is reasonable to assess for hearing loss and tinnitus in returning veterans and refer for audiology evaluation if either is present. (See "Evaluation of hearing loss in adults" and "Etiology and diagnosis of tinnitus".)

The United States National Center for Rehabilitative Auditory Research has developed a computer-based, multimedia hearing loss prevention program for military personnel. Its focus is to encourage veterans to employ hearing protective strategies on a regular basis. Its availability is being expanded to veterans via the Internet and at medical centers throughout the United States [107].

Toxins — Concerns have been raised about exposures to environmental toxins leading to adverse health effects. These hazards include Agent Orange (dioxin) [108], other toxic nerve agents (eg, sarin, cyclosarin) [109,110], and heavy metals [111]. Sulfur mustards (mustard gas) have been used in multiple conflicts, including the Iran-Iraq war, and long-term effects of exposure may include pulmonary, dermal, and ocular disease [112,113]. We recommend that returning veterans be queried regarding potential exposure to toxins.

●Coverage through the PACT Act – In recognition of adverse health effects related to toxic exposures, in 2022, the Promise to Address Comprehensive Toxics (PACT) Act expanded VA health care and benefits for veterans exposed to burn pits, Agent Orange, and other toxins. The VA has added more than 20 burn pit and other toxic exposure presumptive conditions based on the PACT Act [114]. Information on the conditions covered and specific eligibility requirements are provided online.

●Burn pits – “Burn pits” are constructed holes in the ground used for incineration of garbage and waste. While the Department of Defense now prohibits the use of open burn pits for disposal of waste unless there is no feasible alternative, burn pits were commonly used in South and Southwest Asia during operations in Iraq and Afghanistan, particularly through the mid-2010s. The VA created an Airborne Hazards and Open Burn Pit Registry to identify long-term adverse health outcomes associated with airborne hazards and burn pits. If veterans served in any of the listed locations and time periods, there is presumption that the veteran had exposure to burn pits or other toxins.

Veterans with burn pit exposure who have longstanding dyspnea, exercise-intolerance, or cough should be evaluated for deployment-related respiratory disease, particularly constrictive bronchiolitis, as well as more common causes of these symptoms [115-117]. (See "Overview of bronchiolar disorders in adults", section on 'Evaluation'.)

●Agent Orange – The herbicide Agent Orange has received considerable attention due to widespread use in the Vietnam War by the United States for military purposes [118]. The long-term health effects of Agent Orange are controversial, but an association with certain cancers, including prostate cancer, soft tissue sarcomas, and non-Hodgkin lymphoma, has been reported [119,120]. The National Academy of Medicine (NAM) in the United States biennially updates a comprehensive report on the health consequences of Agent Orange exposure, based on ongoing evaluation.

●Gulf War illness – Numerous environmental exposures, including oil well fires, toxic nerve agents, and insect repellents, have been postulated to be associated with persistent symptoms in Persian Gulf War veterans called “Gulf War illness” (also known as “Gulf War Syndrome”), but no single etiological factor has been found to account for these medically unexplained symptoms [121-124]. A report from the NAM in the United States notes that exposure to environmental factors such as oil well fire fumes could represent contributing factors but also notes that similar symptoms have been reported from many other wars in which such factors were not necessarily present [125]. Common symptoms of Gulf War illness include headache, fatigue, joint pain/stiffness, cognitive difficulties, and insomnia [126]. The NAM reviewed efforts to establish a case definition for Gulf War illness and found that none were entirely satisfactory but that one from the United States Centers for Disease Control and Prevention [127] and another from Kansas [128] seemed to have the greatest utility and applicability.

●Insect repellents – Although the safety of independent use of insect repellents diethyl-meta-toluamide (DEET) and permethrin is well documented [129,130], concerns were raised during the Persian Gulf War in the early 1990s after animal studies found that concomitant use of these insect repellants with pyridostigmine bromide (used as prophylaxis against nerve agent exposure) was associated with chronic neurotoxic syndromes [131]. A subsequent randomized trial in humans compared appropriate doses of all three treatments in combination compared with placebo and found no adverse effects [132]. However, fears spawned by the earlier animal studies have occasionally led service members to forgo the use of insect repellents, resulting in higher rates of malaria and other insect-borne diseases compared with those who regularly use the combination of permethrin treatment of clothing and DEET application to the skin. (See "Prevention of arthropod and insect bites: Repellents and other measures".)

Chronic pain — The most common reason for recently deployed veterans to seek medical care is chronic pain associated with musculoskeletal injuries or TBI [77]. Arthritis is common among veterans; one survey found that 25 percent of veterans reported a diagnosis of arthritis [133].

Multidisciplinary care involving physical therapy and mental health treatments such as cognitive behavioral therapy or biofeedback techniques have been successful for the treatment of chronic pain [134,135]. Complementary medicine approaches such as acupuncture, yoga, relaxation training, and meditation may be used as adjunctive therapy. Chronic pain is associated with sleep disruptions, and nonpharmacologic interventions to improve sleep should also be considered [136]. (See "Overview of the treatment of insomnia in adults".)

Though opioids are frequently prescribed for chronic pain, they should be prescribed with caution, if at all. For example, a study conducted in the Veterans Health Administration found that one-half of the patients with chronic noncancer pain received opioids [137]. The median daily dose was 21 mg morphine equivalents, though 4.5 percent of patients receiving opioids had a mean daily dose >120 mg morphine equivalents. Increased risk of overdose has been associated with daily morphine equivalent doses ≥100 mg, a history of opioid dependence, and hospitalization for a toxicity or overdose event in the previous six months [138]. PTSD and other psychiatric conditions are frequently comorbid and are associated with significantly greater rates of high-risk opiate use and consequent adverse events [38,139,140]. (See "Approach to the management of chronic non-cancer pain in adults".)

Readjustment to society — Veterans often have difficulties adjusting to life after deployment.

Housing instability — Clinicians should ask all patients about housing instability and refer those who screen positive to the VA's Supportive Services for Veteran Familiar program to be evaluated for temporary financial assistance. Veterans in the United States are at disproportionate risk of homelessness and housing instability, and many veterans who experience homelessness have medical disabilities, mental illness, substance use disorders, and other chronic medical illnesses [141-144]. Of 5.3 million veterans accessing outpatient care within the United States Veterans Health Administration from 2012 to 2016, 2.8 percent screened positive for housing instability. Among United States veterans, homelessness is associated with increased rates of mortality [145,146].

The United States Department of Veterans Affairs offers temporary financial assistance (TFA) for housing-related expenses for veterans at risk of homelessness. Data from cohort studies suggest that receipt of TFA is associated with higher rates of stable housing [147,148]. In a national cohort study of 41,969 United States Veterans, receipt of TFA was also associated with decreased rates of all-cause mortality and suicidal ideation [149].

Stresses for family members/others — Clinicians should be aware that deployment has a significant impact not only on military service members but also on their families or others close to them [150,151]. Being confronted with "kill or be killed" scenarios and being on guard day and night for a prolonged period of time represent enormous life stressors. This stress can result in a wide variety of physical and psychological symptoms that may become apparent at home and persist for months to years, if not indefinitely.

Stressors on families include the separation from a parent or caregiver who would otherwise be providing childcare, the remaining caregiver left behind having to manage all household duties, and fears that the deployed member might be injured or die. Up to half of military families relocate during deployment to be closer to extended families, but this often comes at the price of disruption in school and friendships for children, interruption in employment for the remaining partner, and loss of support that might be provided by the military community or the previous home community [152]. Frequent uncertainty regarding when the service member will deploy and when they will return home is a significant source of anxiety. Rates of conflict, intimate partner violence, and divorce are higher in families where a member has been deployed [153,154]. In caring for a returning veteran, the clinician should evaluate the situation at home, paying attention to the veteran's marital/partner, parental, and community relationships.

DISABILITY AND FUNCTIONAL ASSESSMENT — Service-connected disability compensation is common.

Functional capacity assessments are commonly performed by military treating facilities (including the United States Veterans Administration [VA] Hospitals). If the veteran has symptoms or signs of functional or mobility problems, then physical, occupational, and/or speech therapy evaluations should be conducted. (See "Disability assessment and determination in the United States".)

Military members in the United States who have physical and/or mental health conditions that render them unfit to perform their required duties are reviewed by a medical evaluation board. The board consists of active-duty clinicians (not involved in the care of the military member) who review the clinical case file and decide whether the individual should be returned to duty, or should be separated, using published medical standards for continued military service (Army Regulation 40-501 Standards of Medical Fitness, SECNAVINST 1850.4E Navy Disability Evaluation Manual) [155]. If the member's medical condition falls below medical retention standards, the case is forwarded to a Physical Evaluation Board (PEB). The PEB is a formal fitness-for-duty and disability determination that may recommend return of the member to duty (with or without assignment limitations, which are documented and outlined in a "physical profile"), transfer of the member from active duty, or medical retirement of the member temporarily or permanently. The standard used by the PEB for determining fitness is whether the medical condition precludes the member from reasonably performing the duties of their office, rank, or position. Military members who are separated or medically retired are given a disability rating by the PEB based off of the Department of Veterans Affairs Schedule for Rating Disabilities [156].

Most United States military personnel are active-duty service members and are therefore eligible for care within the Department of Defense military treatment facilities upon their return from deployment. However, more than one-quarter of those who have been deployed are National Guard or Reserve service members who are activated specifically for deployment. Health problems or injuries that occur during service or are deemed to be service connected when identified after deployment can result in service members being eligible for care in the Department of Defense or VA hospitals/clinics for the remainder of their lives.

ROUTINE CARE — Veterans should receive standard preventive and ongoing care for their medical conditions similar to other patients. (See "Overview of preventive care in adults" and "Geriatric health maintenance".)

INFORMATION FOR PATIENTS — One important resource for helping veterans and their families cope with deployment stress is FOCUS (Families Overcoming Under Stress), which provides both on-site support at a number of military bases, as well as online information and tools. FOCUS provides state-of-the-art resiliency training for both children and adult members of military families at various stages, including deployment, return from duty, and redeployment.

SUMMARY AND RECOMMENDATIONS

●Overview – Although medical care of the military veteran may be similar to that of the general population in many respects, certain clinical concerns are unique or of particular relevance to veterans. These include general conditions more commonly seen in veterans (eg, depression, posttraumatic stress disorder [PTSD]) and veteran-specific conditions (eg, combat-related injuries, certain environmental exposures). (See 'Introduction' above.)

●Framework for evaluation – The initial evaluation should identify key features of military service to provide a framework for evaluating current symptoms and known or potential risks related to service. In addition, patients should be offered screening for conditions commonly seen in veterans, as well as routine acute, chronic, and preventive care. (See 'Framework for evaluation' above.)

●Screening for conditions commonly seen in veterans – Veterans are at higher risk than the general population of certain conditions and should be screened for the following conditions (see 'Screening for all patients' above):

•PTSD (table 1). (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis", section on 'Screening'.)

•Depression (table 2). (See "Unipolar depression in adults: Assessment and diagnosis".)

•Anxiety disorders (table 3). (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Screening, assessment, and diagnosis'.)

•Alcohol and substance use disorder. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Screening tests'.)

•Tobacco use. (See "Overview of smoking cessation management in adults", section on 'Ask about tobacco use and exposure'.)

•Military sexual trauma – Military sexual trauma (MST) should be considered in those with symptoms of PTSD, anxiety, depression, sleep difficulties, or disordered eating. (See 'Sexual trauma' above.)

•Suicide – Veterans who screen positive for PTSD, depression, or anxiety should also be asked about suicidal ideation and intent; if present, the lethality of the plan should be evaluated. Veterans at imminent risk for suicide require immediate psychiatric services and must be monitored continuously until they are no longer an immediate suicide risk. (See 'Suicide' above and "Suicidal ideation and behavior in adults".)

●Conditions related to military service – Certain conditions are uniquely related to military service. Clinicians should be familiar with these conditions and their risk factors. These conditions include combat-related injuries, traumatic brain injury (TBI), moral injury, chronic multisymptom illness, and certain infectious diseases. (See 'Evaluation for selected patients' above.)

●Environmental hazards – Noise-related hearing loss and tinnitus are two of the most prevalent service-connected disabilities among United States veterans. Clinicians should be aware of other exposures to environmental toxins, including those covered by the Promise to Address Comprehensive Toxics (PACT) Act. (See 'Environmental hazards' above.)

●Readjustment to society – Veterans are prone to have difficulties in the transition back to civilian life, including finding suitable housing. Efforts should be made to address any barriers to care and to enlist the help of interdisciplinary teams (eg, psychiatry, physical therapy, social work) in this goal. (See 'Readjustment to society' above.)