INTRODUCTION — The nature of war-related injuries has changed considerably over time. Preventive measures, ranging from improved infection control to protective gear, have been effective in reducing military morbidity and mortality [1,2]. 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 compared with prior wars. 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). Moreover, there is evidence that those who have been previously injured in combat are at greater risk for the development of hypertension, coronary artery disease, diabetes mellitus, and chronic kidney disease [3].
Despite the evolution of war-related injuries over time, there are three aspects of injuries that have not changed for the returning veteran. First, while non-combat injuries (eg, infections, gastrointestinal illness, and musculoskeletal problems not related to battle) have decreased dramatically in more recent conflicts, they invariably outnumber combat-related injuries [4]. Second, the psychological effects of war are greater in number and duration than the physical effects over the long term. Third, complaints in veterans presenting for care after deployment tend to be similar in distribution and frequency to those in the general primary care population [5]. Although the overall medical care of the returning veteran may be similar to that of the general population, there are certain issues (eg, TBI, psychological sequelae, readjustment to society following deployment) that are of particular relevance to veterans.
This topic will provide an overview of medical conditions commonly encountered in returning 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 "Unipolar depression in adults: Assessment and diagnosis".)
●(See "Traumatic brain injury: Epidemiology, classification, and pathophysiology".)
PHYSICAL INJURY DUE TO COMBAT — The rate of combat-related fatalities has decreased over recent wars. This can be attributed to the use of tourniquets, modern body armor, rapid evacuation, early limb salvage, and improved hemostatic resuscitation practices [2,6,7]. Soldiers with combat injuries, which may have been fatal in previous conflicts, are arriving more rapidly to military treatment facilities in better physiologic condition and are able to receive higher levels of care.
There are clear differences between military and civilian trauma populations. Whereas blunt trauma, primarily due to motor vehicle accidents and falls, represents the most common injury among civilians in the United States, penetrating injuries are more common in combat casualties [8]. The most common causes of serious penetrating injuries in civilian trauma centers are stabbings and low-velocity gunshot wounds, whereas in the military they tend to be high-velocity gunshot wounds and high-energy explosive munitions including improvised explosive devices (IEDs), mortars, and rockets which can produce varied fragmentation, concussive blast, and thermal injuries [9].
Amputations — A review of 8056 military casualties in Afghanistan and Iraq found that more than 70 percent were due to extremity injuries severe enough to either result in evacuation from combat or to prevent return to duty within 72 hours [10]. Some form of explosive device was involved with 88 percent of these injuries. Major injury resulted in amputations proximal to the wrist or ankle in 7.4 percent, compared with 8.3 percent in the Vietnam War, although service members are currently able to survive more serious injuries than in prior wars.
Amputee care and the quality of prostheses have improved dramatically as a result of efforts to provide combat amputees with maximum function and mobility. 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 [11]. 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 [12]. 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'.)
Traumatic brain injury — Traumatic brain injury (TBI) is an important cause of disability among returning veterans. 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 1), 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 [13]. Mild TBI is difficult to distinguish from other conditions [14], as symptoms of mild TBI (eg, concentration impairment, irritability, and headaches) overlap with symptoms of posttraumatic stress disorder (PTSD) and depression. Furthermore, veterans with TBI may be at higher risk for PTSD [15], and the combination of the two is associated with cognitive impairment [16]. (See "Acute mild traumatic brain injury (concussion) in adults".)
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 are described as a postconcussion syndrome. The most common complaints of postconcussion syndrome include headache, dizziness, cognitive impairment, and psychological symptoms. Most patients recover quickly from postconcussion syndrome (within several weeks), although a minority have prolonged disability. 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, psychological counseling, and/or psychotropic medications. (See "Postconcussion syndrome".)
Moderate to severe TBI represents only a small fraction of those returning from the wars. Moderate-to-severe TBI usually requires aggressive management and may lead to long-term disability and cognitive dysfunction. A multicenter prospective double-blind, randomized, placebo-controlled trial identified that the N-methyl-d-aspartate antagonist amantadine produced more rapid recovery of neurologic function during the four-week treatment period [17]. 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".)
Other — Spinal cord, penetrating abdominal, and chest injuries are less common than in prior wars, likely due to body armor protecting the trunk and back [18]. Limb and head trauma are the most common types of injuries seen, with ocular trauma also occurring at a higher rate than in previous conflicts [19]. (See "Chronic complications of spinal cord injury and disease" and 'Amputations' above and 'Traumatic brain injury' above.)
PSYCHOLOGICAL SEQUELAE — Potential psychologic sequelae are an essential consideration in the medical care of the returning veteran.
Screening for psychological sequelae — Screening for posttraumatic stress disorder (PTSD) (table 2), depression (table 3), anxiety disorders (table 4), and alcohol and substance use disorders is important upon return from deployment (see "Screening for unhealthy use of alcohol and other drugs in primary care"). However, an initial screening will miss most cases of mental health problems, and repeated screening is necessary, especially between 3 and 12 months after return [20,21].
The effectiveness of screening is unclear. In the only randomized controlled trial to address this issue, postdeployment screening of United Kingdom veterans of the Afghanistan War for PTSD, depression or anxiety, and alcohol misuse was not effective in reducing the prevalence of these disorders 10 to 24 months later or in increasing the frequency of help-seeking [22]. These results may not be generalizable, however, as the screening assessment in this study was done by computer, which may be less effective than a face-to-face interview.
Of veterans who screen positive for a mental health disorder, less than half seek mental health care [23]. There is no evidence to suggest that most available treatments for PTSD, depression, and anxiety disorders are more or less effective in military service members than in civilians. Multidisciplinary suicide prevention programs designed for injured returning veterans may reduce the number of suicides related to combat-related injury [24,25]. The psychological sequelae of combat are important by themselves but are also associated with increased rates of cardiovascular risk factors such as obesity, dyslipidemia, tobacco use, and hypertension [26,27].
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. As war is outside the realm of normal human experience, 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 manifestations, course, assessment, and diagnosis", section on 'Clinical manifestations'.)
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 [28]. PTSD and other psychological sequelae are being identified at higher rates than has historically been the case, and they are frequently not fully manifest until months or years after return [20,29,30]. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis", section on 'Combat'.)
The PTSD checklist (PCL5) may be helpful in screening patients for PTSD and monitoring the progress of treatment over time [31]. The PCL5 (table 2) was developed based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria [32]. 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 manifestations, course, assessment, and diagnosis", section on 'Diagnosis'.)
Veterans who screen positive for PTSD should be asked about suicidal ideation and intent. (See 'Suicide' below.)
Pharmacotherapy (eg, selective serotonin reuptake inhibitors [SSRIs]) 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 "Management of posttraumatic stress disorder in adults" and "Psychotherapy and psychosocial interventions for posttraumatic stress disorder in adults".)
Depression — Depression and anxiety disorders are also significantly associated with war and combat [23,33,34]. 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 [28]. The clinical manifestations of depression are discussed in detail separately. (See "Unipolar depression in adults: Assessment and diagnosis".)
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 3). (See "Screening for depression in adults", section on 'PHQ-9'.)
Veterans who screen positive for depression should be asked about suicidal ideation and intent. (See 'Suicide' below.)
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 "Unipolar major depression in adults: Choosing initial treatment" and "Unipolar depression in adults: Choosing treatment for resistant depression".)
Generalized anxiety disorder — Generalized anxiety disorder (GAD) is characterized by excessive worry that is difficult to control and causes significant distress and impairment. Anxiety disorders are associated with an increased risk for multiple medical conditions, including myocardial infarction, among veterans [35]. Anxiety is often accompanied by other mental health problems among veterans, including depression, panic disorder, and substance use disorder [36]. A diagnostic algorithm to help distinguish GAD from major depression and other disorders can be found in the figure (algorithm 1). (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
A seven-item anxiety questionnaire (GAD-7) has been developed and validated in a primary care setting to help detect GAD (table 4). (See 'Depression' above and "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' below.)
Both pharmacotherapy and cognitive behavioral therapy are efficacious as first-line treatment for generalized anxiety disorder. (See "Generalized anxiety disorder in adults: Management".)
Suicide — Veterans have a 21 percent higher suicide rate compared with the nonveteran population [37]. While high suicide rates among active-duty United States military personnel were reported in the early years of the wars in Afghanistan and Iraq [38], later studies found that rates are comparable to those of the general population, although those of reservists are slightly higher [39].
Incidence and risk factors — Overall suicide rates among veterans in the United States are higher than among nonveterans (30 versus 24 per 100,000) and have increased since the early 2000s [37]. A study found that in 2016, the suicide rate among both male and female veterans was higher than in nonveterans (32 versus 27 per 100,000, and 14 versus 8 per 100,000 respectively) [37]. Among those at highest risk for suicide are soldiers discharged from inpatient psychiatric hospitalizations within the previous 12 months [40]. In other studies, additional risk factors for suicide include male sex, White race, recent demotion, depression, bipolar disorder, alcohol-related problems, sexual-minority status, traumatic brain injury (TBI), dishonorable discharge, and early military separation (separation from the military with <4 years of military service) [41-45].
Deployment factors may also be associated with suicide [44,46]. A study of regular United States Army soldiers active between 2004 and 2009 found that suicide rates were higher in enlisted soldiers deployed either in their first year of service or with less-than-expected junior enlisted rank [46]. Suicide rates were also higher among females than males during deployment, and marriage had a protective effect only during deployment.
Assessment and referral — Identifying PTSD, depression, anxiety, and alcohol and substance use disorder is an important first step in assessing for suicide risk [47]. (See 'Screening for psychological sequelae' above and "Screening for unhealthy use of alcohol and other drugs in primary care".)
Veterans who screen positive for PTSD, depression, an anxiety disorder, or alcohol or substance use disorder should also be asked about suicidal ideation and intent, and, if present, the lethality of the plan should be evaluated [48]. Asking about suicidal ideation is discussed separately. (See "Suicidal ideation and behavior in adults", section on 'Suicidal ideation and behavior'.)
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 [49]. (See "Suicidal ideation and behavior in adults", section on 'Management'.)
Veterans may be less inclined than civilians to seek help from mental health professionals. Service members may be reluctant to be identified with a mental health disorder because of potential career implications, and confidentiality must be assured [50]. In a case-control study, only 30 percent of veterans who had a history of depression and died by suicide had documentation that they were asked about suicidal ideation at their last visit [51]. Some of those visits occurred within seven days of the suicide. Among the veterans who were asked and subsequently committed suicide, 85 percent denied having suicidal ideation. The reasons for these denials are unclear but pose a challenge to the clinician.
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 [24]. Although these programs appear to be helpful in suicide prevention, it is not clear which prevention initiatives are most effective for veterans given the absence of comparative data [52].
The Department of Defense, the VA, and other organizations in the United States have established several programs to prevent suicide in military service members [53], including clinical practice guidelines for assessing and managing those at risk for suicide [54]. Multidisciplinary suicide prevention programs designed for injured returning veterans may reduce the number of suicides related to combat-related injury [24].
Psychological complications of amputation — Amputation increases the risk of psychological sequelae, above and beyond the risk simply associated with having been in a warzone [55]. Loss of a limb can profoundly influence one's self-image. One study found high rates of depression and anxiety up to two years post-amputation, which appear to decline thereafter to rates of the general population [56].
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 [21,57].
Psychological complications of traumatic brain injury — 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 [58-61]. 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 [62,63]. One study found that more than 40 percent of those who had loss of consciousness met criteria for PTSD [62]. 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 VA system with a TBI diagnosis also had PTSD [64]. 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 [62].
Chronic multisymptom illness — Chronic multisymptom illness (CMI) is a term used to describe a condition in veterans from the Gulf War [65]. 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) [65] (see "Combat and operational stress reaction", section on 'Definition'). CMI has not been linked with any particular etiology.
Estimates of the number of Gulf War veterans who suffer from CMI range from 175,000 to 250,000 [66]. CMI-related diagnoses, including chronic fatigue, fibromyalgia, and irritable bowel syndrome are increasingly recognized in veterans of the Iraq and Afghanistan conflicts [67,68].
There is little evidence to support particular therapies. However, treatments include the serotonin reuptake inhibitors, cognitive behavioral therapy, and mindfulness-based stress therapy [66,69]. (See "Psychotherapy and psychosocial interventions for posttraumatic stress disorder in adults", section on 'Introduction'.)
CHRONIC PAIN — The most common reason for recently deployed veterans to seek medical care is chronic pain associated with musculoskeletal injuries or traumatic brain injury (TBI) [63]. Arthritis is common among veterans; one survey found that 25 percent of veterans reported a diagnosis of arthritis [70].
Multidisciplinary care, involving physical therapy and mental health treatments such as cognitive behavioral therapy or biofeedback techniques, has been successful for the treatment of chronic pain [71,72]. 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 [73]. (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 non-cancer pain received opioids [74]. 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 [75]. PTSD and other psychiatric conditions are frequently comorbid and are associated with significantly greater rates of high-risk opiate use and consequent adverse events [76-78]. (See "Approach to the management of chronic non-cancer pain in adults".)
SUBSTANCE USE DISORDER — The stress of war leads to adverse health behaviors for some military service members. One anonymous self-report survey of more than 28,000 United States military personnel found that cigarette smoking was the most common adverse behavior (31.7 percent), followed by heavy alcohol use (21.0 percent) [79]. Illicit drug use excluding prescription drug misuse was reported in 5.2 percent. The rate has declined sharply since 1980, associated with random drug testing and strict intolerance of drug use within military ranks. Although differences in methodology make direct comparisons difficult, rates within the military appear to be no higher than in the general population. However, prescriptions for psychotropic medications, and abuse of prescription medications, have increased markedly in the general population in recent years, and this trend seems to be even more pronounced in the military in association with drawn-out conflicts in Iraq and Afghanistan [79-81]. In another study using data from the Veterans Administration (VA) health care system for veterans of Iraq and Afghanistan seen for an initial visit between 2001 and 2009, alcohol use disorder was diagnosed in 10 percent, drug use disorder in 5 percent, and both diagnoses in 3 percent [82]. Over 55 percent of veterans diagnosed with substance use disorder were also diagnosed with either posttraumatic stress disorder (PTSD) or depression and were 3.0 to 4.5 times more likely to have PTSD or depression than veterans without substance use disorder. Additionally, veterans with mental health diagnoses (and PTSD in particular) were more likely to have chronic pain requiring opioid treatment and were more likely to abuse prescription opioids with adverse health consequences [77]. A 2018 survey of a nationally representative population of United States military veterans found that 20.3 percent of those with alcohol use disorder met criteria for comorbid PTSD, while 16.8 percent with PTSD met criteria for alcohol use disorder; those with both conditions were more likely to also have depression, generalized anxiety disorder, suicidal ideation, and suicide attempts [83]. It is important to recognize that an element of selection bias occurs, with healthier individuals who are less likely to engage in illicit drug use tending to remain in active military service at higher rates. Conversely, for those who leave the military, only about one-quarter receive care in the VA system, and they tend to be disproportionately lower-income with more complex health problems [84,85].
The frequency and intensity of tobacco use increases in military populations after deployment [79]. Smoking rates are particularly high in those with combat-related PTSD. Tobacco cessation efforts that are integrated with PTSD treatment have been found to be more effective than referral to standard smoking cessation programs [86,87]. In advocating for smoking cessation in the veteran population, any concomitant psychological sequelae should also be addressed. (See "Overview of smoking cessation management in adults".)
Although rates of alcohol or substance use disorder are comparable in military service members and their civilian counterparts, alcohol misuse (including drinking and driving, and being late for or missing work due to a hangover) seems to be more common after deployment, with 27 percent of veterans reporting this [88]. Alcohol misuse is associated with combat exposures involving threat of death or injury, as well as current functional impairment [89]. Thus, combat veterans returning from deployment should be screened for alcohol misuse. Their use of prescription and non-prescription 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.)
MILITARY 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" [90]. 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 [91]. 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 posttraumatic stress disorder (PTSD), depression, and suicidal ideation [92]. (See 'Posttraumatic stress disorder' above.)
INFECTIOUS DISEASES — Veterans are at risk for a wide range of infectious diseases depending upon the particular area of deployment. Risk may be decreased by the use of protective measures, such as special clothing, insect repellant, and prophylactic medications.
Malaria — Plasmodium vivax and Plasmodium falciparum are endemic in Afghanistan [93]. All soldiers from the United States deployed to Afghanistan are treated with chemoprophylaxis (mostly with doxycycline) [94] and soldiers deploying to high-risk areas receive primaquine terminal prophylaxis upon return. 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. (See "Malaria: Clinical manifestations and diagnosis in nonpregnant adults and children" and "Non-falciparum malaria: P. vivax, P. ovale, and P. malariae".)
Tuberculosis — Tuberculosis (TB) is endemic in Afghanistan and Iraq. The United States military screens soldiers at high risk of exposure for TB prior to deployment using the purified protein derivative of tuberculin (PPD) and within 10 weeks of return from deployment. Deployment-associated conversion rates are approximately 2.5 percent in soldiers returning from Afghanistan and Iraq [95]. Soldiers identified with latent or active TB infection should receive appropriate treatment. However, it is conceivable that returning veterans, especially in the Reserve or National Guard, could bypass screening processes in place by the military. Providers should inquire as to the PPD status of returning veterans and should screen for TB if status is unknown. (See "Treatment of tuberculosis infection 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)".)
Wound infections — Wounds sustained in battle are frequently infected [96]. Lower-extremity wounds are likely to be due to improvised explosive devices (IEDs) or land mines and are at high risk of infection. Antibiotic therapy should be tailored to cultures due to the propensity of Acinetobacter and other Gram-negative organisms (eg, Enterobacter, Pseudomonas) to cause wound infections, as well as antibiotic-resistant organisms [97,98]. In addition, invasive fungal infections, including mucormycosis, have been reported in United States military personnel who sustained blast injuries during combat in Afghanistan [99]. (See "Clinical assessment of chronic wounds" and "Mucormycosis (zygomycosis)" and "Mucormycosis (zygomycosis)", section on 'Combat-associated'.)
Antibiotic-resistant bacteria — Since the beginning of United States operations in Afghanistan and Iraq, there has been a notable increase in the number of wounded veterans with colonization or infection with antibiotic-resistant organisms [100,101]. Common organisms include methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL)–producing Gram-negative organisms (particularly Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa, and Acinetobacter baumannii) [97,102,103]. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Epidemiology" and "Extended-spectrum beta-lactamases".)
Wounded soldiers arriving to military medical treatment facilities are screened for colonization upon arrival. The colonization status of returning veterans may not be known to providers outside of military treatment facilities. Providers caring for returning veterans should be aware of possible colonization/infection with resistant organisms and should take this into account when considering antibiotic selection and implementing infection control practices. (See "Infection prevention: Precautions for preventing transmission of infection".)
Cutaneous leishmaniasis — Cutaneous leishmaniasis is a recognized parasitic infection in soldiers returning from Afghanistan and Iraq and presents as chronic, painless ulcerations on areas of skin exposure, most commonly the arms and legs [104]. 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). Thus, cutaneous leishmaniasis typically presents in a window from 6 to 12 months after exposure and should be considered in the differential of painless ulcerations in veterans returning from Afghanistan and Iraq. (See "Cutaneous leishmaniasis: Clinical manifestations and diagnosis" and "Skin lesions in the returning traveler".)
Visceral leishmaniasis — There are case reports of visceral leishmaniasis occurring in soldiers returning from Afghanistan and Iraq [105]. 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. Highly sensitive and specific serology-based enzyme-linked immunosorbent assay (ELISA) testing utilizing recombinant kinesin antigen (rK39) is commercially available to aid in the diagnosis. Visceral leishmaniasis should be considered in the differential diagnosis of veterans with chronic fever and weight loss without any obvious cause. (See "Visceral leishmaniasis: Clinical manifestations and diagnosis".)
Q fever — Q fever is a zoonotic infection due to Coxiella burnetii, with both acute and chronic manifestations. The incubation period is relatively short, so the acute presentation of Q fever as a self-limited flu-like illness, pneumonia, or hepatitis is typically seen while soldiers are still deployed or immediately following return [106]. However, it can also present as a chronic infection, most commonly as endocarditis which is the most serious and potentially fatal form. Q fever should be considered in all cases of blood culture-negative endocarditis in returning veterans. Further information regarding Q fever can be found from the United States Centers for Disease Control and Prevention [107].
Brucellosis — Brucellosis is a zoonotic infection endemic to Afghanistan and Iraq that can vary widely in clinical presentation, ranging from asymptomatic, to insidious onset of non-specific findings, to acute illness and death [95]. The incubation period is usually one to four weeks. A presumptive diagnosis of brucellosis can be made by demonstrating high or rising titers of specific antibodies in the serum in the presence of clinical manifestations. This is the most commonly used diagnostic method in clinical practice. The diagnosis of brucellosis is made with certainty when brucellae are isolated from blood, bone marrow, or other body fluids or tissues. Brucellosis should be considered in the differential diagnosis of a fever of unknown origin in veterans who have recently returned from deployment. (See "Brucellosis: Epidemiology, microbiology, clinical manifestations, and diagnosis".)
Anthrax and smallpox vaccinations — Despite controversy regarding the utility of anthrax vaccine and smallpox vaccine, both have been administrated broadly in several military populations [108,109]. While there can be serious short-term side effects following vaccination, no long-term complications have been described following smallpox or anthrax vaccination [110-112]. (See "Vaccines to prevent smallpox, mpox (monkeypox), and other orthopoxviruses" and "Prevention of anthrax".)
Transfusion-related infections — Hemorrhage is the leading preventable cause of mortality in combat casualties [113], and death from hemorrhage usually occurs within 6 to 24 hours of injury [114,115]. Blood products to replace losses must be available at military treatment facilities, which are often located in austere conditions. Stored red blood cells, frozen plasma, and cryoprecipitate products used in battle are fully compliant with US Food and Drug Administration (FDA) regulations. Platelets have a short shelf life and cannot be collected, tested, and transported in time for use for most casualties.
In some cases, transfusion requirements of one or more casualties exceed the supplies of stored blood components and blood components that have been prescreened for transfusion-transmitted infectious pathogens in accordance with FDA regulations are unavailable [116]. To address the need for life-saving blood products in such conditions, non-FDA-compliant, voluntarily donated, and freshly collected blood products (whole blood and apheresis platelets) may be needed [117,118]. 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 [119,120].
US Department of Defense policy requires screening recipients of non-FDA-compliant blood products (specifically fresh whole blood or apheresis platelets collected on site) for HIV, HBV, HCV, human T-lymphotropic virus (HTLV), and rapid plasma reagin (RPR) at 3, 6, and 12 months following the transfusion [121]. 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.
ENVIRONMENTAL HAZARDS
Noise exposure — Noise-related hearing loss and tinnitus are two of the most prevalent service-connected disabilities among United States veterans [122,123]. 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 [124].
Toxins — Although concerns have been raised about exposures to environmental toxins leading to adverse health effects, these exposures have not been widely reported with the conflicts in Afghanistan or Iraq. These hazards include Agent Orange (dioxin) [125], other toxic nerve agents (eg, sarin, cyclosarin) [126,127], and heavy metals [128]. 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 [129,130]. The herbicide Agent Orange has received considerable attention due to widespread use in the Vietnam War by the United States for military purposes [131]. 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 [132,133]. 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.
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 [134-137]. 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 [138]. Common symptoms of Gulf War illness include headache, fatigue, joint pain/stiffness, cognitive difficulties, and insomnia [139]. 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 US Centers for Disease Control and Prevention (CDC) [140] and another from Kansas [141] seemed to have the greatest utility and applicability.
Although the safety of independent use of insect repellents diethyl-meta-toluamide (DEET) and permethrin is well documented [142,143], 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 [144]. A subsequent randomized trial in humans compared appropriate doses of all three treatments in combination compared with placebo and found no adverse effects [145]. 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. Veterans who may be deployed should be counseled on the benefits and safety of insect repellant use. (See "Prevention of arthropod and insect bites: Repellents and other measures".)
DISABILITY AND FUNCTIONAL ASSESSMENT — In 2010, the United States Census Bureau reported that there were a total of 22.0 million living veterans in the United States, of which 3.2 million veterans received service connected disability compensation [146].
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) [147]. 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 his or her 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 [148].
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.
SOCIAL STRESS — Being confronted with "kill or be killed" scenarios, and being on guard day and night for a prolonged period of time, represents an enormous life stressor. 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. Deployment has a significant impact not only on military service members, but also on their families [149,150].
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 [151]. 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 [152,153]. 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.
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
●Although the overall medical care of the returning veteran may be similar to that of the general population, there are certain issues (eg, combat injuries, traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), readjustment to society following deployment) that pertain specifically to the veteran. Physical injuries from combat (eg, amputations, TBI) can lead to significant functional limitations as well as psychological sequelae. (See 'Physical injury due to combat' above and 'Psychological sequelae' above.)
●PTSD and other psychological sequelae in veterans are being identified at higher rates than in the past. Psychological symptoms are frequently not fully manifest until months or years after return from deployment. An initial screening shortly after return from deployment will miss most cases of mental health problems and repeated screening is necessary, especially between 3 and 12 months after return. (See 'Screening for psychological sequelae' above.)
Returning veterans should be screened for:
•PTSD (table 2) (see "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis", section on 'Screening')
•Depression (table 3) (see "Unipolar depression in adults: Assessment and diagnosis", section on 'Screening for depression')
•Anxiety disorders (table 4) (see "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on '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')
●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".)
●Veterans are at risk for a wide range of infectious diseases depending upon the particular area of deployment. (See 'Infectious diseases' above.)
●Noise-related hearing loss and tinnitus are two of the most prevalent service-connected disabilities among United States veterans. Other environmental exposures such as toxic nerve agents have been documented in previous wars but have not been implicated in the more recent wars in Afghanistan and Iraq. (See 'Environmental hazards' above.)
●If the veteran has symptoms or signs of functional or mobility problems, then physical and occupational therapy evaluations should be conducted. (See 'Disability and functional assessment' above.)
●Finally, the clinician should evaluate the situation at home, paying attention to the veteran's familial and community relationships, as veterans are prone to have difficulties in the transition back to civilian life (see 'Social stress' above). 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.