Veteran Mental Health Challenges and Solutions

Table of Contents

Acknowledgments

A Special Message to the Creative Community

Letter from Brian Dyak, President, CEO, and Co-Founder, Entertainment Industries Council Inc.

Letter from Sonja Batten, Deputy Chief Consultant for Specialty Mental Health, U.S. Department of Veterans Affairs

Veterans’ Experiences: Powerful American Drama

The Reality

Make the Connection: An Authentic Resource for Storytellers

Real Character Studies: Overcoming Challenges, In Veterans’ Own Voices

Bryan’s Story, U.S. Marine Corps, 2003–2008, a Recent Combat Veteran

Nicole’s Story, U.S. Army, U.S. Air Force Reserve, 1990–1993, 1996–Present, a Desert-Era Combat Veteran

Chaunte’s Story, U.S. Air Force, U.S. Air Force Reserve, 2000–Present, a Recent Combat Veteran

Jack’s Story, U.S. Marine Corps, 1963–1967, a Vietnam-Era Combat Veteran

Tiffany’s Story, Fiancée of a U.S. Marine Corps Veteran

Mental Health Care for Veterans

Signs and Symptoms of Veterans Experiencing Mental Health Challenges

Barriers to Treatment

Treatment Works

Treatment Settings

Depiction Priorities

Questions to Ask of Your Characters and Storylines Involving Veteran

Mental Health

Sample Characters: Symptoms and Treatments

Appendix

About Picture This: Veteran Mental Health Challenges and Solutions

A Commitment to the Nation’s Veterans: About the U.S. Department of Veterans Affairs and Its Advances in Mental Health Services

U.S. Veterans: Did You Know?

Additional Information and Resources

Language and Terminology

End Notes

ii

Special thanks to our collaborator and sponsor, the U.S. Department of

Veterans Affairs.

Entertainment Industries Council Picture This Team:

Brian Dyak, President, CEO, and Co-Founder

Marie Gallo Dyak, Executive Vice President, Program, Services and

Government Relations

Larry Deutchman, Executive Vice President, Marketing and Industry Relations

Shawn King, Administration and Executive Assistant to the President and CEO

Skylar Zwick, External Communications and Program Director

Ashley Jupin, Program Manager

Anthony Perez, Program Manager

Shana Baiz, Assistant Program Manager

Jeff Coppola, Program Assistant

Rebecca Jackson, Assistant Program Manager

Picture This Associates:

Aaron Dowler

Bridget Phelan

Daniel Menist

Jose Mata Jr.

Kayla Begg

Malika Vastare

Michelle Cheoung

Rebecca M. Kreps

Ryan Badin

iv

At the heart of the Make the Connection campaign are many individual testimonials

from Veterans and their family members. As you will see on the website

(www.MakeTheConnection.net), these stories of successful recovery offer compelling

reasons for others, especially Veterans, to seek treatment. We need your help in

overcoming the national stigma associated with mental health conditions and mental

health treatment. We also need your help in combatting preconceived notions with

facts: Not all Veterans are challenged by these conditions after leaving the service, and

for those who are, treatment is available and effective.

This publication includes written accounts of Veterans who have faced and successfully

overcome hurdles in order to live healthier lives, which we hope will assist you in

creating accurate and compelling depictions of Veteran mental health challenges. As

powerful as these testimonials are on the page, however, written accounts cannot

compare to hearing firsthand from the Veterans themselves. I encourage you to visit

MakeTheConnection.net and watch the true stories of our Veterans. You will meet their

families, see them in their homes and communities, and hear the emotion in their voices

as they talk of positive changes treatment and other sources of connection can bring.

By sharing their stories, these Veterans have done a tremendous public service. It is

now up to you to answer the same call.

With deep gratitude,

Sonja V. Batten, Ph.D.

Deputy Chief Consultant for Specialty Mental Health

U.S. Department of Veterans Affairs

vii Picture This: Veteran Mental Health Challenges and Solutions

Today is a unique time in our nation’s history, ripe

for telling compelling stories of authentic Veteran

experiences. Hundreds of thousands of Service members

are returning from deployment to face arguably the

most challenging economic environment of the last 60

years. Larger numbers than ever are women who have

experienced the rigors and stress of combat situations and

environments—as well as extended separation from young

children. At the same time, Vietnam Veterans are going

through life transitions, including becoming grandparents,

retiring, and aging.

As entertainers and creators, you can tell these stories in a

way that is respectful, interesting, and faithful to the truth.

You can dig into the topic of Veteran mental health in ways

that transcend stereotypes and present a more honest,

compelling, and powerful product. And you can do it by

letting Veterans’ own voices guide you. So many of them

are eager to share their realities with the world. You can

make their experiences resonate with viewers throughout

the country. You can provide a service that is good for your

industry, our Veterans, and our nation.

Veterans have done their part. Now you can do yours. By

taking the time to better understand Veterans’ strengths

and challenges, you can help drive the evolution of a more

positive and accurate social narrative around Veterans’

experiences—as well as the value and benefits of seeking

support and treatment. So take advantage of the resources

available to help you improve your product, build your

audience, and inspire your stories.

The Reality

To begin increasing awareness and understanding of mental

health challenges and dispelling myths about our nation’s

Veterans, it is important to have facts about the realities of

being a Veteran.

Most Veterans honorably serve their country, complete military service, and successfully transition into civilian life. They have the ability to lead in the workplace, in their communities, and at home by using the skills they have learned and perfected during their service.

Just like those who never served in the military, Veterans may experience mental health issues and difficult life events that are unrelated to their service. However, the difficulties of service, such as combat, noncombat training exercises, other traumatic military experiences, and repeated deployments, may complicate their efforts to deal with those issues.

Many currently returning Service members have been deployed multiple times and exposed to more combat than were Veterans of previous generations. They include Service members of all-volunteer Armed Forces, approximately half of whom were Reservists and members of the National Guard who left behind their civilian lives to tackle incredibly difficult tasks.

Older Veterans, such as those who served in Vietnam, comprise one-third of American Veterans. They have transitioned or soon will be transitioning into retirement. When they returned to civilian life years ago, they were busy raising families and working, during an age when mental health issues were not a priority for discussion. Now, at the same time they are facing new life changes, many of these Veterans are confronted with issues they may have tried to bury—for the good of their families and themselves—long ago.

Veterans and others who see the benefit of using mental health services may be unaware of resources tailored specifically to Veterans’ needs. Because of their unique experiences, Veterans often can benefit more from services designed for them and others in the Veteran community.

Veterans’ loved ones also face unique challenges and can benefit from making the connection with others who have had similar experiences. Military service can temporarily separate families, and readjustment can be tough. Family members can explore treatment and support options for themselves and the Veterans in their lives that build resilience and strengthen their families. VA and other community-based resources offer options for loved ones of Veterans seeking assistance and the means to help those they care about.

Many Veterans seek help and support for mental health challenges. In fact, more than 1.3 million Veterans received mental health care at VA in 2011.

Veterans are often willing to offer assistance to others. Many Veterans are involved in peer-to-peer support for their fellow Veterans and their families, and in their communities.

3

Signs and Symptoms of Veterans

Experiencing Mental Health Challenges

Identifying mental health issues can often be difficult.

Accurately portraying these challenges in fiction can also be

tough. The following signs and symptoms are among early

warning signs of mental or emotional issues. Writers and

actors looking to depict Veterans dealing with such challenges

should be aware of some of these possible indicators:

Changes in sleep, appetite, or weight

Decreased energy, motivation, or interests

Problems with attention, concentration, or memory

Uncharacteristic irritability, anger, or “short temper”

Feelings of guilt, worthlessness, helplessness, or hopelessness

Unhealthy behaviors, such as reckless behavior and problems with alcohol or drugs

Thoughts of suicide

Problems functioning at home, work, or school

Some Veterans face challenges that can contribute to

mental health issues, such as stress caused by transitioning

from service to civilian life; reintegrating back into family,

relationships, and routine; or other significant life events,

such as:

Loss of a loved one

Major life changes, such as retirement

Job loss

Exposure to another traumatic event, such as an accident or criminal act

Specific mental health conditions may include:

Anxiety disorders, including post-traumatic stress disorder (PTSD)

Depression or bipolar disorder

Alcohol or drug problems

Schizophrenia

Barriers to Treatment

Veterans may not access mental health treatment because

of a variety of real or perceived barriers to care. Although

Veterans often cite physical barriers such as clinic hours and

distance as reasons for not seeking mental health treatment,

perceived barriers such as negative beliefs about mental

health care also have a significant impact.

Common barriers to seeking mental health treatment include:

Lack of understanding about the signs and

symptoms of mental illness. Some Veterans may write off the signs and symptoms of mental health challenges as an inevitable and unchangeable result of their military service.

Perceptions of weakness or failure. Veterans experiencing mental health conditions often express feelings of embarrassment or fear of being viewed by their peers as weak or having failed, which may prevent them from seeking appropriate treatment.

Misconceptions about the necessity and efficacy of

treatment. Because some mental health challenges, such as PTSD, have only recently become fully understood and defined, many Veterans do not realize they are experiencing real problems that can be successfully treated.

Lack of familiarity with treatment regimens and

resources. Treatment for mental health issues has advanced over the years, encompassing evidence-based psychotherapies that successfully treat various conditions and do not necessarily involve taking medications. However, many older Veterans view treatment as unending, and younger Veterans may believe all treatment involves pharmaceuticals—causing them to avoid seeking treatment.

Belief that treatment is not available to them, or

they don’t deserve support. Service members are trained to look out for their buddies and put the good of the unit before themselves. Veterans retain these attitudes about caring for others first and themselves second, and therefore may believe treatment should be reserved for those who may need it more than they do. They also may think that because they did not see combat—or because their fellow Service members saw more intense action—they are not deserving of the resources available to them.

17

Treatment Works

Showing signs of mental health challenges does not

mean a Veteran has to live with these issues forever. VA

and other resources offer support for confronting and

overcoming whatever holds Veterans back from leading

fulfilling lives. The entertainment industry can present

stories that resonate with audiences and directly impact

the lives of Veterans and their loved ones when characters

and storylines include seeking treatment for emotional

and mental health symptoms and portraying the positive

outcomes of treatment.

The type of mental health treatment to be provided is

highly dependent on the individual and the condition

being treated. There is no one-size-fits-all treatment and

there are no magic pills. For almost every condition, there

are various effective treatments that can help Veterans

cope with symptoms and greatly improve their quality of

life. Treatments can involve counseling, medication, or a

combination of both.

It is important to remember that treatment is often a finite

process: Veterans and others who seek assistance with

mental health-related issues, as with other health issues,

need not remain in treatment forever. They can get help,

get well, and return to their normal routines.

Treatment Settings

The setting for treatment usually depends on both the

Veteran and his or her specific condition. Some settings

available to Veterans include:

Outpatient Care: Most treatment is offered through visits to local primary care offices, psychiatrists, psychologists, mental health clinics, or community centers, and is designed to help Veterans during a difficult time. Telemedicine may be used in specific cases.

Intensive Outpatient Care: This option involves several hours per week of treatment to help address more significant symptoms of mental health conditions.

Supported Work Settings: These settings provide resources, services, and assignments to assist Veterans who are re-entering or integrating into the workforce.

Residential Care: This can be used to support treatment for a wide range of mental health conditions and is designed for people who may benefit from living in a structured environment for a limited period of time.

Inpatient Care: 24-hour care may be initiated as the result of a severe or life-threatening mental health condition. Just as with mental health treatment for civilians, this level of care is not necessary for most Veterans who seek treatment.

18 Picture This: Veteran Mental Health Challenges and Solutions

The effort to share real stories from Veterans is a

collaboration that began with a national Picture This forum

held at the National Association of Broadcasters (NAB)

in Washington, D.C. A group of 43 nationally recognized

experts engaged a panel of entertainment industry

professionals about Veteran mental health communication

priorities. Building on the D.C. forum, leaders in the

entertainment industry gathered in Los Angeles with

VA leaders and Veteran participants in the Make the

Connection campaign to discuss how writers, actors,

directors, producers, and executives can learn from real

Veteran stories and use them to inform their characters

and storylines.

The following statements, made by participants at both

events, reflect a range of familiarity with and reflection on

the challenges our Veterans face and the strengths with

which they can tackle them.

Sen. Gordon Smith, President, National

Association of Broadcasters (NAB)

“I am confident that our work today will greatly advance the

cause of paying our military the respect it deserves. Every

day, soldiers, sailors, airmen, guardsmen and women,

and Marines go out and risk their lives to protect the

freedom that creators, moviemakers, and television

broadcasters especially enjoy: our freedom of speech.

Your focus on accurately portraying our servicemen and

women through fiction is a wonderful thing. There are no

greater contributors to our society than our Veterans, who

give so much so that we can enjoy the freedoms we do. We

at NAB are anxious to help put into people’s ears and eyes

the content that you will produce.”

Dr. Sonja Batten, Deputy Chief Consultant for

Specialty Mental Health, Department of

Veterans Affairs

“Our mission at the U.S. Department of Veterans Affairs

is to serve those who have served our country. There has

never been a time in history when so many Veterans were

eligible for care and have come to VA so soon after they

have left the service.

It is important to realize that not all Veterans require mental

health services. But for those who do, excellent care is

available. Improving Veterans’ mental health is one of the

highest priorities at VA. Last year, about a quarter of the

Veterans who came to a VA Medical Center were seen,

among other things, for mental health conditions. But

there is still more to be done in service to those who served

our country. We need to be careful about balancing our

messages: Most Veterans honorably serve their country,

complete military service, effectively transition into civilian

life, and are able to successfully work through any mental

health or readjustment challenges that they may have. And

those who do have mental health challenges should not be

defined solely by that aspect of their lives.

For us to responsibly depict mental health issues and

the Veterans who face them, we also need to depict

the strengths and unique abilities of our Veterans with

respect to discipline, team focus, ability to carry out a

mission, adaptability, and perseverance. Veterans have

amazing stories. We owe it to them to tell their stories in

a fuller context, and show the positive steps they take to

improve their own lives, as well as what they do for their

own families and communities.”

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A Commitment to the Nation’s Veterans:

About the U.S. Department of Veterans

Affairs and Its Advances in Mental

Health Services

The United States has the most comprehensive system of

assistance for Veterans of any nation in the world.

In 1930, the VA health care system totaled 54 hospitals.

Today, it includes more than 150 medical centers; more

than 350 outpatient, community, and outreach clinics;

and 300 Vet Centers. VA health care facilities provide a

broad spectrum of medical, surgical, and rehabilitative

care. Through treatment and accessible resources, VA

provides Veterans with the tools necessary to lead fulfilling

lives following their selfless service to our country. These

tools are geared specifically toward Veterans and are

delivered in a way that makes them and their loved ones

most comfortable. VA has experience working with all

Veterans—from the oldest to those from recent conflicts—

and has several services and programs geared toward

specific groups, including women and recent Veterans.

A Commitment to Treatment

VA specializes in the care and treatment of Veterans.

In recent years, research from around the world has

dramatically increased our understanding of mental health

conditions and how to treat them. Several million Veterans

have received treatment for mental health conditions

and found solutions for improving their lives. They have

learned what all Veterans should know: Treatment works

and recovery is possible.

A Commitment to Resource Awareness

VA is at the forefront of creating new ways to help Veterans

and their families identify resources and treatment options

that are tailored for them. But it is not enough to offer

these resources: VA is committed to performing local and

national outreach so all Veterans realize the support that

is available to them. Many Veterans are affiliated with a

VA Medical Center, a Veterans Service Organization, or

other community organizations and may be well aware

of their options for health care, including mental health

services and support. For those who do not, VA is taking

the message of treatment availability and effectiveness to

the public sphere.

VA’s Make the Connection public awareness campaign

highlights candid, personal testimonials from Veterans and

their families and provides resources to help them discover

ways to improve their lives. MakeTheConnection.net

helps Veterans recognize that they are not alone—

there are people out there like them who are going

through similar experiences, overcoming challenges,

reaching positive outcomes for treatment and recovery,

and finding paths to fulfilling lives. These messages

are conveyed through the most credible source

of all—the voices of other Veterans. The Make the

Connection campaign encourages Veterans and their

families to “make the connection”—with information and

resources, with the strength and resilience of Veterans

like themselves, with other people, and with available

sources of support, including mental health treatment.

30 Picture This: Veteran Mental Health Challenges and Solutions

Additional Information and Resources:

U.S. Department of Veterans Affairs

Make the Connection

National Center for PTSD

Veterans Crisis Line

Defense and Veterans Brain Injury Center

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

National Resource Directory

National Suicide Prevention Lifeline

Substance Abuse and Mental Health Services Administration

33

Language and Terminology:

Adapted from MakeTheConnection.net,

NLM.NIH.gov, Medicinenet.com

ACT: Acceptance and Commitment Therapy. An effective type of talk therapy for depression, anxiety, and substance use problems. ACT helps people move beyond their struggles with emotional pain and worries. It teaches them to recognize, commit to, and achieve what’s important to them, rather than making choices due to avoidance of painful or uncomfortable experiences.

Acute: Of abrupt onset, in reference to a disease. Acute often also describes an illness that is of short duration, rapidly progressive, and in need of urgent care.

Antidepressant: A medication used to treat depression. The available antidepressant drugs include SSRIs, or selective serotonin reuptake inhibitors, MAOIs, or monoamine oxidase inhibitors, tricyclic antidepressants, tetracyclic antidepressants, and others.

Anxiety: An experience characterized by episodes of intense fear or exaggerated worry and tension most of the time or in everyday social situations. Experiences of anxiety may be accompanied by physical symptoms like heart pounding, trouble breathing, trembling, sweating, or being easily startled.

Bipolar disorder: A mood disorder in which an individual may experience extreme shifts in mood, energy, and activity levels. The individual can go from feeling almost supercharged with tremendous energy to feeling so down that it may be hard for him or her to find the energy to do much of anything. These extreme mood swings can happen over a short period of time or over several months, and there may be periods of “normal” moods in between. Bipolar disorder can make it very difficult to function at work or in social settings. It can also lead to strain on family and personal relationships.

CBT: Cognitive-Behavioral Therapy. A type of talk therapy effective for depression, anxiety, and PTSD. CBT helps people learn new patterns of thinking and practice new positive behaviors.

Chronic pain: A condition characterized by the experience of pain in one or more areas of the body for a prolonged period of time. The pain may be nagging or severe and often seems worse than short-term pain because of its duration. General wear and tear from aging as well as different types of illnesses and injuries can cause chronic pain.

CPT: Cognitive Processing Therapy. A type of cognitive behavioral talk therapy effective for PTSD. CPT helps people learn new patterns of thinking so their memories of trauma do not interfere with their daily lives. CPT uses some exposure therapy (see definition of “PE: Prolonged Exposure Therapy” ).

Dementia: Loss of memory and intellectual capacity that is severe enough to limit a person’s ability to function. Alzheimer’s disease is one common type of dementia.

Deployment: The movement of Armed Forces and their logistical support infrastructure around the world. During deployments, men and women leave their families and homes with other Service members and travel to another location for a set period of time.

Depression: Feelings of sadness or hopelessness that last for more than a few weeks or seriously impact one’s life. Depression is a common problem that affects people in different ways. It not only affects a person’s mood, but also affects a person’s body, actions, and thoughts. Depression can interfere with daily life and normal functioning.

Dissociation: A feeling of detachment from one’s immediate experiences, surroundings, or even from the body. Dissociation is characterized by a sense of the world as a dreamlike or unreal place and may be accompanied by memory problems.

Domiciliary or Residential Rehabilitation

Treatment Program: A safe, homelike facility where Veterans live for a short time while they “get back on their feet.” Such programs provide state-of-the-art, high-quality residential rehabilitation and treatment. Here, Veterans can receive services that help them get a job, return to school, improve social skills, and address physical and mental health problems.

34 Picture This: Veteran Mental Health Challenges and Solutions

Fatigue: Fatigue can result in a lessened capacity for work and reduced efficiency of accomplishment. Fatigue is usually accompanied by a feeling of weariness and tiredness. It can be acute and come on suddenly or be chronic and persistent.

Flashback: The feeling of re-experiencing a traumatic event. Individuals might remember everything about the event as if they were going through it again—vividly recalling the sights, sounds, smells, and other details while losing contact with their current surroundings. They might even have the same feelings or physical sensations that they had at the time of the event.

GAD: Generalized Anxiety Disorder. GAD is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually expect the worst; they worry excessively about money, health, family, or work, even when there are no signs of trouble. They are unable to relax and often experience insomnia. Many people with GAD also have physical symptoms, such as fatigue, muscle tension, headaches, or stomach pain.

Insomnia: A common sleep disorder characterized by trouble falling asleep, staying asleep, or both. It can be acute (short term) or chronic (ongoing). Acute insomnia is common and often is brought on by situations such as stress at work, family pressures, or a traumatic event. Acute insomnia lasts for days or weeks, while chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary, meaning they arise as a symptom or side effect of a medication or another mental or physical illness.

MST: Military Sexual Trauma. MST is sexual assault or sexual harassment during military service. It includes uninvited sexual advances or contact or forced sex while in the military and happens to men and women. MST can be associated with mental and physical problems. Every VA facility provides free MST-related care and has a designated MST Coordinator who serves as a contact person for MST-related issues.

OEF/OIF/OND: Acronyms for Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.

Panic attack: A sudden onset of intense fear or terror, often associated with feelings of impending doom. During these attacks, there are symptoms such as shortness of breath or smothering sensations; palpitations, pounding heart, or accelerated heart rate; chest pain or discomfort; choking; and fear of losing control.

PE: Prolonged Exposure Therapy. An effective treatment for PTSD, PE therapy helps people slowly become more comfortable with sights, sounds, and smells that remind them of the trauma. The therapist helps the individual relive traumatic memories in a safe environment. The memories become less troubling and interfere less with the person’s daily life as the person repeatedly contacts the difficult memory. Other approaches to exposure therapy may use methods such as writing about the traumatic event.

PTSD: Posttraumatic Stress Disorder. An anxiety disorder that may sometimes result when a person experiences a potentially traumatic event. PTSD symptoms can disrupt daily life. They include re-experiencing the trauma through intrusive thoughts or nightmares and distancing from other people or feeling emotionally numb. Other symptoms include being irritable or quick to anger and having trouble sleeping or feelings of anxiety.

Schizophrenia: A mental health disorder characterized by feelings of fear and paranoia that make it very hard to trust others, having a significant effect on personal relationships. Schizophrenia may get in the way of one’s ability to make good decisions. Research shows many people with schizophrenia can recover when correctly diagnosed and treated. Note that schizophrenia is not the same as dissociative identity disorder or multiple personality disorder.

35

Substance use disorders: The excessive use of a substance, especially alcohol or a drug. Substance use problems can impair an individual’s ability to function and can lead to complications including, but not limited to, liver disease, harm to unborn children, high blood pressure, mood swings, and neglect of personal responsibilities and appearance.

TBI: Traumatic Brain Injury. TBI can occur when something outside the body hits the head with significant force, and can cause changes in a person’s ability to think, control emotions, walk, or speak. It can also affect sense of sight or hearing. TBI can be mild to severe. Mild traumatic brain injury or concussion refers to brief changes in or loss of consciousness. Severe traumatic brain injury or concussion refers to longer periods of unconsciousness and memory loss around the event. Note that TBI is not a mental health condition.

Telemedicine, or telemental health: A cutting-edge technology that allows a clinical provider to care for a patient from a remote location, using a camera and special TV that allow the patient and provider to see and hear each other. Telemental health can be used to perform assessments and conduct individual or group psychotherapy and medication management.

Traumatic experience: A traumatic experience is an event that causes physical, emotional, or psychological distress or harm. It is an event that is perceived and experienced as a threat to one’s safety or to the stability of one’s world. At the time of a traumatic event, the person experiencing the event might feel numb and, therefore, not know how to respond. Later on, memories of the trauma can bring out feelings of helplessness, fear, and even horror—as if the person were reliving the trauma all over again.

36 Picture This: Veteran Mental Health Challenges and Solutions

End Notes:

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Use Mass Approaches to Challenge the Stigma of Mental

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and Brett T. Litz, “Targeting Self-Stigma in Returning

Military Personnel and Veterans: A Review of Intervention

Strategies,” Military Psychology 22 (2010): 224 – 236.

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Jeffrey M. Pyne, and Dinesh Mittal, “Beliefs About

Depression and Depression Treatment Among Depressed

Veterans,” Medical Care 46 (2008): 581 – 589.

Gallup, “Listening to the Voices of Veterans, Focus Group

Report for the Substance Abuse and Mental Health

Services Administration” (March 2010).

Hoge, Charles W., Carl A. Castro, Stephen C. Messer, Dennis

McGurk, Dave I. Cotting, and Robert L. Koffman, “Combat

Duty in Iraq and Afghanistan, Mental Health Problems,

and Barriers to Care,” New England Journal of Medicine 351

(2004): 13 – 22.

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Afghanistan: Preliminary Assessment of Readjustment Needs

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Carlson, and Alan Schatzberg, “Monitoring Mental Health

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in Veterans Affairs Health Care,” American Journal of Public

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Maguen, Shira, Jeremiah A. Schumm, Rebecca L. Norris,

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Seal, Karen H., Thomas J. Metzler, Kristian S. Gima, Daniel

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Health 99 (2009): 1 – 8.

37

Seal, Karen H., Shira Maguen, Beth Cohen, Kristian S. Gima,

Thomas J. Metzler, Li Ren, Daniel Bertenthal, and Charles R.

Marmar, “VA Mental Health Services Utilization in Iraq and

Afghanistan Veterans in the First Year of Receiving New

Mental Health Diagnoses,” Journal of Traumatic Stress 23

(2010): 5 – 16.

Stecker, Tracy, John C. Fortney, Francis Hamilton, and Icek

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58 (October 2007): 45 – 49.

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Swords to Plowshares, “Combat to Community: Facts

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(January 2011).

Tanielian, T., and L. H. Jaycox, Invisible Wounds of War:

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and Services to Assist Recovery (Arlington, VA: RAND Corp.,

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38 Picture This: Veteran Mental Health Challenges and Solutions