Mental Health for Veterans

2 Contact Hours

Syllabus

Introduction

Current statistics indicate that there are 23.4 million veterans in the United States.  There are an estimated 2.2 million military service members and 3.1 million military family members. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 18.5 percent of service members returning from Iraq or Afghanistan have post-traumatic stress disorder or depression, and 19.5 percent reported sustaining a traumatic brain injury (TBI) during their deployment. Another compelling statistic from SAMHSA is that an estimated fifty percent of service members returning from Iraq and Afghanistan who need mental health actually do seek it.

Veterans or current military members may seek care at a Military Treatment Facility (MTF) or a Veteran’s Administration Medical Center or Clinic. However, nurses who work in civilian environments, such as community hospitals, clinics, primary care practice settings, need to be prepared to care for military members and veterans. Reasons that military members may seek mental health care in the civilian sector include the perceived stigma of seeking mental health services. Will seeking mental health care be perceived as a weakness? Will seeking mental health care impact my chances for promotion to the next rank, and therefore my military career? Current military members, both active duty and reservists may choose to seek mental health care in the civilian sector for these reasons. The additional dynamic with military reservists is that these part-time citizen soldiers often have full time civilian careers and associated healthcare benefits from their civilian employer(s). Veterans may choose to seek mental health care in the civilian sector if they live a significant distance away from a Veterans Administration Medical Center (VAMC) or VA Clinic. 

Included at the end of this course are a list of web-based resources and references for learners who want to access additional information and resources to assist you in meeting the needs of veterans with mental health concerns. This course is appropriate for Registered Nurses, Licensed Practical Nurses, Clinical Nurse Specialists and Advanced Registered Nurse Practitioners.

Veterans and Mental Health Care: Have You Ever Served in the Military?

A key component of any nursing assessment is to ask the question “Have you ever served in the military?” The veteran’s military service may have exposed him or her to chemical (pollutants, solvents, chemical weapons), biological (infectious diseases biological weapons), psychological (mental or emotional abuse, moral injury) or physical injury (blast injury, bullet wound, shell fragment. vehicular crash. radiation, noise injury) may impact his or her overall health status.  Specific mental health concerns include post-traumatic stress disorder depression and suicide risk assessment.  In addition, the veteran needs to be given information about applying for benefits from the Veterans Administration. 

Behavioral Health History Screening Questions to Ask

PTSD: Have you been concerned that you might suffer from Post-Traumatic Stress Disorder? Symptoms can include numbing, re-experiencing symptoms, hyperarousal/being on guard, and/or avoiding situations that remind(s) you of the trauma.

Depression: Have you been experiencing sadness, feelings of hopelessness, lack of energy, difficulty concentrating, and/or poor sleep?

Risk Assessment: Have you had thoughts of harming yourself or others?  


Military Culture

Westphal and Convoy (2015) convey that nurses need to attain a level of military cultural competence in order to be able to effectively work with military members and veteran’s health care and specifically their mental health care. A concept that is central to military culture is military ethos. Military ethos, also known as warrior ethos has six traits: Selflessness, loyalty, stoicism, moral code, social order and excellence. Each of these traits in a military member can be either a strength or a vulnerability. See the table below, adapted from the Uniformed Services University of the Health Sciences Center for Deployment Psychology Module 1 to illustrate each trait in terms of strengths and weaknesses (or vulnerabilities):

 

TraitStrengthWeakness
SelflessnessPlacing welfare of others above one's own welfareNot seeking help for health problems because personal health is not a priority
LoyaltyCommitment to accomplishing missions and protecting comrades in armsSurvivor guilt and complicated bereavement after losing friends
StoicismToughness and ability to endure hardships without complaintNot acknowledging significant symptoms and suffering after returning home
Moral CodeFollowing an internal moral compass to choose right over wrongFeeling frustrated and betrayed when others fail to follow a moral code
Social OrderMeaning and purpose when defending societal valuesLoss of meaning or betrayal when rejected by society
ExcellenceBecoming the best and most effective professional possibleFeeling ashamed of, or not acknowledging imperfections


Resilience or the ability to regroup and recover is a key facet of military life, especially during and after a deployment. Military members may be deployed for combat operations, non-combat operations or humanitarian missions. Military ethos is a strength and contributes to the resiliency of a military member, and his or her family, when it helps to engage resources, leverage support and promote hope. Conversely. Military ethos can be a vulnerability when beliefs serve as a barrier to resources, support, and hope. 


The Military Family and Veterans Mental Health

When working with military veterans it is critical to include the impact(s) of military service and deployments on both the veteran and the military family. Rossiter et al (2016) highlighted the importance of acknowledging and meeting the needs of military children in civilian practice. The initiative that these authors propose is termed “I Serve 2”, The aim of this initiative is to encourage primary care providers, including nurse practitioners, to ask if the child has a parent or parents that serve in the military. This question is important in completing a health history in children. Military children experience frequent moves, changes in schools associated with these moves, along with stress or anxiety related to deployment of one or both active duty parents to a war zone, military or humanitarian mission. Deployment of one or both parents who serve in the military also impacts the children of military reservists.

Patel (2015) examined the roles that veteran’s caregivers, often their spouse or another immediate family member, play in their recovery process. Patel noted that caregivers assist veteran’s with applying for Veterans Administration benefits, transportation to appointments, activities of daily living and medication management. The Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal agency that supports mental health care. SAMHSA has five core principles to guide and improve behavioral health services for veterans and military families. These core principles include:

  • When appropriate, military families should have access to well-prepared civilian behavioral health care delivery systems.
  • Civilian, military, and veteran service systems should be coordinated.
  • Suicide prevention for military families must be implemented across systems.
  • Emotional health promotion for military families is important in reducing mental and substance use disorders and weathering increased exposure to adverse events.
  • Military families want and need stable housing.

 

Combat Stress

Stress is a normal component of everyday life. Once a stressor is no longer present, an individual will return to normal behaviors. Combat stress is defined as a common response to the mental and emotional strain when faced with dangerous or traumatic situations. Combat stress usually occurs for brief periods of time and symptoms resolve in a few weeks after the service member returns home Symptoms of combat stress include:

  • Irritability and angry outbursts
  • Headaches and fatigue
  • Depression and apathy
  • Loss of appetite
  • Problems sleeping
  • Changes in personality or behavior

There are several things that an individual experiencing combat stress can do to cope with combat stress:

  • Eat right: a healthy diet
  • Exercise regularly
  • Get adequate rest: at least seven hours of sleep each night
  • Reach out for help: talk to a clergy member or a counselor
  • Practice relaxation techniques such as deep breathing and doing things each day that you enjoy


Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (PTSD) can occur when someone experiences a traumatic event such as war, assault, or disaster. PTSD differs from combat stress in that while initial symptoms may be similar to combat stress, PTSD is more severe and can manifest weeks, months or years after experiencing a traumatic event. PTSD often impacts an individual’s abilities to meet daily life responsibilities. 

The Diagnostic and Statistical Manual of Mental Health Disorders (2013) specifies the following diagnostic criteria for PTSD:

Criterion A (one required) The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, in the following ways:

  • Exposure to actual or threatened death, serious injury or sexual violation
  • Witnessing the trauma
  • Learning that a relative or close friend was exposed to a trauma
  • Indirect exposure to aversive details of the trauma, usually in the course of professional duties

Criterion B (one required) The traumatic event is re-experienced in one of the following ways:

  • Unwanted upsetting memories
  • Nightmares
  • Flashbacks
  • Emotional distress after exposure to traumatic reminders

Criterion C (one required) Avoidance of trauma related stimuli after the trauma, in one of the following ways:

  • Trauma related thoughts or feelings
  • Trauma related reminders

Criterion D (two required) Negative thoughts or feelings that began or worsened after the trauma, in the following ways:

  • Inability to recall key features of the trauma
  • Overly negative thoughts or assumptions about oneself or the world
  • Exaggerated blame of self or others for causing the trauma
  • Negative affect
  • Decreased interest in activities
  • Feeling isolated
  • Difficulty experiencing positive affect

Criterion E (two required) Trauma-related arousal and reactivity that began or worsened after the trauma, in the following ways:

  • Irritability or aggression
  • Risky or destructive behavior
  • Hypervigilance
  • Heightened startle reaction
  • Difficulty concentrating
  • Difficulty sleeping

Criterion F (required): Symptoms last for more than one month

Criterion G (required) Symptoms create distress or impairment in normal functioning (occupational, social)

Criterion H (required) Symptoms are not due to medication, substance use or other illness

Acute PTSD lasts no longer than three months. Chronic PTSD lasts longer than three months. Some cases of PTSD may occur years or even decades after the traumatic event(s). In addition to the DSM-5 criteria (APA, 2013) above evidence-based screening tools are utilized by providers to screen for PTSD. One such tool is the PTSD Checklist for DSM-5 (PCL-5). This twenty-item checklist is used to screen individuals for PTSD. According to the American Psychiatric Association, the gold standard for diagnosing PTSD is a structured clinical interview.  The structured clinical interview is completed by mental health providers, including psychiatric mental health nurse practitioners.

Treatment for Post-Traumatic Stress Disorder

The National Center for PTSD (2017) outlines the following evidence-based treatments for post-traumatic stress disorder. The recommended treatment for PTSD is either a trauma focused psychotherapy or medication. Trauma focused psychotherapies are the most highly recommended treatment modality for PTSD. Trauma focused psychotherapy is defined as treatment that is focused on the memory of the traumatic event.  Veterans undergoing a trauma focused psychotherapy usually attend eight to sixteen sessions. Trauma focused psychotherapies use various techniques, such as visualizing, talking about or thinking about the traumatic memory. Other trauma focused psychotherapies involve changing unhelpful beliefs about the trauma. Trauma focused therapies with the strongest evidence are:

Prolonged Exposure (PE): this therapy includes relaxation skills. recalling details of the traumatic memory, reframing negative thoughts about the trauma, writing a letter about the traumatic event, and holding a farewell ritual to leave the trauma in the past.

Cognitive Processing Therapy (CPT): this therapy teaches the veteran to reframe negative thoughts about the trauma. This includes the veteran talking with the mental health provider about negative thoughts and doing short writing assignments. 

Eye-Movement Desensitization and Reprocessing (EMDR): helps the veteran process and make sense of the trauma. EMDR involves calling the trauma to mind while paying attention to a back and forth movement or sound

According to the Veterans Affairs/ Department of Defense Clinical Practice Guideline for Post Traumatic Stress Disorder and Acute Stress Disorder (2017) medication is the recommended treatment for PTSD when trauma focused psychotherapy is not readily available or not preferred. There are four antidepressant medications that are recommended for the treatment of PTSD:

  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Fluoxetine (Prozac)
  • Venlafaxine (Effexor)

 

Traumatic Brain Injury (TBI) and Veterans Mental Health

Westphal and Convoy’s (2015) article discusses the stresses associated with military service and deployments. Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD) have been called the invisible wounds of war because there are no obvious physical deformities or wounds that are evident. These wounds of war impact the veteran and his or her family. Kulas and Rosenheck (2018) completed a study of 164,884 veterans that examined veterans diagnosed with mild TBI, PTSD, and both disorders. They concluded that PTSD pays a dominant role in the development of psychiatric difficulties in veterans. Miles et al (2017) studied 583,733 veterans in the Veterans Health Administration national patient care database to examine TBI and mental health disorders in combat veterans. They concluded that TBI is linked with mental health disorders in veterans.

According to the National Alliance on Mental Health there are three primary mental health disorders that veterans may experience related to their military service: post traumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI). 

 

Depression 

The National Alliance on Mental Illness defines a depressive disorder an individual must have experienced a depressive episode lasting longer than two weeks. A depressive episode significantly interferes with a person’s ability to function day to day. Depression can be triggered by a life crisis, such as a trauma. Trauma that may be experienced by a veteran could include: combat. Injury, natural disasters, or military sexual trauma. Life changes including loss of a loved one or buddy from their unit, retirement, deployment, financial problems, job change, or divorce may also cause stress and could result in depression. Exposure to trauma can alter the body’s response to fear and stress which may lead to depression. It is important to note that not every veteran who is exposed to trauma or experiences life changes will subsequently experience a depressive disorder.

Symptoms of a depression disorder include:

  • Loss of interest or loss of pleasure in all activities
  • Changes in appetite or weight
  • Sleep disturbances
  • Feeling agitated or feeling slowed down
  • Fatigue
  • Feelings of low self-worth, guilt or shortcomings
  • Difficulty concentrating
  • Suicidal thoughts or intentions

Treatment for Depression

Treatment for depression may include counseling, therapy and/or antidepressant medication. The most effective treatment for depression combine psychotherapy with antidepressant medication. 

Psychotherapy for depression may include:

Cognitive Behavioral Therapy (CBT): There is a strong evidence-base that supports the use of Cognitive Behavioral Therapy(CBT) as an effective treatment for depression. CBT helps to assess and change negative thinking patterns associated with depression. The goal of CBT is for the veteran to recognize negative thoughts and to teach coping strategies. CBT is time limited, usually consisting of eight to sixteen sessions.

Interpersonal Therapy (IPT): IPT focuses on improving problems in personal relationships and other life changes that may contribute to depressive disorder. Therapists teach individuals undergoing IPT to evaluate their interactions and to improve how they relate to others. IPT is often time limited like CPT.

Psychodynamic Therapy: Psychodynamic therapy is a therapeutic approach that focuses on recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Another component of this psychotherapy is examining a person’s unconscious processes. 

Antidepressant medications are the treatment of choice for depression.  The aim of medication therapy for depression is to help to reduce or control symptoms of depression. Regardless of the medication that is prescribed, veterans need to be taught that antidepressant medication may take two to four weeks to be effective, and up to twelve weeks to reach maximum effect. 

Medications that are prescribed for depression include:

A) Selective serotonin uptake inhibitors (SSRIs) are the most common medications prescribed for depression:

  • Fluoxetine (Prozac)
  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)

B) Serotonin and norepinephrine reuptake inhibitors (SNRIs):

  • Venlafaxine (Effexor)
  • Desvenlafaxine (Pristiq)
  • Duloxetine (Cymbalta)

C) Norepinephrine-dopamine reuptake inhibitors (NDRIs):

  • Bupropion (Wellbutrin) Therapy
  • Mirtazapine (Remeron)

D) Second generation antipsychotics (SGAs) are classified as atypical antipsychotics that treat schizophrenia, acute mania, bipolar disorders and bipolar mania. SGAs have been used for treatment resistant depression:

·      Aripiprazole (Abilify)

·      Quetiapine (Seroquel)

E) Tricyclic antidepressants, such as Amitriptyline (Elavil) are older medications that are seldom used today as initial treatment for depression. Likewise, MAOIs such as Phenelzine (Nardil) are used less today because they have more side effects than SNRIs. However, MAOIs may be effective for people who do not respond to other medications. 

Brain Stimulation Therapy

Brain stimulation therapies are utilized when other treatments for depression (as specified above) have not been effective. Brain stimulation therapy includes:

Electroconvulsive therapy (ECT): ECT involves transmitting short electrical impulses into the brain. Electroconvulsive therapy can cause some significant side effects, including memory loss. The veteran needs to understand both the potential risks and benefits of ECT before beginning treatment with ECT.

Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of electrical current to activate the brain. It has not been proven effective as maintenance therapy. 

Complementary and Alternative Medicine (CAM)

Complementary and Alternative Medicine (CAM) treatments can be used as an adjunct to other evidence-based treatments for depression in veterans. When complementary and alternative medicine interventions are combined with more evidence-based treatment options, such as prescribed medications and psychotherapy, CAM can contribute to the overall treatment plan for depression in veterans. Complementary treatment which have an evidence-base, indicating that this intervention will contribute positively to the treatment of depression include:

Exercise: exercise increases endorphins and stimulates the secretion of norepinephrine, which can improve a person’s mood

Folate: Studies have shown that when individuals with depression lack folate, or folic acid, they may not be receiving the full therapeutic effect from their prescribed antidepressant medication. Studies have shown that adding a folate supplement, such as L-methyl folate, can enhance the effectiveness of antidepressant medication. 

St John’s Wort: is a supplement with chemical properties similar to selective serotonin uptake inhibitors (SSRIs). Veterans who are taking St Johns Wort for depression need to tell their provider. There are substantial risks associated with combining St Johns Wort with prescribed SSRIs. In addition, while herbal and complementary medicines may show some effectiveness, herbal remedies are not regulated by the Food and Drug Administration.


Veterans and Suicide Risk

The Veterans Administration Suicide Prevention Program (2016) cites the following statistics about veteran suicide:

An average of twenty veterans died from suicide in 2014. Veterans accounted for eighteen percent of all deaths from suicide among adults in the United States in 2014. In 2010, veterans accounted for 22 percent of all deaths from suicide. Approximately sixty six percent of all veteran deaths from suicide were the result of firearm injuries. After adjusting for differences in age, the risk for suicide was eighteen percent higher for male veterans when compared with U. S. adult males. After adjusting for differences in age, the risk for suicide was 2.4 times higher among female veterans, when compared to U. S. adult females.

 The Veterans Administration has identified the following factors that are associated with a veteran’s military service, which may contribute to his or her risk of a suicide attempt. These veteran specific risks include:

  • Frequent deployments
  • Deployments to hostile environments
  • Exposure to extreme stress
  • Physical/sexual assault while in the service (not limited to women)
  • Length of deployments
  • Service related injury

 

According to the Veterans Crisis Line, veterans who are considering suicide often show signs of depression, anxiety or low self-esteem.  The Veteran’s Crisis Line has identified the following warning signs that may indicate a veteran is a suicide risk:

  • Performing poorly at work or school
  • Acting recklessly or engaging in risky activities—seemingly without thinking
  • Showing violent behavior such as punching holes in walls, getting into fights or self-destructive violence; feeling rage or uncontrolled anger or seeking revenge
  • Looking as though one has a “death wish,” tempting fate by taking risks that could lead to death, such as driving fast or running red lights
  • Giving away prized possessions
  • Putting affairs in order, tying up loose ends, and/or making out a will
  • Seeking access to firearms, pills, or other means of harming oneself

 

Suicide Myths and Realities

  • Myth:Asking about suicide will plant the idea in a person’s head.
  • Reality:Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings.
  • Myth:There are talkers and there are doers.
  • Reality:Most people who die by suicide have communicated some intent. Someone who talks about suicide gives the guide and/or clinician an opportunity to intervene before suicidal behaviors occur.
  • Myth:If somebody really wants to die by suicide, there is nothing you can do about it.
  • Reality:Most suicidal ideas are associated with treatable disorders. Helping someone find a safe environment for treatment can save a life. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and overcome the strong intent to die by suicide, you have gone a long way toward promoting a positive outcome.
  • Myth:He/she really wouldn't commit suicide because…
    • he just made plans for a vacation
    • she has young children at home
    • he made a verbal or written promise
    • she knows how dearly her family loves her
  • Reality:The intent to die can override any rational thinking. Someone experiencing suicidal ideation or intent must be taken seriously and referred to a clinical provider who can further evaluate their condition and provide treatment as appropriate.

Source: https://www.mentalhealth.va.gov/suicide_prevention/whentoaskforhelp.asp

Conclusion

The purpose of this course was to provide information and resources on mental health conditions that affect Veterans. PTSD, Depression and Suicide Risk are discussed, along with aspects of a Veteran’s military service that impacts his or her mental health care. The concept of military cultural competence is discussed to enable nurses to have insights into providing holistic care to the Veteran and his or her family.

Resources

This course focuses on Mental Health for Veterans. The websites listed below provide a ready resource for the nurse to access the most current information,  and clinical practice guidelines. When caring for Veterans in the civilian sector, it is also important for the nurse to provide the information on accessing Veteran specific resources for mental health care, A Veteran and his or her family may not be aware of these resources or may not have applied for Veterans Administration benefits that they may be eligible for.

Military Health History Pocket Card for Health Professions Trainees and Clinicians

https://www.va.gov/oaa/archive/Military-Health-History-Card-for-print.pdf

This Veteran’s Administration resource is a pocket military health history card for use by health care professionals in both military and civilian healthcare settings. This resource contains key questions that should be asked when obtaining a health history from a veteran.

 

Military Culture continuing Education Modules

https://deploymentpsych.org/military-culture-course-modules

This free online continuing education course for health care professionals is sponsored by the Center for Deployment Health at Uniformed Services University of the Health Sciences. The three modules enable nurses who may be unfamiliar with the military learn about military culture to be able to better serve and relate to veterans. The course contains four online self-paced modules.

 

Mental Health Clinical Practice Guidelines https://www.healthquality.va.gov/guidelines/MH/

This Veterans Administration website contains the most up to date evidence-based clinical practice guidelines for Veterans Mental Health Care.

 

PTSD Checklist for DSM-5 (PCL-5)

https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

 

Veteran Health Benefits and Services

www.myhealth.va.gov

This website can be accessed by veterans, family members, and caregivers and provides information on veteran’s health benefits and services.

 

Veterans Crisis Line

https://www.veteranscrisisline.net/

The Veterans Crisis Line is a Department of Veterans Affairs (VA) resource that connects Veterans and Servicemembers in crisis and their families and friends with information and qualified, caring VA responders through a confidential, toll-free hotline, online chat, and text messaging service. Veterans and their families and friends can call 1-800-273-8255 and Press 1, chat online at www.VeteransCrisisLine.net, or send a text message to 838255 to receive support from specially trained professionals, 24 hours a day, 7 days a week, 365 days a year. 

 

References

  1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5thEdition), Washington, DC.
  2. Cipriano, P. (2014). A powerful question: have you ever served in the military? American Nurse Today, 9 (3).
  3. Complementary and Alternative Medicine (CAM) for PTSD. (March 30. 2017).
  4. Ganzer, C. (2016). Veteran Women: Mental Health Related Consequences of Military Service. American Journal of Nursing, 116 (11), 32-39.
  5. Kulas, J. and Rosenheck, R. (2018). A comparison of veterans with post-traumatic stress disorder, with mild traumatic brain injury and with both disorders: understanding multimorbidity. Military Medicine, 183 (3.4), e114-e122.
  6. Mental Health Effects of Serving in Afghanistan and Iraq. (August 13, 2015).
  7. Mental Health (April 2, 2018).
  8. Mental Health Clinical Practice Guidelines
  9. Miles, S., Harik, J., Hunt, N., Mignogna, J., Pastorek, N, Thompson, K., et al. (2017). Delivery of mental health to combat veterans with psychiatric diagnoses and TBI histories. PLoS ONE 12 (9), e0814265.
  10. Military OneSource (January 3, 2018), Understanding and dealing with combat stress and PTSD
  11. Military Health History Pocket Card for Health Professions Trainees and Clinicians. (April 2017)
  12. National Alliance on Mental Illness, (August 2017). Depression
  13. National Alliance on Mental Illness, (2018). Veterans and Active Duty: Mental Health Concerns
  14. National Center for PTSD (February 22, 2018), PTSD and DSM-5.
  15. National Center for PTSD (May 11, 2017). PTSD Checklist for DSM-5 (PCL-5). 
  16. National Center for PTSD. (August 18, 2017). Treatment of PTSD. Accessed from https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
  17. Patel, B. (2015). Caregivers of Veterans with “Invisible” Injuries: What We Know and Implications for Social Work Practice. Social Work 60 (1), 9-17.
  18. Rossiter, A., Dumas, M, Wilmoth, and Patrician, P. (2016). “I serve 2”: meeting the needs of military children in civilian practice. Nursing Outlook 64 (6), 485-490. 
  19. Substance Abuse and Mental Health Services Administration. (September 15, 2017). Veterans and Military Families.
  20. Treatment of PTSD. (August 18, 2017). 
  21. U. S. Department of Veterans Affairs. (2016). Suicide Prevention Fact Sheets: New VA Statistics.
  22. U. S. Department of Veterans Affairs. (June 3, 2015).  Suicide Prevention
  23. Uniformed Services University of the Health Sciences Center for Deployment Psychology (2015).  Military Culture Course Modules.
  24. Veterans Crisis Line. (n d).
  25. Westphal, R, and Convoy, S. (2015). Military culture implications for mental health and nursing care.Online Journal of Issues in Nursing, 20(1), 47-54. 


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