Mental Health for Veterans Nursing CE Course

symptoms associated with each condition. These assessments can be an eye-opener for veterans who may not have formally acknowledged their symptoms as a component of an illness. Table 1 outlines several central aspects of mental health screening assessments (Moore et al., 2023; VA, n.d., 2022, 2023). Military service history, deployment exposures, service-related injuries, access to care, and the transition from military to civilian life can shape a veteran’s clinical presentation and treatment needs (Roy & Perkins, 2025).

Table 1

Mental Health History Screening: Questions to Ask

Concern	Questions
Post Traumatic Stress Disorder (PTSD)	Have you been concerned that you might have PTSD? Indications may include reexperiencing symptoms such as nightmares or intrusive thoughts, hyperarousal/being “on guard,” avoiding situations that remind you of the trauma, and/or numbing of emotions.
Major Depressive Disorder (MDD)	Have you been experiencing sadness, feelings of hopelessness/helplessness, a lack of energy, difficulty concentrating, and/or poor sleep?
Suicide	Have you had thoughts of harming yourself or others?
Military Sexual Trauma (MST)	Did you have any unwanted sexual experiences in the military, such as threatening or repeated sexual attention, comments, or touching? Did you have any sexual contact against your will or when unable to say no, such as when forced, asleep, or intoxicated?

 (VA, n.d., 2022, 2023)

 

Military Cultural Competence

The unique needs and challenges veterans and their families face are well cited across the literature. The need for a culturally competent approach to mental health services and treatment continues to be of the utmost importance. HCPs should convey to veterans that they recognize the importance of their military background and have taken the time to acquire a foundational understanding of military culture. The ability to tailor clinical practice based on understanding and appreciation for the veteran’s background is imperative to establish rapport and build effective therapeutic working relationships. Resilience, or the ability to regroup and recover, is crucial to military life, especially during and after deployment. Military ethos is the backbone of military culture and is the foundation of resilience. Conversely, military ethos can be a vulnerability when these beliefs hinder resources, support, and hope. Comprised of six traits, Table 2 illustrates each trait’s impact as a strength or weakness (Collins et al., 2024; Heward et al., 2024; SAMHSA, 2022; Uniformed Services University [USU], n.d.).

Table 2

Military Ethos: Strengths and Weaknesses

Trait	Strength	Weakness
Selflessness	placing the welfare of others above personal welfare	not seeking help for health problems because personal health is not a priority
Loyalty	committing to accomplishing missions and protecting comrades in arms	feeling survivor’s guilt and complicated bereavement after losing friends
Stoicism	displaying toughness and an ability to endure hardships without complaining	not acknowledging significant symptoms and suffering after returning home
Moral Code	following an internal moral compass to choose right over wrong	feeling frustrated and betrayed when others fail to follow a moral code
Social Order	achieving meaning and purpose when defending societal values	losing meaning or feeling betrayed when rejected by society
Excellence	becoming the best and most effective professional possible	feeling ashamed of, or not acknowledging, imperfections

(Heward et al., 2024; USU, n.d.)

 

Combat Stress

Stress is a normal component of everyday life; once the stressor is removed, an individual will typically resume normal behaviors. However, veterans are often impacted by combat stress (also known as battle stress), which is a natural reaction to the mental and emotional strain placed on the mind and body in dangerous and traumatic situations. Combat stress can be challenging to detect since the symptoms can vary, including physical, emotional, and behavioral manifestations. The most common symptoms of combat stress include:

• irritability and angry outbursts, including changes in personality or other behaviors
• excessive worry and anxiety
• withdrawal from others
• headaches and fatigue
• depression and apathy
• loss of appetite
• sleep disturbances (Benedek & West, 2026; Military OneSource, 2024c)

There are several strategies to help veterans cope with combat stress. These include educating veterans on the following:

• caring for their own personal health
• consuming a healthy, well-balanced diet with regular meals
• engaging in daily exercise
• focusing on sleep hygiene and adequate rest, aiming for 7 to 9 hr of sleep per night
• employing relaxation techniques such as deep breathing or meditation
• addressing spirituality and spiritual needs (e.g., prayer, guidance from a chaplain, religious services)
• engaging in leisurely activities
• seeking help and counseling (e.g., individual counseling, group therapy, or support from friends and loved ones; Benedek & West, 2026; Military OneSource, 2024c)

Combat Stress and Stress Disorders

Combat stress is often confused with stress disorders, such as acute stress disorder (ASD) and PTSD; however, there are key distinctions between these conditions. Combat stress typically occurs for brief periods and is considered a natural reaction to the traumatic events endured during a deployment. Furthermore, these symptoms usually resolve after a service member returns home. In contrast, ASD and PTSD are similar psychiatric conditions characterized by neural functioning changes in response to overwhelming stress, trauma, or horror. Both ASD and PTSD may be preempted by either direct or indirect exposure to the trauma, including bearing witness to or hearing about horrific events. In both conditions, symptoms are not due to medication, substance use, or any other identifiable illness and cause significant distress or functional impairment. In many cases, PTSD may be a continuation of ASD. Table 3 clarifies the main differences between these conditions according to the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition, Text Revision (DSM-5-TR; American Psychiatric Association [APA], 2022; Benedek & West, 2026).

 

Table 3

Differences Between ASD and PTSD

ASD	PTSD
does not specify a time limit for symptom onset	may be a continuation of ASD or may manifest up to 6 months after exposure to trauma
symptoms may last from 3 to 30 days	symptoms last for more than 30 days
symptoms may begin immediately after the traumatic event, but symptoms must last at least 3 days for a diagnosis of ASD to be made	refer to Table 4 for the full diagnostic criterion

(APA, 2022; VA, 2023)

 

PTSD

According to the VA, at some point in their lifetime, 7 out of 100 veterans will have PTSD. The lifetime risk of PTSD is higher in females (13%) compared to males (6%). The lifetime prevalence of PTSD among veterans also varies by service era, with those who served in Operations Iraqi Freedom and Enduring Freedom having the highest prevalence, at 29%; followed by the Persian Gulf War (Desert Storm), at 21%; the Vietnam War, at 10%; and World War II and the Korean War, at 3% (VA, 2026b).

PTSD may be categorized as either acute or chronic. Acute PTSD lasts at least 1 month but no longer than 3 months, whereas chronic PTSD lasts longer than 3 months. Less commonly, some cases of PTSD may occur years or even decades after the traumatic event(s). According to the DSM-5-TR, the main symptoms of PTSD include repeated recollections, psychological or physical reactions, and a significant decline in disposition or mental functioning or a change in responsiveness associated with the traumatic event. Table 4 outlines the full criteria required for the diagnosis of PTSD (APA, 2022).

Table 4

DSM-5-TR Diagnostic Criterion for PTSD

The patient may have been a participant, victim, or witness/bystander. Alternatively, in the case of violent acts, the patient may have learned about a loved one’s experience as a victim or participant or had recurrent professional experiences with unsettling or unpleasant details (e.g., law enforcement officers, social workers, first responders). Professional incidents typically occur firsthand and not through images or videos.

The unwanted and unpleasant symptoms begin after the initial traumatizing experience and must include at least one of the following: recollections of the initial traumatizing experience that are repeated, compulsory, and anguishing/unpleasant (in older pediatric patients, this may include play scenarios resembling the experience in some aspect) significant psychological reactions to environmental or inner triggers associated with the initial traumatizing experience significant physical responses to environmental or inner triggers associated with the initial traumatizing experience flashbacks, during which the patient temporarily mentally disconnects from their current environment and reality and has the sensation that the initial traumatizing experience is happening again repetitious nightmares associated with the initial traumatizing experience

The patient consistently prevents exposure to internal or external triggers related to the initial traumatizing experience by performing at least one of the following: not allowing oneself to think, feel, or remember the initial traumatizing experience or things related to the experience preventing exposure to things (e.g., locations, items, persons) that may provoke thinking, feeling, or remembering the initial traumatizing experience

The patient experiences a significant decline in disposition and mental function following the initial traumatizing experience, observed through at least two of the following: a consistent and extreme negative opinion or outlook regarding the world, people, and themselves (e.g., people are not to be trusted, the world is not safe, I am damaged permanently) a consistent predominance of undesirable feelings (e.g., rage, terror, remorse, disgrace) a lack of closeness or connection with those around them a lack of memory regarding a crucial portion of the initial traumatizing experience a faulty thought pattern regarding the reason for or the repercussions of the initial traumatizing experience, leading to a sense of guilt directed at themselves or someone else a significantly decreased desire for or engagement in substantial events a consistent paucity of desirable feelings (e.g., joy, love, contentment)

The patient experiences a significant change in responsiveness following the initial traumatizing experience, observed through at least two of the following: unsafe or self-harming actions extreme edginess or precariously startled poor ability to initiate or maintain adequate sleep cantankerous disposition with frequent gratuitous fits of rage exhibited as loud outbursts or outwardly aggressive behavior behavior that is overly cautious and alert challenges maintaining focus

Symptoms last for at least 30 days

The symptoms are not directly related to the use of a substance, medication, or preexisting medical diagnosis or health concern.

The symptoms cause substantial anguish or drastically affect the patient’s ability to function professionally, socially, or otherwise.

(APA, 2022)

 

Screening for PTSD

Various screening instruments are used to evaluate for PTSD, such as the PTSD Checklist for DSM-5-TR (PCL-5), which is a 20-item tool. Other examples of validated PTSD screening instruments include the following:

• Primary Care PTSD Screen for DSM-5-TR (PC-PTSD-5)
• Short Post-Traumatic Stress Disorder Rating Interview (SPRINT)
• Trauma Screening Questionnaire (TSQ; APA, 2022; Sareen, 2025; VA, 2023)

Regardless of the screening tool used, all positive cases must be followed by a structured clinical interview to confirm the presence of the required criteria, which is the gold standard for diagnosing PTSD (APA, 2022; Sareen, 2025; VA, 2023).

 

Treatment for PTSD

The VA last updated its CPGs for PTSD in 2023. They recommend engaging patients in shared decision-making (SDM), including educating patients about effective treatment options and developing a treatment plan based on individual needs and preferences. The VA (2023) recommends individualized, trauma-focused psychotherapy as a highly recommended treatment for PTSD. Trauma-focused psychotherapy focuses directly on the memory of the traumatic event. Trauma-focused psychotherapy utilizes various techniques, such as visualizing the trauma, analyzing the trauma (i.e., through talk or reflection), and altering unhelpful beliefs about the trauma. Trauma-focused therapies with the most robust evidence include the following (Stein, 2026; Stein & Norman, 2025; Torrico et al., 2024; VA, 2023, 2025b):

• Prolonged exposure includes relaxation skills, recalling details of the traumatic memory, reframing negative thoughts about the trauma, writing a letter about the traumatic event, or holding a farewell ritual to leave the trauma in the past.
• Cognitive processing therapy (CPT) teaches the individual to reframe negative thoughts about the trauma by talking with the HCP about negative thoughts and completing short writing assignments.
• Eye-movement desensitization and reprocessing helps the individual process and make sense of the trauma and involves calling the trauma to mind while paying attention to a back-and-forth movement or sound.

When individual trauma-focused psychotherapy is not readily available, not preferred, or ineffective, the VA (2023) recommends medications to treat PTSD. The following three antidepressant medications are recommended for monotherapy treatment:

• sertraline (Zoloft)
• paroxetine (Paxil)
• venlafaxine (Effexor)

Paroxetine (Paxil) and sertraline (Zoloft) are selective serotonin reuptake inhibitors (SSRIs). SSRIs are usually the safest initial choice for PTSD, as they are associated with the fewest side effects. Venlafaxine (Effexor) is a serotonin-norepinephrine reuptake inhibitor (SNRI). Both SSRIs and SNRIs can increase serotonin levels in the body, posing a risk for serotonin syndrome, which is characterized by agitation, anxiety, confusion, high fever, sweating, tremors, a lack of coordination, dangerous fluctuations in blood pressure, and a rapid heart rate. Serotonin syndrome is a potentially life-threatening condition for which patients must seek immediate medical attention. HCPs should counsel patients on the importance of not abruptly stopping the medication, as withdrawal symptoms may occur with the sudden discontinuation of SSRIs and SNRIs. Withdrawal symptoms are most commonly seen with abrupt discontinuation of paroxetine (Paxil) and venlafaxine (Effexor). All these medications should be started at lower initial doses and titrated as indicated and tolerated. Table 5 outlines the possible side effects of SSRIs and SNRIs. Other antidepressants can be prescribed; however, these are the most effective for patients who have PTSD (Stein, 2026; Torrico et al., 2024; VA, 2023).

Table 5

SSRIs and SNRIs: Side Effects, Warnings, and Monitoring

	SSRIs	SNRIs
Possible Side Effects	Nausea, vomiting, diarrhea, headaches, dry mouth, drowsiness, insomnia, nervousness, agitation, restlessness, sexual dysfunction, appetite change leading to weight loss or weight gain	Nausea, headaches, dizziness, excessive sweating, dry mouth, tiredness, constipation, insomnia, sexual dysfunction, anorexia
Warnings and Monitoring	Serotonin syndrome, suicide risk, and risk of withdrawal symptoms if stopped abruptly
US Food & Drug Administration Boxed Warning	Patients with underlying depression who are treated with SSRIs and SNRIs may experience worsening depression and/or the emergence of suicidal ideation and suicidality. This risk may persist until significant remission occurs. Research has demonstrated that SSRIs and SNRIs increase the risk of suicidality when compared to placebo controls. All patients being treated with antidepressants (for any indication) should be counseled on the risk for increased suicidality and should monitor and report worsening symptoms, suicidality, and unusual changes in behavior, especially during the first few months of treatment.

(National Alliance on Mental Illness [NAMI], 2017; Stein, 2026; Torrico et al., 2024; VA, 2023)

Caution is advised when prescribing venlafaxine XR (Effexor) to patients with hypertension. Patients prescribed venlafaxine XR (Effexor) should have their blood pressure checked at baseline, periodically after starting, and following any dose increase to evaluate for hypertension (Stein, 2026; Torrico et al., 2024; VA, 2023).

TBI and Veterans’ Mental Health

The American Association of Neurological Surgeons (AANS) defines TBI as a disruption in brain function and/or structure due to external physical force. A mechanical force or trauma external to the body leads to the brain’s rotational acceleration within the skull. The brain moves rapidly back and forth inside the skull, prompting a cascade of events, such as chemical changes, neuronal depolarization, metabolic derangements at a cellular level, and decreased blood flow. The stretching, damage, and/or death of brain cells associated with the injury subsequently provoke a clinical syndrome characterized by an immediate and/or transient alteration in brain function. The impact of a TBI on brain function can cause varying symptoms and damage to the brain based on the extent of the injury (AANS, 2024). TBI and PTSD are sometimes called the invisible wounds of war since no obvious physical deformities or injuries are evident. Research has found a co-occurrence between PTSD and TBI, but the relationship between the causality of these two conditions remains unclear (Sohn & Ramezani, 2024). Brenner and colleagues (2023) conducted a longitudinal cohort study of 860,892 active-duty military personnel, examining the prevalence of TBI and mental health disorders. They found that 108,785 of the study participants had at least one documented TBI. Their analysis revealed a significantly increased risk of mental health conditions, particularly mood disorders (67% vs. 37%) and SUD (100% vs. 14%), following a TBI (Brenner et al., 2023). Causes of TBI in veterans may include, but are not limited to, the following:

• blow to the head
• nearby blast or explosion
• sudden, abrupt stops or changes in movement (Mortezaei et al., 2025; VA, 2024b)

Symptoms of TBI can range from mild to severe, and most are acute, resolving with rest. However, the lingering symptoms following the acute phase of TBI can impact functioning and long-term quality of life and contribute to significant disability. Many veterans suffer from the lingering neurologic deficits of TBI, but symptoms are often unpredictable and inconsistent. Table 6 lists some of the acute and long-term symptoms of TBI (Mortezaei et al., 2025; VA, 2024b).

Table 6

Symptoms of TBI

Acute Effects

headaches that worsen or fail to improve

nausea with or without vomiting

dizziness

blurred vision

tinnitus

fatigue, unusual tiredness, or changes in sleep patterns

inability to wake from sleep

unequal pupils

memory and attention changes (e.g., inattention, confusion)

loss of coordination

Long-Term Effects

chronic headaches

changes in mental processing (e.g., cognition, memory, thinking, and reasoning)

changes in mood and behavior (e.g., depression, anxiety, personality changes, aggression, acting out, social difficulties, agitation, irritability, restlessness)

communication impairments (e.g., understanding, expression)

alterations in sensory processing (e.g., hearing, sight, taste, touch)

(Evans, 2025; Ferry & DeCastro, 2023; VA, 2024b)

 

Treatment for TBI

PTSD and mild TBI are highly co-occurring, a combination observed in military personnel returning from combat. Since depression, PTSD, and suicidal thinking are all associated with TBI and its recovery in veterans, the VA (2024b) recommends treatment with combined psychotherapy for PTSD and TBI. A hybrid psychotherapeutic approach combining cognitive training for TBI with CPT for PTSD was efficacious in a clinical trial among military veterans affected by both disorders. The clinical trial randomly assigned 100 veterans with PTSD and mild to moderate TBI to receive CPT or hybrid CPT-compensatory cognitive training. The combined therapy was delivered individually during 12 weekly 60-to-75-min sessions. At the end of treatment and then 3 months later, both groups showed improvements in lingering TBI symptoms, PTSD symptoms, and quality of life. Combined therapy was also associated with improvements in multiple neuropsychological functioning domains (Jak, 2023; Stein & Norman, 2025). Rehabilitation is an essential aspect of TBI treatment in veterans. Most treatment plans are comprehensive and multifactorial, addressing the areas of deficit. Some of the most common treatments include one or more of the following:

• physical therapy
• occupational therapy
• speech and language therapy
• recreational therapy
• psychotherapy
• family and group therapies (VA, 2024b)

The VA’s Polytrauma/TBI System of Care is an integrated network of specialized rehabilitation programs dedicated to serving veterans with TBI and/or more severe secondary injuries. The Defense and Veterans Brain Injury Center, now known as the Traumatic Brain Injury Center of Excellence, is a program that serves veterans and their families who have experienced a TBI by providing medical care, innovative research initiatives, and educational programs (SAMHSA, 2025c; VA, 2024b).

 

Depression

MDD—frequently referred to as depression—is a serious mental health condition that can cause severe impairment in thinking and daily functioning. Depression is among the most common mental disorders in the United States. Symptoms must be present for at least 2 weeks to be diagnosed. Without treatment, depression can have devastating complications. Research suggests that depression is caused by a combination of factors, including genetic, biologic, environmental, and psychological. Depression can occur at any age but is most prevalent in adulthood. Some of the most common risk factors include personal or family history of depression, significant life changes, stress, trauma, and certain medications. In veterans, depression is most commonly triggered by life crises, especially trauma, combat injury, natural disasters, or MST. However, life changes—including the loss of a loved one or fellow soldier, retirement, deployment, financial problems, job change, or divorce—are also linked to veterans’ stress and depression. Exposure to trauma can alter the body’s response to fear and stress, leading to depression. While not every veteran exposed to trauma or life changes will subsequently develop depression, this condition is nearly 3 to 5 times more likely in those with PTSD than those without PTSD (Moore et al., 2023; National Institute of Mental Health [NIMH], 2024; VA, 2025b). Symptoms of a depressive disorder include:

lack of interest or enjoyment in activities

• poor or depressed mood
• insomnia or hypersomnia
• psychomotor excitement or delay
• fatigue
• feelings of worthlessness or excessive guilt
• decreased concentration
• feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic
• weight loss or gain
• thoughts of death or suicide (APA, 2022; Moore et al., 2023; NIMH, 2024; VA, 2025b)

Screening for Depression

The VA recommends initially screening veterans for depression using the Patient Health Questionnaire-2 (PHQ-2). The PHQ-2 asks the following priority questions:

• Over the past 2 weeks, how often have you been bothered by any of the following problems?
• little interest or pleasure in doing things
• feeling down, depressed, or hopeless (APA, 2022; VA, 2022)

Patients with suspected depression should undergo additional screening with the PHQ-9 tool, which is a multipurpose, 9-item symptom checklist used to screen for, diagnose, monitor, and measure the severity of depression. It incorporates DSM-5-TR diagnostic criteria for depression and a question that screens for the presence and duration of suicidal ideation. The tool is brief and easily used in clinical practice. It is completed by the patient, rapidly scored by the HCP, and can be used repeatedly to assess for improving or worsening symptoms. In addition to the PHQ-9, HCPs must evaluate the acute safety risks (e.g., harm to self or others, psychotic features) and administer an appropriate assessment of the patient’s functional status, medical history, past treatment, and family history. Table 7 reviews the DSM-5-TR diagnostic criteria for depression (Moore et al., 2023; Roy & Perkins, 2025; VA, 2022).

 

Table 7

DSM-5-TR Diagnostic Criteria for a Major Depressive Episode 

Criterion A (at least five signs are required over a period of at least 14 days)	The presence of either (a) lack of interest/enjoyment or (b) depressed mood, in addition to the following: significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed poor or sad mood for the majority of the day, most days; may include self-reports of unhappiness, unfulfillment, or despondency or tearfulness observed by others psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms reduced mental clarity, focus, or decision-making almost every day feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month the inability to sleep at night or stay awake during the day, despite getting an adequate amount of sleep the night before most days feeling lethargic, weary, or exhausted most days a preoccupation with death, consistent suicidal ideations with or without a specific plan, or an attempted suicide
Criterion B (required)	Symptoms create substantial anguish or dysfunction in essential settings, such as work, school, or around friends/family.
Criterion C (required)	The symptoms are unrelated to the effects of a physical illness or substance use.
Criterion D	Another mental health disorder cannot better explain the symptoms.
Criterion E	There is no history of a period of manic or hypomanic symptoms (unrelated to substance use or another physical illness).

 (APA, 2022)

 

Treatment for Depression

An individualized treatment plan should be developed using SDM and will vary based on the patient’s severity level (mild, moderate, or severe), as outlined in Table 8. Treatment for depression may include counseling, therapy, and/or antidepressant medication. The most effective treatment for depression is a combination of psychotherapy with antidepressant medication (VA, 2022).

Table 8

Severity Level of Depression

Severity	PHQ-9 Total Score
Mild	10 to 14
Moderate	15 to 19
Severe	20 or above

(APA, 2022; VA, 2022)

Evidence-Based Psychotherapy for Depression

Acceptance and Commitment Therapy (ACT). ACT is an action-oriented intervention in which individuals learn to stop avoiding, denying, and struggling with their inner emotions. Instead, they learn to accept these deeper feelings as appropriate responses to specific situations. ACT emphasizes acceptance of emotional distress and engagement in goal-directed behaviors to reduce symptom severity. To facilitate effective behavior change, ACT emphasizes identifying personal values and learning to help individuals commit to making necessary changes in their behavior (Anusuya & Gayatridevi, 2025; Rush, 2026; VA, 2022).

Cognitive Behavioral Therapy (CBT). This combination of cognitive and behavioral therapies is evidence-based and very commonly used. Strong clinical evidence supports the use of CBT as an effective treatment for depression, anxiety (including panic disorder), PTSD, eating disorders, SUD, and obsessive-compulsive disorder. Cognitive therapy focuses on identifying and then improving maladaptive beliefs. Behavioral therapy teaches patients to increase rewarding activities. Patients learn to track their activities and identify the affective and behavioral consequences. Patients then learn techniques to schedule activities to improve their mood. CBT helps patients assess and restructure negative thinking patterns. CBT’s goal is for the patient to recognize negative thoughts and learn positive and effective coping strategies. CBT is time-limited and typically consists of 8 to 16 sessions. Patients learn to track their thoughts and activities to identify the affective and behavioral consequences. They subsequently learn techniques to change their thinking and activities to improve their mood. CBT has demonstrated efficacy in veterans, active service members, and family members suffering from depression. CBT can also be administered via computer-based programs, which is referred to as computer-based CBT (Lebow, 2025; Rush, 2026; VA, 2022).

Interpersonal Therapy (IPT). IPT focuses on improving personal relationships as a core component of solving psychological problems such as depression and eating disorders. While an event or a relationship may not always cause depression, depression affects relationships and can create interpersonal problems. IPT is a short-term treatment that teaches patients to evaluate their interactions to understand and improve how they relate to others. IPT is derived from attachment theory and treats depression by focusing on improving interpersonal functioning and exploring relationship-based difficulties. IPT targets four primary areas: interpersonal loss (grief), role conflict (interpersonal disputes), role change/transitions, and interpersonal skills (Lebow, 2025; Rush, 2026; VA, 2022).

Mindfulness-Based Cognitive Therapy (MBCT). MBCT integrates traditional CBT interventions with mindfulness-based skills to help individuals attend to the present moment in a nonjudgmental, accepting manner. Unlike CBT, MBCT does not modify or eliminate dysfunctional thoughts but instead focuses on assisting individuals to become more detached and observe their thoughts objectively without necessarily attempting to change them. MBCT employs meditation, imagery, experiential exercises, and relaxation techniques (Lebow, 2025; Rush, 2026; VA, 2022).

Problem-Solving Therapy (PST). PST is a structured psychological intervention that helps individuals focus on developing specific coping skills for problem areas. Through a collaborative relationship with the therapist, individuals learn to identify and prioritize key problem areas and break them into manageable tasks to develop appropriate coping behaviors and solutions (Lebow, 2025; Rush, 2026; VA, 2022).

Psychodynamic Psychotherapy. This form of therapy strives to enhance individual insight. It is based on the theory that an individual’s current concerns are largely influenced by their childhood experiences, previous relationships, and past conflicts, especially if unresolved. This form of therapy attempts to improve function by shedding light on unconscious patterns or behaviors that began in childhood. It may be used in the treatment of depression, eating disorders, and personality disorders (Lebow, 2025; Rush, 2026; VA, 2022).

Pharmacotherapy

Antidepressant medications are the pharmacologic treatment of choice for depression to reduce or control symptoms. HCPs should counsel individuals that antidepressants typically take 2 to 4 weeks to yield an effect and 12 weeks to achieve the maximum benefit. For individuals who demonstrate only a partial or no response to initial monotherapy after a minimum of 4 to 6 weeks of treatment, the VA recommends switching to another monotherapy (medication or psychotherapy) or augmenting therapy by adding a second agent. After the initiation of therapy or a change in treatment, individuals should be monitored at least monthly until remission is achieved. For those who achieve remission on antidepressants, the medication should be continued at the therapeutic dose for at least 6 months to reduce the risk of relapse (Moore et al., 2023; Rush, 2026; VA, 2022). The VA (2022) recommends the following medications with strong evidence:

• SSRIs (e.g., citalopram [Celexa], escitalopram [Lexapro], fluoxetine [Prozac], paroxetine [Paxil], and sertraline [Zoloft]; refer to Table 5 for side effects and monitoring) 
• SNRIs (e.g., duloxetine [Cymbalta], venlafaxine [Effexor], levomilnacipran [Fetzima], and desvenlafaxine [Pristiq]; refer to Table 5 for side effects and monitoring)
• Mirtazapine (Remeron)
• common side effects include sedation, increased appetite, weight gain, dizziness, and elevated cholesterol levels
• rare and serious side effects include angle-closure glaucoma (eye pain, changes in vision, swelling or redness in or around the eye), agranulocytosis (low white blood cells), serotonin syndrome, and a boxed warning for increased suicidality (Moore et al., 2023; NAMI, 2017; Rush, 2026; VA, 2022)

The VA (2022) recommends tailoring the individual’s treatment for uncomplicated mild to moderate depression based on the following factors:

• patient preference
• safety and side effect profile
• history of prior response to a specific medication
• presence of concurrent medical illnesses
• concurrently prescribed medications
• cost of medications
• provider competence

The current evidence does not support recommending one specific evidence-based psychotherapy or pharmacotherapy over another (VA, 2022).

Grief and Bereavement

According to Mental Health America (n.d.), grief consists of the physical, psychological, emotional, and behavioral expression of loss or the perceived threat of loss. They define mourning as a natural process someone goes through to accept a major loss. Bereavement means to be deprived by death (Mental Health America, n.d.). While these terms are often used interchangeably, bereavement is often the trigger that starts the grieving process. In veterans, many other situations and circumstances incite the grieving process. For veterans, grief may develop from the loss of:

• a military comrade who died in battle
• a sense of closeness with fellow service members
• identity as a member of the armed forces
• physical health and ability (e.g., disability acquired during service, such as amputation of a limb)
• mental health, such as PTSD, loss of sense of safety and control, or lingering effects of a TBI (VA, 2025c, 2025d)

Veterans may also experience survivor's guilt, which is a sense of remorse for having survived when others did not. Loss is an incredibly stressful and painful event, and the expression of grief is personal. Grief is a process, and it is common for feelings to waver through periods of exacerbation and relief with varying timelines in the aftershock of loss. Grief reactions can impair physical, behavioral, emotional, and spiritual well-being and are impacted by cultural backgrounds and beliefs. While there is no specific or “normal” way to grieve, there are several common grief reactions that often induce physiologic, emotional, mental, and social symptomatology, as listed in Table 9. Thoughts and images of the deceased are common in grief reactions, which may be accompanied by auditory, visual, or tactile illusions (VA, 2025c, 2025d).

Table 9

Common Grief Reactions

Physiologic	Sleep disturbances Increased stress hormones Suppression of the immune system and health decline
Emotional	Strong feelings of sadness, loneliness, fear, anxiety, resentment, and anger Sense of guilt upon reengaging in normal activities due to the betrayal of a fallen loved one or comrade
Mental	Denial or trouble accepting the loss Impaired concentration or decision-making Fear of forgetting the deceased
Social	Loneliness, social withdrawal, self-consciousness, impaired relationships

(VA, 2025c, 2025d)

Complicated grief causes prolonged sadness, guilt, or anger. These emotions often lead to behavior changes, such as:

• withdrawal from all interactions with friends and family members (social isolation)
• lashing out at others
• obsessively ruminating on past events (VA, 2025c)

Distinguishing Grief from Depression

According to the DSM-5-TR, feelings of emptiness and loss are predominant in grief, and symptoms often decrease in intensity over days to weeks. In contrast, depression is characterized by a persistently depressed mood and the inability to anticipate happiness or pleasure. Self-esteem is typically preserved in grief, whereas in depression, feelings of worthlessness and self-loathing are common. If a bereaved individual thinks about death and dying, their thoughts are usually focused on the deceased and possibly “joining” the deceased. In depression, these thoughts are focused on ending one’s own life due to intolerable feelings of being worthless, not deserving to live, or being unable to cope with the pain of depression (APA, 2022).

Managing Grief

The VA recommends the following self-care strategies for grieving veterans:

• allow time to grieve
• talk to others about the grieving experience and seek support from family, friends, and comrades
• stay active and busy
• exercise regularly
• engage in purposeful work that is consistent with personal values
• consume a healthy diet
• postpone making any major life decisions (e.g., moving or changing jobs)
• consider journaling to record thoughts and feelings
• focus on spiritual or religious beliefs or seek guidance from a chaplain or pastor
• consider seeking professional help from a counselor or therapist (VA, 2025c, 2025d)

 

Suicide and Suicide Prevention

Suicide is a complex, multifactorial phenomenon involving various risk factors and warning signs. Suicide is defined by the Centers for Disease Control and Prevention (CDC) as death caused by self-directed injurious behavior with the intent to die as a result of the behavior. Suicidal behavior encompasses suicide attempts (a nonfatal, self-directed, potentially injurious act intended to result in death that may or may not result in injury) and suicide ideation (thinking about, considering, or planning suicide; CDC, 2026a). Suicide has devastating psychological impacts on family, friends, and loved ones, and it can provoke a consequential ripple effect on others and the community. According to statistics from the National Veteran Suicide Prevention Annual Report, the number of veteran suicides was 6,398 in 2023. Between 2001 and 2023, the suicide rate among veterans has steadily risen from 23.2 (per 100,000 individuals) in 2001 to 35.2 (per 100,000 individuals) in 2023. This rate is significantly higher than the rate of suicide among nonveterans in 2023 (16.9 per 100,000 individuals). Firearms were the method of suicide in 74.5% of male veteran suicide deaths and 49.0% of female veteran suicide deaths in 2023. Overall, a firearm was the method involved in 73.3% of veteran suicides versus only 52.9% of nonveteran suicides (VA, 2025a).

Suicide Myths and Realities

The NAMI highlights various myths and realities related to suicide (Fuller, 2020):

Myth: Asking/talking about suicide will plant the idea in a person’s head.

Reality: Asking about suicide does not create suicidal thoughts. Asking the question allows the individual to talk about their thoughts or feelings and reduces the stigma around suicide.

Myth: Most suicides are impulsive and occur without warning.

Reality: Most people who die by suicide have previously communicated some intent and/or exhibited warning signs.

Myth: If somebody is suicidal, there is nothing anyone can do about it.

Reality: Most suicidal ideations are short-term and situation-specific. Helping someone find a safe environment for treatment can save a life. The acute risk for suicide is often time limited. If someone helps the person survive the immediate crisis and overcome the strong intent to die by suicide, a positive outcome is possible. If an underlying mental health condition is diagnosed, treatment can be sought to reduce/ameliorate symptoms.

Myth: Suicide impacts only patients with mental health conditions.

Reality: Mental health conditions do not always include suicidal thoughts/intent, and individuals who attempt suicide do not always have a history of a mental health condition (54% do not have a diagnosable disorder).

Myth: People who attempt suicide are selfish and take the easy way out.

Reality: Most people who attempt suicide are doing so to reduce their pain and suffering, which has led to feelings of hopelessness and helplessness.

 

Warning Signs and Screening

Although statistical data demonstrate that most people who die by suicide received some form of health care services within the year preceding their death, suicidal ideation is rarely detected. HCPs must develop a keen awareness and understanding of the risk and protective factors associated with suicide to identify individuals at risk for suicide across clinical settings. HCPs must also acquire the skills to evaluate whether an individual is in distress, depressed, in crisis, or at heightened risk, prompting timely intervention. While suicide does not have a single cause, the risk for suicide generally increases as the number of contributing risk factors rises. The more warning signs present, the greater the risk of suicide becomes, intensifying the need for timely assessment and intervention (American Foundation for Suicide Prevention [AFSP], n.d.; CDC, 2026b; Schreiber & Culpepper, 2026).

A prior suicide attempt is the most predictive risk factor for suicide. The following additional warning signs are correlated with the highest likelihood of the short-term onset of suicidal behaviors:

• threatening, talking, or thinking about hurting or killing oneself
• searching for ways to kill oneself, including seeking access to drugs or other lethal means (e.g., stockpiling or obtaining weapons, strong prescription medications, or items associated with self-harm)
• talking, writing, or posting on social media about death, dying, and suicide
• self-destructive behavior such as substance use (AFSP, n.d.; CDC, 2026b; Schreiber & Culpepper, 2026; Veterans Crisis Line, n.d.-b)

Veterans who are considering suicide may exhibit signs of depression, anxiety, or low self-esteem. The Veterans Crisis Line (n.d.-b) and the VA (2024a) CPG for suicide have identified the following warning signs that may indicate a veteran is at increased risk of suicide:

• performing poorly at work or school
• acting recklessly or engaging in risky activities that could lead to death (e.g., driving at fast speeds or running red lights)
• showing unusual rage, anger, frustration, or violent behavior (e.g., punching holes in walls or getting into fights)
• giving away prized possessions, putting affairs in order, or tying up loose ends
• anxiety, agitation, sleeplessness, or mood swings
• hopelessness, expressing/feeling that there is no way out or reason to live
• increasing alcohol or substance use
• withdrawing from family and friends (Veterans Crisis Line, n.d.-b; VA, 2024a)

These higher-level warning signs are medical emergencies, as they warrant immediate attention, evaluation, referral, and hospitalization. Any individual who is displaying these warning signs is considered to be at high risk for suicide and requires immediate intervention to ensure safety. These individuals should be immediately referred for admission to an inpatient facility, as specialty care is urgently needed. If a placement is impossible, refer individuals to their local emergency department. Suicide precautions and one-on-one monitoring should be employed until the imminent risk declines (VA, 2024a).

 

Suicide Risk Assessment

A suicide risk assessment is a process in which clinical information is gathered to determine an individual’s risk for suicide. The risk for suicide is multifactorial, premised on the individual’s suicidal behaviors, warning signs, risk factors, and protective factors. A risk assessment identifies behavioral and psychological characteristics associated with an increased risk for suicide, allowing HCPs to implement effective, evidence-based treatments and interventions to reduce this risk. The risk assessment for suicide is an ongoing process, as suicidal behaviors can fluctuate quickly and unpredictably (AFSP, n.d.; Schreiber & Culpepper, 2026; VA, 2024a). A complete risk assessment must include the following vital aspects:

information about past, recent, and present suicidal ideation and behavior

details of the patient’s context and history

synthesis of this information into a prevention-oriented suicide risk formulation anchored in the patient’s life context (AFSP, n.d.; Schreiber & Culpepper, 2026; VA, 2024a)

According to the VA (n.d., 2024a), an assessment of risk factors as part of a comprehensive evaluation of suicide risk should include the following components:

• current suicidal ideation
• prior suicide attempt(s)
• current psychiatric conditions (e.g., mood disorders, SUDs) or symptoms of any preexisting psychiatric condition (e.g., hopelessness, insomnia, and agitation)
• prior psychiatric hospitalization
• recent biopsychosocial stressors
• availability of firearms

The VA (n.d., 2024a) has identified the following factors associated with a veteran’s military service, which may contribute to their risk of a suicide attempt. These veteran-specific risks include the following:

• frequent deployments
• deployments to hostile environments
• exposure to extreme stress
• physical/sexual assault while serving
• length of deployments
• service-related injury

A complete suicide risk assessment must also include a validated, evidence-based screening tool, which encompasses a set of directed questions to assess the risk level. A critical aspect of suicide prevention involves tailoring interventions to the perceived suicide risk level. HCPs must understand how to perform a proper risk assessment, ascertain the patient’s risk level, and respond according to evidence-based guidelines. Several tools are available for use across various clinical settings, and the most common are outlined below (National Action Alliance for Suicide Prevention, 2018; Schreiber & Culpepper, 2026).

Suicide Severity Rating Scale (C-SSRS)

C-SSRS is one of the most widely used, validated, and evidence-based instruments in suicide risk assessment. The C-SSRS is supported by extensive evidence and existing literature that reinforces the tool’s validity as a screening method for longitudinally predicting future suicidal behaviors. This tool provides a framework to assess suicide risk, determine the risk level, and guide appropriate action according to that risk level. Also, the C-SSRS measures nonsuicidal self-injury, which is a deliberate self-harm behavior performed without the intent to die (Columbia Lighthouse Project, n.d.-a; Schreiber & Culpepper, 2026).

Suicide Assessment 5-Step Evaluation and Triage (SAFE-T)

SAFE-T is a tool that incorporates the DSM-5-TR guidelines for suicide assessment and is used most commonly by HCPs in emergency departments. The SAFE-T helps identify risk and protective factors; inquire about suicidal thoughts, behavior, and intent; and determine the patient’s risk level. It provides appropriate interventions directly at the bottom of the tool to enhance safety. According to the SAFE-T screening tool, assessing the risk of suicide involves three levels: low, moderate, and high. Table 10 provides an overview of suicide risk stratification, defining features, and accompanying evidence-based interventions (Columbia Lighthouse Project, n.d.-b; SAMHSA, 2024b).

 

Table 10

Level of Suicide Risk, Defining Features, and Associated Interventions

Risk Level	Features	Interventions
Low	modifiable risk factors, strong protective factors no plan, intent, or suicidal behavior	prepare outpatient referral (warm handoff to behavioral health provider [i.e., direct communication] with the receiving provider) consider safety planning with patients and family members give personal and direct referrals to outpatient behavioral health/other providers for follow-up, provide emergency/crisis contacts and phone lines
Moderate	multiple risk factors and only a few protective factors suicidal ideation with a plan but no intent or behavior	consider inpatient admission to a hospital or mental health facility, depending on risk assessment develop a crisis plan and involve the patient and family members in safety planning make personal and direct referrals to outpatient behavioral health/other providers for follow-up (do not leave the patient to make the appointment) provide emergency/crisis contacts and phone lines
High	individuals with psychiatric disorders displaying severe symptoms or who have endured acute precipitating events protective factors are unapparent or insignificant (i.e., do not offset risk) those who may have endured a potentially lethal suicide attempt or who embrace persistent suicidal ideation with strong intent or prior suicide rehearsal	arrange immediate inpatient admission to a hospital or mental health facility for close monitoring with strict suicide precautions

 (Columbia Lighthouse Project, n.d.-b; Minnesota Department of Health, 2019; SAMHSA, 2024b)

 

Protective Factors

Protective factors are associated with a lower risk of suicide and have been shown to safeguard individuals from suicidal thoughts and behaviors. Some of the most well-established suicide protective factors include the following:

• presence of adequate social support and family connections (connectedness)
• effective clinical care for mental, physical, and SUDs, along with access to a variety of clinical interventions and support for help-seeking
• supportive and effective clinical care from medical and mental health professionals
• skills in coping, problem-solving, conflict resolution, and other nonviolent ways of handling disputes
• cultural and religious beliefs that discourage suicide and support instincts for self-preservation (e.g., intentional participation in religious activities; CDC, 2026b; Schreiber & Culpepper, 2026)

 

Suicide Prevention

For suicide-related issues, prevention offers the most positive impact on veterans and their family members. The VA has focused on the early identification of those experiencing difficulties as the key to suicide prevention. All veterans at any risk level should be provided with information on the Veterans Crisis Line (dial 988 and press 1 for veterans), as well as local crisis and peer support contacts. The acronym SAVE may help fellow citizens prevent veteran suicide, which stands for:

S—signs of suicidal thinking should be recognized

A—ask the most important question of all: Are you thinking of killing yourself?

V—validate the veteran’s experience

E—encourage treatment and expedite getting help (VA, 2025e, 2026d; Veterans Crisis Line, n.d.-a)

The VA (2024a, 2025e, 2026d) recommends using CBT interventions focused on suicide prevention for veterans with a recent history of self-directed violence to reduce incidents of future self-directed violence. Evidence-based clinical approaches that help reduce suicidal thoughts and behaviors include the following:

• CBT for Suicide Prevention
• The Collaborative Assessment and Management of Suicide
• Dialectical Behavior Therapy
• Connectedness with caring contacts (social/familial support systems) for postdischarge suicide prevention (NIMH, 2026; VA, 2024a, 2025e, 2026d)

For patients in a suicidal crisis, HCPs should take immediate action and implement a safety plan through the following steps:

• keep patients in a safe health care environment under one-on-one observation
• do not leave patients who are suicidal alone
• arrange immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis clinic
• screen patients who are suicidal and their visitors for items that could be used to attempt suicide or harm others
• ensure patients who are suicidal are kept away from anchor points for hanging and material that can be used for self-injury
• examples of lethal means that are readily available in hospitals and clinics that have been used in suicides include bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing (The Joint Commission, n.d.; NIMH, 2026)

 

Safety Planning

Safety planning is critical and should be conducted by collaboratively identifying possible coping strategies and providing resources to reduce risk. A safety plan is not a “no-suicide contract,” which is not recommended by experts in suicide prevention. Safety planning is an intervention for lowering an individual’s imminent suicide risk following a risk assessment. A trained HCP should perform safety planning in collaboration with the patient. Components of a safety plan include the following:

• identifying warning signs
• utilization of coping strategies
• ability to socialize with others as a means of distracting from suicidal thoughts
• connection to and contact with family or friends to seek help during a suicidal crisis
• contact information for mental health professionals or resources for assistance
• restricting access to means for completing suicide (NIMH, 2026; VA, 2024a, 2025a, 2026d)

Table 11 outlines the 6-step process of safety planning using a brief intervention tool.

 

Table 11

Brief Safety Planning Intervention

Step	Questions to Ask	Strategies
Step 1: Warning signs	How will you know when the safety plan should be used?	Using the patient’s words, list thoughts, images, mood, situation, or behavior that indicate a crisis may be developing.
Step 2: Internal coping strategies	What can you do if you become suicidal again to help yourself not act on your thoughts?	List things the patient can do to take their mind off problems without contacting another person (relaxation techniques, physical activity).
Step 3 should be used if Step 2 does not resolve the crisis or lower the risk.
Step 3: Social contacts (distraction)	Who or what social settings help take your mind off these problems?	List social settings and people that provide a distraction, including safe places to go and people to call.
Step 4 should be used if Step 3 does not resolve the crisis or lower the risk.
Step 4: Family members or friends who can offer help	Among family and friends, who do you think you can contact in a crisis?	List several people (in priority order) to call in the event of a crisis.
Step 5 should be used if Step 4 does not resolve the crisis or lower the risk.
Step 5: Professionals and agencies to contact	Who are your mental health professionals we should identify as being on your safety plan?	List professionals or agencies to contact during a crisis, including full names and telephone numbers (clinic number, cell phone, pager). Include local urgent care services and the Suicide and Crisis Lifeline Phone: 988
Step 6 should be used if Step 5 does not resolve the crisis or lower the risk.
Step 6: Making the environment safe	“Do you own a firearm, such as a gun or rifle?” and “What other means do you have access to and may use to attempt to kill yourself?” “How can we develop a plan to limit your access to these means?”	Determine which means the patient would consider using during a suicidal crisis and determine their access to those means.

(NIMH, 2026; VA, 2024a, 2025a, 2026d)

HCPs should review and reiterate the patient’s safety plan at every interaction until the patient is no longer at risk for suicide. A safety plan should always include a discussion on how to restrict access to lethal means. When assessing a patient’s access to firearms or other lethal means, HCPs should inquire about prescription medications and chemicals. Next, they should discuss ways of removing or locking up firearms, other weapons, and medicines during crisis periods (NIMH, 2026; VA, 2024a, 2025a, 2026d).

Resources for Veterans and Families

When caring for veterans, HCPs must be equipped to offer realistic, practical, and useful information regarding mental health care. Veterans and their family members may be unaware of the available resources and treatment options. In addition to those listed below, HCPs should maintain familiarity with local resources and treatment facilities for referring patients as needed.

 

Veteran Health Benefits and Services

https://www.va.gov/health-care/manage-health

This website can be accessed by veterans, family members, and caregivers, providing information on veteran health benefits and services (VA, 2026c).

Veterans Crisis Line

https://www.veteranscrisisline.net

The Veterans Crisis Line is a VA resource that connects veterans and service members 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 can call 988 (Press 1), chat online at www.VeteransCrisisLine.net, or send a text message to 838255 to receive support from specially trained professionals 24 hr a day, 7 days a week, 365 days a year (Veterans Crisis Line, n.d.-a).

 

VA Mental Health Services

https://www.va.gov/health-care/health-needs-conditions/mental-health

According to the VA, veterans are entitled to free mental health care for at least a year after separation, regardless of their discharge status, service history, or eligibility for VA health care.

This resource offers training via online self-help portals geared toward overcoming everyday challenges (e.g., anger management, parenting, and problem-solving skills), smartphone apps, telehealth services, or assistance with referrals to nearby VA health facilities (VA, 2025f).

Military OneSource

https://www.militaryonesource.mil

Military OneSource provides a list of confidential resources and support for veterans and their family members based on areas of need, including sexual assault, PTSD, TBI, intimate partner violence, child maltreatment, and beyond (Military OneSource, n.d.).

Suicide and Crisis Lifeline

https://988lifeline.org

Previously known as the National Suicide Prevention Lifeline, the Suicide and Crisis Lifeline is available 24/7 by simply dialing 988 for free and confidential support for those in crisis (Suicide and Crisis Lifeline, n.d.).

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US Department of Veterans Affairs. (2026d). Suicide prevention: Overview. https://www.mentalhealth.va.gov/suicide_prevention/index.asp

USAFacts. (2026). Where are US troops stationed? https://usafacts.org/articles/where-are-us-military-members-stationed-and-why

Veterans Crisis Line. (n.d.-a). 24/7, confidential crisis support for veterans and their loved ones. Retrieved September 16, 2026, from https://www.veteranscrisisline.net

Veterans Crisis Line. (n.d.-b). How you can help. Retrieved September 15, 2026, from https://www.veteranscrisisline.net/how-you-can-help

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