Response – Mental and Physical Health Challenges Among Veterans

Response – Mental and Physical Health Challenges Among Veterans

Responding to Alexa

Hello,

Thank you for the informative posting on the health risks that affect veterans in terms of chronic diseases, including diabetes, obesity, mental illness, and cardiovascular diseases. For instance, the female veteran at 28 years has revealed the many problems that veterans endure in their post-service lives, such as housing insecurity and joblessness, which have a detrimental impact on their health. The differential diagnoses provided—major depressive disorder (MDD), hypothyroidism, and obstructive sleep apnea—are all correlated with fatigue, weight gain, and increased sleep.

Notably, it is imperative to acknowledge that veterans are considered a high-risk population regarding mental health concerns. In addition, veterans have higher rates of depression compared to non-veterans, possibly due to trauma and transition in life post-service, as highlighted by Inoue et al. (2023). Using the Patient Health Questionnaire (PHQ-9) for MDD assessment is particularly significant since it assesses the intensity of the depression episode (Sun et al., 2020). Nonetheless, given the patient’s background of homelessness and the challenging life circumstances that they might be experiencing at the moment, it would also be warranted to screen for PTSD, which, in veterans especially, often manifests with symptoms of depression, fatigue, and sleep disturbances.

Aside from the pharmacological intervention, referring the patient to community-based programs, which have a touch on employment and housing, can help improve not only her mental but her physical health as well (Castillo, 2020). Cognitive behavioral therapy should be incorporated, but veteran support groups could also be an important component of the care plan. Veterans like to stick in groups, and this can also help enhance the mental health of the patient while dealing with issues of social exclusion.

References

Castillo, E. G. (2020). Community interventions to promote mental health and social equity. Current Psychiatry Reports, 21(5), 1–14. https://doi.org/10.1007/s11920-019-1017-0

Inoue, C., Shawler, E., Jordan, C. H., Moore, M. J., & Jackson, C. A. (2023). Veteran and military mental health issues. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK572092/#:~:text=Factors%20such%20as%20separation%20from

Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry, 20(1), 474. https://doi.org/10.1186/s12888-020-02885-6

Responding to Aldo

Hello,

Thank you for this enlightening posting regarding the 28-year-old female veteran who presents with complaints of fatigue and weight gain and has a past medical history of depression. Your list of differential diagnoses is well thought out and reflected upon; indeed, the symptoms that were presented did point toward MDD, hypothyroidism, and obstructive sleep apnea. Also, your inclusion of PTSD and adjustment disorder is a critical reminder that the mental health struggles of veterans pertinent to their service often cannot be seen.

Expanding on your differential diagnosis process, the CMP and thyroid function tests and free T4 results are useful in ruling out metabolic disorders; however, considering the patient’s status of homelessness and unemployment, a psychosocial assessment will be helpful, according to Swarup et al. (2021). Social determinants of health, such as housing instability, often complicate hypothyroidism or sleep apnea and must be addressed in tandem with the patient’s medical conditions. Also useful for veterans is the use of certain resources, such as the El Paso VA Health Care System and the Healthcare for Homeless Veterans (HCHV) program. These services could not only help her with her housing problems but also give her the necessary resources to manage her MDD or PTSD.

Another approach would be to explore how various alternative practices, such as physical exercises or mindfulness-based interventions, interact with conventional pharmacologic and psychotherapeutic treatments. Such alternative non-pharmacological practices, Goldberg et al. (2021) explain, can serve as an important reinforcement to conventional pharmacologic and psychotherapeutic interventions. Various studies have been conducted showing that a combination of regular physical activities with mindfulness practices greatly reduces depressive symptoms, thereby improving the overall indices of their lives, as recently demonstrated by Creswell et al. (2019).

References

Creswell, J. D., Lindsay, E. K., Villalba, D. K., & Chin, B. (2019). Mindfulness training and physical health. Psychosomatic Medicine, 81(3), 224–232. https://doi.org/10.1097/psy.0000000000000675

Goldberg, S. B., Pace, B., Griskaitis, M., Willutzki, R., Skoetz, N., Thoenes, S., Zgierska, A. E., & Rösner, S. (2021). Mindfulness-based interventions for substance use disorders. Cochrane Database of Systematic Reviews, 2021(10). https://doi.org/10.1002/14651858.cd011723.pub2

Swarup, S., Goyal, A., Grigorova, Y., & Zeltser, R. (2021). Metabolic syndrome. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29083742/

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PEER RESPONSE 1:

 BY: Alexa Mae Carey

​       As the United States recovers from several decades of warfare, several studies have raised significant concerns aboutthe health status of veterans and service members. Research has shown that US veterans have the worst health outcomes, with a disproportionate number being affected by chronic diseases such as diabetes, obesity, mental conditions, cancer, and heart disease (Betancourt et al., 2023). Even after age adjustment, veterans experience chronic conditions more than non-veterans, with mental health being more prevalent. This is the case of a 28-year-old female veteran who comes to the clinic complaining offatigue, increased sleeping, and weight gain. The veteran is unemployed and homeless and has a history of recurring depression.

Response – Mental and Physical Health Challenges Among Veterans

From the patient’s history, the three most likely differential diagnoses include major depressive disorder (MDD), hypothyroidism, and obstructive sleep apnea. MDD is a primary consideration due to the patient history of depression, fatigue, and weight gain. The patient might be suffering from depression, as research has shown that veterans have a high prevalence of mental health disorders (Finnegan & Randles, 2023). Hypothyroidism has been considered as it is a common cause of fatigue and weight gain, while obstructive sleep apnea could also contribute to patient symptoms, particularly weight gain, fatigue and sleep disturbance from being homeless. To confirm MDD diagnosis, the patient will be given a Patient Health Questionnaire (PHQ-9) to assist with the assessment of depressive symptoms severity (Sun et al., 2020). Treatment for MDD would include starting sertraline at 50 mg daily, with potential titration to a maximum of 200 mg based on the patient’s response. Non-pharmacological approaches wouldinclude cognitive-behavioral therapy (CBT) through VA mental health services. Education should cover medication adherence, potential side effects, regular physical activity, and a balanced diet. Follow-up should occur in 4 weeks to monitor symptom improvement, adjust the sertraline dose if needed, and reassess her living situation and mental health support. To ensure holistic care, the patient will be given names of community resources that can offer support for her symptoms and situation, including unemployment and homelessness. These would include the Nevada Department of Veterans Services, which provides a wide range of assistance, including mental health services, food assistance, and employment support. Nevada Department of Veterans Services would assist with mental health services, job training, and homelessness. The patient would also be referred to the VA Southern Nevada Healthcare System for further assistance with mental health and rehabilitation​.

PEER RESPONSE 2:

BY: Aldo

The 28-year-old female veteran presenting with fatigue, increased sleeping, weight gain, and a history of depression brings several differential diagnoses into consideration. One primary differential diagnosis is major depressive disorder (MDD), as she reports a prior history of depression and her current symptoms align with the atypical presentation of MDD, which often includes hypersomnia and weight gain. Another important consideration is hypothyroidism, as this condition can similarly present with fatigue, weight gain, and mood disturbances. Additionally, sleep disorders, such as obstructive sleep apnea, should be evaluated, as this could account for her excessive sleep and fatigue. Lastly, given her status as a veteran, post-traumatic stress disorder (PTSD) or adjustment disorder might also be relevant, particularly in light of her current stressors, including housing instability and unemployment, which could exacerbate underlying mental health issues.

To determine the underlying cause of her symptoms, several diagnostic tests should be performed. A comprehensive metabolic panel (CMP) is essential to evaluate her overall metabolic health, while thyroid function tests (TSH and free T4) are critical to rule out hypothyroidism. Additionally, a complete blood count (CBC) will help assess for anemia, which could contribute to her fatigue, and checking her vitamin D and B12 levels is important, as deficiencies in these vitamins can cause fatigue and mood changes. Screening for depression using the PHQ-9 will help assess the severity of her depressive symptoms, and a PCL-5 (PTSD Checklist) could be used to evaluate any PTSD-related symptoms.

In terms of resources available for veterans in El Paso, Texas, there are several options that can be integrated into her care plan. The El Paso VA Health Care System offers a comprehensive range of services for veterans, including mental health support, primary care, and assistance for homeless veterans through the Healthcare for Homeless Veterans (HCHV) program. This program could be particularly beneficial in helping her secure stable housing. Another valuable local resource is the Lee & Beulah Moor Children’s Home, which offers housing and support for women and children at risk of homelessness, providing her with a temporary housing option. Additionally, the Veterans One Stop Center in El Paso provides various services, including job placement, counseling, and housing assistance, which would address both her immediate housing and employment needs.

The treatment plan for this patient should include both medical and psychosocial interventions. Diagnostics would include ordering the appropriate lab tests (TSH, free T4, CMP, CBC, and vitamin levels) as well as conducting a thorough assessment of her mental health using tools like the PHQ-9 and PCL-5. If hypothyroidism is confirmed, thyroid hormone replacement therapy should be initiated. If major depressive disorder is diagnosed, a selective serotonin reuptake inhibitor (SSRI) such as sertraline would be recommended, as SSRIs are a first-line treatment for depression. Additionally, cognitive behavioral therapy (CBT) should be considered, as it is a proven treatment for both depression and PTSD. Alongside pharmacologic treatment, patient education should focus on the importance of medication adherence, lifestyle modifications, and regular follow-up visits. Providing resources on healthy eating, physical activity, and proper sleep hygiene can help improve her overall health.

In terms of follow-up, the patient should be scheduled for a return visit within 4 to 6 weeks to monitor her response to treatment and make any necessary adjustments to her care plan. Additionally, she should be referred to the El Paso VA Health Care System for ongoing mental health support and housing assistance through their HCHV program, which will provide a more stable environment conducive to her recovery. By addressing both her medical needs and her current social challenges, the care plan aims to improve her overall health and well-being.