Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

In Brief

Summer 2012 • Volume 7 • Issue 1

Behavioral Health Issues Among 

Afghanistan and Iraq U.S. War Veterans

Since 2001, more than 2.2 million U.S. veterans have 

served in Afghanistan (Operation Enduring Freedom, 

or OEF) and Iraq (Operation Iraqi Freedom, or OIF).1

Although more than two-fifths of these veterans 

receive healthcare and social services through the U.S. 

Department of Veterans Affairs (VA),2

 the remainder 

may seek services elsewhere—from community clinics, 

primary care providers, and other community centers. 

This In Brief introduces some of the problems facing 

OEF and OIF veterans and can help healthcare and social 

service professionals understand these veterans’ needs.

Returning Veterans and Possible 

Behavioral Health Issues

Although the majority of veterans who return from 

Iraq and Afghanistan do not have a behavioral health 

condition and have not experienced a traumatic brain 

injury,3

 all veterans experience a period of readjustment 

as they reintegrate into life with family, friends, and 

community. The veterans’ juggling of military and 

family responsibilities, reintegration into civilian life in 

the United States after living in unfamiliar settings, and 

processing exposure to combat may contribute to problems 

for veterans themselves, as well as their spouses and 

family members.4, 5 Behaviors needed to survive in a war 

zone, such as maintaining a constant state of alertness, 

may initially translate into troublesome behaviors in 

civilian life, such as feeling edgy or jumpy and being 

easily startled. Healthcare and social service providers and 

clergy—from the community, military, or VA—may be the 

first contacts sought for help by veterans and their families, 

making it important for these providers to know about 

problems faced by veterans.

Those returning from a combat zone may experience 

a variety of common stress reactions, including 

sleeplessness, nightmares, and feelings of sadness, 

rejection, abandonment, or hopelessness. Veterans may 

also struggle to concentrate; engage in aggressive behavior, 

such as aggressive driving; and use alcohol, tobacco, and 

drugs excessively. However, the intensity and duration of 

these and other worrisome behaviors can indicate a more 

serious problem and the need for professional treatment.6 

The VA offers screening, diagnostic assessment, and 

treatment to help veterans overcome discrimination or 

barriers that prevent them from seeking treatment.

Substance Abuse Among OEF and 

OIF Veterans

Few data have been reported on illicit drug use among OEF 

and OIF veterans, but one study of VA healthcare users reports 

that more than 11 percent of OEF and OIF veterans have been 

diagnosed with a substance use disorder (SUD)—an alcohol 

use disorder, a drug use disorder, or both.7

 In addition, the data 

available for alcohol use show that some veterans use alcohol 

to self-medicate.5

VA data show that almost 22 percent of OEF and OIF veterans 

with post-traumatic stress disorder (PTSD) also have an SUD.8

 

Alcohol Consumption Guidelines

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), at-risk alcohol consumption is having 5 or more 

drinks in 1 day for men and 4 or more drinks in 1 day for women—or more than 14 drinks per week for men and 7 drinks per 

week for women—1 or more times in the past year. Individuals are considered at risk for alcohol abuse or dependence if they 

need to drink a lot more to achieve the same desired effect as when they drank previously, have problems with work or family 

caused by drinking, or have been unable to cut down or quit.9
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

2 

In Brief

Studies show that alcohol misuse and abuse, hazardous 

drinking, and binge drinking are common among OEF and OIF 

veterans.11,12,13,14 Veterans sometimes drink alcohol as a way 

to numb the difficult feelings and erase the memories related 

to their war experiences.4,5 For example, increased combat 

exposure involving violence or human trauma among OIF 

veterans was linked to more frequent and greater quantities of 

alcohol use than was less exposure to such combat.15 

In addition, a recent national study of OEF and OIF 

veterans receiving VA health care was the first to show that 

those diagnosed with mental disorders, particularly PTSD, 

were notably more likely to receive prescription opioid 

medication for conditions related to pain than those with 

no mental health diagnoses. They were more likely to have 

co-occurring SUDs, to receive higher-dose opioid regimens 

and early refills, and to take the opioids for longer periods 

of time. These veterans were also at higher risk for adverse 

clinical outcomes.10 

Studies show that alcohol misuse and abuse, hazardous 

drinking, and binge drinking are common among OEF and OIF 

veterans.11,12,13,14 Veterans sometimes drink alcohol as a way 

to numb the difficult feelings and erase the memories related 

to their war experiences.4,5 For example, increased combat 

exposure involving violence or human trauma among OIF 

veterans was linked to more frequent and greater quantities of 

alcohol use than was less exposure to such combat.15 

Binge Drinking 

Lack of a uniform definition of heavy episodic or 

binge drinking has caused difficulties in discussing this 

phenomenon. The NIAAA National Advisory Council 

approved the following definition: “A ‘binge’ is a pattern of 

drinking alcohol that brings blood alcohol concentration to 

0.08 gram percent or above. For a typical adult, this pattern 

corresponds to consuming 5 or more drinks (male) or 4 or 

more drinks (female) in about 2 hours.”16 

Mental Disorders Among OEF and 

OIF Veterans 

Studies show that between 36.9 and 50.2 percent of OEF and 

OIF veterans in the VA healthcare system have received a 

mental disorder diagnosis, such as PTSD or depression.8,17 

VA data show that among OEF and OIF veterans using 

VA services, 27 percent (more than 167,500) have been 

diagnosed with PTSD.8,18 Other studies reveal that rates of 

PTSD among OEF and OIF veterans who were wounded 

or hospitalized because of combat were higher than rates 

among those who were not.19,20, 21 In addition to manifesting 

the traditional symptoms of PTSD listed in the Diagnostic 

and Statistical Manual of Mental Disorders, Fourth Edition, 

Text Revision (DSM-IV-TR), OEF and OIF veterans who 

have experienced trauma may increase their drinking or drug 

use, display risk-taking behaviors, and experience somatic 

symptoms, such as headaches and sweating, when thinking 

about combat experiences.4,5,14,15 

Studies have shown that symptoms may worsen over the 

first 12 months after a veteran returns home—particularly 

among Army Reserve and National Guard troops, likely 

due to variables related to readjustment to civilian life and 

employment or more restricted access to military health 

care.12,14 The reasons for this decline are unknown, but the 

initial relief of returning home may mask PTSD, or it may 

be that signs and symptoms do not appear as problems 

until individuals begin to engage in routine work or social 

functioning.22 When considering PTSD, it should be noted 

that it is often associated with co-occurring disorders that 

complicate assessment and treatment. These disorders 

include depression, SUDs, and traumatic brain injury. 

In relation to depression, 2004–2007 data from the National 

Survey on Drug Use and Health show that an estimated 9.3 

percent of U.S. veterans between ages 21 and 39 (312,000 

people) experienced at least one major depressive episode 

(MDE) in the past year.23 More than three-fourths of 

respondents reported either severe or very severe impairment 

in home, work, or interpersonal relationships. 

Post-Traumatic Stress Disorder 

PTSD may develop after an individual has been exposed to 

an event that involved the deaths of others, or an event that 

threatened death or serious injury to oneself or others, and the 

person’s response to the event involved fear, helplessness, or 

horror. Traumatic experiences that lead to PTSD among OEF 

and OIF veterans involve exposure to combat—including 

knowing someone who was injured or killed, killing an 

enemy combatant, or being shot at.24 Signs and symptoms of 

PTSD include re-experiencing the traumatic event by way 

of flashbacks, nightmares, and intrusive thoughts about the 

event; efforts to avoid thoughts, feelings, or conversations 

associated with the trauma; efforts to avoid activities, 

places, or people that arouse recollections of the trauma; and 

diminished interest or participation in significant activities. 

Other indicators of PTSD include sleep difficulties, feelings of 

detachment from others, angry outbursts, and startling easily. 

The DSM-IV-TR provides a fuller description of PTSD.25 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

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Behavioral Health Issues Among Afghanistan and Iraq U.S. War Veterans

Summer 2012, Volume 7, Issue 1

The number of women involved in OEF and OIF and the scope 

of their duties are unmatched historically, and the rates at which 

they experience certain behavioral health issues vary from those 

for male veterans.26 For example, female veterans are more than 

twice as likely as male veterans to have experienced a past-year 

MDE—16.6 percent versus 8.0 percent.23 VA data also show 

that female veterans are much more likely than male veterans 

to screen positive for military sexual trauma—1 in 5 versus 1 

in 1008

—and such trauma is associated with both substance use 

and mental disorders, including PTSD, depression, and other 

anxiety disorders.26 

Suicide 

In fiscal year 2009, 94 men and 4 women who were 

veterans of OEF and OIF took their own lives.27 Another 

report showed that between 2002 and 2005, 144 out of 

490,346 OEF and OIF veterans took their own lives, for 

an overall rate of 21.9 per 100,000;28 this number does 

not take into account active-duty service members who 

took their own lives. The suicide rate among men who 

deployed and left the military between 2002 and 2005 is 

slightly higher than among men in the general population, 

with varying statistical significance between age groups; 

rates are particularly high in veterans ages 30 to 64. In 

addition, male veterans take their own lives at a higher 

rate than do female veterans, according to a VA summary 

of data from 2001 through 2005, but female veterans have 

a suicide rate that is nearly twice the rate of women in the 

general population.28 These high suicide rates, coupled 

with the fact that more than 6,000 military veterans take 

their own lives each year, resulted in VA increasing its 

efforts to prevent suicide among veterans.27 

Reactions to war experiences can lead individuals to think 

about killing themselves.5

 Common suicide warning signs 

include threatening to, or talking about wanting to, hurt or 

kill oneself, feeling hopeless, feeling uncontrolled anger 

or rage, and feeling trapped. A list of warning signs is 

available at the National Suicide Prevention Lifeline Web 

site (http://www.suicidepreventionlifeline.org/GetHelp). 

In the general population, suicide completion risk factors 

include being male, having access to—and knowledge 

of—firearms, and having co-occurring medical conditions 

and behavioral health problems. This profile describes 

many OEF and OIF veterans, making suicide risk 

management particularly challenging for this group.29 

Specific risk factors for veterans include frequent 

deployments, experiencing traumatic events while 

deployed, and experiencing a service-related injury.30 

Behavioral health issues, such as depression, PTSD, 

SUDs, and traumatic brain injury, also increase the 

likelihood of attempted suicide.8

 One study showed that 

veterans with PTSD were more than four times as likely 

to report thoughts of suicide—a strong predictor of a 

suicide attempt—than were those without PTSD.31 A 

recent study also showed that veterans who are unmarried 

or who report lower satisfaction with their social networks 

are at higher risk for suicide.32 

Suicide Prevention Resources 

The National Suicide Prevention Lifeline Web site 

(http://www.suicidepreventionlifeline.org) has a special 

section for veterans with information about the Veterans 

Crisis Line (a partnership between VA, Substance Abuse 

and Mental Health Services Administration [SAMHSA], 

and the National Suicide Prevention Lifeline); a link to 

VA’s Confidential Veterans Chat; and an anonymous SelfCheck Quiz for veterans to see how they may benefit from 

services (http://www.veteranscrisisline.net). 

Veterans Chat is a confidential live chat service available 

for veterans and their family members or friends who 

wish to chat online, one-on-one, with a VA mental health 

clinician. Veterans can participate in a live chat by visiting 

the link above and first clicking on “Confidential Veterans 

Chat,” checking the “I agree to the Terms of Service” box, 

and then clicking on “Click to Start Your Confidential 

Chat Now.” The Self-Check Quiz is a confidential, safe, 

and easy way for veterans to learn whether stress and 

depression are affecting them. Veterans can click on the 

“Take a Self-Check Quiz” button to take the quiz. 

Veterans, service members, and their family members 

who are in emotional distress are urged to call the 

Veterans Crisis Line at 1-800-273-TALK (8255) and 

press “1” to be connected directly to a qualified, caring 

VA professional. All calls are confidential. To chat online 

and to receive confidential support 24 hours a day, 7 

days a week, veterans can visit the Web site (http://www. 

veteranscrisisline.net). 

Additional information about suicide prevention can be 

found at SAMHSA’s Suicide Prevention Web site (http:// 

mentalhealth.samhsa.gov/suicideprevention/fivews.asp). 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

4 

In Brief In Brief
 

Other behavioral health issues 

A study of OIF veterans found that combative behaviors— 

such as angry verbal outbursts, destruction of property, 

threatening others with violence, and engaging in 

dangerous behaviors (e.g., driving under the influence of 

alcohol)—were associated with violent combat exposure.15 

OEF and OIF veterans also experience high levels of 

conflict in family and social relationships, such as frequent 

arguments and poor communication.4, 12 

What Primary Care and Behavioral 

Health Providers Can Do To Help 

Ask and assess. Healthcare providers can screen OEF 

and OIF veterans for substance abuse, PTSD, depression, 

risk of suicide, other behavioral health issues, and the 

co-occurrence of these problems. Several short online 

screening tools are useful for quickly assessing behavioral 

health problems among veterans, as is a helpline for 

providers working with veterans with post-deployment 

health issues.33,34 

Intervene. Healthcare professionals can provide brief 

interventions, including giving feedback about screening 

results, describing risks associated with a behavioral health 

disorder, and advising about ways to begin addressing 

substance use or mental disorders. 

The SAMHSA publication, Quick Guide for Clinicians 

Based on Treatment Improvement Protocol (TIP) 34: Brief 

Interventions and Brief Therapies for Substance Abuse, 

summarizes guidance on brief therapies for individuals with 

SUDs (http://kap.samhsa.gov/products/tools/cl-guides/pdfs/ 

QGC_34.pdf). 

The screening, brief intervention, and referral to treatment 

(SBIRT) approach provides effective strategies for 

interventions before the need for extensive or specialized 

substance abuse treatment emerges. SBIRT uses brief treatment 

in a community setting. The National Institute on Drug 

Abuse’s Physicians’ Outreach Initiative (NIDAMED) provides 

resources for medical and healthcare professionals about 

drug use and SBIRT (http://www.drugabuse.gov/nidamed). 

NIAAA’s Helping Patients Who Drink Too Much: A Clinician’s 

Guide, Updated 2005 Edition provides helpful information 

about SBIRT and alcohol use (http://pubs.niaaa.nih.gov/ 

publications/Practitioner/CliniciansGuide2005/guide.pdf). 

TIP 50, Addressing Suicidal Thoughts and Behaviors in 

Substance Abuse Treatment, provides information for 

treatment providers and administrators about working 

with clients who have suicidal thoughts and behaviors. 

Included in the TIP are basic suggestions for addressing 

suicidal thoughts and behaviors, background information 

about suicide and SUDs, representative vignettes involving 

clients with suicidal thoughts and behaviors, and an 

implementation guide for treatment program administrators. 

A literature review on the topic can be found on SAMHSA’s 

Web site (http://www.kap.samhsa.gov/products/manuals/ 

tips/pdf/TIP50_LitRev.pdf). 

Online Screening Tools for Assessing Behavioral Health Problems Among Veterans 

For alcohol and drug abuse: 

CAGE and CAGE-AID Questionnaires 

http://www.partnersagainstpain.com/printouts/A7012DA4.pdf 

NIDA-Modified Alcohol, Smoking, and Substance 

Involvement Screening Test 

http://www.drugabuse.gov/nidamed/ 

nmassist-screening-tobacco-alcohol-other-drug-use 

For PTSD: 

Primary Care PTSD Screen 

http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp 

For depression: 

The Patient Health Questionnaire-2 

http://www.cqaimh.org/pdf/tool_phq2.pdf 

For suicide: 

Suicide Assessment Five-Step Evaluation and Triage: Pocket 

Card for Clinicians 

http://store.samhsa.gov/product/Suicide-Assessment-FiveStep-Evaluation-and-Triage-SAFE-T-/SMA09-4432 

Assessing Suicide Risk: Initial Tips for Counselors (wallet card) 

http://store.samhsa.gov/product/Assessing-Suicide-Risk-InitialTips-for-Counselors/SVP06-0153 

For assistance working with veterans: 

DoD/VA Clinical Practice Guideline for Post-Deployment 

Health Evaluation and Management and other guidelines

http://www.pdhealth.mil/guidelines/default.asp 

Deployment Health Clinical Center Helpline for Clinicians/ 

Providers 1-866-559-1627 
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Behavioral Health Issues Among Afghanistan and Iraq U.S. War Veterans

Summer 2012, Volume 7, Issue 1

Refer. If the screening result indicates that the veteran is 

in need of specialized care for behavioral health issues, the 

provider can refer the veteran for an indepth assessment, 

diagnosis, and appropriate treatment. Many evidence-based 

treatments (EBTs) for substance use and mental disorders 

are available and include psychotherapies, behavioral and 

pharmacological therapies, and combinations of these. EBTs 

shown to be effective for PTSD include exposure therapy 

(particularly, prolonged exposure and exposure therapy 

using virtual reality), which involves repeated exposure 

to traumatic thoughts, emotions, or memories in a safe 

environment to reduce the power they have to cause distress; 

cognitive processing therapy; eye movement desensitization 

and reprocessing; and cognitive–behavioral therapy.35 

Healthcare providers can refer veterans to local VA medical 

centers, behavioral health counselors, and local veterans’ 

organizations and support groups. Some Alcoholics 

Anonymous and Narcotics Anonymous groups are created 

specifically for veterans. 

What Social Service Providers Can 

Do To Help 

Know the facts. Understand the patterns and prevalence of 

behavioral health issues among returning veterans. Adjusting 

from war to civilian life affects veterans and their families. 

Observe. Be attuned to the signs and symptoms of 

substance use and mental disorders among veterans. 

Veterans may not discuss these problems without being 

asked for fear that disclosure will affect their careers, 

embarrass them, or be interpreted as a sign of weakness.24,36 

Educate. Teach veterans about wellness and coping skills, 

such as how to return to regular patterns of sleep and 

exercise, use relaxation techniques, and reconnect with 

social supports.4, 5 Social service providers also can educate 

other organizations in the community about the warning 

signs of PTSD, suicide contemplation, and other issues that 

veterans may be facing. These organizations can then refer 

veterans who need help. 

Refer. Refer veterans and their families to appropriate 

resources and behavioral health service providers as 

necessary (see Locating Substance Abuse Treatment and 

Mental Health Services Providers). 

Social service professionals who provide referrals contribute 

to recovery and better health.36 Peer counseling options are 

also available through VA medical centers, the Wounded 

Warrior Project, and many state-based networks and 

nonprofit organizations. 

Locating Substance Abuse Treatment and 

Mental Health Services Providers 

SAMHSA provides an online treatment locator for mental 

health services across the Nation (http://store.samhsa. 

gov/mhlocator); this Web site also provides a link to VA’s 

facility locator. A similar treatment center locator for SUDs 

is available from SAMHSA (http://www.findtreatment. 

samhsa.gov). In addition, SAMHSA’s Treatment Referral 

Line is available by calling 1-800-662-HELP (4357). 

Resources 

SAMHSA resources 

SAMHSA has many valuable resources that can assist 

providers working with veterans. These include upcoming 

pharmacologic guidelines for treating people with PTSD and 

co-occurring opioid use disorders, and guidelines for using 

pharmacological agents to treat those with co-occurring 

mental and substance use disorders. For these and other 

publications, visit the SAMHSA online store (http://www. 

store.samhsa.gov/home). 

Also see: 

http://www.store.samhsa.gov/pages/searchResult/veterans 

http://www.samhsa.gov/militaryfamilies 

For veterans and their families 

For behavioral health issues, visit the U.S. Department 

of Veterans Affairs’ Web site about mental health (http:// 

www.mentalhealth.va.gov/MENTALHEALTH/index.asp). 

For information on a number of topics, including 

education, relocations, parenting, and stress, Military 

OneSource is available for active-duty, Guard, and Reserve 

members and their families. The service, provided by the 

U.S. Department of Defense, is completely private and 

confidential, with few exceptions. For immediate help 24 

hours a day, 7 days a week, either call 1-800-342-9647 or 

visit the Web site (http://www.militaryonesource.com). 

For wellness resources for the military community, 

including assessments and topic-specific information, 

questions about psychological health or traumatic brain 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

6 

In Brief

injury, or immediate help 24 hours a day, 7 days a week, 

call 1-800-342-9647, or visit the afterdeployment.org Web 

site (http://www.afterdeployment.org). 

Providing Services to Family Members 

of OEF and OIF Veterans 

Veterans’ spouses and other family members are often more 

willing than veterans to seek care, making families important 

links to veterans’ recovery and well-being.12 Family members are 

an important part of the services team. Family members’ referrals 

to resources and educational materials can be the first step to a 

veteran’s healthful adjustment to civilian life and recovery. 

Additional Web sites to visit 

U.S. Department of Defense/Department of Veterans Affairs 

Suicide Outreach: Resources for Suicide Prevention 

http://www.suicideoutreach.org 

U.S. Department of Veterans Affairs: Returning Service 

Members (OEF/OIF) 

http://www.oefoif.va.gov/index.asp 

Mental Health America 

http://www.nmha.org 

Military Pathways 

http://www.militarymentalhealth.org 

National Alliance on Mental Illness 

http://www.nami.org 

National Resource Directory 

https://www.nationalresourcedirectory.gov 

For healthcare and social service providers 

Anger Management for Substance Abuse and Mental 

Health Clients Series 

http://store.samhsa.gov/product/SMA08-4213 (A Cognitive 

Behavioral Therapy Manual) 

http://store.samhsa.gov/product/SMA08-4210 (Participant 

Workbook) 

Identifying and Helping Patients With Co-Occurring 

Substance Use and Mental Disorders: A Guide for Primary 

Care Providers, Substance Abuse in Brief Fact Sheet, Vol. 4, 

Issue 2, 2006 

http://store.samhsa.gov/product/MS994 

SAMHSA’s Recovery Month Toolkit 2006 Military and 

Veterans, http://www.recoverymonth.gov/ResourcesCatalog/2006/Targeted-Outreach/Recovery-MonthToolkit-2006-Military.aspx 

TIP 42: Substance Abuse Treatment for Persons With CoOccurring Disorders 

http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssa 

mhsatip&part=A74073 

TIP 49: Incorporating Alcohol Pharmacotherapies Into 

Medical Practice 

http://www.ncbi.nlm.nih.gov/books/NBK64041 

TIP 50: Addressing Suicidal Thoughts and Behaviors in 

Substance Abuse Treatment 

http://www.ncbi.nlm.nih.gov/books/NBK14731 

NIDA: Resources for Medical and Health Professionals 

http://www.drugabuse.gov/medical-health-professionals 

U.S. Department of Veterans Affairs, National Center for PTSD 

http://www.ptsd.va.gov/index.asp 

afterdeployment.org 

http://www.afterdeployment.org 

Deployment Health Clinical Center 

http://www.pdhealth.mil/clinicians/default.asp 

Iraq and Afghanistan Veterans of America 

http://iava.org/content/invisible-injuries 

Issues Facing Returning Veterans, Resource Links, Volume 6, 

Issue 1, 2007 

http://www.attcnetwork.org/learn/topics/veterans/docs/ 

VetsNwsltr2007.pdf 

Military Cultural Competence Essential Learning Course 

http://www.essentiallearning.net/student/content/sections/ 

Lectora/MilitaryCultureCompetence/index.html 

Real Warriors, Real Battles, Real Strength 

http://www.realwarriors.net 

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In Brief 

This In Brief was written and produced under contract number 270-09-0307 by the Knowledge Application Program (KAP), a Joint

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2012). Behavioral Health Issues Among 

Afghanistan and Iraq U.S. War Veterans. In Brief, Volume 7, Issue 1.

Originating Office: Quality Improvement and Workforce Development Branch, Division of Services Improvement, Center for 

Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 

20857.

In Brief

Behavioral Health Issues Among Afghanistan 

and Iraq U.S. War Veterans

HHS Publication No. (SMA) 12-4670

Printed 2012