By Melinda Young

EXECUTIVE SUMMARY

It may help case managers identify obstacles and problems for patients who are serving or have served in the military if they view this service as a social determinant of health, a researcher suggests.

  • Veterans struggle with many of the same social determinants of health as non-veterans, including housing instability, gambling, substance use, depression, food insecurity, and post-traumatic stress disorder.
  • It is important to ask patients if they had served in the military and to screen for depression and other problems.
  • One study revealed that veterans who served in combat early in their military service experienced higher rates of negative mental health.

Case managers sometimes work with military veterans who struggle with social determinants of health, such as housing issues and behavioral health challenges. But one researcher says that military service can be considered a social determinant of health.

“We typically look at specific social determinants of health as an influencer of the needs or health status of an individual or group of people, but in this case, military service itself is considered a primary social determinant of health,” says Charles William White, EdD, MBA, faculty member in the department of public health at California State University in Fullerton.

Case managers are familiar with some of the social determinants of health that can affect veterans. These include housing instability, gambling, substance use, depression and post-traumatic stress disorder (PTSD), and food insecurity.1-6 But few case managers may consider how much of a physical and emotional strain military service is on individual patients.

“This combines all the individual social determinants into one,” White explains. “It’s very unusual that an occupation has the ability or power to combine all those social determinants of health uniformly across the population.” For example, the Office of Disease Prevention and Health Promotion’s HealthyPeople.gov website explains how the worksite is a physical determinant of health.1

Consider the Issue of Control

It is the issue of control that makes military service a social determinant that case managers and other healthcare providers should consider when seeing these patients. “Military service has direct control over the people on a military base, providing them with housing, food, education, and employment,” White notes. “The military base also has control of all the environmental factors within that base community.”

Civilians can find different places to live, different jobs, and different sources of food and environmental factors. “Those are more random influences, rather than a direct ability of the occupation to directly influence all of those social determinants of health into one,” he says. “The culture, the values, the prescribed norms are all regulated by military service. Those folks in military service are required to follow all those norms and rules. When we deploy forces to another country, say Afghanistan or Iraq, that’s a prime example of how the occupation — military service — puts those individuals into situations that they have no control over.”

As the authors of one study noted, people may join the military to escape dysfunctional and chaotic situations, which may increase their vulnerability to long-term social stressors.2 The researchers found that people with military service had a higher prevalence of poor physical health, but there was no association between military service and food and housing insecurity, says Mark Schure, PhD, assistant professor of health and human development at Montana State University in Bozeman.

The researchers analyzed data from respondents in nine states, using the 2011 or 2012 Behavioral Risk Factor Surveillance System, a phone survey that involved random-digit dialing of landline and cellphone numbers of adults. Veterans were a subset of the general population.2

“If you look at prior military service variable, you’re 1.06 times more likely to have poor mental health, but it’s not significant,” Schure says of the study results.

The results did not suggest a strong association between military service and mental health — a finding that was a little surprising, and possibly attributed to the limitations of its database because military service respondents were a small percentage of the data set.

“In Montana, we have one of the highest [per capita] veteran populations and the highest suicide rate in the state,”7 Schure says. “I feel there are still a lot of barriers that need to be addressed both on the population level and clinical level to make sure veterans have access to the care they need and are properly screened for mental health issues.”

Military Service and Mental Health

The nature of military’s physical control and culture can cause major problems, such as substance use disorder, depression, anxiety, and suicide. If healthcare providers and case managers do not consider military service to be a social determinant of health, they may miss opportunities to suggest patients seek help in the community.

For example, in a paper, White told the story of his brother, a decorated U.S. Army officer with 24 years of service, who shot himself in the head after dropping off his preschoolers at school. There were no apparent mental health symptoms or history. But he had served in numerous combat missions in Afghanistan and Iraq, and sometimes spoke about losing fellow soldiers.1

When case managers work with veterans, they could keep in mind the patients’ military service could be a risk factor for mental and behavioral health issues and routinely screen for depression and other problems — even if the patient does not volunteer a mental health challenge.

“Research says the military really turns into a family unit, so the ties that the service people have with one another is much stronger than you would see in other occupations,” White notes. “So many times, there are significant transition problems or issues when someone leaves active military service and goes into civilian life. That transition can be very hard.”

A recent study revealed combat exposure in the first two years of military service was associated with higher rates of mental health diagnoses when compared with deployment and no combat exposure, and no deployment.6

Even small things, such as the visual and tactile experiences of returning from an overseas deployment, can affect a person’s mental well-being. “If you’re deployed in a desert situation that you’ve never been in before, and then you come back after six months, then it’s [disturbing],” White explains. “My brother said that the color green of grass was so overwhelming to his troops when they came back to the United States because for six months they were in a desert.”

These are the sensitivities case managers should ask about when working with patients serving in the military or recently discharged. “We do little to record social determinants of health in the medical record, so we may not ask someone if they are a veteran or on active military duty,” White says. “We need to collect more information about social determinants of health at the point of entry into the healthcare system.”

Veterans Affairs (VA) has worked with veterans to identify mental health issues and develop ways to reduce suicide of veterans. “But, we’re still seeing extremely high suicide rates out of the military community, and it continues to be that way despite interventions happening,” White says.

Between 2005 and 2018, the overall suicide rate among veterans was between 17 and 18 episodes a day, despite numerous public awareness campaigns, new training mandates, and VA outreach programs.8

“There’s quite a bit of research demonstrating that the amount of exposure in combat missions compounds over time, so the more exposure you have to active combat, the higher risk of PTSD that a soldier has,” White says. “When military service folks are in active combat, their exposure to death and dying is extremely high compared to folks in the civilian world.”

While people in military service are trained to be psychologically strong, they also are trained to use lethal weapons. Research suggests owning a gun in the home increases the likelihood of successful suicide.9

“An active duty deployment gives someone exposure to death among themselves and also among the combatants they’re engaged with. That is extremely mentally challenging,” White says. “When you’re exposed to that kind of death or killing, that has an impact on your mental health.”

Case managers are not the healthcare professionals who can help prevent or change a military service social determinant of health, but they can help veterans access the resources they need. “When we have an opportunity, we should look into the world of people who are serving and look into their potential needs,” White says. “That’s the most important thing.”

White wrote his paper for this purpose: “My article is to build awareness about this issue and reconfirm that suicide in the military is a pressing issue,” he explains. “Case managers need to think about how they can best meet the needs of folks who’ve had military service.”

REFERENCES

  1. White CW. Professional case management and military service as a social determinant of health. Prof Case Manag 2021;26:46-49.
  2. Cypel YS, Katon JG, Schure MB, et al. Food insecurity in US military veterans. Food Nutr Bull 2020;41:399-423.
  3. Szymkowiak D, Montgomery AE, Tsai J, O’Toole TP. Frequent episodic utilizers of Veterans Health Administration homeless programs use: Background characteristics and health services use. J Public Health Manag Pract 2020; doi: 10.1097/PHH.0000000000001252. [Online ahead of print].
  4. van der Maas M, Nower L. Gambling and military service: Characteristics, comorbidity, and problem severity in an epidemiological sample. Addict Behav 2021;114:106725.
  5. Montgomery AE, Rahman FAKM, Cusack M, et al. Correlates of transitions into housing instability among veterans accessing Veterans Health Administration health care. Med Care 2020;58:1105-1110.
  6. Campbell MS, O’Gallagher K, Smolenski DJ, et al. Longitudinal relationship of combat exposure with mental health diagnoses in the military health system. Mil Med 2021;186:160-166.
  7. Veterans Health Administration, VA Montana Health Care System. Montana veteran demographics. Jan. 6, 2017. https://leg.mt.gov/content/Committees/Interim/2017-2018/State-Administration-and-Veterans-Affairs/Meetings/Sept-2017/Montana%20Veteran%20Demographics%20(as%20of%20Jan.%206%202017).pdf
  8. Shane L. Suicide rate among veterans up again slightly, despite focus on prevention efforts. Military Times. Nov. 12, 2020. https://www.militarytimes.com/news/pentagon-congress/2020/11/12/suicide-rate-among-veterans-up-again-slightly-despite-focus-on-prevention-efforts/
  9. Handgun ownership associated with much higher suicide risk. Stanford Medicine News Center. June 3, 2020. https://med.stanford.edu/news/all-news/2020/06/handgun-ownership-associated-with-much-higher-suicide-risk.html