Depression is one of the most common and expensive mental disorders, costing the United States an estimated $66 billion per year. Veterans diagnosed with depression account for slightly more than 14 percent of the total. From 2000-07, the medical records of more than 206,000 veterans entering the VA health care system were assessed. Findings revealed that one in three patients was diagnosed with at least one mental health disorder—41 percent were diagnosed with either a mental health or a behavioral adjustment disorder. The diagnosis rate for posttraumatic stress disorder (PTSD) was 20 percent followed by 14 percent for depression, yet studies show that depression is under-diagnosed in this population.
Clinical depression is a serious medical illness that is much more than temporarily feeling sad or blue. It involves disturbances in mood, concentration, sleep, activity level, interests, appetite and social behavior. Although depression is highly treatable, it is frequently a life-long condition in which periods of wellness alternate with recurrences of illness.
The onset of the first episode of major depression may not be obvious if it is gradual or mild. The symptoms of major depression characteristically represent a significant change from how a person functioned before the illness. The symptoms of depression include:
Like most groups, women have a higher rate of depression than men, and male veterans—regardless of their form of service—have nearly twice the rate of alcohol and drug use. In a study of approximately 100,000 returning veterans, 25 percent received a mental health diagnosis and more than 30 percent received a mental health diagnosis or had a behavioral adjustment problem. There was no correlation found between diagnosis and gender or ethnicity. However, older veterans had a higher rate of PTSD among the National Guard and reserve units while younger veterans had a higher rate among active-duty personnel.
Data shows that within the first year following a mental health diagnosis, two-thirds of patients receive very minimal or no psychiatric care. Without early intervention for specific subgroups of combat veterans, many veterans will go untreated and experience a several-month-long episode of depression—a period that will often repeat over a lifetime. This leaves them at risk for substance use, economic and relationship problems and other consequences of untreated depression.
There is no single cause of major depression. Psychological, biological and environmental factors may all contribute to its development. Scientific research has firmly established that major depression is a biological, medical illness. There is also an increased risk for developing depression when there is a family history of the illness.
A study found that the risk factors for suicide for U.S. veterans with depression differed in significant ways from those of the general population. Specifically, the risk for suicide generally increases with age, but in the veteran population, younger veterans are at the most risk. The study divided veterans into three age groups: 18-44, 45-64 and 65 or older. Among this population, younger veterans had moderately higher rates than middle-aged patients (about 95 percent versus 74 percent) and modestly higher rates than elderly patients (about 95 percent versus 90 percent).
Other risk factors for suicide mirrored those found among the general population. Veterans struggling with their diagnoses were more likely to commit suicide or battle with substance abuse. Depressed male veterans were three times as likely to commit suicide compared to females, and Caucasians were at a higher risk than African Americans or Latinos. Notably, people diagnosed with PTSD were less prone to suicide than those who were not diagnosed with PTSD. This is thought to be because compared to depression, PTSD had become a more acceptable set of symptoms and patients with the disorder more readily seek out psychiatric care.
Older adults comprise the fastest-growing segment of the U.S. population with the most significant growth among those over age 80. The percentage of older veterans is 38 percent of the total veteran population in 1999, and may number between 7.8 and 9 million until 2020. A considerable number of older veterans experience depression which is associated with substantial suffering, disability, suicide risk and decreased health-related quality of life. Older adults receive treatment in primary care settings where depression is often inadequately treated or even diagnosed.
Although major depression can be a devastating illness, it is highly treatable. Between 80-90 percent of persons diagnosed with major depression can be effectively treated and return to their usual daily activities and feelings. Many types of treatment are available, and the type chosen depends on the individual and the severity and patterns of his or her illness. There are three well-established types of treatment for depression: medications, psychotherapy and electroconvulsive therapy (ECT). For some people who have a seasonal component to their depression, light therapy may be useful. Transcranial magnetic stimulation (TMS) may be helpful for depression that has not responded to one medication trial. These treatments may be used alone or in combination. Additionally, peer education and support can promote recovery. Attention to lifestyle, including diet, exercise and smoking cessation can result in better physical and mental health.
Medication. Research has shown that imbalances in neurotransmitters (chemicals in the brain) like serotonin, dopamine and norepinephrine can be altered with antidepressants. It often takes two to four weeks for antidepressants to start having an effect, and six to12 weeks for antidepressants to take full effect.
Individuals and their families must be cautious during the early stages of medication treatment because normal energy levels and the ability to take action often return before mood improves. At this time—when decisions are easier to make, but depression is still severe—the risk of suicide may temporarily increase. A greater risk of self-harm occurs in individuals taking antidepressants who are under 25. In 2004, the FDA put a black box warning on antidepressants noting increased risk of suicidal thoughts and feelings in the first months of treatment.
Psychotherapy. There are several types of psychotherapy that have been shown to be effective for depression including cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). Research has shown that mild to moderate depression can often be treated successfully with either of these therapies used alone. However, severe depression appears more likely to respond to a combination of psychotherapy and medication.
Antidepressant treatment is just as effective in elderly patients as in younger adults. However, many elderly patients discontinue medication use prematurely, resulting in inconsistent recovery. Investigators have found that up to one-third of depressed older veterans did not consistently fill antidepressant prescriptions during treatment for reasons such as cognitive impairment and beliefs that are culturally influenced.
Veterans often learn best from someone who has been there. The feeling of being unlike non–veterans—in terms of the experiences with combat and loss—can hamper individual treatment. Group sessions with veterans can offer support and understanding to each other that may lead to better outcomes.
As part of a comprehensive research agenda aimed at advancing the care of veterans with depression, Veterans Association (VA) researchers are developing, testing and implementing new models of primary care to improve the outcomes among veterans affected by depression. Translating Initiatives for Depression into Effective Solutions (TIDES) is a model of care for veterans with depression that involves collaboration between primary care providers and mental health specialists with support from a depression-care manager. The program has shown impressive results with eight out of 10 veterans effectively treated in three VA regions without the need for referrals to additional specialists.
For more information about programs related to veterans and depression:
Veterans Health Administration www.research.va.gov
Reviewed by Ken Duckworth, M.D., October 2009