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Advice to psychiatrists who work with veterans

Veterans, Our experts, Clinical practice

Professor Mal Hopwood has worked with military veterans for all of his career as a consultant psychiatrist. He has been director of the Veterans Psychiatry Unit at Austin Health, and adviser to the Department of Veterans’ Affairs. Professor Hopwood is currently Director of the Professorial Psychiatry Unit at the Albert Road Clinic in Melbourne. He is also a member of the Centenary of Anzac Centre’s Expert Council, which guides and manages the work of the centre.

Professor Hopwood shares his thoughts on how psychiatrists, and other mental health practitioners, can approach their work with veterans.

In some respects, good psychiatric care of veterans differs little from that of any other group of patients, and should include all the usual elements of good care. But there are particular considerations for this population that are key for any psychiatrist to successfully manage veteran mental health. Firstly and fundamentally it’s important to know if your patient is a veteran, and to understand what that entails, including having some knowledge of military service, culture and systems.

Remember that a veteran’s mental health problems may not be related to their military experiences. Like the rest of the population, mental ill-health can arise due to a wide range of factors. But even if the origin lies within their civilian life, there are military factors which will likely impact both their presentation and the management of their treatment.

Always enquire about a history of traumatic events, but don’t assume that the only relevant diagnosis is posttraumatic stress disorder (PTSD). Depression and substance abuse are also common after trauma as is a combination of these complaints.

When treating trauma-related disorders, it’s important to follow the latest treatment guidelines. In relation to PTSD, excellent resources are available: the NHMRC-approved Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder developed by Phoenix Australia provide clear guidance on the most effective treatments, as examined in the RANZCP’s PTSD guidelines review report. Later in 2020, a revised edition of the NHMRC PTSD guidelines will be available.

In essence, contemporary treatment of PTSD involves trauma-focussed psychotherapies. Guidelines generally acknowledge the limitations of pharmacotherapies except in the most severe disorders or for comorbid conditions.

Inpatient care may be especially appropriate for initial treatment of comorbidities such as major depression and substance abuse. In addition, DVA funds a range of PTSD trauma recovery day therapy programs around the country.

Military and veteran culture can be perplexing for those unfamiliar with it, but for psychiatrists and other mental health practitioners it pays to spend some time learning about it. Veteran patients are more likely to fully engage in the therapeutic relationship and trust their practitioner if they feel that their military experience is understood. But remember when working with a veteran to tap into their expertise, and don’t pretend to know what you don’t – as this will only get the patient off side. The Anzac Centre’s Practitioner Support Service provides free training in Understanding the Veteran Experience.

One aspect that can be particularly helpful to have an understanding of is the Department of Veterans’ Affairs (DVA) treatment entitlements, and pensions and related compensation systems. In the past 10 to 15 years the treatment eligibility requirements have been greatly simplified, and in the case of PTSD, is relatively straightforward. The DVA website has more information on this and many other aspects of working with veterans.

Finally, the Centenary of Anzac Centre is a valuable resource for psychiatrists and other practitioners. The centre’s Treatment Research Collaboration taps into a network of experts in veteran mental health nationally and internationally. It not only conducts research, but integrates and translates research findings for the benefit of both the research and practitioner communities. It currently has a particular focus on investigating factors leading to treatment resistance in the management of trauma.

The Practitioner Support Service can assist those who are less experienced in veteran care, need support with a particularly complex case, have specific questions, or need to know about the latest research evidence. The free, nation-wide service provides expert multidisciplinary support and guidance to practitioners, and can be contacted through the website or by phone: 1800 VET 777.

Key points for psychiatrists working with veterans

  1. Conduct an appropriate broad assessment.
  2. Incorporate knowledge of military and veteran culture in building the therapeutic relationship.
  3. Don’t make diagnostic assumptions (e.g., it’s always and only PTSD).
  4. Keep familiar with current treatment guidelines for trauma-related mental health problems.