In 2015, over 1.3 million veterans were receiving disability compensation for a mental related condition such as PTSD, general anxiety disorder, major depressive disorder, etc. These conditions, either directly service connected or secondary to another service connected condition represented almost 7% of the total of all disability compensation claims paid out by the VA at an average rating level of 30%. The most veterans also receive a 100% rating for a mental health condition compared to any other condition, almost 200,000 compared to the next highest condition at just over 30,000 for musculoskeletal conditions. However, there is a secondary condition that many veterans are unaware of related to their mental health condition that may often either cause them to be denied service connection and/or cause other major problems in their lives such as homelessness, loss of jobs and relationships, and physical illnesses. This is substance abuse. Substance abuse includes illicit or illegal drugs, alcohol, and prescription painkillers or narcotics that someone becomes addicted to regardless of any pain they are treating such as opiates.
Primary and Secondary Diagnoses
Many psychiatrists and psychologists will diagnose a veteran with a mental health and a substance use or abuse disorder, including alcohol, under what is known as an Axis I. Axes are different diagnoses levels; Axis I is for clinical disorders such as mental health and substances, Axis II is personality disorders, Axis III is medical conditions, and Axis IV is social stressors (Axis V was general functional ratings which is no longer used). Under an Axis I there can be many diagnoses listed together.
If there is more than one disorder listed on the Axis I, then it is important to determine if one is secondary to another. Usually, the first disorder is primary and the second is secondary. For example, if it looks like this: Axis I: Major depressive disorder, ETOH abuse disorder. This would imply in most clinical areas that the alcohol abuse was secondary to the depression, in other words, the depression caused or led to the alcohol abuse. However, not all psychiatric providers abide by this form of diagnosing so it is up to the veteran to get clarification in writing.
How to Determine if Substance Abuse or Alcohol is Secondary to Mental Health
One way a veteran can help their treatment provider determine if their substance or alcohol use is secondary to their mental health condition is by providing a timeline or history. Identifying when the substance or alcohol use started or became a problem and comparing it to when symptoms of a mental health problem began. Be careful not to compare the use to when there was a diagnosis because often veterans are not diagnosed with a mental health condition until after there has been a substance or alcohol problem for quite a while. In fact, substance and alcohol use are often catalysts for finding mental health problems among veterans as many veterans do not report mental health symptoms due to the stigma attached and risks of losing their careers. Drinking with their troops is much more socially acceptable, unfortunately, than seeking out mental health treatment in the military. Veterans should review symptoms with a mental health provider and check with family members to find out when they first started exhibiting symptoms and compare it to when they first started using alcohol or substances to ensure the timeline is accurate. The collateral evidence is usually more accurate than the veteran’s own memory of symptoms as if it often difficult to see symptoms in yourself as opposed to others, especially subtle behavior changes.
Why is it Important to Know Which is Primary?
Most veterans who have a substance or alcohol problems will have an undiagnosed mental health disorder that precipitated the use disorder and they should 1) get proper treatment and 2) file for disability compensation. First, substance and alcohol use disorders cannot be treated properly and successfully if there is an underlying mental health disorder and it is not being treated as well. The substance or alcohol use disorder is often a coping mechanism for the mental health problem and when the mental health condition continues to be untreated, the veteran will continue to use alcohol or substances to treat the condition on their own. The VA has shown that there is a strong correlation between mental health and substance and alcohol use disorders:
- More than two of ten veterans with PTSD also have a substance use disorder;
- War veterans with PTSD and alcohol problems tend to binge drink in response to bad memories of combat trauma;
- Almost one in three veterans seeking substance abuse treatment also has PTSD;
- Veterans who smoke is almost double for those with PTSD compared to those without a PTSD diagnosis; and
- One in ten veterans returning from the wars in Iraq and Afghanistan have a problem with substances and/or alcohol.
Filing a claim for compensation can help provide options for veterans with co-occurring mental health and substance use disorders. First, a medical evaluation can be conducted to determine the extent and primary diagnosis. An independent medical exam can often be utilized if a VA C&P examiner decides that the veteran’s substance use disorder precipitates their mental health disorder. Most psychiatric treatment providers working with co-occurring disorders understand that there is usually a mental health disorder that causes the need for coping mechanisms, which is what the substance and alcohol use disorder usually stems from, a need to find a way to cope with something. Ensuring that an evaluation is done by a specialist who understands the concepts of co-occurring disorders is vital to a veteran’s claim. Second, once compensation has been awarded, the veteran is entitled to health care treatment as well as monetary compensation. Most veterans with a co-occurring disorder have difficulty finding or keeping a job so financial stress is important to address. Also, mental health disorders often lead to suicide and sic of ten veterans who attempt suicide were not getting medical or mental health treatment, so having a treatment provider or a primary care provider is essential to keeping veteran’s safe and alive.
Another addiction issue is if a veteran is being treated for pain and becomes addicted to medication used to treat the pain. If the treatment is from the VA, this is also subject to compensation and the veteran should file a claim for compensation based on service connection for injuries caused by VA healthcare.
Keeping our veterans safe is vital to our mission. This blog, among the many we have published that discuss ways for veterans to address their mental health conditions, is just one way we try to get the message out. Co-occurring disorders involving substance and alcohol use are among the most misunderstood and stigmatized disorders veterans suffer from. If you know a veteran who is suffering from these, please ask them to get help.