issues for veteran populations but not for active-duty service members. Among current service members, the needs of active-duty personnel differ from those of National Guard and reserve members and may vary according to service branch. Within veteran populations, the most important co-occurring medical and psychosocial treatment needs for patients who have PTSD may vary according to era and location of service. Dementia and other neurologic conditions that occur more frequently in aging populations, for example, constitute important comorbidity issues for veterans of World War II and Vietnam, but not for veterans of more recent conflicts.


Comorbid conditions that include symptoms of depressive or anxiety disorders, substance use disorders, and high-risk behaviors appear to affect at least as many veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) as PTSD alone (Hoge et al., 2004; Santiago et al., 2010). A large body of literature on trauma-exposed veteran and civilian populations supports the frequent co-occurrence of PTSD symptoms with depression (Erickson et al., 2001; Freuh et al., 2000; O’Donnell et al., 2004; Perlman et al., 2011; Shalev et al., 1998), traumatic grief (Prigerson, 2009; Shear, 2001, 2005), and alcohol use and drug use problems (Cerda et al., 2008; Cisler et al., 2011; Kulka, 1990; Zatzick and Galea, 2007) that may lead affected people to engage in high-risk behaviors that, in turn, are associated with exposure to additional traumatic events (Hearst et al., 1986; Kulka, 1990; Pat-Horenczyk et al., 2007). High rates of moral injury (defined as the perpetration of or failure to prevent atrocities or the witnessing of acts that transgress moral beliefs) (Litz et al., 2009) have been documented in active-duty military personnel deployed in the OEF and OIF theaters of war (MHAT IV, 2006).

The National Vietnam Veterans Readjustment Study, one of the first major epidemiologic investigations of Vietnam veterans, documented high rates of co-occurrence of PTSD and psychiatric disorders (Kulka, 1990). Three-fourths of male Vietnam veterans who had PTSD also had a lifetime diagnosis of alcohol abuse or dependence, 44% had a lifetime diagnosis of generalized anxiety disorder, and at least 20% had a lifetime diagnosis of depression or dysthymia. Of female Vietnam veterans who had PTSD, 44% had a lifetime diagnosis of depression and 23% had current depression. Research conducted in the 1980s also suggested that men who served in Vietnam were at increased risk for trauma, including fatal motor vehicle crashes and completed suicide (Hearst et al., 1986).

Stepped-care approaches begin with lower-intensity treatments, such as support groups, and phase in more intensive procedures, such as evidence-based interventions—such as cognitive behavioral therapy (CBT) and

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