When war follows combat veterans home

Cognitive behavioral therapy—including coping skills training, relapse prevention, contingency management, and behavioral couples’ therapy—and 12-step treatment programs are evidence-based options for the treatment of substance abuse disorders. Behavioral counseling interventions in the primary care setting (typically lasting 5-15 minutes) result in decreases in alcohol consumption, heavy drinking episodes, drinking above recommended amounts, and the number of days spent in the hospital, but have not been demonstrated to affect mortality, alcohol-related liver problems, outpatient visits, legal problems, or quality of life.⁵⁶ Resources can be found at www.niaaa.nih.gov. For patients with dual diagnoses, it is not yet known whether sequential therapy (in which substance abuse is treated first, followed by treatment of the comorbid mental illness) or concurrent therapy results in better outcomes.⁵⁷

CASE Your patient’s history of recent combat service, acknowledgement of employment and behavioral difficulties, and initial screening results lead you to diagnose alcoholism and depression. Additionally, she denies any suicidal ideation, but admits to experimenting with synthetic marijuana. After some discussion, she agrees to see your clinic’s social worker, and you start her on an SSri with scheduled follow-up.

CORRESPONDENCE
Shawn Kane, MD, USASoc, Attn: Surgeon (AomD), 2929 Desert Storm Drive, Ft. Bragg, NC 28310, or PO Box 3639 Pinehurst, NC 28374; shawn.kane@us.army.mil