• Just over 50% of veterans with one mental health disorder also had a comorbid disorder (DVA, 2018).
• A key factor in managing complex cases is sequencing the treatment for comorbid conditions.

Key characteristics and prevalence

Veterans commonly present with comorbid disorders and complex needs that require careful treatment planning. For example DVA (2018) identified:

• up to 90% of veterans with posttraumatic stress disorder (PTSD) will meet criteria for another mental health problem
• just over half of recently transitioned ADF members with one mental disorder also had a comorbid disorder
• alcohol disorders were the most common comorbid condition, with approximately 95% of those meeting criteria for alcohol disorder also having a comorbid condition

Screening and assessment

Case formulation is used to understand complex veteran presentations. Case formulation assists in:

• focussing on presenting problems that are likely to have the most impact on a veteran's recovery
• setting priorities for treatment.

Case formulation goes beyond summarising information gathered during assessment and provides an explanatory story that is used to focus treatment.

The following case formulation model can be easily adapted to fit in with most treatment approaches. It takes into account factors that lead to and perpetuate presenting issues as well as the client’s vulnerabilities and strengths. A case formulation includes the following elements:

• presenting problems
• factors that cause the individual to be vulnerable to the development of these problems (predisposing factors)
• factors that trigger the onset of the presenting problems (precipitating factors)
• factors that might be barriers or supports for change (prognostic factors)

The case formulation culminates in a hypothesis about the relationship between presenting problems and what maintains them (perpetuating factors). Please refer to this one page case formulation template:

In order for the case formulation to be a useful tool, it needs to move beyond describing or listing the above factors. It should describe the relationships between these factors and provide a coherent story about the way the veteran is presenting in counselling.

DVA offers an online training course in case formulation.

Psychological intervention: Sequencing

An important aspect of managing complex cases is the sequencing of treatment for comorbid conditions. Treatment sequencing tends to focus on those disorders which:

1. present the most severely
2. are the most disabling
3. are the most likely to lead to further harm

Effective treatment for complex presentations also addresses problems that are likely to impact on the veteran’s ability to engage in treatment. Before treatment begins, problems must be resolved that impair:

• alertness
• motivation
• attention
• emotional stability

Suggestions for treatment sequencing for commonly co-existing mental health problems in veterans are outlined below.

Depression and high-risk alcohol use

When depression and high-risk alcohol use conditions are severe:

1. treat the alcohol problems first, 
2. maintain active monitoring of the risk of self-harm or suicide

This is because depression may have an organic basis associated with alcohol dependence, including:

• delirium
• impaired liver function or 
• systemic illness

Treatment for depression without a reduction in alcohol use, will only have limited effectiveness. Depression may lift once the veteran is successfully treated for high-risk alcohol use. If both conditions are mild to moderate in severity, treatments can commence simultaneously.

Posttraumatic stress disorder and high-risk alcohol use

Treatment for PTSD and high-risk alcohol use can commence simultaneously, excluding the trauma-focussed component.

The trauma-focussed component should commence only when the veteran has demonstrated a capacity to manage distress without resorting to alcohol.

Posttraumatic stress disorder, depression and high-risk alcohol use

Where conditions are severe:

1. treat the alcohol use first
2. actively monitor the risk of self-harm or suicide

Initial phases of PTSD treatment, excluding trauma-focussed treatment can commence simultaneously with the treatment of alcohol-use problems.

Where all conditions are mild to moderate, simultaneous treatment can commence, excluding the trauma-focussed component of PTSD. This can commence when the veteran is able to tolerate two to three days per week without using alcohol.

Posttraumatic stress disorder, depression and panic disorder and/or generalised anxiety disorder

Where PTSD, depression and panic disorder and/or generalised anxiety disorder (GAD) are severe, treat the depression first. This is because depression has been demonstrated to impair the effective treatment of anxiety disorders.

If the conditions are mild to moderate, treat the PTSD first. This is because improvements in PTSD are likely to result in reductions in demoralisation and depression.

Moderate to severe depression and panic disorder and/or generalised anxiety disorder

Where moderate to severe depression and panic disorder and/or GAD are present, focus on treating the depression first, and ensuring you include breathing control to reduce panic. This is because depression is potentially life threatening and there is evidence that poor morale and impaired attention will impair:

• learning of arousal management
• attention to exposure cues
• compliance with self-care treatment

See also