Nov 1, 2021
For Veterans, Mental Health Is the Next Battlefront

When Army Staff Sgt. Earl Granville (pictured above, on the left) runs in a race with a team of fellow veterans as part of the Achilles Freedom Team, they often take turns carrying a cinderblock strapped to their backs.

They call the block “Cindy,” and what she represents, Granville said, is “the heavy, mental adversity we all face as human beings. Guilt, stress, depression, anxiety – all those bad feelings that hold you down and keep you from enjoying life.”

When one teammate gets tired of carrying Cindy, they hand her to another.

“It’s a reminder that no one has to carry their burden alone,” Granville said. “We all carry the burden together.”

It’s a message that Granville devotes his life to telling. The 37-year-old Pennsylvania resident lost part of his left leg in 2008 during a tour in Afghanistan, when a roadside bomb hit his vehicle and killed two of his friends, Spc. Derek Holland and Maj. Scott Hagerty.

But for Granville, the months he spent rehabilitating from the blast were nothing compared to the internal struggles he faced when his twin brother, Staff Sgt. Joe Granville, died by suicide two years later. The invisible wounds he felt were crushing.

“When I lost my leg, I felt so lucky to be alive,” he said. “But when I lost my brother, I was a wreck. It nearly destroyed me.”

For Veterans and Active Military Members, Mental Health Statistics Are Sobering

Deployments – particularly repeated deployments – have taken a toll on the mental health and well-being of many veterans and active duty members. Called “shell shock” by World War I soldiers, these invisible wounds of war – which include depression, post-traumatic stress disorder (PTSD), and traumatic brain injury – are widespread.

The statistics are sobering. According to one of the largest studies of mental health risk among the U.S. Military, the rate of major depression among soldiers was five times as high as civilians, and the rate of PTSD was nearly 15 times higher. Veterans with PTSD also have high psychiatric comorbidity rates. One study showed that major depressive disorder is three-to-five times more likely to emerge in those with PTSD than those without. And nearly 20% of service members returning from Iraq and Afghanistan reported experiencing a probable traumatic brain injury, according to a study from the RAND Center for Military Health Policy Research.

Left untreated, these invisible wounds can have devastating effects on veterans and their families. According to the RAND Center, people affected with depression, PTSD, and traumatic brain injury can exhibit higher rates of other unhealthy behaviors, higher rates of physical health problems, and higher rates of suicide.

One recent study showed that more than 30,000 active duty and veterans of post 9/11 wars have died by suicide over the last 20 years. That’s more than four times the number of service members killed in war operations during that time.

Military and Veteran Resources

Our health resources for veterans can help you or a family member cope with military deployment and find assistance and support post-deployment. You do not have to be a Cigna customer to access these resources.

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Transitioning to Life Back Home

Those life changes can make the adjustment to civilian life difficult for some veterans.

“Most of us join as soon as we become adults,” said Granville, the Army Staff Sergeant. “Our whole adult life is combat boots and a rifle. Then we’re taken out of this huge culture that’s full of purpose and passion.”

Granville says he refers to the veterans who want to hang on to the “glory days” as suffering from Uncle Rico Syndrome, named for the character who was obsessed with reliving high school days as a popular football player in the movie, Napoleon Dynamite.

To lift himself up after the death of his brother, Granville focused on what he calls finding the “three Ps” – a purpose, a passion, and a part of something bigger than himself, all of which he had in the Army. For Granville, his purpose came from motivational speaking. His passion is physical fitness and traveling. And he’s a part of several charities, a member of the Achilles Freedom Team, and sees it as his duty to honor his friends, Derek and Scott, by helping their families.

Dr. Will Lopez, a U.S. Air Force veteran and the senior medical director for Cigna behavioral health, said this kind of structure is important in helping veterans adjust to civilian life and maintain strong mental health and well-being.

“When you serve, you have a lot of structure,” he said. “Back in civilian life, you have to figure things out on your own.”

It can also be a struggle for veterans to determine how to translate their military skills to the civilian world.

“In many cases, there’s no direct job translation,” Lopez said. “And these factors can create barriers that prevent veterans from being successful.”

Invisible Wounds with Visible Symptoms

While the wounds that veterans suffer from may not be apparent to outsiders, loved ones can attest that the outward signs are very real.

“I think the first thing that shows up is a change in sleep patterns,” said Alexandra Bradley, an informatics consultant with Cigna’s national accounts and co-lead of the Salute employee resource group (ERG), who is the daughter of a Navy Commander as well as a spouse of an Army Colonel. “Then it’s the need to carve out time on their own. And then, in many families, it’s about money.”

Ayanna Bernard, a Cigna Salute ERG co-lead and Army veteran, military spouse and military mom, said many military families, especially lower enlisted, live paycheck to paycheck. Working to make ends meet can cause huge amounts of stress for spouses and service members alike.

The impact on mental health and well-being can linger long after deployment. In addition, PTSD symptoms may not emerge until weeks or even years after a traumatic event. The symptoms include avoiding people or activities that remind the person of the traumatic event; negative thoughts and hopelessness; self-destructive behavior; trouble sleeping and concentrating; and angry or aggressive behavior.

Symptoms of traumatic brain injury are also very broad, and it can be tricky to diagnose because all too often, veterans don’t realize they have it.

Traumatic brain injury in veterans is typically caused by exposure to blasts, which can also result in more significant brain injuries than those from falls or motor vehicle accidents – the most common causes of brain injury for civilians, said Dr. Gregory Przybylski, a senior medical principal for Cigna who also serves on the New Jersey Neuroscience Institute.

But if a veteran doesn’t lose consciousness from the blast, “they may not recognize they have a brain injury,” Przybylski said. “Then, if they experience headaches or dizziness or memory difficulties, are they going to attribute it to the blast or not?”

Przybylski said the symptoms of traumatic brain injury are also very broad, but they include four key categories:

  • Thinking and learning, which include dizziness, distractibility, and difficulty communicating.
  • Motor sensory, which include visual impairment, such as blurred vision, double vision, and light sensitivity, as well as hearing impairment, such as tinnitus and sound sensitivity.
  • Emotional, which includes depression, anxiety, and heightened emotions.
  • And behavioral, which includes a lack of energy and impulse control.

The last two categories overlap with depression and PTSD – creating more confusion for veterans and families as they try to figure out “where you fit in this alphabet soup,” Bradley, the military spouse, said.

Compounding Factors Further Impact Mental Health and Well-Being

Complicating matters is that veterans can suffer from more than one invisible wound, which, in turn, further compounds mental health issues.

It doesn’t help that military members can spend long periods of time away from family and friends.

“A huge part of successful rehabilitation from traumatic brain injury depends not only on your support services at home, but also your family network and friend network, because they often take up a large portion of the burden of your rehabilitation,” Przybylski said.

When people withdraw or are isolated from their support systems, they can turn to alcohol or drugs. And when patients are impaired by substance abuse, they’re more likely to be even more angry and aggressive – which can further alienate them from family and friends, Przybylski said.

At the same time, since veterans have a much higher incidence of PTSD than the general population, the combination of PTSD and traumatic brain injury “is more profound in terms of its effects on an individual,” Przybylski said. “With PTSD, you have difficulty concentrating. You’re distracted. You have difficulty communicating.”

“It’s not just additive – it’s a combination that makes it much more difficult for someone to successfully rehabilitate.”

And when you combine traumatic brain injury with substance abuse and PTSD, “the resulting cognitive impairment can make it even more difficult for a person to cope,” Przybylski said.

For Veterans, a Mental Health Stigma Remains

Help is available – through the U.S. Department of Veterans Affairs, the Cigna Veteran Support Line, employer-sponsored insurance, a company’s employee assistance program (EAP), and a number of charities

But one of the biggest barriers in mental health treatment is that people – and veterans in particular – often have trouble asking for help.

“A lot of this comes from the military culture,” said Lopez, the Air Force veteran and psychiatrist. “We’re tough. We have to get our boots on and keep going.

“Unfortunately, a lot of barriers to getting help are self-imposed,” Lopez said. “Even in the 21st century, we still have a lot of stigma around mental health.”

Doug Pallister, senior manager of operations at Evicore (a Cigna company), who served as Command Sgt. Major for the 75th Ranger Regiment, put it this way: “I always ask people, ‘If you broke your leg, what would you do?’ They’d say, `I’d go to the doctor.’ So I ask, ‘If you break your head, what should you do?’ The answer is, you also need to go to the doctor.’

“The challenge is, as much as we like to say there’s no stigma, there really is a stigma around mental health,” Pallister said.

Misconceptions about Veterans Abound

Another issue that prevents many veterans from talking about their experiences is that all too often, civilians will assume that because they’ve deployed, they suffer from PTSD.

“People can be shy about wanting to share their experiences, because they’re afraid if they open up just a little bit, someone will put them in a box, and then it could affect their career,” Pallister said.

“I’ve served in combat,” he said. “I’ve lost some friends. I have the typical feelings that you would have. But I don’t have PTSD.”

It’s an issue Granville has had to deal with many times. Once, he was even invited to a hunting trip by a group who said it would help him with his PTSD.

“I said to them, ‘Just because I lost my leg, doesn’t mean I have PTSD,’” Granville said. “There’s a huge misconception that if you’ve served, then maybe you’re struggling mentally.”

Social Determinants Remain a Factor

Too often, when veterans do ask for help, the mental health resources available can be dependent upon who they are and where they live.

“Social determinants of health are a big issue,” said Przybylski, who also serves on the New Jersey Advisory Council on Traumatic Brain Injury. “The resources available and circumstances vary widely depending on where you live.”


The chart above shows that social and economic factors like education, income, discrimination, and more, can impact health and well-being.


Wendy Barnes, who served for 10 years as a Medical Service Corps Officer and is now president of Express Scripts, said there are opportunities to expand mental health resources to underserved areas through virtual and telehealth.

“There are really some phenomenal resources out there,” said Barnes, who is also the executive sponsor for Cigna’s Salute ERG. “But I don’t think we have nearly the breadth that there should be, and I still think there is an opportunity for more expansive coverage.

“We all don’t have the benefit of living in major metropolitan areas that have a plethora of mental health services,” she said. “That’s one reason that virtual access is so exciting.”

What Loved Ones of Veterans Can Do

When a veteran does ask for help, the most important thing to do is just listen.

“We all have two ears and one mouth for a reason,” Pallister said. “So my big takeaway is, listen more than you talk, especially if it’s one of your subordinates or direct reports.

“And don’t try to make it like you know where they’re coming from unless you’ve actually been there,” he said. “Just because your uncle fought in Korea doesn’t mean you understand the kid who did three tours in Iraq and one in Afghanistan.”

Pallister’s other piece of advice is this, “Don’t baby a veteran. And don’t try to put the person in a box. The majority of veterans are no different than any other guy or gal walking down the street.”

From the perspective of a military spouse, Bradley’s advice comes in three parts.

“First, remind them that you love them, and love is unconditional,” she said. “Second, remind yourself that you love yourself, because it’s easy to take on the burden and think that you’re responsible.

“And the third thing is to get help,” she said. “If you have EAP, call your EAP. Cigna has a veteran support line. Find someone to talk to. And find some active care that you can do for yourself every day – go for a walk, go and get a coffee, because if you don’t find a way to look outside your tunnel, you’ll never get out of it.”

Help Is Available

Cigna’s health resources for veterans and the military can help you or your family member find support and assistance. Help is available – even if you are not a Cigna customer.

Learn more