U.S. Veterans’ Mental Health and Substance Use History

The Invisible Wound, Made Visible

A 130-year analysis of veteran health in America reveals that what has changed isn’t the wound itself, but its name, its medical explanation, and the substances used to cope. The trauma of the past wasn’t absent; it often went unspoken due to social stigma and was described using the medical language of the time.

Understanding this history is a critical step in breaking the stigma that still prevents many veterans from seeking help for addiction and mental health conditions.

The Early History of Combat Trauma (1865-1945)

The Civil War: “Soldier’s Heart” and “Opium Slavery”

The Civil War was the first time the U.S. medical establishment tried to grapple with combat trauma formally. Lacking a modern framework, they diagnosed suffering soldiers with “nostalgia”—a condition described as a “morbid homesickness” so severe it could lead to death.

To avoid the stigma of this perceived “mental failing,” a physical diagnosis emerged: “Soldier’s Heart.” This was a critical first attempt to legitimize the wound by rooting it in a physical organ, describing symptoms we’d now recognize as panic disorder and hypertension.

Substance Use and Public Perception: Alongside this crisis was America’s first opioid epidemic. Battlefield medicine relied on opiates. Surgeons prescribed opium, laudanum, and morphine for wounds and camp diseases. While 19th-century record-keeping was spotty, the problem was pervasive enough to alarm public officials.

It’s estimated that thousands of veterans became addicted, a condition they called “Opium Slavery.” This opioid addiction wasn’t seen as a medical condition but as a moral failing. Addicted veterans were viewed as “immoral and unmanly,” deserving “punishment, not help,” which forced the problem underground and led to many deaths from accidental overdoses.

Treatment and Self-Harm: Treatment for these psychological wounds was institutional. The precursors to the VA, the National Homes, maintained “insane wards” for veterans. Those deemed “hopelessly insane” were often transferred to state lunatic asylums.

World War I: “Shell Shock”

In WWI, the term “shell shock” was coined to describe a collection of symptoms that rendered soldiers unable to function. The scale was unprecedented, with estimates that probably over 250,000 men suffered from the condition.

• Fatigue
• Tremors
• Nightmares
• Confusion

The debate continued: was it a physical concussion from artillery (“the big guns pounding”), or was it something else?

Perception and Self-Harm: Military leadership often dismissed shell shock as “cowardice or malingering.” Soldiers in the trenches, however, had a more compassionate view. They dreaded shell shock more than being wounded and felt sorry for them.” Symptoms were also ‘culturally bound’—the paralysis and mutism common in WWI are rare today. In an era where a psychological wound was equated with cowardice, a soldier’s mind may have produced the only “legitimate” symptoms the culture would accept: physical ones.

Sadly, records from this era also confirm that “intentional self-injury” was a documented event. The undiagnosed trauma led to high rates of suicide and heavy alcohol abuse after the war.

Treatments: Treatments for shell shock were crude and included:

• “Forward psychiatry” (prompt rest near the front lines)
• Hypnosis
• “Re-education”
• Electric shock therapy

World War II: “Battle Fatigue”

During World War II, “shell shock” was replaced with “battle fatigue.” The sheer scale of the conflict forced military medicine to acknowledge a new truth: any soldier, no matter how strong, has a breaking point.

The numbers were staggering: 1,393,000 soldiers were treated for battle fatigue.

In fact, 40% of all medical discharges were for psychiatric reasons, and combat fatigue was responsible for one out of every four casualties. On Okinawa alone, there were 26,000 psychiatric casualties.

This new understanding didn’t eliminate stigma. Lt. Gen. George S. Patton, for example, infamously “did not believe ‘battle fatigue’ was real.” The U.S. Army in Europe also acknowledged that at least 40,000 men deserted.

Substance Use and Public Perception: The “Greatest Generation” Didn’t Return Untroubled.

Two influential social factors often obscured their trauma:

1. A supportive public that met them with ticker-tape parades.
2. The GI Bill, which provided a path to college and homeownership, acted as a sociological buffer.

The hidden alcoholism of the 1940s and ’50s replaced the “Opium Slavery” of the 1860s. A “work hard, play hard” military culture normalized heavy drinking as the primary, and legal, tool for coping with stress.

The Turning Point: A New Understanding (1950-1980)

The Korean War: “Combat Exhaustion”

The Korean War continued the World War II model. The terminology remained “battle fatigue” or “combat exhaustion.”

Symptoms we’d now associate with PTSD—nightmares, irritability, hyperarousal—were recognized, but the military still viewed the condition as “transient.” The focus was on “salvage” and returning soldiers to duty, with little attention paid to chronic, long-term problems, and any attention that was paid “waned” after the acute phase.

The Vietnam War: “Post-Vietnam Syndrome”

The Vietnam War shattered the old models. Returning to a nation divided and often hostile, these veterans refused to suffer in silence. They organized “rap groups” and invited anti-war psychiatrists to listen.

Substance Use and Self-Harm: Co-occurring substance use disorders (SUDs) were rampant, as veterans used alcohol and illicit drugs to self-medicate their unrecognized trauma. This led to a “cycle of clinical deterioration” and a crisis of self-harm.

Some reports at the time claimed 10-15% of servicemen were addicted to heroin.

A 1971 study of returning Army enlisted men found that 43% reported using narcotics in Vietnam, and 20% of those users reported becoming addicted while there.

The suicide crisis was also devastating.

While widespread myths of 50,000 or more veteran suicides have been debunked, careful projections estimate that fewer than 9,000 suicides occurred among Vietnam veterans from their discharge through the early 1980s.

Later research confirmed the deadly link: an analysis of suicide risk found that while PTSD or depression alone were profound risk factors, veterans suffering from both PTSD and depression had a 15.2-fold increased risk of suicide.

Treatment and Perception: These veterans were often failed by the system. They were misdiagnosed with schizophrenia, and VA rules refused to connect symptoms to service if they emerged months or years after discharge.

This “hostile homecoming” acted as a trauma multiplier.

The 1980 Revolution: A New Diagnosis

The advocacy of Vietnam veterans, joined by feminist groups and Holocaust survivors, achieved a monumental victory in 1980: Post-Traumatic Stress Disorder (PTSD) was added to the DSM-III.

This wasn’t just a new name; it was a new beginning. It was the most profound conceptual shift in the history of military psychiatry.

It officially externalized the cause of the trauma.

• Before 1980, the question was: “What is wrong with you?” Diagnoses implied an “inherent individual weakness.”
• After 1980, the question became: “What happened to you?” PTSD was the first diagnosis to require a “catastrophic stressor… outside the range of usual human experience.”

This victory was necessary, but it’s also the source of the modern misconception.

Making the wound visible and diagnosable allowed the public to measure it for the first time. People mistook this new visibility for newness.

The Modern Veteran: A New Disconnect and New Wounds

The post-Vietnam era, marked by the All-Volunteer Force (AVF), completed the modern story’s final piece: the significant civilian-military divide.

The Civilian-Military Divide

When the draft ended in 1973, the “bridge” between the military and the public broke. Today, less than 1% of Americans serve. The result is “admiration without understanding.”

• 84% of modern veterans say the public has “little or no understanding” of the problems they face.
• 71% of the public agrees with them.

Perception as a Barrier: This knowledge vacuum is often filled by media stereotypes of the “broken veteran.” The public, with no personal connection to service, sees the visible diagnosis of PTSD and assumes the problem is new. This public misunderstanding becomes a new burden.

In fact, 80% of veterans state that embarrassment or shame—fueled by these stereotypes—acts as a barrier to seeking mental health care.

The “Signature Wounds” and Complex Risks of the Post-9/11 Wars

While the trauma is timeless, the nature of modern wounds has created genuinely new clinical challenges.

The pervasive use of Improvised Explosive Devices (IEDs) made Traumatic Brain Injury (TBI) a “signature wound” of the wars in Iraq and Afghanistan.

New Clinical Challenges: The key clinical feature of this era is the staggering comorbidity of TBI and PTSD.

Their overlapping symptoms make diagnosis incredibly complex:

• Sleep problems
• Irritability
• Memory issues

One study of veterans with a history of TBI found that 90% had at least one comorbidity (PTSD, depression, or headache). Another study of veterans with confirmed TBI found 85% had at least one psychiatric diagnosis.

Substance Use: This complex clinical picture is complicated by substance use. More than 1 in 10 U.S. veterans have been diagnosed with an SUD. Opioid use became a significant issue, with the number of opioid prescriptions from military physicians quadrupling between 2001 and 2009.

Research shows veterans with PTSD are more likely to be prescribed opioids, with one study finding 17.8% of veterans with PTSD receiving them.

The Modern Suicide Crisis: The veteran suicide crisis also reflects a new complexity.

• Over 140,000 veterans have died by suicide since 2001, with 6,407 in 2022 alone.
• By 2022, 75% of veteran suicides involved a firearm.

Shockingly, the data shatters simple narratives: the suicide rate for post-9/11 veterans who were undeployed is 48% higher than for veterans who were deployed. This points to several catastrophic risk factors independent of combat:

• The intense stress of military life itself
• Difficult transitions back to civilian life
• Military Sexual Trauma (MST)

The Dual Burden on Today’s Veterans

The historical record is clear: the invisible wound is not a new phenomenon.

Self-medication is not new.

The consequences are not new.

• Opium Slavery” in 1865 became the normalized alcoholism of 1945.
• “Soldier’s Heart” in 1865 became “Shell Shock” in 1918.
• “Shell Shock” became “Battle Fatigue” in 1945.
• “Battle Fatigue” became PTSD in 1980.

The misconception of the “untroubled past” is a product of a century of stigma and a modern public disconnect.

This leaves today’s veteran with a unique dual burden:

1. A New Clinical Burden: They face a genuinely new and complex comorbidity of TBI and PTSD that is difficult to treat.
2. A New Sociological Burden: They must carry these wounds while being profoundly misunderstood by a public that stereotypes them as “broken.”

Understanding this history is the first step to dismantling the stigma. The battle after the battle is real, and it has always been here.

If you or a veteran in your family is struggling, you are not alone, and you are not the first. Help is available.

Reach out today to learn about treatment options specifically designed for veterans.

Written by

Chris Carberg

Founder & CEO, AddictionHelp.com

Chris Carberg is the Founder and CEO of Addiction Help. Chris battled a serious addiction to prescription drugs (opioids and sedatives) and alcohol, getting clean and sober in 2005. Chris has been a founder in several health-driven internet startups but Addiction Help represents his life's work. He has dedicated his life to helping addicts like himself reach recovery and see their lives and dreams restored.

Reviewed by

• Fact-Checked
• Editor

Kent S. Hoffman, D.O.

Co-Founder & Chief Medical Officer

Kent S. Hoffman, D.O. has been an expert in addiction medicine for more than 15 years. In addition to managing a successful family medical practice, Dr. Hoffman is board certified in addiction medicine by the American Osteopathic Academy of Addiction Medicine (AOAAM). Dr. Hoffman has successfully treated hundreds of patients battling addiction. Dr. Hoffman is the Co-Founder and Chief Medical Officer of AddictionHelp.com and ensures the website’s medical content and messaging quality.