Post-traumatic stress disorder (PTSD) is one of the most common mental health problems seen in the Veterans Health Administration (VHA). Based on a 2008 survey by the RAND Corporation, it is estimated that about 300,000 Veterans who have returned from Iraq and Afghanistan are suffering from PTSD or major depression. VHA continues to devote considerable resources to identifying and treating PTSD. Presented here are four recently completed HSR&D research studies that address several aspects of PTSD.

Keywords: post-traumatic stress disorder, mental health, OEF, OIF, trauma, clinical tools, brain injury

1. Understanding Barriers and Facilitators for Veterans Seeking PTSD Treatment

In this study, investigators sought to learn more about what prevents—or aides—Veterans who would like to find and begin treatment for PTSD. (Study No.: DHI 05-111, Nina Sayer, PhD.)

Questions

What prevents or facilitates treatment initiation for PTSD? Are these barriers and facilitating factors different in Veterans from the Vietnam era (VE) than for Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)?

Results

The study results indicate that the following factors act as barriers for Veterans seeking PTSD treatment:

• Avoidance of trauma-related memories and feelings
• Values that conflicted with treatment-seeking
• Access barriers, such as lack of knowledge about what constitutes PTSD or where PTSD services are available
• An invalidating post-trauma/post-deployment environment

Facilitators to treatment included:

• Recognition and acceptance of PTSD and an understanding of where services are available
• Treatment-encouraging beliefs
• Social network encouragement (spouses, other Veterans)

Authors described that, in general, VE Veterans had more barriers and fewer facilitators than OEF/OIF Veterans, and ascribed these barriers to a lack of understanding of PTSD during the VE, as well as their negative homecoming experiences. Overall, OEF/OIF Veterans had more facilitators: they showed a basic understanding of available PTSD services, experienced improved access to PTSD services and reduce stigma.

Impact

Both social (friends, family, post-deployment environment) and system-level (care providers, benefits, etc.,) components play important roles in determining whether a Veteran will begin treatment for PTSD. The authors suggest that any PTSD treatment initiation model should include elements from social networks, as well as the healthcare and disability systems, and should be mindful of Veterans' post-trauma/post-deployment environments. Authors also suggest that these findings have implications for the development of interventions that promote timely help-seeking for PTSD. They recommend tailoring outreach strategies for Veterans who have experienced post-trauma or post-deployment invalidation, and who do not have an extensive or supportive social network.

Publication Notice: This study resulted in the following publications:

• Spoont MR, Sayer N, Friedemann-Sanchez G, Parker LE, Murdoch M, Chiros C. "From trauma to PTSD: beliefs about sensations, symptoms, and mental illness." Qualitative Health Research. October 2009.
• Sayer NA, Friedemann-Sanchez G, Spoont M, Murdoch M, Parker LE, Chiros C, Rosenheck R. "A qualitative study of determinants of PTSD treatment initiation in veterans." Psychiatry. January 2009.

2. Outcomes for National Guard Soldiers with Comorbid Mild TBI/PTSD

This study sought to describe the occurrence of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) in National Guard members returning from deployment in Iraq. (Study No.: RRP 08-252, Melissa A. Polusny, PhD.)

Question

What is the scope of mild TBI (mTBI) and PTSD among National Guard soldiers returning from deployment in Iraq? To what extent do these problems impact Veterans' psychosocial functioning, physical health, and quality of life over time?

Results

Using survey data from an existing sample of 1,892 National Guard soldiers deployed to Iraq who had provided in-theater screening data on blast exposure and PTSD symptoms one month before returning home (Time 1) and again one year following soldiers' return (Time 2), investigators learned:

• At Time 1, rates of self-reported mTBI were 9%.
• At Time 2, rates of self-reported mTBI increased to nearly 21%.
• Rates of probable PTSD (7% at Time 1 and 14% at Time 2) and probable depression (9% at Time 1 and 18% at Time 2) both doubled during the one year following deployment.
• One year post-deployment, 40% reported problematic drinking while 29% reported clinically significant sleep problems.
• Those with probable PTSD, regardless of mTBI status, reported greater depressive symptoms, greater problematic alcohol use, more sleep problems, lower quality of life, and poorer social adjustment. There were minimal differences between those reporting mTBI and those with no mTBI/PTSD on psychosocial outcomes.

Implications

Authors suggest that self-reported rates of mTBI and mental health problems increased during the year following deployment. Further, they observed that Veterans with probable PTSD, regardless of mTBI status, reported poorer psychosocial functioning in many areas. Further studies are needed to increase the understanding of factors that influence increases in reported mTBI during the first year after returning from deployment.

3. OEF/OIF Veterans with PTSD: Gender and Medical Needs

Investigators in this study sought to understand both the general medical care needs of men and women Veterans, and, more specifically, the needs of those Veterans who have a dual diagnosis of PTSD and substance use disorder (SUD). (Study No.: SHP 08-161, Rachel Kimerling, PhD.)

Question

What is the burden of disease for men and women Veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) who have been diagnosed with PTSD? Further, what is the burden of disease for those same Veterans who have a dual diagnosis of PTSD/Substance Use Disorder(SUD)?

Results

Of the approximately 90,000 OEF/OIF Veterans identified in the study group, researchers found:

• 27% of women and 35% of men had a diagnosis of PTSD
• Women and men with PTSD had more medical conditions than did those with no mental health conditions
• The most frequent medical conditions among women with PTSD were: lumbosacral spine disorders, headache, lower extremity joint disorders, skin disorders, tendonitis/myalgia, dental disorders, allergies, vision defects, acute upper respiratory tract infections, and overweight/obesity.
• The most frequent medical conditions among men with PTSD were: lumbosacral spine disorders, lower extremity joint disorders, hearing problems, tobacco use disorder, hyperlipidemia, tendonitis/myalgia, skin disorders, dental disorders, hypertension and sleep disturbance.
• 13% of women and 23% of men had a dual diagnosis of PTSD and SUD.
• Dual diagnosis indicated a higher prevalence of diagnosed injuries than did those with PTSD alone.
• Among women, those with dual diagnosis had higher rates of infections, gastrointestinal disorders, and genitourinary disorders than did those with PTSD alone.
• Dual diagnosis was also associated with increased use of emergency department care and acute inpatient stays.

Implications

The authors suggest that VHA's efforts to care for OEF/OIF Veterans with PTSD should take into account the increased need for mental, as well as medical, health service needs. The authors also suggest the possibility that medical treatments may need to be tailored to meet the special needs of patients with PTSD, and that medical and mental health services may need to be closely integrated for this special population.