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  • Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem
    Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing.
    Date: March 17, 2020
  • All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
    After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
    Date: January 31, 2020
  • VA Healthcare Benefits May Reduce Racial/Ethnic Disparities in Seeking Mental Health Treatment among Veterans
    This study assessed whether racial/ethnic disparities in mental health treatment seeking for psychiatric conditions common in the Veteran population (PTSD, major depressive disorder, alcohol-use disorder or AUD) were attenuated for military Veterans compared to civilians, and whether attenuation was more pronounced among Veterans who had VA healthcare coverage in the past 12 months. Findings showed that unlike civilians, racial/ethnic minority Veterans did not differ from whites in time to initiate treatment for PTSD and depression, and showed a shorter time to initiate treatment for AUD. Racial/ethnic minority Veterans with past year VA healthcare coverage were the most likely to seek treatment for all three disorders, whereas racial/ethnic minority civilians were the least likely to seek treatment for all three disorders. Among racial/ethnic minority patients, shortened time to treatment initiation for Veterans relative to civilians remained significant after adjusting for additional demographic and clinical covariates for PTSD and major depressive disorder, but not alcohol use disorder. Findings suggest that military service and benefits available to Veterans may reduce racial/ethnic disparities in seeking mental health treatment seen in the civilian population.
    Date: January 27, 2020
  • Past Year Opioid Misuse Associated with Past-Year Suicide Attempt among High-Risk Veterans
    The main objective of this study was to test the relationship between past-year suicide attempt and past-year opioid misuse among Veterans at high risk of suicide who also reported using at least one illicit substance or alcohol in the past year. Findings showed that past-year opioid misuse was associated with past-year, but not lifetime, suicide attempt in high suicide-risk Veterans: 82% of opioid misusers had attempted suicide in the past year versus 56% of those who misused other substances. The relationship between past-year opioid misuse and past-year suicide attempt remained significant when psychosocial factors associated with suicide attempt and opioid misuse were included as covariates. Suicide attempt rates did not differ among those who misused different types of opioids. Among Veterans with past-year suicide attempt, those who misused opioids in the past year were more likely to use overdose as a method to attempt suicide compared to those who misused other substances. Opioid misuse may be a marker of more lethal near-term suicide behavior, supporting current VA opioid therapy guidelines in which suicide risk assessment during opioid therapy is recommended. Lethal means restriction of toxic substances among Veteran opioid misusers also may be important.
    Date: December 1, 2019
  • History of Military Sexual Trauma Common among Older Women Veterans
    This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
    Date: November 11, 2019
  • Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
    This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
    Date: March 7, 2019
  • Veterans More Likely than Non-Veterans to Receive Both Alcohol Screening and Brief Intervention for Alcohol Misuse
    This study sought to describe receipt of alcohol screening and brief intervention across Veteran status in a sample of U.S. residents receiving healthcare. Overall, Veterans were more likely than non-Veterans to be screened for both quantity of alcohol use (69% vs. 64%) and heavy episodic drinking (36% vs. 29%). Male Veterans were less likely than male non-Veterans to endorse heavy episodic drinking (15% vs. 22%) and unhealthy alcohol use (15% vs. 19%), while female Veterans did not differ from female non-Veterans on alcohol consumption measures. Among individuals who endorsed unhealthy alcohol use, Veterans were more likely than non-Veterans to report being offered advice about alcohol’s harms (48% vs. 30%) and being advised to reduce or abstain from alcohol use (25% vs. 18%). Rates of brief intervention were low among females reporting unhealthy alcohol use: only 24% of female non-Veterans and 28% of female Veterans reported receiving advice about alcohol’s harms.
    Date: December 1, 2018
  • No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
    The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for alcohol use disorders (AUDs) in patient-centered, alcohol-related care. Investigators in this study examined whether 12 months of alcohol care management via the CHOICE intervention – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). Findings showed that the CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders. Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively. Current quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial’s results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
    Date: May 1, 2018
  • VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
    This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
    Date: March 7, 2018
  • Greater Risk of Opioid Prescription Overlap in Veterans Using Medicare Part D–Reimbursed Pharmacies
    This study sought to identify trends in dispensed prescriptions for opioids and the frequency of overlapping days’ supply of prescriptions for opioid medications in Veterans dually eligible for VA and Medicare Part D benefits. Findings showed that over the study period, there was an increasing reliance on the use of Part D–reimbursed pharmacies for opioid prescriptions among Veterans. Although opioid overlap appears to be declining within the VA healthcare system, overlap is increasing among opioid prescriptions dispensed from Medicare Part D–reimbursed pharmacies. Predictors for overlap included female gender, Part D enrollment, no VA medication copay, sleep disorders, psychiatric diagnoses, and substance or alcohol abuse. Veterans who were Hispanic, older, and had higher incomes had lower odds of overlap.
    Date: May 1, 2017
  • Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
    The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
    Date: March 1, 2017
  • Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
    This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/ alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
    Date: March 1, 2016
  • Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
    This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
    Date: December 21, 2015
  • Alcohol Misuse among Female Veterans
    This study examined the demographic/military, interpersonal violence, and mental health correlates of alcohol misuse among female Veterans seeking VA healthcare. Findings showed that younger age, adulthood physical abuse, military sexual trauma, past-year psychological aggression by an intimate partner, and PTSD and depression symptom severity showed significant associations with alcohol misuse. Two of these associations – younger age and past-year psychological intimate partner violence – remained significant when examined in logistic regression models. Female Veterans at risk for alcohol use disorders may benefit from screening and intervention efforts that take into account exposure to interpersonal violence and mental health symptoms.
    Date: December 7, 2015
  • Factors Contributing to Insensitive Clinical Alcohol Screening in VA Primary Care
    This study sought to understand factors that might contribute to low sensitivity of alcohol screening. Findings showed that most observed screening was done verbally; lesser used methods included paper-based or laminate-based screening. During verbal screening, questions were often not asked verbatim and were otherwise adapted. Other verbal screening practices that might contribute to low sensitivity of clinical screening included making inferences, assumptions, and/or suggestions to input responses. Clinical staff introduced and adapted screening questions to enhance the comfort of Veterans. For example, using introductory statements such as, “I have several questions to ask you that we ask of all Veterans every year – so we are not just singling you out.” Non-verbal approaches to screening – or patient self-administration – might enhance validity and standardization of screening, while also addressing limitations of the clinical reminder and issues related to perceived discomfort.
    Date: August 1, 2015
  • Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
    This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
    Date: July 1, 2015
  • Prevalence of Alcohol Misuse among Women Veterans High Regardless of Care Setting
    This study sought to estimate the prevalence and correlates of alcohol misuse in women Veterans – and to assess the associations between alcohol misuse and mental health use in a group comprising both VA healthcare system users and non-users. Findings showed that women Veterans who did not use VA healthcare had a higher prevalence of alcohol misuse (32%) compared to women Veterans who did use VA healthcare (27%). The prevalence of binge drinking was similar for VA non-users (26%) and VA users (24%). The prevalence of past-year mental healthcare among women Veterans with alcohol misuse was higher for VA users than for non-users: 26% versus 5% for mild alcohol misuse, and 43% versus 17% for moderate-to-severe alcohol misuse. Among VA non-users, 46% of women Veterans with PTSD and 66% of those with sexual assault in the military screened positive for alcohol misuse. Among VA healthcare users, the prevalence of alcohol misuse was notably high among younger women (ages 18-44, 43%), those who served in OEF/OIF (51%), and those with combat exposure (41%).
    Date: May 1, 2015
  • No Significant Association between Public Support Income, VA Disability Compensation, and Money Spent on Alcohol and Drugs among Homeless Veterans
    This study describes the amount of money homeless Veterans report spending on alcohol and drugs, and examines the association between public support dollars received – and VA disability compensation in particular – and dollars spent on alcohol and drugs. Findings showed that about one-third of homeless Veterans reported spending money on alcohol and about one-fifth reported spending money on drugs in the past month. However, no positive association was found between public support income and money spent on alcohol or drugs, and there was no association found between VA disability compensation and substance use. This suggests that the amount of income homeless Veterans received from disability and other public support sources did not influence their amount of substance use. Employment income was positively associated with days of alcohol use and money spent on alcohol, as well as with money spent on drugs. Other sources of income (e.g., family and friends, panhandling) were also positively associated with alcohol use and money spent on alcohol along with drug use and money spent on drugs. In contrast, public support income was negatively associated with alcohol use and money spent on alcohol.
    Date: March 1, 2015
  • Veterans Receiving Brief Alcohol Misuse Intervention Rate VA Providers and Care Higher than Veterans without Intervention
    This study assessed the relationship between receipt of brief alcohol intervention and patient-reported indicators of care quality. Findings showed that among Veterans who screened positive for unhealthy alcohol use, a higher proportion who reported receipt of a brief alcohol intervention, compared to those who did not, rated their provider (87% vs. 82%) and VA healthcare (83% vs. 76%) as high quality. Sixty-one percent of Veterans in this study screened positive for mild unhealthy alcohol use, and 21%, 11%, and 8% screened positive for moderate, severe, and very severe unhealthy alcohol use, respectively. Of drinkers reporting unhealthy alcohol use, 44% of Veterans reported receipt of a brief intervention for unhealthy alcohol use in the previous year. Overall, 84% and 79% of Veterans rated their provider and VA healthcare as high quality, respectively. Thus, although the literature suggests providers may be concerned that discussions of unhealthy alcohol use may negatively impact relationships with their patients, study findings do not support concerns that delivering alcohol-related advice adversely affects patients’ perceptions of care.
    Date: February 18, 2015
  • OEF/OIF/OND Veterans with PTSD at Greater Risk of Autoimmune Disorders
    This study examined whether PTSD, other psychiatric disorders (i.e., depression, anxiety, psychosis, alcohol use disorder, substance use disorder), and military sexual trauma (MST) increase the risk for autoimmune disorders. Findings showed that Veterans diagnosed with PTSD had significantly higher risk for diagnosis of any of the autoimmune disorders – alone or in combination – compared to Veterans with no psychiatric diagnoses. Veterans with PTSD had twice the risk of being diagnosed with an autoimmune disorder compared to those without any psychiatric disorders, and 51% increased risk compared to Veterans with psychiatric disorders other than PTSD. Veterans with a higher number of comorbid psychiatric diagnoses also were more likely to be diagnosed with an autoimmune disorder, but high levels of comorbidity did not entirely account for the effect of PTSD on increased risk. The magnitude of the association between PTSD and autoimmune disorders was similar in women and men. However, overall, women had almost three times higher prevalence of autoimmune disorders. MST was much more common in women than men (13% vs. 0.5%), and was independently associated with increased risk for autoimmune disorders in both women and men. Findings underscore the need to identify and treat PTSD and other psychiatric disorders in Veterans in order to enhance not only mental but also physical health.
    Date: February 15, 2015
  • Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
    This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
    Date: December 1, 2014
  • Predictors of Worsening Mental Health among OEF/OIF Veterans
    This study sought to identify predictors of worsening mental health, including PTSD and alcohol use, as well as variables that are protective (resilience factors) against worsening mental health in a national sample of OEF/OIF Veterans. Findings showed that 14–25% of these returning OEF/OIF military personnel showed clinically worse mental health, PTSD, or alcohol use at 6-month follow-up. Eleven variables were significantly associated with a decline in overall mental health status from Time 1 to Time 2: Black race, being in the National Guard, more bothersome physical health problems, worse mental health at Time 1, less PTSD symptom severity, lack of psychiatric care between Time 1 and Time 2, more difficult deployment environment, less perceived threat, less sexual harassment, higher levels of hardiness, and lower levels of self-efficacy. Nine variables predicted a worsening of PTSD symptom severity: being younger than 26 years old, unemployed, divorced or separated, higher PTSD symptom severity at Time 1, lack of any psychiatric treatment between Time 1 and Time 2, difficult childhood family environment, greater sexual harassment in one’s unit, lower levels of deployment preparedness, and higher levels of post-deployment social support. Fourteen variables predicted worsening alcohol use, including being male, under 26 years old, less educated, Hispanic, separated or divorced, and being in the National Guard or Marines. National Guard and other Reserve soldiers worsened on both the general mental health and alcohol use measures from Time 1 to Time 2 compared to active duty soldiers, suggesting that these groups may require help with reintegration. Higher education, self-efficacy, unit support, and deployment preparedness had a protective effect on both worsening PTSD and alcohol use.
    Date: October 1, 2014
  • Adverse Childhood Experiences More Common among Men with Military Service
    Those with a history of military service may be a specific subpopulation of interest regarding adverse childhood experiences (ACE), as some may enlist to escape personal problems, potentially elevating the prevalence of ACE among military populations. This study sought to compare the prevalence of ACE among individuals with and without histories of military service based on service during the draft era (enlisted prior to 1973) or during the all-volunteer era (enlisted on/after 1973). Findings showed that men with military service during the all-volunteer era had a higher prevalence of all 11 ACE items than men without military service in this era. Notably, men with military service during this era had more than twice the odds of men without military service history of reporting household drug or alcohol abuse while growing up, suffering physical abuse or witnessing domestic violence, or some form of sexual abuse (being touched or being forced to touch, or to have sex before age 18). During this era, men with military service had more than twice the prevalence of experiencing 4 or more ACE categories (27% vs. 13%) compared to those without military service. Markedly fewer differences in ACE were found among women with and without military service histories across either era. Women with military service histories from both eras had similar patterns of elevated odds for physical abuse, household alcohol abuse, exposure to domestic violence, and emotional abuse compared with women without military service. Identifying the presence of ACE among military service members and Veterans may aid in better understanding the etiology of trauma-related mental and behavioral health conditions as well as the cumulative impact of trauma.
    Date: September 1, 2014
  • Negative Mental Health Beliefs are a Significant Barrier to Care for OEF/OIF Veterans with Mental Health Problems
    The primary aim of this study was to document concerns about stigma and personal beliefs about mental illness and treatment among OEF/OIF Veterans. Findings showed that OEF/OIF Veterans endorsed a variety of mental health beliefs that may serve as barriers to care. Concerns about stigma in the workplace were most commonly reported, followed by negative beliefs about treatment-seeking, concerns about stigma from loved ones, and negative beliefs about mental illness. Although more than one-third of the Veterans in the study generally disagreed with survey items reflecting negative beliefs about mental health treatment, 50% of the survey respondents were classified in the “neither agree nor disagree” category, suggesting that they may be neutral or undecided in their beliefs about treatment. Veterans with probable mental health problems were more likely to report negative mental health beliefs than Veterans without mental health problems. Specifically, Veterans with probable diagnoses of depression and PTSD were more concerned about stigma from loved ones and in the workplace than Veterans without these conditions. Negative beliefs about treatment-seeking were related to lower likelihood of seeking mental healthcare for Veterans with probable PTSD, depression, and alcohol abuse. Although concern about stigma in the workplace was most commonly reported, it was unrelated to healthcare use.
    Date: June 1, 2014
  • Characteristics and Outcomes of Homeless Male and Female Veterans
    This study examined a recent national sample of homeless Veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program to report differences between homeless male and female Veterans on individual characteristics at referral, as well as housing and clinical outcomes over a one-year period after program admission. Findings showed that among Veterans who stayed in the program, there were no gender differences in housing outcomes over time, except females tended to stay more nights in someone else’s place, while males stayed more nights in transitional housing. Homeless female Veterans were younger, more likely to have recently served in the military, had shorter homeless histories, were less likely to have been incarcerated, and were less likely to have alcohol and drug use disorders. Despite being less likely to report combat exposure, female Veterans were more likely to have PTSD than male Veterans. Homeless female Veterans also were much more likely to have dependent children with them, and to plan to live with family members in supported housing. For all Veterans, it took an average of over 40 days to be admitted to HUD-VASH after referral, an average of over 40 days to obtain a voucher after being admitted, and then an average of more than 50 days to sign a lease after obtaining a voucher.
    Date: April 14, 2014
  • Strong Association between Substance Abuse and Homelessness among Veterans
    This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD. These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed. Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories. Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
    Date: February 1, 2014
  • Homelessness More Prevalent among Female Veterans
    This review of the literature sought to assess and summarize the body of knowledge on homelessness among female Veterans, in order to inform policy and highlight important gaps in this literature that could be filled by future research. Findings showed that female Veterans now comprise a larger share of the homeless Veteran population than of the overall Veteran population. Homeless female Veterans are characteristically different from their male counterparts, both with respect to demographic and clinical factors. For example, homeless female Veterans are younger, have higher levels of unemployment, and have lower rates of drug or alcohol dependence or abuse, but they have higher rates of mental health problems than homeless male Veterans. Female Veterans are at an increased risk of homelessness relative to the non-Veteran female population. Studies identified factors that may increase the risk of homelessness among women Veterans, including: unemployment, disability, PTSD, sexual assault or harassment during military service, anxiety disorder, poor health status, and older age.
    Date: June 26, 2013
  • Same-Day Receipt of Integrated VA Primary Care-Mental Health Services Increases Odds of Subsequent Mental Health Visit
    This study evaluated whether same-day receipt of Primary Care-Mental Health Integration (PC-MHI) services was associated with the likelihood of receiving a mental health encounter in the following 90 days. Findings showed that of the Veterans in this study, 7% received same-day PC-MHI services. Those who received same-day PC-MHI services had more than twice the odds of receiving a subsequent mental health encounter within 90 days compared with Veterans who did not receive same-day PC-MHI services, after adjustment for other covariates. Overall, 48% of the Veterans in this study had a subsequent visit for a mental health condition within 90 days of their initial visit. Among those with same-day PC-MHI, 74% had a follow-up, as compared to 45% who did not receive same-day services. OEF/OIF Veterans had greater odds of a 90-day return visit compared with non-OEF/OIF Veterans. Also, Veterans in the two younger age groups (18-44 yrs and 45-64 yrs) had greater odds of a return visit than Veterans in the oldest age group (65+yrs). Each of the mental health disorders, with the exception of alcohol use disorder, was positively associated with a 90-day return visit, while Veterans with a physical comorbidity were less likely to return in the following 90 days.
    Date: January 1, 2013
  • OEF/OIF Veterans Most in Need of Psychiatric Care are Accessing Mental Health Services, Primarily at VA
    In this study, investigators conducted the first survey to employ a random sample of U.S. military post-9/11 that examined treatment use and perceived problems with treatment, including both VA and non-VA service users. Findings showed that 43% of the Veterans in this study screened positive for PTSD, major depression, or alcohol misuse. Overall, 40% of Veterans had ever received VA inpatient mental health care, 46% had ever received VA outpatient care, and 16% had ever received inpatient or outpatient care in both VA and non-VA settings. Nearly 70% of Veterans with probable PTSD or major depression and 45% of Veterans with probable alcohol misuse reported accessing mental health care in the past year. Authors suggest that Veterans who are ambivalent about accessing mental healthcare may be more willing to do so if they are made aware that a substantial number of Veterans are getting the help they need. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express stigma beliefs and concern about being seen as weak. This suggests barriers to accessing care may be distinct from barriers to engaging in care. Veterans with higher PTSD and depression symptoms were more likely to access care. This finding suggests that, above a certain threshold of symptoms, Veterans were significantly more likely to seek mental health services, even if they viewed those services in a negative light.
    Date: November 15, 2012
  • OEF/OIF Veterans with PTSD and Associated High Irritability May Be at Increased Risk of Criminal Arrest
    This study tested the hypothesis that anger and irritability associated with PTSD and/or traumatic brain injury (TBI) is related to criminal behavior. Findings showed that, of the Veterans in this study, 9% reported arrests since returning home from military service. Most were associated with non-violent criminal behavior resulting in incarcaration for less than 2 weeks. Number of arrests was found to be significantly related to younger age, male gender, having witnessed family violence, prior history of arrest, alcohol/drug misuse, and PTSD with high anger/irritability. Arrests were not significantly related to combat exposure or TBI. Veterans with PTSD who reported very frequent symptoms of anger and irritability may be at increased risk of engaging in criminal behavior. However, PTSD with negative affect was less strongly related to criminal justice involvement than were other civilian risk factors such as younger age, male gender, witnessing family violence, prior criminal record, and substance misuse.
    Date: October 1, 2012
  • Prescription Drug and Alcohol Misuse Associated with Higher Suicide Deaths among Veterans with Depression
    This study sought to assess the association between factors noted in the electronic medical record and suicide mortality for a cohort of Veterans who had received treatment for depression. Findings showed that suicidal behaviors and substance-related variables were the strongest independent predictors of suicide. Compared with Veterans without a suicide attempt or ideation, those with a suicide attempt in the prior year were 7 times more likely to die of suicide, and Veterans with suicidal ideation without an attempt were 3 times more likely to die of suicide. Veterans with prescription drug misuse and those with alcohol abuse were 7 times and 3 times, respectively, more likely to die of suicide than those without. Based on these findings, the authors suggest that prescription drug and alcohol misuse assessments should be prioritized in suicide assessments among Veterans diagnosed with a depressive disorder. Veterans for whom providers considered a hospitalization for psychological issues had 3 times higher risk of suicide death than those for whom hospitalization was not considered.
    Date: October 1, 2012
  • Variables Associated with Risk of Community Violence among Subset of OEF/OIF Veterans
    One-third of the OEF/OIF Veterans in this study reported aggression against others in the previous year (e.g., kicking, slapping, using fists, fights), and 11% reported having engaged in severe acts of violence within the past year (e.g., use of a knife or gun or other lethal weapon, beat up a person). Risk factors in the current sample were similar to those associated with violence among Veterans from previous eras – younger age, PTSD, alcohol abuse, and past criminal arrests. When these risk factors were controlled as covariates, a stable living situation and the perception of having control over one’s life were independently associated with reduced odds of severe violence. Positive social support and having enough money to cover basic needs were associated with reduced odds of other forms of physical aggression. Data also suggest that Veterans who perceive that they have control over their future and who have greater psychological resilience may have greater internal motivation to refrain from violence.
    Date: June 1, 2012
  • Cannabis Use Disorder Diagnoses in the VA Healthcare System Double Over the Past Seven Years
    The prevalence of cannabis use disorder (CUD) diagnoses overall within VA has increased nearly 60% (from 0.66% to 1.05%) over the past 7 years, with the prevalence of CUD diagnoses among those without other illicit substance use disorders (SUD) having risen 115% (from 0.27% to 0.58%) during the same time period. Rates of other substance use disorder diagnoses within VA (i.e., alcohol-only and other-drug disorder) increased to a much smaller degree. Although rates of CUD diagnosis within VA have increased dramatically, they remain significantly lower than rates of CUD observed in the U.S. population. States with laws allowing for the legal use of cannabis for medicinal purposes had significantly higher rates of CUD diagnoses within VA in 2002, 2008, and 2009. Rates of psychiatric diagnoses, and PTSD specifically, were higher among patients with a CUD diagnosis but no other illicit SUD, as compared to other SUD groups. Rates of specialty SUD treatment utilization among those with a CUD diagnosis but no other illicit SUD have decreased within VA.
    Date: May 7, 2012
  • Association between Alcohol Screening Scores and Alcohol-Related Risks among Women Veterans
    Among the women Veterans in this study, 24% screened positive for alcohol misuse. Many of these women reported symptoms of alcohol misuse that would not be identified by VA’s current required alcohol screening program because of their lower AUDIT-C scores. Increasing scores on the AUDIT-C reflected increasing prevalence of self-reported alcohol-related risks and consequences. For three out of the five alcohol-related consequences (i.e., tolerance of alcohol, blackouts, feeling the need to cut down on drinking), adjusted prevalence increased at AUDIT-C scores >3. The remaining alcohol-related consequences (i.e., morning drinking, family/friends worried) increased at scores >4, as did self-reported problem drinking and drug use. Associations between health risks (i.e., >2 sexual partners, sexually transmitted diseases, injuries, domestic violence, hepatitis/cirrhosis) and AUDIT-C scores were less consistent, but prevalence generally increased at scores >5.
    Date: May 1, 2012
  • Importance of Pre-Operative Alcohol Screening
    Among the Veterans in this study, 16% of men and 5% of women screened positive for alcohol misuse at levels associated with increased post-operative complications in the year before surgery. A majority of male and female surgical patients with alcohol misuse were relatively healthy and did not have diagnoses or chronic conditions commonly associated with alcohol misuse that might alert providers to their alcohol misuse. This finding highlights the value of routine pre-operative alcohol screening to proactively identify Veterans who misuse alcohol and to potentially implement interventions before surgery. Screening positive for alcohol misuse (AUDIT-C >5) was more common among men who were: younger than 60 years old, divorced or separated, current smokers, or ASA class 1-2 (pre-operative assessment by anesthesiologist as healthy patient or patient with mild systemic disease), and among men with cirrhosis, hepatitis, or substance use disorders.
    Date: April 11, 2012
  • Gender Differences in Healthcare Utilization among Veterans with PTSD
    Overall, female OEF/OIF Veterans with PTSD were more likely to have slightly higher mental health, primary care, and emergency care utilization compared to male Veterans with PTSD. Women Veterans with comorbid PTSD and depression were 12.5 times more likely to have a mental health inpatient hospitalization compared to their female counterparts without depression, and they were twice as likely to have a mental health hospitalization compared to male Veterans with comorbid PTSD and depression. Diagnoses of comorbid PTSD and depression were present in 72% of women and 57% of men. Both men and women with PTSD and alcohol use disorders had more than double the mean number of mental health outpatient visits compared to their counterparts with PTSD but without alcohol use disorders. Comorbid PTSD and alcohol use disorders diagnoses were present in 8% of women and 29% of men. Regardless of gender, Veterans with comorbid PTSD and depression or comorbid PTSD and alcohol use disorders had higher healthcare utilization in all areas, as compared to their counterparts with PTSD but without these comorbid disorders.
    Date: February 7, 2012
  • Mental and Physical Health – and Substance Use in Veterans One Year after Deployment to Iraq or Afghanistan
    Within one year of returning from deployment, OEF/OIF Veterans in this study reported significantly worse mental health functioning than the general population. In addition, 39% screened positive for “probable alcohol abuse,” which is considerably higher than numbers reported based on mandated screening of VA outpatients. OIF (Iraq) Veterans reported more depression/functioning problems, as well as alcohol and drug use than OEF (Afghanistan) Veterans. Marine and Army Veterans reported worse mental and physical health than Air Force or Navy Veterans. Men reported more alcohol and drug use than women, but there were no gender differences in PTSD or other mental health domains. The authors suggest that continued identification of Veterans at risk for mental health and substance use problems is important for the development and implementation of evidence-based interventions intended to increase resilience and enhance treatment.
    Date: January 1, 2012
  • Gender Differences in Combat Exposure, Military Sexual Trauma, and Mental Health among Active Duty Soldiers
    This study examined gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health outcomes among OEF/OIF active-duty personnel. Findings showed that although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. For example, 7% of women reported injury in the war zone, and 4% reported killing in war, compared to 2% and 1%, respectively, for a Gulf War cohort. MST was a significant predictor of both PTSD and depression symptoms: 12% of women and less than 1% of men reported MST in the war zone. There were no gender differences in PTSD symptoms; however, there was a stronger association between injury in combat and PTSD symptoms for women than for men. Men were more likely to report hazardous alcohol use, while female gender was more likely to be associated with depression symptoms.
    Date: December 13, 2011
  • Male Veterans Reporting Sexual Assault are More Likely to Engage in Unsafe Drinking than Veterans with No History of Sexual Assault
    This study explored the rates of sexual assault in male Veterans reporting alcohol misuse – and the potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. Findings showed that male Veterans reporting sexual assault are more likely to engage in increased alcohol consumption, experience more lifetime alcohol-related consequences, and have more risk factors for unsafe drinking when compared with their peers who have no history of sexual assault. In addition, the odds of using any illicit substance in the last 90 days were three times higher in the sexual assault group. There also was a two-to-four times greater likelihood of almost all risk factors for unsafe drinking in the sexual assault group. Authors note that SUD treatment settings may be a context in which a history of sexual assault is high and that it may interact with core indicators of treatment success (e.g., psychiatric and physical comorbidities). Therefore, universal sexual assault screening, like the approach in VA, may be relevant for men presenting to SUD treatment settings.
    Date: September 1, 2011
  • Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
    This study sought to determine the association between the co-location of primary care services and quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
    Date: August 1, 2011
  • Effect of Housing Vouchers on Homeless Veterans with Mental Illness
    This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
    Date: May 1, 2011
  • Complications Following Total Joint Arthroplasty Significantly Related to Pre-Operative Alcohol Misuse among Veterans
    This study evaluated the association between a standardized, pre-operative alcohol screening score (AUDIT-C [ Alcohol Use Disorders Identification Test – Consumption]) and the risk of post-operative complications in Veterans who underwent total joint arthroplasty at one VA facility between 2004 and 2007. Findings show that complications following total joint arthroplasty were significantly related to alcohol misuse. Of the 185 Veterans in this study, 32 had alcohol screening scores suggestive of alcohol misuse, and 12 Veterans had at least one post-operative complication. Therefore, AUDIT-C scores signified a 29% increase in the expected mean number of complications with every additional AUDIT-C point above 1. The authors suggest that pre-operative alcohol misuse screening, and perhaps pre-operative counseling or referral to treatment for heavy drinkers, may be indicated for patients undergoing total joint arthroplasty.
    Date: February 1, 2011
  • Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
    This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
    Date: January 28, 2011
  • Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
    This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
    Date: December 22, 2010
  • Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
    This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
    Date: December 1, 2010
  • Gender Differences in Mental Health Diagnoses among OEF/OIF Veterans
    This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
    Date: October 21, 2010
  • PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
    This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
    Date: October 1, 2010
  • VA’s Brief Alcohol Intervention Strategy Successful
    This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
    Date: September 28, 2010
  • Alcohol Screening Results Up to One Year Prior to Surgery Associated with Increased Post-Operative Complications for Veterans
    This study evaluated whether results of alcohol screening with the AUDIT-C ( Alcohol Use Disorders Identification Test – Consumption), administered up to one year before surgery, were associated with the risk of post-operative complications in Veterans undergoing major non-cardiac surgery in VA. Findings showed that AUDIT-C scores of 5 or higher up to one year before surgery were associated with increased post-operative complications. Overall, 16% of the total study population screened positive for alcohol misuse with AUDIT-C scores >5, and 8% had post-operative complications. There also was a dose-response relationship between AUDIT-C scores and post-operative complications, with complications increasing from 6% among low-risk drinkers to 14% among Veterans with the highest AUDIT-C scores. The authors suggest that AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative templates in VA’s computerized patient record system in order to alert clinicians to alcohol misuse at the time of referral to surgery.
    Date: September 28, 2010
  • Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
    This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
    Date: September 22, 2010
  • Dementia More Prevalent among Older Veterans with PTSD
    This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
    Date: September 1, 2010
  • Responding to Decline in MRSA Infection
    This JAMA Editorial reports on the current status of MRSA (methicillin-resistant S aureus) infection rates – and what it may mean for the future. Using data from 2005-2008, the CDC’s surveillance system showed a continuous decline of invasive MRSA disease. This includes an estimated 9.4% annual decrease in hospital onset and an estimated 5.7% annual decrease in healthcare-associated community-onset infections. There are a variety of theories for these decreases, such as general infection control efforts (e.g., wider use of alcohol-based hand rubs). However, it may be presumptuous to assume that hospital-based prevention efforts have a major effect on the natural history of such a wide-spread pathogen. Natural biologic trends are likely to override the best-laid attempts at infection control. Therefore, only by improving existing surveillance and prevention research programs can clinicians and infection control researchers begin to explain the decrease in MRSA disease.
    Date: August 11, 2010
  • Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
    Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
    Date: July 1, 2010
  • Homelessness Affects Substance Use Treatment Outcomes and Costs among Veterans
    This analysis evaluated homelessness among Veterans who had entered VA outpatient substance use disorder treatment, and also explored associations between housing status, treatment outcomes, and use of VA services over one year. Findings suggest that the problem of homelessness among Veterans with substance use disorders remains large, with 65% of 622 Veterans in this study spending at least one night homeless at some point during the study period. Veterans experiencing homelessness during the six months prior to treatment admission had more severe alcohol, medical, employment, legal, and psychiatric problems than Veterans with housing. Abstinence rates did not differ between the homeless and housed groups, and about 65% of participants in each group remained engaged in treatment for 90 days. In addition, results showed that homeless Veterans used more services and had higher total costs than housed Veterans, e.g., homeless Veterans had more inpatient admissions and were more likely to use the emergency room.
    Date: July 1, 2010
  • Majority of OEF/OIF Veterans Interested in Interventions/Information to Help with Community Readjustment
    An estimated 40% of OEF/OIF combat Veterans who used VA medical services perceived some to extreme overall difficulty readjusting to civilian life within the past 30 days. Between 25% and 56% of the participants had some to extreme difficulty in specific areas related to social functioning, productivity, community involvement, and self-care. For example, 31% reported more alcohol and drug use, and 57% reported more anger control problems since returning from Iraq or Afghanistan. Almost all Veterans (96%) expressed interest in services to help them readjust to civilian life. Veterans with probable PTSD (n=291) reported more reintegration problems and expressed interest in more kinds of services for these problems than did Veterans without probable PTSD (n=463). The most commonly preferred ways to receive reintegration services or information were at a VA facility, through the mail, and via the Internet. Almost all OEF/OIF Veterans in this study had access to the Internet and used it regularly.
    Date: June 1, 2010
  • Rates of Depression Rise among VA Nursing Home Residents
    Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
    Date: April 1, 2010
  • Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
    In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
    Date: April 1, 2010
  • Implementation of a VA Quality Improvement Initiative Improves Knowledge and Perceptions Regarding MRSA Prevention
    Implementation of the initiative at 17 VAMCs was associated with temporal improvements in knowledge and perceptions regarding MRSA prevention. Between baseline and follow-up, there were increases in the number of respondents who: correctly identified that alcohol-based hand rub is more effective at inactivating MRSA than soap and water, reported cleaning their hands when entering and exiting a patient room in the past 30 days, reported using alcohol-based hand rub over soap and water when cleaning their hands, and felt comfortable reminding others about proper hand hygiene.
    Date: February 3, 2010
  • Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
    This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
    Date: February 1, 2010
  • Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
    This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
    Date: December 1, 2009
  • Candidate Quality Measures for VA Alcohol Use Disorder Treatment
    The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment quality. Findings show that nine candidate process measures of outpatient AUD treatment quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
    Date: December 1, 2009
  • Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
    Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
    Date: November 1, 2009
  • Low Rates of HIV Screening among Veterans with Substance Use Disorders
    This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
    Date: October 1, 2009
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care
    Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care.
    Date: August 1, 2009
  • Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
    This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
    Date: July 16, 2009
  • Alcohol Screening Scores Predict Fracture Risk
    The Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) is a three-item screen that can be routinely administered to primary care patients and has been widely adopted for alcohol screening. Research is needed to determine whether it might be valid for purposes other than screening, such as predicting alcohol-related health problems such as osteoporotic and other bone fractures. This study examined the association between AUDIT-C scores and the risk for fractures among Veterans who received care at seven VA primary care clinics across the country. Findings show that after adjusting for comorbidities and demographics, having an AUDIT-C score of 10 or greater was associated with doubling the risk of an osteoporotic fracture compared to AUDIT-C scores of 1 to 3, while an AUDIT-C of 6 or greater was associated with about a 1.5-fold increase in the risk of a fracture that was not typical of osteoporosis. This suggests that alcohol screening scores could help clinicians quickly assess and provide feedback to patients on their alcohol-related fracture risks, much the way other screening tests (e.g. blood pressure or lipids) are used.
    Date: July 1, 2009
  • Alcohol Misuse and Counseling among Minority Veterans
    This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
    Date: May 1, 2009
  • Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
    The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
    Date: April 1, 2009
  • Spinal Cord Injury and Alcohol Use are Risk Factors for Osteoporosis Hospitalization
    Spinal cord injury (SCI) is associated with severe osteoporosis, increasing the risk of low-impact fractures that occur in the absence of trauma. Findings from this study show that hospitalization for low-impact fractures was more common in motor complete SCI (no motor function below the neurological level of injury) and was associated with greater alcohol use after injury. Osteoporosis diagnosis, prevention, and management were not included in the treatment plans for any of the Veterans hospitalized with fractures. These findings suggest that future studies should address prevention and treatment of bone loss among Veterans with motor complete SCI.
    Date: March 1, 2009
  • Assessing Healthcare Utilization among Veterans with Depression
    Nearly half of VA primary care patients with significant depressive symptoms also used non-VA care. Among dual users, 94.9% used both VA and non-VA care for physical health problems, but only 20.3% used both for emotional health problems. Lower levels of alcohol use and the presence of PTSD were associated with the use of non-VA outpatient care for emotional health services. Authors suggest that care management strategies for Veterans with depression should include communication and coordination with non-VA providers.
    Date: March 1, 2009
  • Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
    Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
    Date: July 1, 2008

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