- Positive IPV Screen Significantly Associated with Health Outcomes and Healthcare Use among Women Veterans Over 45
This study examined the proportion of women older than childbearing age who screen positive when routinely screened for past-year intimate partner violence (IPV) at VA clinics, as well as associations of a positive screen with health conditions and use of healthcare services. Findings showed that of the study cohort, 255 middle-aged (45-59 years; 9%) and 79 older (60 years and older, 5%) women screened positive for past-year IPV. A positive screen was significantly associated with negative mental and physical health outcomes, as well as increased use of healthcare services. Those screening IPV+ in both the middle-aged and older groups were more likely than those screening IPV- to be diagnosed with each category of mental health condition (i.e., anxiety, PTSD, depression). Middle-aged women screening positive had more than twice the odds of having a diagnosis of depression, anxiety, PTSD, and substance use, and four times the odds of suicidal behaviors or self-harm, while older women screening positive had more than three times the odds of having a depression diagnosis. Middle-aged women screening IPV+ had more than double the rate of psychosocial visits in the subsequent 20 months, and older women had a near doubling. Middle-aged women who screened IPV+ also had increased rates of primary care and ED visits, as well as higher odds of having any inpatient admission. These associations were not seen for the older women. Screening for IPV in middle-aged and older women may improve detection and service delivery in this underserved population.
Date: April 21, 2020
- Women Veterans Significantly More Likely than Male Veterans to Use Any Healthcare Up to One Year Post-Discharge
This study examined gender differences among a national sample of Veterans in the use of VA and non-VA health services during the first 15 months of the transition from military to civilian life. Findings showed that women Veterans were twice as likely as men to use any healthcare (VA or non-VA) immediately post-military and 84% more likely than men to do so a year later – but the use of VA care was comparable between men and women. There was no difference at baseline (within 90 days of separation) and only a 22% increase for women relative to men at one year. Use of the Veterans’ Choice Program was uncommon for both genders. While unstable housing was similar across genders (10% for women and 12% for men), women Veterans with unstable housing at military separation were less likely to use healthcare a year later, especially for the subgroup with mental/behavioral health issues. Sleep problems, anxiety, and depression were associated with healthcare use for both men and women following transition. VA housing assistance services could be gender-tailored for the 10% or 12% of Veterans with unstable housing; this could be implemented via outreach in the first 15 months post-separation. Sleep problems, depression, and anxiety remain drivers of healthcare use; whether expert treatment is provided in the community is unknown and should be assessed.
Date: March 1, 2020
- Rates of Mental Health Diagnoses are Higher among Veterans with Obesity
The objective of this study was to examine rates of mental health diagnoses among a national cohort of women and men VA primary care patients with and without obesity. Findings showed that rates of any mental health diagnosis were higher among women than men and people with versus without obesity.
Depression and PTSD diagnosis rates were higher for women and men with versus without obesity. For example, there was a 25% higher PTSD diagnosis rate among men with obesity versus without. Women with obesity had higher rates of psychotic disorder diagnoses than women without obesity; this was not found for men. Substance use disorder diagnosis rates were lower for women and men with versus without obesity. Anxiety diagnosis rates were slightly lower among women with versus without obesity; this was not found for men. A sizable proportion of women (46%) and men (62%) with obesity had no mental health diagnoses. Results provide further support for the finding that many Veterans have concurrent obesity and mental health diagnoses. Integrated treatments addressing obesity and mental health could benefit patients, providers, and the healthcare system by meeting patients’ physical and mental health needs in less time than separate treatments.
Date: January 30, 2020
- Health is the Main Concern of Newly Separated Veterans
This large study is the first in-depth investigation of U.S. Veterans’ health and well-being as they leave military service. Findings showed that health concerns were the most salient for newly separated Veterans, with many reporting that they had chronic physical (53%) or mental (33%) health conditions – and that they were less satisfied with their health than either their work or social relationships. Chronic pain, sleep problems, anxiety, and depression were most commonly reported by Veterans. Men were more likely to report a hearing condition, high blood pressure, and high cholesterol, while women were more likely to report anxiety and depression at both survey timepoints. Compared with officers, enlisted personnel reported consistently poorer health, vocational, and social outcomes, and deployed Veterans reported poorer health than non-deployed Veterans. Veterans’ work functioning declined in the first year after leaving military service. Findings suggest several important directions for future prevention and early intervention efforts (i.e., health concerns such as chronic pain, sleep, and anxiety), which, if implemented, have the potential to put Veterans on the path to more successful and fulfilling post-military lives.
Date: December 28, 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
- Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
Date: March 1, 2019
- Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population.
Date: February 8, 2019
- Women Veterans Who Report Stranger Harassment on VA Grounds More Likely to Delay or Miss Healthcare
This study examined the prevalence of self-reported harassment among women Veterans who use VA healthcare. Findings showed that one in four women Veterans reported inappropriate and/or unwanted comments or behavior by male Veterans on VA grounds. Eight percent said that this usually or always took place at VA. Negative interactions included sexual/derogatory comments and questions about the women’s Veteran identity and right to VA care. Those who reported harassment were less likely to report feeling welcome at VA, and more likely to report feeling unsafe and delaying/missing care. Younger women were more likely to report harassment, as were women Veterans with self-reported fair or poor health status, those with MST and/or other trauma exposures, and those with anxiety. VA Women’s Health Services has responded by establishing a national workgroup, gauging effective harassment reduction programs outside VA, convening an expert panel, piloting interventions, and launching a national culture campaign.
Date: January 24, 2019
- Comparisons between VA and Non-VA Hospitals May Not Accurately Account for Mental Health Diagnoses
While CMS publishes performance metrics on Hospital Compare, the risk-adjustment algorithms underlying these metrics are often unclear. Further, recently published literature questions whether existing risk-adjustment algorithms accurately adjust for mental health comorbidities. This study sought to determine whether current risk-adjustment algorithms fairly compare VA hospitals with non-federal hospitals. In their analysis, investigators used the CMS Hierarchical Condition Categories (HCC) risk adjustment system version 21 (V21) because it is publicly available and has been used to adjust metrics published on the CMS Hospital Compare website. Investigators also measured mental health comorbidities using the PsyCMS (Psychiatric Case Mix System). Findings showed that current comparisons between VA and non-VA hospitals are flawed because the risk adjustment algorithms used to make patients comparable do not adequately control for mental health issues. Of 5,472,629 VA patients, the V21 model identified 694,706 as having mental health or substance use HCCs. The PsyCMS identified another 1,266,938 Veterans with mental health diagnoses. The top 10 mental health diagnoses missed by the V21 model included nicotine dependence (40%), depression not otherwise specified (31%), PTSD (27%), and anxiety (10%). Overall, the V21 model under-estimated costs for patients with low costs and over-estimated costs for patients with above average costs except for the top decile. For Veterans with a mental health diagnosis, the V21 model under-estimated the cost of care by $2,314 per patient. Risk scores may need to be developed based on a broader set of hospital data. Without such efforts, safety net hospitals, such as VA, may be penalized and patients and policymakers misled.
Date: December 14, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- Delivery of Brief Cognitive Behavioral Therapy in Primary Care Improves Mental Health Symptoms in Chronically Ill Veterans
This trial sought to determine whether an integrated brief cognitive behavioral therapy (bCBT) intervention would improve depression, anxiety, and quality of life for medically ill Veterans. Findings showed that integrated bCBT resulted in significant immediate and 12-month improvements related to depression and anxiety. Brief CBT also resulted in significant short-term improvements related to physical health quality of life for Veterans with chronic lung conditions. Delivery of bCBT in VA primary care clinics resulted in Veterans receiving an average of 3.9 sessions with high levels of Veteran engagement (84% receiving care) and treatment completion (63% with 4 or more sessions). Veterans and VA providers reported very high satisfaction with bCBT.
Date: June 20, 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
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Disclosure of Clinical Adverse Events between VA Surgeons and their Patients
This study assessed surgeons’ reports of disclosing adverse events and aspects of their experiences with the disclosure process. Findings showed that surgeons reporting they were less likely to discuss preventability of the adverse event, or who reported difficult communication experiences were more negatively affected by disclosure than others: 60% indicated that the event had moderately, quite a bit, or extremely affected them. Most surgeons did not report significant impacts of the event on job satisfaction, confidence, professional reputation, or sleep, but 27% reported anxiety about future outcomes or events.
Date: July 20, 2016
- New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.
Date: July 1, 2016
- Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
Date: June 24, 2016
- Systematic Review of PTSD Screening Instruments
Investigators in this study conducted a systematic review of self-report screening instruments for PTSD among primary care and high-risk populations. Findings showed that the Primary Care Post-Traumatic Stress Disorder screener (PC-PTSD) and the 17-item PTSD-Checklist (PCL) were the best performing instruments. Both show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both also are easy to administer and interpret, and can readily be incorporated into a busy practice. Two multi-condition instruments (My Mood Monitor, and the Provisional Diagnostic Interview-4 Anxiety) and three anxiety/general distress instruments (K6, GAD-7, and the Anxiety and Depression Detector) were evaluated in primary care settings, but performed less well than instruments that were specifically designed to detect PTSD. Both patients and physicians felt that screening facilitated discussion of mental health issues in the subsequent primary care visit, and 80% of primary care physicians reported that the screen was helpful in interactions with their patients.
Date: August 4, 2015
- Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
Date: June 10, 2015
- Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes
This study sought to describe the postmenopausal symptom experience in women with type 2 diabetes – and to examine the association between glucose control and symptom severity. Findings showed that, despite higher BMI and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups. Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health.
Date: June 1, 2015
- Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
Date: May 15, 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
- Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
Date: December 3, 2014
- 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
- Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
Date: July 17, 2014
- Only Small Percentage of Veterans with Mental Illness Access VA Employment Services
This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically.
Date: July 1, 2014
- Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. No data supported the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition. The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% and the percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80%. No studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
Date: July 1, 2014
- Factors Related to Use of Psychotherapy among Veterans
This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Findings showed that need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders (SUD), more comorbid psychiatric diagnoses, and more inpatient psychiatric stays. In the year after initiating psychotherapy, half of the sample received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy. Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD. Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.
Date: May 19, 2014
- Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among OEF/OIF Veterans
This study examined the association between epilepsy and TBI, including penetrating TBI (pTBI), in OEF/OIF Veterans. Findings showed that epilepsy was associated with previous TBI diagnosis. The estimated risk of epilepsy among Veterans with pTBI was nearly 18 times greater than among those without TBI, even after controlling for other factors. When examined separately, risk for epilepsy was also elevated among Veterans with severe, moderate, and mild TBI. Even among this relatively young group of Veterans, stroke was one of the strongest risk factors for epilepsy. Veterans with epilepsy also were more likely to be younger than 50 years and white, and were more likely to have previously diagnosed substance use disorder, depression, anxiety, bipolar disorder, schizophrenia, and PTSD than those without epilepsy. Headache, cardiac conditions, cerebrovascular disease, and cognitive impairment/dementia were also epilepsy risk factors. An increasing burden of epilepsy in this Veteran population is likely. These Veterans should be followed closely, and systems of care, such as VA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care.
Date: April 1, 2014
- Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans
This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD.
Date: March 11, 2014
- Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
Date: February 1, 2014
- Veterans with Non-Specific Anxiety Diagnosis Less Likely to Access Mental Healthcare than Veterans with Specific Anxiety Disorders
This study sought to determine the rates of specific and non-specific anxiety diagnoses in a national sample of Veterans receiving outpatient care at VAMCs – and to examine patterns of mental healthcare use in the year following diagnosis. Findings showed that “Anxiety Disorder Not Otherwise Specified” (anxiety NOS) was diagnosed in 38% of this Veteran cohort. Most Veterans with a specific anxiety diagnosis received mental health services, with treatment rates for patients with the most frequently diagnosed specific anxiety disorders (PTSD, generalized anxiety disorder, and panic disorder) ranging between 60% and 67%. In contrast, only 32% of patients with anxiety NOS received mental health services during the 12 months following diagnosis. Most Veterans with an anxiety NOS diagnosis did not go on to receive a specific diagnosis in the next 12 months. However, most anxiety NOS patients who later received a diagnosis of a specific anxiety disorder (87%) received mental health services in the year following their index date, compared to 29% of Veterans who did not receive a subsequent specific anxiety disorder diagnosis. Patient factors that increased the likelihood of an anxiety NOS diagnosis included: female gender, older age, the absence of specific comorbid diagnoses (i.e., substance-use disorders, bipolar disorder), and absence of service-connected disability. Veterans diagnosed in specialty mental health or integrated primary care-mental health settings were less likely to receive an anxiety NOS diagnosis than patients in primary care.
Date: October 22, 2013
- Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
Date: October 1, 2013
- Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans.
Date: July 1, 2013
- 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
- Patient and Facility Characteristics Associated with Prescribing Benzodiazepines for Veterans with PTSD
This study examined patient and facility-level correlates of benzodiazepine prescribing among Veterans with PTSD in the VA healthcare system. Findings showed that 30% of the Veterans in this study received a benzodiazepine. The majority (94%) of Veterans with any benzodiazepine use received = 30 days’ supply, and approximately two-thirds received more than 90 days of continuous benzodiazepine treatment. Among patient characteristics predicting benzodiazepine use, the largest odds ratios were observed for anxiety disorder comorbidity. Other characteristics associated with increased risk for benzodiazepine exposure included female gender, age = 30 years, rural residence, service connection = 50%, Vietnam era service, and duration of PTSD diagnosis. However, case-mix adjustment for these variables accounted for <1% of the variation in benzodiazepine prescribing across VA facilities. Main study findings were corroborated in replication analyses using data from two additional years (FY2003 and FY2006).The wide variation in facility-level benzodiazepine prescribing across VA cannot be explained by differences in patient characteristics across facilities.
Date: February 1, 2013
- Post-deployment Health Outcomes Associated with Multiple Deployment-Related Factors
This study examined the unique contributions of various deployment-related exposures and injuries to current post-deployment physical, psychological, and general health outcomes in National Guard members. Findings showed that various deployment-related experiences increased the risk for post-deployment adverse mental and physical health outcomes, individually and in combination. Most adverse outcomes had associations with multiple deployment-related factors. Deployment-related mild traumatic brain injury (TBI) was associated with post-deployment depression, anxiety, PTSD, and post-concussive symptoms such as headaches and dizziness. Combat exposures with and without physical injury were associated not only with PTSD, but also with numerous post-concussive and non-post-concussive symptoms (e.g., chest pain, indigestion). Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. The experience of seeing others wounded or killed, or experiencing the death of a buddy or leader, was associated with indigestion and headaches, but not with depression, anxiety, or PTSD. Findings indicate that an integrated interdisciplinary healthcare approach would be beneficial for Veterans with multiple deployment-related health issues. Such a system of care is currently being used within the VA Polytrauma programs.
Date: November 1, 2012
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Risk of Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
This study examined mental disorder comorbidity and suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and suicide risk. Findings showed that among Veterans who died by suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
Date: October 22, 2012
- Women Veterans Report Poorer Health Outcomes Compared to Civilian and Active Duty Women
Veteran women reported consistently poorer health compared with other women, including poorer general health, greater likelihood of health risk behaviors (e.g., smoking), and greater likelihood of chronic conditions and mental health disorders. Veterans were most likely – and active duty least likely – to report frequent poor physical health. Veterans were more likely than civilian and active duty women to be obese or overweight – and to have cardiovascular disease. National Guard or Reserves (NG/R) women also were more likely to be overweight or obese than both civilian and active duty women. Veterans were more likely than civilians to report a history of depressive disorder and more likely than active duty women to report a history of anxiety disorder. NG/R women were more likely than civilian and active duty women to report both depression and anxiety. Tobacco use and lack of exercise were most commonly reported among Veterans and least commonly reported among active duty women. Compared to civilians, Veteran women were more highly educated and had higher incomes. Despite these protective factors, Veteran women reported faring better than civilians on only two indicators – health insurance and receiving clinical breast exams.
Date: May 1, 2012
- Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for OEF/OIF Veterans
There was a significant association between VA’s Primary Care-Mental Health Integration (PC-MHI) program and OEF/OIF Veterans’ receipt of short- or long-term mental or medical care. Of the 181 Veterans who participated in the PC-MHI program, 60% sought mental health care within one month after their initial encounter in PC-MHI, and 82% after one year, while 18% sought medical care within one month, and 74% within one year. The average length of time to a subsequent specialty mental health care visit after the Veterans’ first PC-MHI encounter was about 5 months. The average length of time to a subsequent medical care visit after the first PC-MHI encounter was about 10 months. While PTSD was the primary condition associated with OEF/OIF Veterans remaining in VA care for mental health care, retention in long-term medical care was not associated with mental health disorders measured in this study (PTSD, substance use disorder, major depressive disorder, and anxiety/phobia).
Date: April 30, 2012
- Meditation-Based Mantram Intervention Shows Potential as Adjunctive Therapy for Veterans with PTSD
The Mantram Repetition Program (MRP) shows potential when used as an adjunct to treatment as usual (TAU) for mitigating chronic PTSD symptoms in Veterans. In this study, twice as many Veterans in the MRP + TAU group had clinically meaningful reductions in PTSD symptoms compared to Veterans in the TAU alone group: 24% vs. 12%, respectively, and PTSD symptoms continued to improve in the MRP + TAU group at six-week follow-up. Compared to Veterans in the TAU alone group, Veterans in the MRP + TAU group also experienced significant reductions in depression and greater improvements in mental health-related quality of life and spiritual well-being. Reductions in anxiety were equivalent between groups. Of Veterans in the MRP + TAU group, 97% reported moderate or high satisfaction with MRP, and dropout rates were equivalent and low (7%) in both groups.
Date: March 12, 2012
- Use of Mental Health and Non-Mental Health Outpatient Care by OEF/OIF Veterans with Military Sexual Trauma
The most notable factor that influenced the receipt and intensity of MST-related care was gender. Male Veterans used less care than female Veterans and had a lower intensity of MST-related care compared to women, even after controlling for total number of healthcare visits. Other sociodemographic and military variables associated with less use and/or less intensity of MST-related care were younger age, unknown race/ethnicity, being in the Marines or Air Force, and being in the National Guard or Reserve. Among all Veterans who screened positive for MST, the majority (76%) received at least one MST-related care visit within a year of the positive screen. In examining diagnostic characteristics of MST-related care, the most common primary diagnoses related to a Veterans’ MST-related care were mental health diagnoses. Overall, more than half of all Veterans received MST-related care with an associated mental health primary diagnosis (57% of women and 50% of men); the most common diagnoses were PTSD, depression, and other anxiety disorders. The authors note that the high proportion of Veterans accessing MST-related care confirms the effectiveness of VA’s universal screening program to promote the use of mental health services for Veterans with positive MST screens.
Date: March 7, 2012
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 2012
- Prevalence and Risk Factors for Non-Fatal Injuries among Veterans with TBI – Post-Discharge from VA Polytrauma Care
This study examined the prevalence of, and potential risk factors for, non-fatal injuries among Veterans with TBI after discharge from VA inpatient polytrauma rehabilitation programs. Caregivers reported that nearly one-third (32%) of Veterans discharged from VA Polytrauma Rehabilitation Centers had incurred subsequent, medically treated injuries; most were associated with falls (49%) and motor vehicles (37%). Factors associated with Veterans’ increased odds of subsequent injury included poor or fair general health and requiring assistance with activities of daily living or instrumental activities of daily living. A number of caregiver-reported ongoing symptoms/health problems among Veterans (e.g., depression, vision loss, hearing loss) were also associated with greater injury odds. Moreover, the odds of subsequent injury increased as the number of reported symptoms/comorbid health problems increased. Compared to male Veterans, the small proportion of female Veterans (n=23) had approximately four and a half times the odds of sustaining subsequent injury. Caregivers who reported their own health as poor or fair were more likely to report subsequent injuries for Veterans compared to caregivers who reported their own health as excellent, very good, or good. Caregivers with higher than average or average depressive or anxiety symptoms, or lower than average physical functioning scores, also were more likely to report injuries among Veterans compared to caregivers without these symptoms.
Date: January 1, 2012
- Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
Date: September 8, 2011
- Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
Date: August 1, 2011
- Women’s Health Issues Journal Focuses on Women Veterans
This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
Date: July 6, 2011
- Study Evaluates Workshop to Assist OEF/OIF Veterans with Reintegration and Resiliency
Few programs to promote healthy reintegration exist that are evidence-based and designed for individuals who are not receiving formal mental health care. In response to this need, a two-hour workshop, Life Guard, was developed for the Arkansas National Guard. This pilot study evaluated the effectiveness of the Life Guard workshop for OEF/OIF National Guard Veterans. Findings show that Veterans who participated in the workshop reported significant declines in symptoms of depression, anxiety, and PTSD, in addition to increased satisfaction with relationships. Results also show high levels of exposure to traumatic events, physical injury, and symptoms of psychosocial distress. The authors suggest that these findings support the continued evaluation of Life Guard as a valuable tool to help service members with reintegration and resiliency.
Date: February 1, 2011
- 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
- Pain Screening Implementation for Veterans Falls Short
This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
Date: August 6, 2010
- Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
Date: June 17, 2010
- Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
Date: June 9, 2010
- Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
Date: May 11, 2010
- Characteristics and Needs of Veteran Cancer Survivors
Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4) chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors.
Date: March 1, 2010
- Veterans Diagnosed with Traumatic Brain Injury Significantly More Likely to Experience Mental Illness
In April 2007, VA implemented national screening for symptomatic TBI resulting from combat exposure. Using VA data for 13,201 OEF/OIF Veterans who were screened for TBI in VISN 23, investigators examined rates of psychiatric disorders in relation to both TBI screening results and post-screening confirmation of TBI status. Findings show that among 836 Veterans with confirmed TBI, 85% had at least one psychiatric diagnosis, and 64% had two or more distinct diagnoses. Compared to Veterans with negative TBI screens, those with positive screens but without confirmed TBI were three times more likely to have PTSD – and were two times more likely to have depression and substance-related diagnoses. Veterans with clinically confirmed TBI were more likely than those with positive screens but no confirmed TBI to have diagnoses of PTSD, anxiety, and adjustment disorders. Nearly half of all OEF/OIF Veterans screened for TBI in VISN 23 had at least one psychiatric disorder, with PTSD (25.9%) and depression (25.6%) being the most common.
Date: February 1, 2010
- Predictors Associated with Homelessness among Women Veterans
Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
Date: February 1, 2010
- 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
- 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
- Areas for Mental Health Intervention for Patients with Hepatitis C
In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
Date: March 1, 2009