- Use and Predictors of Healthcare among New Post-9/11 Veterans with Mental Health Conditions
This study sought to identify the healthcare programs and services that new post-9/11 Veterans who screened positive for mental health problems used – and any factors that predicted that use within the first 90 days of military separation. Findings showed that Veterans from the most junior enlisted ranks were the least likely to access healthcare programs and services, whereas few differences emerged by gender or racial/ethnic minority status. Nearly half of Veterans in the sample (47%) used VA for their healthcare, while 19% sought services from non-VA providers. Veterans exposed to combat, those with a medical discharge, and those with a chronic medical or mental health problem were all more likely to report using VA healthcare services. Findings suggest that Veterans, particularly those from the junior enlisted ranks who are most at risk for poor transitions, should be encouraged to use programs and services provided by both VA and non-VA healthcare alternatives.
Date: May 12, 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
- 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
- Opioid Use among Afghanistan and Iraq War Veterans
This study sought to understand current opioid use in
OEF/OIF/OND Veterans who are regular users of VA care and did not have a cancer diagnosis at the time of this study. Findings showed that opioid use among
OEF/OIF/OND Veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of Veterans. Approximately 23% of all
OEF/OIF/OND Veterans received opioids, with 7-8% receiving them chronically. The prevalence of high-dose opioids, concurrent use of multiple opioids, and use of long-acting opioids was fairly low. Diagnoses of PTSD, major depressive disorder, and tobacco use disorder were strongly associated with chronic opioid use. Back pain also was strongly associated with chronic use. Findings suggest that the use of opioids is less common among
OEF/OIF/OND Veterans compared with Veterans as a whole, and provide a strong baseline for evaluating the impact of recently implemented opioid-related policies.
Date: March 25, 2017
- Gender and Smoking Impact Severity of Musculoskeletal Pain among
This study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in Veterans of the wars in Afghanistan and Iraq. Findings showed that both gender and current smoking status were significantly associated with increased odds of moderate to severe musculoskeletal pain. Male Veteran non-smokers were more likely than female Veteran non-smokers to report moderate to severe pain; however, there were no gender differences in moderate to severe pain among Veteran smokers. Relative to female non-smokers, female Veteran smokers had increased odds of reporting moderate to severe musculoskeletal pain.
Date: March 14, 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
- Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of
OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
Date: June 1, 2016
- Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among
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
- Factors Associated with VA and Non-VA Mental Health Service Use among National Guard Soldiers
This study sought to determine the associations between mental health need, enabling, and predisposing factors and mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. Findings showed that overall mental health service use was strongly associated with need, including higher number of mental health conditions and worse physical health. Among those using services, predisposing factors (middle age and female gender) and enabling factors (employment, income greater than $50,000, and private insurance) were associated with greater non-VA service use. Among the survey respondents reporting mental health treatment in the prior 12 months, 81% received any VA treatment and 19% received only non-VA treatment. Approximately 30% of those receiving VA treatment also had received treatment from a non-VA source.
Date: February 3, 2016
- Influence of Military Sexual Trauma among Male Veterans
This study examined the demographic and diagnostic profiles, as well as interpersonal and vocational post-deployment functioning, in a large sample of
OEF/OIF male Veterans. Of the Veterans in this study, 18% self-reported military sexual trauma (MST) perpetrated by a member of their unit, compared to only 0.3% having been reported during a clinical diagnostic interview. MST was a significant predictor of lower social support, even after statistically controlling for other trauma exposure, and was significantly associated with perceived emotional mistreatment post-deployment. MST was not significantly associated with job loss or unemployment. Greater ratings of stressful life events were associated with a greater likelihood of job loss and unemployment, while greater ratings of social support were associated with a decreased likelihood of unemployment.
Date: November 1, 2015
- Predictors of
OEF/OIF Army Active Duty Members’ Linkage to VA Healthcare Post-Deployment
This study sought to describe the rates and predictors of linkage to VA healthcare in the first 365 days after separation for Army Active Duty members who served in Iraq and/or Afghanistan from FY08 through FY11. Findings showed that within 12 months of separation, 48% of
OEF/OIF Army Active Duty members used VA healthcare. There was significant variation in linkage to care rates by VA healthcare facility: between 31% and 72% of Active Duty members assigned to a facility’s catchment area used at least one VA healthcare service. The most notable variables associated with greater linkage to VA healthcare included probable serious injury during index deployment, separation due to disability, and receipt of VA care before or after military separation as a VA enrollee or non-enrollee. When compared with junior enlisted Army members, higher-ranking service members had considerably lower odds of seeking VA healthcare.
Date: October 1, 2015
- Association between Separation from Military due to Misconduct and Homelessness
This study analyzed the association between misconduct-related separations and homelessness among recently returned active-duty military service members. Findings showed that the incidence of homelessness at their first encounter with VA healthcare was significantly greater for Veterans who experienced separation due to misconduct compared to Veterans with a normal separation, as well as within one year and at five years. Although only 6% of the Veterans in this study separated for misconduct, they represented 26% of homeless Veterans at their first VA healthcare encounter, 28% within 1 year of separation, and 21% within 5 years. The overall incidence of homeless among Veterans was 0.3% at the time of their first VA healthcare encounter, 1% within one year, and 2% within 5 years. These findings support reports of recently returned Veterans with records of misconduct having difficulties re-entering civilian life.
Date: August 25, 2015
- Gender Differences in Chronic Pain among Veterans
This study examined a) gender differences in trauma, social support, and family conflict among
OEF/OIF/OND Veterans with chronic pain, and b) whether these variables were differentially associated with pain severity, functioning, and depressive symptom severity as a function of gender. Findings showed that 69% of Veterans in the study reported experiencing pain for 3 months or longer (67% of men and 71% of women); 75% stated pain had been present for more than one year. The most problematic sites of pain were: back (37%), joint (33%), headache (12%), and neck (9%). Men and women Veterans did not differ significantly in terms of pain severity, pain interference with function, depressive symptom severity, or use of prescription opioids. Relative to men, women Veterans reporting chronic pain evidenced higher rates of childhood interpersonal trauma (51% vs. 34%) and military sexual trauma (54% vs 3%), as well as lower levels of combat exposure. Being married was associated with greater pain-related functional difficulty for women and lower difficulty for men. Combat exposure was associated with pain-related functional difficulty for women but was unrelated for men. Childhood interpersonal trauma was more strongly associated with pain-related functioning among men. Family conflict was associated with greater pain-related functional difficulty and depressive symptoms for men, but was unrelated for women. Thus, gender may be a salient target of investigation when examining development of and/or adaptation to chronic pain, and is an important consideration in tailoring treatment programs to meet the needs of Veterans with chronic pain.
Date: June 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
- Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
Date: March 27, 2015
- Antipsychotics Prescribed to Substantial Minority of Veterans with PTSD without Bipolar Disorder or Schizophrenia
Given limited knowledge about the use of antipsychotics in Veterans with PTSD returning from Iraq and Afghanistan, this study examined the rates of antipsychotic use in this patient population. Findings showed that antipsychotics were prescribed to a substantial minority of
OEF/OIF/OND Veterans with PTSD who did not also have a diagnosis of bipolar disorder or schizophrenia. Of the Veterans in this study, 20% received no psychiatric medications, 61% received psychiatric mediations other than antipsychotics, and 19% received antipsychotics. Male Veterans and those in the Army, of lower rank, and with active duty status (vs. National Guard/Reserve) were more likely to be prescribed antipsychotics. Comorbid psychiatric conditions, particularly substance use and personality disorders, as well as suicidal ideation also were associated with greater use of antipsychotics compared to other types of psychiatric medications. Antipsychotics were prescribed much later after the date of PTSD diagnosis than other psychiatric medications, suggesting they were not first-line medications. Given limited evidence of the benefit of antipsychotics for PTSD and their potential adverse metabolic side effects, authors suggest that clinicians carefully weigh the risks and benefits of antipsychotic use in Veterans with PTSD.
Date: March 3, 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
- Having Dependent Children Associated with Increased Risk of PTSD among
This is the first study to examine whether being the parent of a dependent child was, in itself, associated with the likelihood of post-deployment PTSD diagnosis among Veterans. Findings showed that after controlling for demographics, mental healthcare use, and other serious mental illness,
OEF/OIF Veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. This association was stronger among men than women. Other variables associated with increased odds of PTSD diagnosis included male gender, white race, Hispanic ethnicity, younger age, Priority 1 status, more than one dependent child, depression or SUD diagnosis, greater use of mental health services, and more medical comorbidities. Veterans with dependent children had greater VA mental healthcare utilization, including inpatient psychiatric admissions and mental health counseling visits. Thus, it may be of value for clinicians to consider parental status when treating Veterans with PTSD.
Date: January 19, 2015
- Gender Differences in Attitudes and Their Relationship to VA Mental Healthcare Use
This study explored gender differences in attitudinal barriers to and facilitators of care for
OEF/OIF Veterans, and determined the relationship of those factors to VA mental health service use among female and male Veterans with probable mental health conditions. Findings showed that Veterans were similar in their perceptions of VA healthcare and their perceived fit within the VA healthcare setting. Men held slightly more negative attitudes about mental illness and treatment than women. For both women and men, perceived entitlement to VA care was associated with increased likelihood of service use, and negative beliefs about treatment seeking (e.g., a problem would have to be really bad to seek mental health treatment) were associated with a reduced likelihood of seeking mental healthcare in the past six months. For female Veterans only, positive perceptions of VA healthcare were associated with increased likelihood of seeking VA mental health treatment. For male Veterans only, researchers found a positive relationship between VA service use and negative attitudes toward mental health treatment (e.g., mental health treatment does not work). Perceived similarity to other VA healthcare users was also associated with increased likelihood of service use, while negative beliefs about mental illness (e.g., people with mental health problems are violent or dangerous) were associated with lower likelihood of service use.
Date: November 3, 2014
- Predictors of Worsening Mental Health among
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
- Enrollment in VA Healthcare Most Likely in First Year after Return from Deployment for Army Reserve/National Guard Members
This study examined rates and predictors of Reserve Component (RC) members’ enrollment and use of VA healthcare services in the first year following demobilization from an index deployment. Findings showed that, of the Veterans in this study, 57% of Army National Guard (ARNG) members and 46% of Army Reserve (AR) members used VA care within 12 months of demobilization, suggesting that Reserve Component members are most likely to enroll in VA healthcare in the year following return from deployment. Female members were more likely to enroll in VA healthcare than male members, an important finding given that women are the fastest growing segment of the Veteran population. The percent of ARNG and AR members in each VA facility’s catchment area who received VA healthcare as an enrollee varied substantially – from as low as 25% to more than 85%, even after adjusting for driving time, demographics, and service-related factors. Investigators suggest that future research and QI efforts with VA and DoD should strive to better understand this variation and the extent to which it is explained by factors such as the availability of non-VA healthcare options, actual or perceived quality of VA care, and/or availability of education and outreach interventions.
Date: October 1, 2014
- Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an
OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be
OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
Date: September 1, 2014
- Detection of Suicidal Ideation Not Associated with Increased Mental Health Utilization in Year Following SI Assessment
This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care
OEF/OIF Veterans. Findings showed that 32% of the Veterans in this study had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare utilization over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity. When a Veteran’s inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only.
Date: July 30, 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
OEF/OIF Servicewomen Remain Reluctant to Report Military Sexual Assault despite More Knowledge about Reporting Options
This study sought to identify factors associated with officially reporting sexual assault in-military (SAIM), examining demographic, military, and sexual assault characteristics, as well as perceptions and experiences of reporting. Findings showed that 18% of the active duty service members and 12% of the Reserve/National Guard members in this study experienced SAIM. However, despite increased knowledge about how to report SAIM, there was no increase in rates of reporting compared to earlier VA-enrolled samples; the number of servicewomen who knew how to officially report increased from 57% to 65%, but the rates of reporting were similar, 26% vs. 25%. Restricted reporting (law enforcement not informed, command structure not involved) was rated more positively, but unrestricted reporting (law enforcement and command structure notified, criminal investigation initiated) was used more often. Experiences of servicewomen who reported SAIM reinforced concerns of those who did not report, i.e., loss of confidentiality, adverse treatment by peers, no action taken against the perpetrator. Officers were less likely to report than enlisted servicewomen.
Date: July 1, 2014
- High Prevalence of Reintegration Difficulty among
OEF/OIF/OND Veterans, Particularly among VA Healthcare Users
This study sought to estimate the prevalence of perceived reintegration difficulty in the entire population of
OEF/OIF/OND Veterans. Findings showed that the estimated prevalence of “at least a little” reintegration difficulty among this population was 54% and was higher among VA healthcare users than among non-users (62% vs. 45%). Among those with at least a little reintegration difficulty, VA healthcare users reported higher levels of combat exposure and were more likely to meet criteria for probable TBI and PTSD compared to non-users. [Veterans with probable TBI were more than twice as likely to be VA healthcare users.] VA users also reported higher levels of psychological distress, physical symptoms, and reintegration difficulty, and were much more likely to report having sought medical care for physical or mental health problems over the past three months. Veterans with reintegration difficulty who also had service-connected mental and physical health conditions were two to four times more likely to be VA healthcare users. And as time since deployment increased, the likelihood of being a VA user also increased.
Date: June 11, 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
- Food Insecurity among
OEF/OIF Veterans Dramatically Higher than among General Population
This study sought to document the prevalence and correlates of food insecurity among Veterans of the wars in Iraq and Afghanistan. Findings showed that at nearly 27%, the prevalence of food insecurity among
OEF/OIF Veterans in this study was dramatically higher than the U.S. prevalence of food insecurity (15% in 2012). In addition, Veterans reported very low food security at double the U.S. rate: 12% vs. 6%. Veterans were more likely to be food-insecure if they were younger, not married/partnered, and were not employed or on active duty. Food-insecure veterans also were more likely to use tobacco, report more frequent binge drinking, and slept fewer hours at night.
Date: May 8, 2014
- Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among
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
- Increasing Number of Women Veterans Use VA Maternity Benefits
This study examined the number and cost of inpatient deliveries in VA over a five-year period – from FY2008 to FY2012. Findings showed that the volume of women Veterans using VA maternity benefits increased by 44% – from 12.4 to 17.8 deliveries per 1,000 women Veterans. Also, the number of deliveries increased during each year – from 1,442 delivery claims in FY2008 to 2,730 in FY2012. A majority of women using VA maternity benefits were age 30 and older, resided in urban areas, and had a service-connected disability. Also, 42% were
OEF/OIF/OND Veterans. Over the five-year study period, VA paid more than $46 million in delivery claims to community providers for deliveries of women Veterans ($4,993 per Veteran). The rate of C-section delivery was 34%, which is similar to the national average of 32%. Given the sizeable increase in delivery rates, the authors suggest that VA increase its capacity for pregnant Veterans and ensure care coordination systems are in place to address the needs of pregnant Veterans with service-connected disabilities. Coordinating community-based maternity care with ongoing VA care is critical because many women Veterans have complex medical and mental health conditions that may increase their risk of adverse pregnancy outcomes.
Date: January 1, 2014
- Prevalence of “Polytrauma Triad” among Iraq and Afghanistan War Veterans
This study sought to determine the prevalence of TBI, PTSD, and pain among Veterans from the
OEF/OIF/OND wars, who received VA healthcare. Findings showed that large and increasing numbers of
OEF/OIF/OND Veterans accessed the VA healthcare system over the three-year study period. Of these Veterans, about 10% were diagnosed with TBI, 30% with PTSD, and 40% with pain. Approximately 6% had all three diagnoses — or the polytrauma triad. Overall, while the absolute number of
OEF/OIF/OND Veterans increased by more than 40% from FY09 through FY11, the relative proportion of Veterans diagnosed with TBI, and the high rate of comorbid PTSD and pain in this population have remained stable.
Date: January 1, 2014
- Traumatic Brain Injury during Most Recent Deployment Strongest Predictor of Post-Deployment PTSD
Investigators in this study examined whether deployment-related TBI predicts PTSD symptom severity when accounting for combat intensity and pre-deployment characteristics. Findings showed that, at the pre-deployment assessment, 57% of service members reported prior TBI; at post-deployment assessment, 20% reported deployment-related TBI. Even when accounting for pre-deployment psychiatric symptoms, prior TBI, and combat intensity, TBI sustained during the most recent deployment was the strongest predictor of post-deployment PTSD symptoms. Deployment-related TBI nearly doubled the likelihood of post-deployment PTSD for service members who reported minimal to no PTSD symptoms before deployment. The probability of post-deployment PTSD was greatest for service members with severe pre-deployment symptoms, high combat intensity, and deployment-related TBI.
Date: December 11, 2013
OEF/OIF Veterans with PTSD Experience More Pain Complaints than Veterans without PTSD
This study sought to extend previous work by evaluating the association among PTSD, major depressive disorder (MDD), and pain among Iraq and Afghanistan war era Veterans. Findings showed that Veterans with PTSD reported pain-related complaints at greater rates than Veterans without PTSD. PTSD – with or without MDD – was associated with increased risk of back, muscle, or headache pain. The highest rate of pain complaints was found in Veterans with comorbid PTSD and MDD. Women Veterans were more likely to report back pain, muscle aches, and headaches, but the relationship between psychiatric diagnsoses and pain did not differ in men and women. Veterans with PTSD/MDD were less likely to be employed, more likely to be receiving disability compensation, and more likely to report combat-related injury than Veterans without either disorder. Observed associations of PTSD and MDD with pain complaints suggest that integrated, multidisciplinary treatment may be beneficial, particularly for Veterans with multiple mental health comorbities and pain.
Date: August 7, 2013
- Low Rates of VA Vocational Service Use among
OEF/OIF Veterans with Mental Health Conditions
This study assessed nationwide patterns of supported employment and vocational service use among
OEF/OIF Veterans with the top four mental health conditions: PTSD, depression, substance use disorder, or traumatic brain injury (TBI). Findings showed that of the Veterans with mental health diagnoses included in this study, only 8% had a vocational services encounter during the study period, with 2% of these receiving evidence-based supported employment. Moreover, retention was low, with most Veterans attending just one to two appointments. Veterans with TBI – and those with more mental health conditions overall – were more likely to access vocational services. Among Veterans whose employment was tracked, 51% with at least one supported employment encounter worked competitively, compared to 21% of those who did not receive supported employment. Thus, supported employment was effective when it was provided. Results indicate that recovery-oriented, evidence-based, supported employment is the best way to assist unemployed Veterans with mental health conditions to achieve competitive employment. However, resources are limited for Veterans without psychosis and those who are not homeless. Given that
OEF/OIF Veterans with TBI are more likely to need vocational services, the authors suggest supported employment could be effectively integrated into VA polytrauma clinics.
Date: August 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
- High TBI Screening Rates among
This study describes the early results of VA’s TBI screening program, and identifies patient and facility characteristics associated with receiving a TBI screen. Findings showed that TBI screening rates are high in VA, with more than 90% of eligible Veterans screened. Of Veterans who were screened, 21% met the VA definition of a positive screen, with blast or explosion the most common exposure reported. Factors associated with a positive TBI screen included: male gender, having served in the Army, having had multiple deployments, and having mental health diagnoses in the previous year. A positive TBI screen was less likely among Veterans who were separated from duty for more than 18 months, or Veterans who had a chronic disease diagnosis. The most common symptoms reported in the period after injury were sleep problems (78%), irritability (69%), and headaches (63%), and these symptoms continued to be current problems at time of screening.
Date: March 1, 2013
- VA’s Traumatic Brain Injury Screening Process is Inclusive and Effective in Referral for Further Services
This study evaluated VA’s TBI screening and evaluation program and documented follow-up care and demographics of Veterans who do and do not receive care. Findings showed that VA’s TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of Veterans who were evaluated received further VA healthcare, and evaluations confirming TBI were associated with significantly higher healthcare use. Of the
OEF/OIF/OND service members who were screened for TBI between 10/07 and 10/09, 22% screened positive. Of these Veterans, 55% received a comprehensive TBI evaluation. Of Veterans with comprehensive evaluations, TBI was confirmed in 58%, yielding a best estimate that 7% of those screened were confirmed to have TBI. Patients with a positive screen were more likely to be male (94% vs. 88%) and enlisted (96% vs. 93%) than the screened patient population overall.
Date: February 1, 2013
OEF/OIF Veterans who Screen Positive for Depression Receive Timely Assessments for Suicidal Ideation
This study describes brief structured assessment (BSA) processes for suicidal ideation, including frequency of administration, among
OEF/OIF Veterans who screened positive for depression – and identifies individual and system factors that are associated with BSA completion. Findings showed that overall, 81% of Veterans received a BSA for suicidal ideation within one month of screening positive for depression, and 94% of BSAs were conducted within one day of positive screens. Assessment for suicidal ideation was 50% to 80% more likely to occur when Veterans received a diagnosis of PTSD or depression, respectively, on the day of assessment. Neither race/ethnicity nor age was associated with BSA receipt.
Date: January 23, 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 Delay Initiating Mental Health Care and Completing Effective Mental Health Treatment
This study sought to describe time to initiation (and predictors of time to initiation) of first primary care visit, mental health outpatient visit, and minimally adequate mental healthcare among Veterans with mental health diagnoses seeking VA healthcare post-deployment. Findings indicate delays in initiating and completing minimally adequate mental healthcare among
OEF/OIF/OND Veterans using VA services. Among these Veterans, the median time to engagement in mental healthcare was more than two years from the end of the last deployment. Further, after more than three years post-deployment, 75% of Veterans with mental health diagnoses – who were in the VA healthcare system for at least one year – had still not engaged in minimally adequate mental healthcare. There was a median lag time of 7.5 years between coming in for an initial mental health treatment session and beginning a course of minimally adequate mental healthcare. All of the mental health diagnoses, as well as number of comorbid mental health diagnoses, were associated with an increased chance of initiating minimally adequate mental health outpatient care sooner. PTSD had the strongest association with early initiation. Male Veterans waited nearly two years longer to initiate minimally adequate mental healthcare compared to female Veterans. Younger Veterans (<25 years of age) took longer to initiate and seek minimally adequate care; racial/ethnic minorities also took longer than their White counterparts.
Date: December 1, 2012
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
- 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
- Relationship between Compensation Status and Treatment Outcomes for Veterans with PTSD
This study examined the relationship of compensation status, treatment expectations, military cohort, length of stay, and treatment outcomes in Veterans enrolled in residential PTSD programs. Findings showed that PTSD compensation status may have little influence on treatment outcomes for Veterans engaged in VA residential PTSD programs. Veterans who already had pensions and were seeking increased compensation for PTSD endorsed marginally lower treatment expectations as compared to Veterans with stable compensation for PTSD; however, these differences did not result in significant differences in symptom changes during the course of treatment. Veterans seeking initial compensation for PTSD did not report lower treatment expectations or poorer treatment outcomes. Positive treatment expectations were associated with longer lengths of stay and greater improvement in symptoms. Compared to non-
OEF/OIF/OND Veterans reported lower treatment expectations and higher PTSD and depressive symptoms at intake, yet experienced similar treatment gains at discharge. It is unclear whether their decreased treatment expectations reflect less motivation to get better (due to secondary gain issues) or less socialization to treatment and, therefore, less belief in treatment efficacy.
Date: October 9, 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
- Substance Use Disorders Significantly Increase the Risk of All-Cause Mortality among Veterans with PTSD
This study sought to estimate the predictive association between substance use disorders (SUDs) and the risk of mortality among a cohort of Veterans with PTSD. Findings showed that having a substance use disorder significantly increased the risk of all-cause mortality among Veterans with PTSD. The association between SUDs and non-injury-related mortality was most pronounced in the youngest age group (<45 years), which included
OEF/OIF Veterans, compared with the 45-64 or >65 group. Regardless of age group, SUD was a strong predictor of injury-related mortality. It was a significantly stronger predictor of injury-related vs. non-injury related death among Veterans in the 45-64 years and >65 years age groups. However, it is important to note that injury-related mortality accounted for a relatively small proportion of all deaths (~10%) among Veterans with PTSD.
Date: September 10, 2012
- Higher Rates of Reproductive and Physical Health Problems in
OEF/OIF Women Veterans with Mental Illness
OEF/OIF women Veterans with any mental health diagnoses had significantly higher prevalence of nearly all categories of reproductive and physical disease diagnoses compared to women Veterans without mental health diagnoses. Women with mental health diagnoses had approximately two to four times the odds of receiving diagnoses of sexually transmitted infections, cervical dysplasia, dysmenorrhea, and gynecologic pain syndromes, as well as other reproductive and gynecologic health conditions, with prevalence being highest in women with comorbid PTSD and depression. The most striking difference was in sexual dysfunction (a relatively rare outcome), in which women Veterans diagnosed with mental health disorders had 6 to 10 times the odds of receiving this diagnosis than women without mental disorders.
Findings were similar after adjusting for demographics, military service characteristics, and distance to/type of nearest VAMC. The magnitude of the associations of mental and physical health diagnoses were reduced after adjusting for primary care utilization, but most remained significant.
Date: September 1, 2012
- Pain and PTSD Common Comorbidities among
OEF/OIF Veterans with Spinal Cord Injury Undergoing Inpatient Rehabilitation
Pain and PTSD were more likely to manifest as comorbidities than as isolated conditions during inpatient rehabilitation for spinal cord injury. Comorbid pain and PTSD symptoms were more common than either condition alone, and nearly as common as not having either condition. Veterans with pain at the beginning of rehabilitation showed declines in pain ratings over the course of rehabilitation. In contrast, Veterans in the “PTSD Alone” group showed increasing pain over the course of rehabilitation. Factors not associated with pain and PTSD status were: demographic and SCI characteristics, number of comorbid traumatic injuries, and the prevalence of individual comorbid injuries.
Date: August 1, 2012
- Majority of
OEF/OIF Veterans with PTSD Use VA Healthcare for PTSD-Related Treatment, and Users are Increasing
Approximately 58% of
OEF/OIF Veterans with PTSD used VA healthcare services and received some PTSD-related treatment from 2002 through 2010. Moreover,
OEF/OIF Veterans with PTSD have been increasingly likely to use VA services over time. There is insufficient information about the quality of PTSD-related services. Developing a broader understanding of the concept of quality as it relates to PTSD treatment may lead to a better understanding of the services that
OEF/OIF Veterans with PTSD receive when they access VA care.
Date: July 1, 2012
- Effect of Environmental Exposures on Non-Specific Physical Symptoms in
Reporting of environmental exposures was relatively low in
OEF/OIF Veterans, but reporting more environmental and other exposures, in particular screening positive for TBI, was related to greater non-specific physical symptom severity immediately after deployment. Soldiers reported higher rates of exposure to blasts than to any other single exposure: 15% reported exposure to one blast, 9% to two blasts, 8% to three blasts, 2% to four blasts, and 29% to five or more blasts. Overall, nearly 22% of Veterans screened positive for TBI. These data suggest that VA healthcare providers should ask Veterans about environmental exposures and address any concerns about exposures expressed by patients, especially when they co-occur with physical symptoms.
Date: June 1, 2012
- Variables Associated with Risk of Community Violence among Subset of
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
- Prevalence and Severity of Neurobehavioral Symptoms is High among
OEF/OIF Veterans with Traumatic Brain Injury
Of the 55,070 Veterans with a positive TBI screen who then received the Comprehensive TBI Evaluation, clinicians diagnosed TBI during deployment in 30,267 (55%), no TBI during deployment in 20,934 (38%), and indeterminant in the remaining 3,869 (7%). Moderate to very severe post-concussive symptoms were common in those with and without clinician-diagnosed TBI. However, the odds of reporting moderate to severe symptoms – ranging from a high of 82% for symptoms of irritability and sleep problems to a low of 19% for changes in sense of taste and smell – were significantly higher in Veterans with TBI. Moreover, the odds of reporting that these symptoms moderately to extremely interfered with life was higher in those diagnosed with TBI. Among those with TBI, clinicians believed that current symptoms were more likely due to TBI alone in 10% of participants, a combination of TBI and behavioral health conditions in 61%, and behavioral symptoms alone in 23%.
Date: May 30, 2012
- Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for
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
- Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among
OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
Date: March 7, 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
- Gender Differences in Healthcare Utilization among Veterans with PTSD
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
- Majority of
OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among
OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for
OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
Date: January 4, 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
- 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
- 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
- History of Military Sexual Trauma Increases Risk of Sexual Health Diagnoses among
This study examined the prevalence rates of sexually transmitted infections (STIs) and sexual dysfunction disorders (SDDs) among
OEF/OIF Veterans with and without reported military sexual trauma (MST). Investigators also explored whether the presence of a co-existing mental health diagnosis (e.g., PTSD, depression, substance use disorder) was associated with higher rates of STIs and SDDs among Veterans who screened positive for MST. Findings show that a number of STI and SDD diagnoses were more common among
OEF/OIF Veterans who reported a history of MST compared to Veterans without a history of MST. There were no instances in which any of the sexual health diagnoses were significantly higher among Veterans who did not report a history of MST, even after controlling for age and length of time in VA healthcare. Moreover, among Veterans with a history of MST, the risk of having an STI or SDD increased in the presence of certain mental health diagnoses. Among women with a history of MST, those with a diagnosis of PTSD, depression, or a substance use disorder were significantly more likely to have an STI than women without these diagnoses. Among men with MST, only substance use disorder increased their risk for an STI. Among women with a history of MST, those with a diagnosis of depression were significantly more likely to have an SDD than women without a depressive disorder. Among men with MST, those with a diagnosis of PTSD or depression were more likely to have an SDD diagnosis than men without either disorder. This study emphasizes the importance of sexual health screening, particularly among Veterans with a history of MST.
Date: December 5, 2011
- Unique Culture of Modern Military Family
This article discusses challenges faced by military couples, as well as strengths inherent to the military culture (e.g., community environment and camaraderie) that clinicians can use in helping families develop resiliency. Couple-based interventions also are described.
Date: December 1, 2011
- Factors Associated with Veterans Seeking PTSD Service Connection
This study sought to describe the reasons Veterans seek PTSD disability benefits and examined differences between those who served in different military service eras. Findings show five inter-related categories of reasons for seeking PTSD service connection: 1) tangible need (e.g., financial, healthcare), 2) need for problem identification or clarification (getting a thorough, official PTSD evaluation), 3) justification/legitimization of disability status (e.g., recognition of military trauma), 4) encouragement from trusted others (e.g., clinician, commanding officer, family), and 5) professional assistance (e.g., Veterans advocate). For Vietnam Veterans, reasons for applying for PTSD service-connection were affected by changes associated with aging, as well as decades of difficulty understanding and coping with post-deployment difficulties. In comparison,
OEF/OIF Veterans wanted to avoid the problems Vietnam Veterans had in obtaining needed services and benefits by being more proactive.
Date: November 22, 2011
- Barriers to Healthcare Access for Women Veterans
This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be
OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
Date: November 1, 2011
- 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
- Majority of
OEF/OIF Veterans with Chronic Non-Cancer Pain are Prescribed Opioids by VA Outpatient Providers
This study sought to describe the prevalence of prescription opioid use, types and doses of opioids received, as well as factors associated with the prescription of opioids among
OEF/OIF Veterans. Findings showed that about two-thirds of
OEF/OIF Veterans with chronic non-cancer pain were prescribed opioids over a one-year timeframe. Of Veterans prescribed any opioids, 59% were prescribed opioids ‘short-term’ compared to 41% prescribed opioids ‘long-term’ (more than 90 days). The mean duration of opioid prescription was 61 days for Veterans in the short-term group and 285 days for Veterans in the long-term group. Several findings suggest a need for improvement in adherence to pain and opioid treatment guidelines. For example, among long-term opioid users, 51% were prescribed short-acting opioids only (guidelines recommend transitioning to long-acting opioids); only 31% were administered one or more urine drug screens (guidelines suggest more frequent drug screening); and 33% were also prescribed sedative-hypnotic medications (monitoring by prescribing physicians is recommended to prevent possible overdose or death). Diagnoses associated with an increased likelihood of receiving an opioid prescription included: low back pain, migraine headache, PTSD, and nicotine use disorder.
Date: September 7, 2011
- Profile of Caregivers and Care Provided for
OEF/OIF Veterans Following Acute Rehabilitation for TBI and Polytrauma
The Family and Caregiver Experience Study (FACES) sought to describe the care and support needs of
OEF/OIF Veterans with moderate to severe polytrauma after they received acute rehabilitation – and to describe the providers of that care. Findings showed that a significant portion of caregivers provide time-consuming, unpaid care for Veterans, years after injury. Policymakers may need to target additional resources to meet the long-term needs of caregivers who may not be eligible for support mandated by the Caregivers and Veterans Omnibus Health Services Act of 2010.
Date: August 25, 2011
- Most Veterans with New PTSD Diagnoses Who Attend PTSD Clinics May Not Receive Minimally Adequate Treatment
This study sought to assess receipt of PTSD specialty treatment among Veterans newly diagnosed with PTSD – and to identify predictors of receiving minimally adequate specialty treatment (MAST), which is defined as 9 or more visits over 12 months to a VA PTSD specialty clinic. Findings showed that only 33% of Veterans in this study who began VA PTSD specialty care received minimally adequate specialty treatment.
OEF/OIF Veterans were less likely to receive MAST (29% vs. 36%) and attended fewer clinic visits (mean 8.2 vs. 9.9) than non-
OEF/OIF Veterans. However, they were more likely to have an initial PTSD visit within 30 days of a positive PTSD screen.
Date: August 1, 2011
- Updated Literature Review Examines Research and Findings on Women Veterans’ Health
Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning
OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning
OEF/OIF Veterans. Local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
Date: July 6, 2011
- Many Risk Factors for Post-Traumatic Stress Symptomatology among
OEF/OIF Veterans have Pre-Deployment Origins
This study sought to identify the mechanisms through which previously documented risk factors (among Vietnam Veterans) contribute to post-traumatic stress symptomatology (PTSS) in a national sample of
OEF/OIF Veterans exposed to combat operations who had returned from deployment in the 12 months preceding the study. Findings showed that PTSS appears to be accounted for by multiple chains of risk, many of which originate in pre-deployment experiences (e.g., history of trauma, troubled family backgrounds) that put both female and male
OEF/OIF Veterans at risk for additional stress exposure. Moreover, earlier experiences of stress may lead to the depletion of resources over time, as well as greater risk of subsequent stress exposure. The majority of previously documented risk pathways in Vietnam Veterans held for both women and men in this sample of
OEF/OIF Veterans, providing support for the generalizability of mechanisms of risk for PTSS across Veteran populations. Relationship concerns during deployment increased risk for PTSS, especially among female Veterans. Warfare exposure had a direct effect on PTSS, suggesting that those who experience high levels of objective events of combat, even those who don’t report experiencing high levels of threat or fear, appear to be at risk for PTSS.
Date: June 27, 2011
- Painful Musculoskeletal Conditions More Prevalent among Female Compared to Male
This study sought to describe gender differences in the prevalence of painful musculoskeletal conditions in male and female
OEF/OIF Veterans. Findings showed that the prevalence of back pain, musculoskeletal conditions, and joint disorders increased significantly in years 1-7 after deployment among both female and male Veterans using VA care. Moreover, the odds of having back pain, a musculoskeletal condition, or a joint disorder was higher for female compared to male Veterans and increased over time.
Date: June 14, 2011
- Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for
In April 2007, an
OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for
OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among
OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that
OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
Date: June 7, 2011
- Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from
This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female
OEF/OIF Veterans. Study results suggest that women
OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment).
There were no differences between men and women in reports of perceived threat in the war zone.
Date: May 30, 2011
- Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among
This book follows a group of
OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
Date: May 19, 2011
- Low Follow-Up Rates for Positive TBI Screens
This retrospective study evaluated VA’s TBI screening program in terms of predictors of screening and positive-screen follow-up. Findings show that almost 90% of Iraq and Afghanistan war Veterans in this study were offered TBI screening, and 17% screened positive; 52% of those screening positive had subsequent appointments in a TBI/polytrauma specialty clinic during the 18-month study period. Of 1,185 patients evaluated in a TBI/polytrauma clinic following a positive screen, 55% were given a TBI diagnosis, and of 92 patients not evaluated in a TBI/polytrauma clinic following a positive screen, 8.5% were given a TBI diagnosis. Screening likelihood increased with time since implementation of the TBI screening program and was greater at the first clinic encounter. There was considerable variation by facility; for example, Veterans seen in a VAMC were more likely to be screened than those seen in a CBOC. Screening was particularly likely to occur during TBI/polytrauma and primary care clinic appointments. Younger, male, Army Veterans without psychiatric diagnoses were more likely to be screened compared with women Veterans, Iraq/Afghanistan Veterans from other branches of the military, and those who were at least 40 years old.
Date: February 11, 2011
- National Guard Soldiers Prefer Family-Based Interventions for PTSD and Co-Occurring Family Problems
This is the first study that has examined Army National Guard soldiers’ interest in and preference for various treatment approaches for post-deployment reintegration problems. Findings show that, among a sample of Army National Guard soldiers recently returned from
OEF/OIF combat deployment, a majority showed a preference for couples or family counseling over individual counseling. The percentage of soldiers willing to consider couples counseling was significantly greater than the percentage willing to consider individual counseling. Among soldiers who also were parents, 80% preferred family counseling, while 75% reported they would consider individual counseling.
Date: February 1, 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
- 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
- Suicide Risk Factors for OIF Veterans
This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
Date: January 22, 2011
- Concussion/mild TBI During Deployment Does Not Result in Significant Post-Deployment Health Effects Separate from PTSD
This study assessed the longitudinal associations between concussion/mild TBI (mTBI) and PTSD symptoms reported in-theater and longer-term psychosocial outcomes in 953 combat-deployed National Guard soldiers. Findings show that the rate of self-reported concussion/mTBI was 9% at Time 1 (one month before returning home from Iraq) and 22% at Time 2 (one year later). Differences may be explained by recall bias and/or poor reliability of the TBI screening instrument. Prevalence of probable PTSD at Times 1 and 2 was 8% and 14%, respectively; and for probable depression was 9% and 18%, respectively. At Time 2, 42% screened positive for problematic drinking and 29% endorsed clinically-significant non-specific somatic complaints. Self-reported post-concussive symptoms at Time 2 were common. For example, among those who reported neither mTBI nor PTSD, 23% reported balance problems, 57% reported tinnitus, 60% reported memory problems, and 64% reported concentration problems and irritability. Post-concussive symptom prevalences were even higher among those who reported mTBI and/or PTSD. The increased post-concussive symptoms reported by soldiers who also reported concussion/mTBI were no longer statistically significant after adjusting for post-deployment PTSD symptoms, suggesting that post-concussion symptoms may be largely explained by PTSD. Findings suggest that early identification and evidence-based treatment of PTSD may be important to the management of post-concussive symptoms following deployment.
Date: January 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
- Differences in Mental Health Diagnoses among
OEF/OIF Soldiers Transitioning from DoD to VA Care
This study assessed the transition of healthcare from DoD to VA for service members traumatically injured in
OEF/OIF, and their subsequent psychiatric care. Findings show that although none of the 994 DoD inpatients received a diagnosis of PTSD, 21% (209) had other mental health diagnoses, primarily drug abuse (12%). Of the 216 service members who transitioned to VA care, 71% (153) subsequently had at least one psychiatric diagnosis, with PTSD (52%) and depression (40%) the most common.
OEF/OIF service members who were discharged from DoD care in FY06 were more likely to transition into VA care (31%) than were patients discharged in earlier years. Of service members who sought VA care, 38% did so within six months of DoD discharge, and 75% within one year of discharge. Nearly 88% of those service members who transitioned to VA healthcare were still using VA care in the final year of the study, FY09. Treatment retention was significantly greater for those receiving psychiatric care: 98% vs. 62% for those not receiving psychiatric care.
Date: November 2, 2010
- Gender Differences in Mental Health Diagnoses among
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
- Greater Burden of Medical Illness among
OEF/OIF Veterans with PTSD
This study sought to determine whether the burden of medical illness is higher in
OEF/OIF Veterans with PTSD who used VA outpatient care compared to
OEF/OIF Veterans with no mental health conditions. Findings show that among women and men
OEF/OIF Veterans who used VA outpatient care between FY06 and FY07, the burden of medical illness (measured as a count of diagnosed conditions) was greater for those with PTSD than for those with no mental health conditions. The median number of medical conditions for women Veterans was 7.0 for those with PTSD versus 4.5 for those with no mental health conditions; for men, the rates were 5.0 versus 4.0. For Veterans with PTSD, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders; among men, the most frequent were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high-frequency conditions were more common in those with PTSD than in those with no mental health conditions.
Date: September 18, 2010
- Negative Emotionality May Contribute to Worse Post-Deployment PTSD and Poorer Intimate Relationships among National Guard Iraq War Soldiers
This study examined the contribution of the pre-existing personality trait of negative emotionality (NEM) and comorbid problem drinking to the association between post-deployment PTSD symptoms and relationship distress among combat-exposed OIF National Guard soldiers. Findings show that NEM predisposes combat-exposed soldiers to more severe PTSD symptoms, which, in turn, contribute to poorer intimate relationships. Higher levels of pre-existing NEM predicted higher levels of post-deployment PTSD symptoms. Soldiers with probable PTSD were more likely to experience relationship distress than those without probable PTSD. Soldiers with positive hazardous drinking screens were more likely to screen positive for PTSD than those with negative drinking screens, however, those with positive drinking screens were no more likely to experience relationship distress than those with negative drinking screens.
Date: September 16, 2010
- Mild Traumatic Brain Injury and PTSD: A Synthesis of the Evidence
HSR&D’s Evidence-based Synthesis Program (ESP) recently produced an important report on TBI and PTSD. This article summarizes that report, in which investigators examined data from 32 studies published between 1980 and June 2009, in addition to a large survey of
OEF/OIF Veterans conducted by the RAND Corporation. Findings show that the prevalence of comorbid traumatic brain injury and PTSD in published studies varies widely, ranging from 0% to 89%. However, in three large studies evaluating
OEF/OIF Veterans, the prevalence of probable mild TBI ranged from 5% to 7%; among Veterans with probable mild TBI, the prevalence of probable PTSD ranged from 33% to 39%. There were no published studies addressing the relative accuracy of diagnostic tests used for assessing history or symptoms of mild TBI or PTSD when one condition co-occurs with the other. There also were no published studies that evaluated the effectiveness and harms of therapies in adults with these comorbid conditions. Future efforts are needed to improve the evidence on which the assessment and treatment of mild TBI and PTSD are based.
Date: July 13, 2010
- Military Sexual Trauma: Important Mental Health Issue for
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
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
- JRRD Single-Topic Issue Reports on Results of First National Survey of Veterans with Traumatic Limb Loss
This issue of JRRD reports the results of the first nationally representative survey of Vietnam Veterans and service members and Veterans from
OEF/OIF who sustained major traumatic limb loss while serving. Members of a Prosthetics Expert Panel, which included 27 professionals from academic and clinical settings, clinicians and researchers from VA and DoD, and three Veterans with limb loss, analyzed Survey findings. Panel members then wrote articles based on the Survey data, presenting survey findings as well as Expert Panel recommendations.
Date: June 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
OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic:
OEF/OIF Veterans with PTSD,
OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that
OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than
OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that
OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence.
OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than
OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of
OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
Date: February 2, 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
- Minority of
OEF/OIF Veterans Receive Recommended Treatment for PTSD
This study examined
OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of
OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425
OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of
OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of
OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547
OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
Date: February 1, 2010
- Mental Health Treatment Seeking among OIF National Guard Soldiers
This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
Date: February 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
- Veterans’ Age and Disability Status Associated with Choice of Medicare Plans
Medicare-eligible Veterans may choose between care in VA or Medicare (or both), and they also have to choose between obtaining Medicare services in the fee-for-service (FFS) sector or in a Medicare Advantage (MA) plan. This study sought to assess factors associated with enrollment in an MA vs. FFS plan in 2000-2004 among this population. Findings show that age and disability status were both significantly associated with choice of MA vs. FFS plan. For example, age-eligible Veterans were more likely to be enrolled in an MA plan if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid, while disability-eligible Veterans were more likely to be enrolled if they were married or elderly. Minority Veterans and Veterans with lower disease risk scores (better average health) were more likely to be enrolled in an MA plan than white Veterans or Veterans with higher risk scores. Overall, Veterans living in zip codes with greater population density and higher per capita income were also more likely to enroll in an MA plan. The authors suggest that future studies examine the Medicare health plan choice of disabled Veterans, particularly
OEF/OIF Veterans who begin to qualify for Medicare, to better understand the possible impact of MA enrollment on continuity, duplication, cost, and quality of care.
Date: November 1, 2009
- Geographic Access to Rehabilitation for
This study sought to ascertain specific geographic areas where the need for VHA rehabilitation services appears greatest and potential access gaps may exist. Findings show that VA provides access to rehabilitation care for the majority of traumatically injured
OEF/OIF Veterans; however, more than 10% of Veterans may have potential access barriers due to excessive travel time. For the combined cohort, the median distance to Level I, Level II, and Level III facilities was 411 miles, 121 miles, and 64 miles respectively, and the median distance to the closest VA facility was 22 miles. Clark County, Nevada, and El Paso County, Texas had the highest number of patients with potential access gaps due to excessive travel times.
Date: October 1, 2009
- Special Issue of Pain Medicine Highlights VA Research on Pain among
This publication is in follow-up to a Pain Research Summit held in September 2007 by VA’s Rehabilitation R&D Service and VA/HSR&D’s Polytrauma and Blast-Related Injury Quality Enhancement Research Initiative (PT/BRI-QUERI). This Special Issue begins with four articles that build on the growing epidemiological literature on the prevalence and correlates of pain among
OEF/OIF Veterans, and considers the evidence for the assessment and management of pain in this population. The Issue also includes several original articles that provide a sample of the relatively large and growing body of research on pain, including research that focuses on the most prevalent and challenging of pain conditions observed among
OEF/OIF Veterans, such as neuropathic pain, chronic widespread pain, musculoskeletal/joint pain, and pain secondary to spinal cord injury.
Date: October 1, 2009
OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
Using national data from all returning
OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that
OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than
OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with
OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
Date: September 29, 2009
- Demands on VHA for Post-Deployment Healthcare Needs of
OEF/OIF Veterans will be Overshadowed by the Needs of Older Veterans
This article discusses the implications for the Veterans healthcare system of the demand for healthcare services from
OEF/OIF Veterans. Findings show that although the pressing needs of newly discharged Veterans require immediate attention, especially in the areas of TBI, PTSD, and physical disability services, the demand for immediate post-deployment VA healthcare services by
OEF/OIF Veterans will be overshadowed by the demands of aging Korean and Vietnam War Veterans (and, eventually, aging
OEF/OIF Veterans), in terms of the number of patients and the average cost of their care. Thus, the major demand on VA healthcare services will be from aging Veterans whose usage and needs for services will be relatively stable and predictable; however, it is the extra cost for
OEF/OIF Veterans that is difficult to quantify because of the unknowns (e.g., nature, severity, and number of PTSD and TBI cases).
Date: September 1, 2009
- Emerging Issues Related to PTSD for
OEF/OIF Women Veterans
The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
Date: August 24, 2009
- Mental Health Diagnoses Associated with Cardiovascular Risk Factors among
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
- 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
OEF/OIF Veterans with Spinal Cord Injury and Additional Problems Require Timely Intervention to Avoid Rehabilitation Delays
Soldiers returning from Iraq and Afghanistan with spinal cord injury often have additional medical and psychosocial problems that require timely intervention to avoid significant delays in rehabilitation. Rehabilitation was often delayed because other problems needed to be addressed first.
Date: March 1, 2009
- Advances in Couple Therapy for Returning Soldiers and their Spouses
The authors of this article present a case study about a service member who suffers from PTSD and his wife, who are treated with an adaptation of integrative behavioral couple therapy (IBCT). At the end of the 13 weeks of treatment, this couple reported that their relationship was considerably stronger.
Date: August 1, 2008