- Positive IPV Screen Significantly Associated with Health Outcomes and Healthcare Use among Women Veterans Over 45
This study examined the proportion of women older than childbearing age who screen positive when routinely screened for past-year intimate partner violence (IPV) at VA clinics, as well as associations of a positive screen with health conditions and use of healthcare services. Findings showed that of the study cohort, 255 middle-aged (45-59 years; 9%) and 79 older (60 years and older, 5%) women screened positive for past-year IPV. A positive screen was significantly associated with negative mental and physical health outcomes, as well as increased use of healthcare services. Those screening IPV+ in both the middle-aged and older groups were more likely than those screening IPV- to be diagnosed with each category of mental health condition (i.e., anxiety, PTSD, depression). Middle-aged women screening positive had more than twice the odds of having a diagnosis of depression, anxiety, PTSD, and substance use, and four times the odds of suicidal behaviors or self-harm, while older women screening positive had more than three times the odds of having a depression diagnosis. Middle-aged women screening IPV+ had more than double the rate of psychosocial visits in the subsequent 20 months, and older women had a near doubling. Middle-aged women who screened IPV+ also had increased rates of primary care and ED visits, as well as higher odds of having any inpatient admission. These associations were not seen for the older women. Screening for IPV in middle-aged and older women may improve detection and service delivery in this underserved population.
Date: April 21, 2020
- Rates of Mental Health Diagnoses are Higher among Veterans with Obesity
The objective of this study was to examine rates of mental health diagnoses among a national cohort of women and men VA primary care patients with and without obesity. Findings showed that rates of any mental health diagnosis were higher among women than men and people with versus without obesity.
Depression and PTSD diagnosis rates were higher for women and men with versus without obesity. For example, there was a 25% higher PTSD diagnosis rate among men with obesity versus without. Women with obesity had higher rates of psychotic disorder diagnoses than women without obesity; this was not found for men. Substance use disorder diagnosis rates were lower for women and men with versus without obesity. Anxiety diagnosis rates were slightly lower among women with versus without obesity; this was not found for men. A sizable proportion of women (46%) and men (62%) with obesity had no mental health diagnoses. Results provide further support for the finding that many Veterans have concurrent obesity and mental health diagnoses. Integrated treatments addressing obesity and mental health could benefit patients, providers, and the healthcare system by meeting patients’ physical and mental health needs in less time than separate treatments.
Date: January 30, 2020
- VA Healthcare Benefits May Reduce Racial/Ethnic Disparities in Seeking Mental Health Treatment among Veterans
This study assessed whether racial/ethnic disparities in mental health treatment seeking for psychiatric conditions common in the Veteran population (PTSD, major depressive disorder, alcohol-use disorder or AUD) were attenuated for military Veterans compared to civilians, and whether attenuation was more pronounced among Veterans who had VA healthcare coverage in the past 12 months. Findings showed that unlike civilians, racial/ethnic minority Veterans did not differ from whites in time to initiate treatment for PTSD and depression, and showed a shorter time to initiate treatment for AUD. Racial/ethnic minority Veterans with past year VA healthcare coverage were the most likely to seek treatment for all three disorders, whereas racial/ethnic minority civilians were the least likely to seek treatment for all three disorders. Among racial/ethnic minority patients, shortened time to treatment initiation for Veterans relative to civilians remained significant after adjusting for additional demographic and clinical covariates for PTSD and major depressive disorder, but not alcohol use disorder. Findings suggest that military service and benefits available to Veterans may reduce racial/ethnic disparities in seeking mental health treatment seen in the civilian population.
Date: January 27, 2020
- History of Military Sexual Trauma Common among Older Women Veterans
This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
Date: November 11, 2019
- Veterans with PTSD and/or Depression More Likely to Participate in Cardiac Rehabilitation than Veterans without These Disorders
This study sought to determine whether Veterans with depression and/or PTSD were more or less likely than those without depression or PTSD to participate in cardiac rehabilitation (CR) programs following hospitalization for heart attack or coronary revascularization. Findings showed that Veterans with PTSD and/or depression were more likely to participate in CR than Veterans without these mental health disorders. Between 2010 and 2014, cardiac rehabilitation participation rates were consistently higher in patients with PTSD or depression (9-12%) than in those without either condition (7-11%). Investigators found that in comparison to Veterans without PTSD or depression, the odds of participation in CR were 24% greater in patients with depression alone, 38% greater in patients with PTSD alone, and 57% greater in patients with both PTSD and depression. Investigators were not able to determine why patients with mental disorders were more likely to participate in cardiac rehabilitation. Overall participation in cardiac rehabilitation is low in patients with coronary heart disease, but the presence of PTSD or depression does not reduce participation further.
Date: June 4, 2019
- Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
Date: March 7, 2019
- Veterans Encouraged by a Loved One to Face Stress Induced by Trauma-Focused Therapy More Likely to Stay in Treatment
One in three Veterans drop out of trauma-focused treatment. Social system factors may be especially important to understanding these dropout rates, yet when and how family relationships influence PTSD treatment dropout remains unknown. This study examined two support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage Veterans to participate in treatment and face distress) and PTSD symptom accommodation (changes in loved one’s behavior to reduce Veterans’ PTSD-related distress). Findings showed that Veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than Veterans who did not have such encouragement, even after accounting for individual-level predictors of dropout, such as Veterans’ attitudes, therapeutic alliance, and symptom severity. There was a significantly greater likelihood of treatment dropout among those whose loved ones reported greater symptom accommodation. Findings suggest that clinicians should consider routinely assessing to what degree Veterans entering trauma-focused treatments have encouragement by a close loved one to participate in activities that may be distressing.
Date: March 1, 2019
- Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
Date: March 1, 2019
- Reduced Psychiatric Symptoms among Veterans Associated with More In-Person Social Contact but Not More Facebook Contact
This study sought to determine whether social contact on Facebook—or in-person—is associated with a lower risk of screening positive for psychiatric disorders or suicidality in Veterans. Findings showed that although Veterans who frequently use Facebook also are typically social in their offline life, it is their offline (in-person) social interaction – not their social contact on Facebook – that is associated with reduced psychiatric symptoms. More frequent in-person social interaction was associated with significantly decreased risk of symptoms of major depression and PTSD, compared with contact every few weeks or less. In contrast, increased frequency of social interaction on Facebook had no associations with mental health outcomes. Neither social contact on Facebook nor in-person contact was associated with suicidality. Results suggest that “face-to-face” time may matter more than “Facebook” for Veterans trying to harness the mental health-promoting benefits of social contact with friends and family.
Date: January 15, 2019
- Comparisons between VA and Non-VA Hospitals May Not Accurately Account for Mental Health Diagnoses
While CMS publishes performance metrics on Hospital Compare, the risk-adjustment algorithms underlying these metrics are often unclear. Further, recently published literature questions whether existing risk-adjustment algorithms accurately adjust for mental health comorbidities. This study sought to determine whether current risk-adjustment algorithms fairly compare VA hospitals with non-federal hospitals. In their analysis, investigators used the CMS Hierarchical Condition Categories (HCC) risk adjustment system version 21 (V21) because it is publicly available and has been used to adjust metrics published on the CMS Hospital Compare website. Investigators also measured mental health comorbidities using the PsyCMS (Psychiatric Case Mix System). Findings showed that current comparisons between VA and non-VA hospitals are flawed because the risk adjustment algorithms used to make patients comparable do not adequately control for mental health issues. Of 5,472,629 VA patients, the V21 model identified 694,706 as having mental health or substance use HCCs. The PsyCMS identified another 1,266,938 Veterans with mental health diagnoses. The top 10 mental health diagnoses missed by the V21 model included nicotine dependence (40%), depression not otherwise specified (31%), PTSD (27%), and anxiety (10%). Overall, the V21 model under-estimated costs for patients with low costs and over-estimated costs for patients with above average costs except for the top decile. For Veterans with a mental health diagnosis, the V21 model under-estimated the cost of care by $2,314 per patient. Risk scores may need to be developed based on a broader set of hospital data. Without such efforts, safety net hospitals, such as VA, may be penalized and patients and policymakers misled.
Date: December 14, 2018
- Mantram Repetition Effective in Treatment of Veterans with PTSD
Mantram teaches people to intentionally slow down thoughts and to practice “one-pointed attention” by silently repeating a personalized mantram – a word or phrase with spiritual meaning. This study compared Mantram therapy to Present-Centered Therapy – a supportive, problem-solving, non-trauma-focused treatment for PTSD. Findings showed that among Veterans with PTSD, individually-delivered Mantram was generally more effective than Present-Centered Therapy for reducing PTSD symptom severity. Moreover, significantly more Mantram participants than Present-Centered Therapy participants who completed the two-month follow-up no longer met criteria for PTSD (59% vs. 40%, respectively). There also were significant improvements for Veterans with insomnia who participated in the Mantram group as compared to the Present-Centered Therapy group. Mantram may appeal to Veterans who prefer therapies that are not trauma-focused, are shorter in duration than most treatments, include some element of spirituality, and/or that reduce sleep disturbances.
Date: June 20, 2018
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
Date: March 7, 2018
- Evidence-based Psychotherapy Template Use Associated with Treatment Quality for Veterans with PTSD
This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA, testing the hypothesis that template use would be associated with quality of care for Veterans with PTSD. Findings showed that facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater rates of psychotherapy adequacy (8 psychotherapy visits in 14 weeks). Overall, an average of 4% of Veterans with a PTSD diagnosis received at least one EBP template. Among Veterans receiving psychotherapy for PTSD, an average of 9% received an EBP template. VA facilities with a greater percentage of patients who were service-connected at 50% or higher administered EBP templates to a smaller proportion of Veterans diagnosed with PTSD. The overall reach of EBP template usage was low, indicating that greater efforts are needed to improve usage.
Date: September 30, 2017
- Benefits and Harms of Cannabis for PTSD
This systematic review sought to assess the effectiveness of plant-based cannabis use in patients with PTSD – and to identify ongoing studies in this area. Findings show that evidence is insufficient to draw conclusions about the benefits and harms of plant-based cannabis preparations in patients with PTSD, but ongoing studies may soon provide important results.
Date: September 5, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Study Identifies which VA Mental Health Program Characteristics are Associated with Patient Satisfaction
This study examined the relationships between a set of patient satisfaction measures and a large collection of mental health program characteristics for Veterans with a recent mental health encounter in the VA healthcare system. Findings showed that broad measures of mental healthcare program reach (i.e., proportion of patients served) and intensity (i.e., number of visits) – and nearly all measures of treatment continuity were consistently and positively associated with patient satisfaction. More narrow performance measures – those that focus on specific diagnostic populations (e.g., those with PTSD and serious mental illness) – were less likely to be positively associated with satisfaction. Satisfaction with access to VA healthcare among Veterans with mental health conditions was higher than satisfaction with care encounters.
Date: May 19, 2017
- Current Diagnosis of PTSD is Risk Factor for Pregnant Women
This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies.
Date: May 1, 2017
- 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
- Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
- Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
Date: June 24, 2016
- Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
Date: March 1, 2016
- Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
Date: December 21, 2015
- Alcohol Misuse among Female Veterans
This study examined the demographic/military, interpersonal violence, and mental health correlates of alcohol misuse among female Veterans seeking VA healthcare. Findings showed that younger age, adulthood physical abuse, military sexual trauma, past-year psychological aggression by an intimate partner, and PTSD and depression symptom severity showed significant associations with alcohol misuse. Two of these associations – younger age and past-year psychological intimate partner violence – remained significant when examined in logistic regression models. Female Veterans at risk for alcohol use disorders may benefit from screening and intervention efforts that take into account exposure to interpersonal violence and mental health symptoms.
Date: December 7, 2015
- Effect of Childhood Physical and Sexual Abuse on Female Veterans’ Health and Healthcare Use
This study sought to investigate whether childhood physical abuse and childhood sexual abuse predict health symptoms and healthcare use. Findings showed that childhood physical abuse was an important contributor to both physical and mental health for female Veterans. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, greater depressive and PTSD symptoms, and more frequent use of medical healthcare. No significant association was found between childhood sexual abuse and poor physical or mental health, and it was not a predictor for healthcare use. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment, as well as inform mental health assessment and treatment planning, among female Veterans.
Date: October 1, 2015
- Effectiveness of Mindfulness-Based Stress Reduction Therapy for Veterans with PTSD
This randomized clinical trial compared mindfulness-based stress reduction with present-centered group therapy, a treatment that addresses current life problems. Findings showed that mindfulness-based stress reduction therapy resulted in a greater decrease in PTSD symptom severity. However, the magnitude of the average improvement suggests a modest effect. Veterans in the mindfulness-based stress reduction group were more likely to show clinically significant improvement in self-reported PTSD symptom severity at two-month follow-up, but they were no more likely to have loss of PTSD diagnosis. Improvements in quality of life made during treatment were maintained at 2-month follow-up for Veterans in the mindfulness-based stress reduction group, but reports of quality of life returned to baseline levels for those in present-centered group therapy.
Date: August 4, 2015
- Systematic Review of PTSD Screening Instruments
Investigators in this study conducted a systematic review of self-report screening instruments for PTSD among primary care and high-risk populations. Findings showed that the Primary Care Post-Traumatic Stress Disorder screener (PC-PTSD) and the 17-item PTSD-Checklist (PCL) were the best performing instruments. Both show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both also are easy to administer and interpret, and can readily be incorporated into a busy practice. Two multi-condition instruments (My Mood Monitor, and the Provisional Diagnostic Interview-4 Anxiety) and three anxiety/general distress instruments (K6, GAD-7, and the Anxiety and Depression Detector) were evaluated in primary care settings, but performed less well than instruments that were specifically designed to detect PTSD. Both patients and physicians felt that screening facilitated discussion of mental health issues in the subsequent primary care visit, and 80% of primary care physicians reported that the screen was helpful in interactions with their patients.
Date: August 4, 2015
- Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
Date: June 10, 2015
- Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
Date: May 15, 2015
- 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
- Early Discontinuation and Sub-Optimal Dosing for Drug to Treat Sleep Disorders Associated with PTSD
This study sought to identify a cohort of Veterans with PTSD initiating prazosin, and then characterize the typical duration of use and dosing patterns over the first year following initiation. Findings showed that approximately 20% of Veterans never refilled the initial prescription, while only 38% of Veterans continued the medication for at least one year. Veterans taking serotonin- reuptake inhibitor (SSRIs) or serotonin-norepinephrine reuptake inhibitor (SNRIs) antidepressants were more likely to maintain prazosin treatment for one year (41%) compared to non-users (33%). One-year prazosin persistence also increased with the patient’s age and number of concurrent medications. Prazosin persistence was not associated with gender, or rural residence. The mean maximum dose of prazosin reached in the first year of treatment was 3.6 mg/day, with only 15% of Veterans reaching the minimum guideline recommended dose of 6 mg/day. Research is needed to identify what factors inhibit patients from reaching the minimum recommended target dose and what characteristics are associated with prazosin response.
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
- Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
Date: March 1, 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 OEF/OIF Veterans
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
- High Rates of Post-Traumatic Growth among Veterans with PTSD
Post-traumatic growth (PTG) is defined as positive, meaningful psychological changes that an individual can experience as a result of struggling with traumatic and stressful life events. Findings from this study show that post-traumatic growth is prevalent among Veterans, particularly for those with PTSD: 50% of all Veterans and 72% of Veterans who screened positive for PTSD reported at least moderate PTG in relation to their worst traumatic event. The “worst” traumatic event found to be most strongly associated with PTG was a life-threatening illness or injury. Among Veterans with PTSD, those with PTG reported better mental functioning and general health than those without PTG. Veterans who reported a moderate level of PTSD symptoms reported the greatest levels of PTG, compared to those with minimal or severe symptoms. Greater social support, purpose in life, and intrinsic religiosity were all independently associated with PTG, suggesting clinical interventions designed to promote these factors may help foster psychological growth from trauma among symptomatic Veterans.
Date: January 1, 2015
- Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
Date: December 3, 2014
- Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
Date: December 1, 2014
- Women Veterans with PTSD at Significantly Increased Risk of Spontaneous Pre-term Delivery
Using a cohort of deliveries covered by VA from 2000 to 2012, investigators in this study examined the association between PTSD and spontaneous pre-term delivery (before 37 weeks). Findings showed that mothers with active PTSD were at 35% increased odds of having a spontaneous pre-term delivery (two excess pre-term births per 100 deliveries), even after adjusting for psychiatric and medical comorbidities. Thus, PTSD’s health effects may extend, through birth outcomes, into the next generation.
Date: December 1, 2014
- Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences.
Date: November 24, 2014
- Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings
This trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Findings showed that telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of Veterans randomized to the Telemedicine Outreach for PTSD (TOP) intervention received Cognitive Processing Therapy (CPT) compared to 12% of Veterans who were randomized to usual care. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD). The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
Date: November 19, 2014
- Study Highlights Mental Health Services Important to Women Veterans
Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration.
Date: November 17, 2014
- VA PACT Implementation Increases Primary Care among Veterans with PTSD
This study assessed the association between PACT and the use of health services among Veterans with PTSD. Findings showed that the period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care. Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits. For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations.
Date: November 10, 2014
- Predictors of Worsening Mental Health among OEF/OIF Veterans
This study sought to identify predictors of worsening mental health, including PTSD and alcohol use, as well as variables that are protective (resilience factors) against worsening mental health in a national sample of OEF/OIF Veterans. Findings showed that 14–25% of these returning OEF/OIF military personnel showed clinically worse mental health, PTSD, or alcohol use at 6-month follow-up. Eleven variables were significantly associated with a decline in overall mental health status from Time 1 to Time 2: Black race, being in the National Guard, more bothersome physical health problems, worse mental health at Time 1, less PTSD symptom severity, lack of psychiatric care between Time 1 and Time 2, more difficult deployment environment, less perceived threat, less sexual harassment, higher levels of hardiness, and lower levels of self-efficacy. Nine variables predicted a worsening of PTSD symptom severity: being younger than 26 years old, unemployed, divorced or separated, higher PTSD symptom severity at Time 1, lack of any psychiatric treatment between Time 1 and Time 2, difficult childhood family environment, greater sexual harassment in one’s unit, lower levels of deployment preparedness, and higher levels of post-deployment social support. Fourteen variables predicted worsening alcohol use, including being male, under 26 years old, less educated, Hispanic, separated or divorced, and being in the National Guard or Marines. National Guard and other Reserve soldiers worsened on both the general mental health and alcohol use measures from Time 1 to Time 2 compared to active duty soldiers, suggesting that these groups may require help with reintegration. Higher education, self-efficacy, unit support, and deployment preparedness had a protective effect on both worsening PTSD and alcohol use.
Date: October 1, 2014
- 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
- Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
Date: July 17, 2014
- Only Small Percentage of Veterans with Mental Illness Access VA Employment Services
This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically.
Date: July 1, 2014
- 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
- Factors Related to Use of Psychotherapy among Veterans
This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Findings showed that need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders (SUD), more comorbid psychiatric diagnoses, and more inpatient psychiatric stays. In the year after initiating psychotherapy, half of the sample received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy. Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD. Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.
Date: May 19, 2014
- PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment
This study is the first randomized controlled trial to compare the efficacy of delivering “cognitive processing therapy-cognitive only” (CPT-C) via video-teleconferencing (VTC) to in-person delivery among a sample of rural Veterans. Findings showed that the use of clinical video-conferencing services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was as effective as face-to-face treatment. Significant reductions in PTSD symptoms were identified at post-treatment and 3- and 6-month follow-ups. High levels of therapeutic alliance, treatment compliance, and satisfaction, and moderate levels of treatment expectancies were reported, with no differences between groups. VTC technology evidenced very few disruptions, and no sessions were canceled due to technological difficulties. There were no adverse events associated with delivering CPT-C through videoconferencing.
Date: May 1, 2014
- Characteristics and Outcomes of Homeless Male and Female Veterans
This study examined a recent national sample of homeless Veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program to report differences between homeless male and female Veterans on individual characteristics at referral, as well as housing and clinical outcomes over a one-year period after program admission. Findings showed that among Veterans who stayed in the program, there were no gender differences in housing outcomes over time, except females tended to stay more nights in someone else’s place, while males stayed more nights in transitional housing. Homeless female Veterans were younger, more likely to have recently served in the military, had shorter homeless histories, were less likely to have been incarcerated, and were less likely to have alcohol and drug use disorders. Despite being less likely to report combat exposure, female Veterans were more likely to have PTSD than male Veterans. Homeless female Veterans also were much more likely to have dependent children with them, and to plan to live with family members in supported housing. For all Veterans, it took an average of over 40 days to be admitted to HUD-VASH after referral, an average of over 40 days to obtain a voucher after being admitted, and then an average of more than 50 days to sign a lease after obtaining a voucher.
Date: April 14, 2014
- Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among OEF/OIF Veterans
This study examined the association between epilepsy and TBI, including penetrating TBI (pTBI), in OEF/OIF Veterans. Findings showed that epilepsy was associated with previous TBI diagnosis. The estimated risk of epilepsy among Veterans with pTBI was nearly 18 times greater than among those without TBI, even after controlling for other factors. When examined separately, risk for epilepsy was also elevated among Veterans with severe, moderate, and mild TBI. Even among this relatively young group of Veterans, stroke was one of the strongest risk factors for epilepsy. Veterans with epilepsy also were more likely to be younger than 50 years and white, and were more likely to have previously diagnosed substance use disorder, depression, anxiety, bipolar disorder, schizophrenia, and PTSD than those without epilepsy. Headache, cardiac conditions, cerebrovascular disease, and cognitive impairment/dementia were also epilepsy risk factors. An increasing burden of epilepsy in this Veteran population is likely. These Veterans should be followed closely, and systems of care, such as VA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care.
Date: April 1, 2014
- Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans
This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD.
Date: March 11, 2014
- Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare
This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy.
Date: February 3, 2014
- Strong Association between Substance Abuse and Homelessness among Veterans
This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD.
These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed.
Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories.
Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
Date: February 1, 2014
- 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
- Increased Prescribing Rates for Concurrent Sedative Medications among Veterans with PTSD
This is the first national study that sought to characterize polysedative prescribing in Veterans with PTSD. Findings showed that, over time, there was an increase in the use of polysedatives among Veterans with PTSD: from 34% to 37% for two or more sedative classes, and from 10% to 12% for three or more classes. This represents a concerning clinical trend and a relative increase of nearly 25%. The most common combination of sedatives was an opioid plus a benzodiazapine, which were taken concurrently by 16% of Veterans with PTSD. Two other combinations that were used more frequently than expected were opioids plus skeletal muscle relaxants – and benzodiazepines plus atypical antipsychotics. Polysedative use varied across demographic subgroups, with higher rates among women, Veterans residing in rural settings, younger adults, Native Americans, and Whites. Also, benzodiazepine prescribing was markedly elevated among women (44%) compared to men (34%), and was somewhat lower among older adults (31%) compared to younger adults (36%).
Date: December 16, 2013
- 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
- Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
Date: December 6, 2013
- Veterans with Non-Specific Anxiety Diagnosis Less Likely to Access Mental Healthcare than Veterans with Specific Anxiety Disorders
This study sought to determine the rates of specific and non-specific anxiety diagnoses in a national sample of Veterans receiving outpatient care at VAMCs – and to examine patterns of mental healthcare use in the year following diagnosis. Findings showed that “Anxiety Disorder Not Otherwise Specified” (anxiety NOS) was diagnosed in 38% of this Veteran cohort. Most Veterans with a specific anxiety diagnosis received mental health services, with treatment rates for patients with the most frequently diagnosed specific anxiety disorders (PTSD, generalized anxiety disorder, and panic disorder) ranging between 60% and 67%. In contrast, only 32% of patients with anxiety NOS received mental health services during the 12 months following diagnosis. Most Veterans with an anxiety NOS diagnosis did not go on to receive a specific diagnosis in the next 12 months. However, most anxiety NOS patients who later received a diagnosis of a specific anxiety disorder (87%) received mental health services in the year following their index date, compared to 29% of Veterans who did not receive a subsequent specific anxiety disorder diagnosis. Patient factors that increased the likelihood of an anxiety NOS diagnosis included: female gender, older age, the absence of specific comorbid diagnoses (i.e., substance-use disorders, bipolar disorder), and absence of service-connected disability. Veterans diagnosed in specialty mental health or integrated primary care-mental health settings were less likely to receive an anxiety NOS diagnosis than patients in primary care.
Date: October 22, 2013
- Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
Date: October 1, 2013
- Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
Date: October 1, 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
- Women Veterans who Experience Intimate Partner Violence are at Higher Risk for Some Medical and Mental Health Conditions
This study sought to fill gaps in knowledge by examining demographic and clinical characteristics of women Veterans who have disclosed intimate partner violence (IPV) victimization to a VA healthcare provider. Findings showed that lifetime IPV was documented in about one-quarter (24%) of women Veterans’ medical records and was associated with higher risk of many medical conditions and with increased healthcare use. Women Veterans with documented IPV had higher rates of military sexual trauma, injury/poisoning, mental health disorders, infectious or parasitic diseases, and digestive system disorders. More than 95% of women Veterans with documented IPV had a mental health diagnosis, including: 60% with episodic mood disorders, 57% with neurotic disorders, 48% with PTSD, and 72% with other depression. In addition, 45% reported military sexual trauma. Compared with women who had no documented IPV, those with documented IPV had a higher average number of healthcare encounters per month and were more likely to have visited the emergency department – and to have had a mental health/behavioral health/social work visit during the study period.
Date: August 5, 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
- Homelessness More Prevalent among Female Veterans
This review of the literature sought to assess and summarize the body of knowledge on homelessness among female Veterans, in order to inform policy and highlight important gaps in this literature that could be filled by future research. Findings showed that female Veterans now comprise a larger share of the homeless Veteran population than of the overall Veteran population. Homeless female Veterans are characteristically different from their male counterparts, both with respect to demographic and clinical factors. For example, homeless female Veterans are younger, have higher levels of unemployment, and have lower rates of drug or alcohol dependence or abuse, but they have higher rates of mental health problems than homeless male Veterans. Female Veterans are at an increased risk of homelessness relative to the non-Veteran female population. Studies identified factors that may increase the risk of homelessness among women Veterans, including: unemployment, disability, PTSD, sexual assault or harassment during military service, anxiety disorder, poor health status, and older age.
Date: June 26, 2013
- Significant Disparities among Women Veterans with and without Mental Illness in Delaying or Going without Medical Care
This study examined associations of PTSD and depressive symptoms with unmet medical needs and barriers to care among women Veterans. Findings showed that there was a significant degree of disparities reported by women Veterans with and without mental health symptoms in delaying or going without needed medical care. The majority of those who screened positive for both PTSD and depressive symptoms had unmet medical care needs in the prior 12 months (59%) – compared to 30% of women with PTSD symptoms only, 18% of those with depressive symptoms only, and 16% of women with neither set of symptoms. This pattern remained the same after adjustment (e.g., for demographics, insurance, combat exposure). Overall, among women Veterans in this study who reported unmet medical needs (19% of the women surveyed), those with both PTSD and depressive symptoms were more likely than women in the other groups to identify affordability as a reason for going without or delaying care (69%). Being unable to take time off work (31%) was the second most common reason reported among this group. Women with PTSD symptoms (w/ or w/o depression) were less likely than all other groups to have health insurance to cover non-VA care.
Date: May 1, 2013
- Racial Differences in Veterans’ Perception of the Quality of PTSD Compensation Examinations
This study examined factors potentially associated with Veterans’ perceptions of the quality of their PTSD compensation examination, including racial differences. Findings showed that the overall quality of PTSD compensation examinations was predominantly rated as "excellent" or "very good" by both African American and Caucasian Veterans. However, compared to Caucasian Veterans, African American Veterans rated their examinations as having been of lower quality. They also rated their examiners lower on interpersonal qualities but not on competence. Of Veterans participating in this study, 47% of Caucasian Veterans vs. 34% of African American Veterans rated the quality of their examination as “excellent.” Ratings were not significantly related to the Veterans' age, gender, marital status, eventual diagnosis with PTSD, functioning score, the examiners’ perception of the prevalence of malingering, or the presence of a third party in the examination. The authors note that the Veterans’ perspective is only one component of the quality of the PTSD compensation examination.
Date: April 1, 2013
- More than One in Eight Women Veterans Screen Positive for PTSD and A Significant Segment Does Not Receive Treatment
This study sought to identify PTSD prevalence and mental healthcare use in a representative national sample of women Veterans. Findings showed that more than one in eight women Veterans in this study (13%) screened positive for PTSD, and less than half of this group received mental health treatment (either VA or non-VA). VA healthcare was used by 31% of the women Veterans who screened positive for PTSD and by 11% of women Veterans who screened negative for PTSD. Among women Veterans who screened positive, 49% used mental healthcare services, including 66% of VA users and 41% of non-VA users. Predictors of mental healthcare use included having a diagnosis of depression and utilizing VA healthcare, while lacking a regular healthcare provider and household income below the federal poverty line predicted non-use of mental healthcare. Because the majority of women Veterans utilize non-VA healthcare, and these providers may be unaware of their Veteran status and PTSD risk, the authors suggest that more effective efforts be made to help identify women Veterans with PTSD – and to engage them in care.
Date: February 23, 2013
- Patient and Facility Characteristics Associated with Prescribing Benzodiazepines for Veterans with PTSD
This study examined patient and facility-level correlates of benzodiazepine prescribing among Veterans with PTSD in the VA healthcare system. Findings showed that 30% of the Veterans in this study received a benzodiazepine. The majority (94%) of Veterans with any benzodiazepine use received = 30 days’ supply, and approximately two-thirds received more than 90 days of continuous benzodiazepine treatment. Among patient characteristics predicting benzodiazepine use, the largest odds ratios were observed for anxiety disorder comorbidity. Other characteristics associated with increased risk for benzodiazepine exposure included female gender, age = 30 years, rural residence, service connection = 50%, Vietnam era service, and duration of PTSD diagnosis. However, case-mix adjustment for these variables accounted for <1% of the variation in benzodiazepine prescribing across VA facilities. Main study findings were corroborated in replication analyses using data from two additional years (FY2003 and FY2006).The wide variation in facility-level benzodiazepine prescribing across VA cannot be explained by differences in patient characteristics across facilities.
Date: February 1, 2013
- Most 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
- Benzodiazepine Prescribing for Veterans with PTSD Remains Common and Varied across the VA Healthcare System
This study examined variation in benzodiazepine prescribing frequency across the VA healthcare system (by VAMC, VISN, and region), and evaluated differences in prescribing frequency among rural vs. urban residents, and between community-based outpatient clinics (CBOCs) relative to medical centers. Findings showed that benzodiazepine prescribing among Veterans with PTSD remains common despite guideline recommendations against their use, and the level of practice variation was extensive. While prescribing variation at the regional, network, and facility levels declined over the study period, facility-level benzodiazepine prescribing variation remains high at 15% to 57%. Rural veterans with PTSD received equivalent, if not higher, quality of care (as reflected by benzodiazepine prescribing frequency) from community-based outpatient clinics compared to medical centers. The authors suggest that the wide variation in prescribing practices reflects uncertainty among providers regarding best practices, and is ultimately due to the limited number of effective PTSD treatments supported by a strong evidence base.
Date: January 1, 2013
- Prolonged Exposure or Cognitive Processing Therapy May Reduce Use of Mental Health Services in Veterans with PTSD
This study evaluated the impact of a course of Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) on VA mental health and medical service utilization and healthcare costs. Findings showed that Veterans who had successfully completed PE or CPT for PTSD experienced a reduction of both PTSD and depression symptomatology; they also reduced their mental health service utilization by 32% in the year following treatment when compared to the year prior to the initiation of PE or CPT. There was a slight, non-significant decline in primary care usage among Veterans who had completed therapy, while emergency department usage remained virtually the same. Per Veteran, there was a 39% reduction in total costs – from an average of $5,173 in the year prior to treatment to $3,133 in the year following treatment. These preliminary findings suggest that the successful completion of PE and CPT for the treatment of PTSD significantly reduces mental health service use and outweighs the cost of treatment.
Date: January 1, 2013
- Many 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
- Quality of VA’s PTSD Disability Assessment Would Improve by Using Evidence-Based Assessment
This trial compared usual disability examiner practices with a standardized assessment that incorporates evidence-based assessments. Findings showed that administering a standardized disability assessment resulted in more complete diagnostic information on functional impairment and PTSD symptoms. Standardized assessments were 85% complete for diagnosis compared to 30% for non-standardized assessments; and for functional impairment, the rates were 76% compared to 3%. Standardized assessment elicited an increase in relevant information and nearly eliminated variation between examiners and medical centers. While the standardized examination was more sensitive than routine examination, it did not result in a significant change in the overall prevalence of diagnosed PTSD.
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
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Risk of Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
This study examined mental disorder comorbidity and suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and suicide risk. Findings showed that among Veterans who died by suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
Date: October 22, 2012
- Pre-Military Trauma Associated with Post-Recruit Training Suicide Attempts among Marines
This study examined pre- and post-Marine recruit training risk factors for suicide attempts among current and former Marines in the 10 years following training. Findings showed that stressful and traumatic life events (e.g., childhood physical, sexual and emotional abuse, sexual harassment during recruit training) and suicide attempts made before recruit training had strong associations with suicide attempts after recruit training. Those who experienced at least one life stressor prior to joining the Marines had 4 times the odds of suicide attempt compared to those who did not report any life stressors prior to joining. Half of the Marines in this study who died by suicide (per death certificate) in the 10 years following recruit training (n=3) reported at least one significant life stressor prior to joining the Marines. Marines who experienced military sexual harassment during recruit training had 3 times the odds of suicide attempt in the 10 years following training compared with those who did not report this experience. Marines with PTSD symptoms consistent with a diagnosis had about double the odds of suicide attempts compared with those without PTSD symptoms.
Date: October 20, 2012
- Rape and Sex Partnership Adversely Associated with Lower Physical Functioning in Women Veterans
This study sought to determine whether current physical health status in women Veterans is associated with rape in military (RIM) and same-sex partnering. Findings showed that women Veterans who reported a history of rape (during childhood or adolescence, in-military or post-military) and those with same-sex sexual partners at some point in their lives had significantly lower current physical health status compared to women without such histories. Of the participants in the study, 11% reported having women as sex partners (WSW). Women with same-sex partners reported significantly higher lifetime substance use disorder (SUD) and higher rates of rape, both lifetime and in separate time periods, compared to women who reported having sex with men exclusively. Three-quarters (74%) of WSW reported lifetime rape and one-third (35%) reported RIM compared to 48% and 23% in women with men as partners only. Physical health status was lowest for women with a history of chronic pain. Other factors significantly associated with lower physical health status were depression, PTSD, and not having a current SUD.
Date: October 15, 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, 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
- Couple Therapy is Effective for Treating PTSD
Among couples in which one partner was diagnosed as having PTSD, a PTSD-specific couples therapy – compared with a wait-list for therapy – resulted in greater decreases in severity of PTSD and comorbid symptoms, and increases in relationship satisfaction: 81% of patients who received cognitive-behavioral conjoint therapy (CBCT) no longer had PTSD at the end of treatment vs. 21% of patients on the wait-list. CBCT did not increase relationship satisfaction among partners, which may have been due to a high level of satisfaction before treatment. Treatment gains were maintained at 3-month uncontrolled follow-up.
Date: August 15, 2012
- Age Differences in PTSD Diagnoses and Treatment Seeking among Veterans
Among the Veterans in this study sample who screened positive for PTSD, the percentage of positive screens decreased as age increased: 17% for Veterans aged 18-29 years, 13% for Veterans ages 30-44, 13% for Veterans ages 45-59, 6% for Veterans ages 60-74, and 2% for those ages 75 years and older. While older Veterans were less likely to screen positive for PTSD, they also were less likely to initiate specialty mental health treatment when they had positive screens. For example, 66% of Veterans ages 18-29 had mental health visits compared to 19% of Veterans ages 75 years and older. There also were significant differences by age in types of treatment received. Veterans ages 18-29 years received the most diagnostic visits, while Veterans ages 45-59 and 60-74 years received more visits for group psychotherapy than other age groups. Veterans ages 75 years and older received the fewest visits involving psychotherapy and medications or phone contact. The authors suggest that future research is needed to examine whether alternative approaches to PTSD in primary care settings may improve specialty treatment initiation rates, particularly among older Veterans.
Date: August 13, 2012
- No Advantage in Collaborative Care vs. Usual Care for Veterans with PTSD
Over a 6-month period, primary care patients with PTSD in both the Three Component Model (3CM, collaborative care) and usual care groups showed small but clinically insignificant improvement in PTSD, depression, and functioning. No additional benefit was found for Veterans assigned to the 3CM treatment compared to those receiving usual care, despite the fact that 3CM patients were more likely to receive an antidepressant and had more mental health visits. Among Veterans who provided a numeric rating for PTSD care, half rated it as excellent or very good; however, 3CM was associated with lower perceived quality of PTSD care. Almost two-thirds of Veterans rated their overall care as excellent or very good, and the groups did not differ. Costs were similar for both groups, except that Veterans assigned to 3CM had higher outpatient pharmacy costs.
Date: August 3, 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
- Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress, suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
- Variables Associated with Risk of Community Violence among Subset of OEF/OIF Veterans
One-third of the OEF/OIF Veterans in this study reported aggression against others in the previous year (e.g., kicking, slapping, using fists, fights), and 11% reported having engaged in severe acts of violence within the past year (e.g., use of a knife or gun or other lethal weapon, beat up a person). Risk factors in the current sample were similar to those associated with violence among Veterans from previous eras – younger age, PTSD, alcohol abuse, and past criminal arrests. When these risk factors were controlled as covariates, a stable living situation and the perception of having control over one’s life were independently associated with reduced odds of severe violence. Positive social support and having enough money to cover basic needs were associated with reduced odds of other forms of physical aggression. Data also suggest that Veterans who perceive that they have control over their future and who have greater psychological resilience may have greater internal motivation to refrain from violence.
Date: June 1, 2012
- Cannabis Use Disorder Diagnoses in the VA Healthcare System Double Over the Past Seven Years
The prevalence of cannabis use disorder (CUD) diagnoses overall within VA has increased nearly 60% (from 0.66% to 1.05%) over the past 7 years, with the prevalence of CUD diagnoses among those without other illicit substance use disorders (SUD) having risen 115% (from 0.27% to 0.58%) during the same time period. Rates of other substance use disorder diagnoses within VA (i.e., alcohol-only and other-drug disorder) increased to a much smaller degree. Although rates of CUD diagnosis within VA have increased dramatically, they remain significantly lower than rates of CUD observed in the U.S. population. States with laws allowing for the legal use of cannabis for medicinal purposes had significantly higher rates of CUD diagnoses within VA in 2002, 2008, and 2009. Rates of psychiatric diagnoses, and PTSD specifically, were higher among patients with a CUD diagnosis but no other illicit SUD, as compared to other SUD groups. Rates of specialty SUD treatment utilization among those with a CUD diagnosis but no other illicit SUD have decreased within VA.
Date: May 7, 2012
- Changes in Health Conditions and VA Healthcare Costs among Women Veterans between 2000 and 2008
The number of women Veterans treated in the VA healthcare system increased from 156,305 in 2000 to 266,978 in 2008; 88% of these women were under 65 years of age. The mean costs of care increased from $4,962 per woman Veteran in FY00 to $6,570 in FY08. Gender-specific, cancer, musculoskeletal, and mental health and substance abuse conditions accounted for a greater share of overall costs during the study period. Psychiatric conditions represented the largest share of costs for female VA patients during the study years. There was a modest rise in costs for psychiatric conditions among all female Veteran patients driven by the growing number of women treated for depression and PTSD. From 2000 to 2008, the proportion of women treated for PTSD increased by 133%, while the proportion of women treated for depression increased by 41%.
Date: May 1, 2012
- Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for OEF/OIF Veterans
There was a significant association between VA’s Primary Care-Mental Health Integration (PC-MHI) program and OEF/OIF Veterans’ receipt of short- or long-term mental or medical care. Of the 181 Veterans who participated in the PC-MHI program, 60% sought mental health care within one month after their initial encounter in PC-MHI, and 82% after one year, while 18% sought medical care within one month, and 74% within one year. The average length of time to a subsequent specialty mental health care visit after the Veterans’ first PC-MHI encounter was about 5 months. The average length of time to a subsequent medical care visit after the first PC-MHI encounter was about 10 months. While PTSD was the primary condition associated with OEF/OIF Veterans remaining in VA care for mental health care, retention in long-term medical care was not associated with mental health disorders measured in this study (PTSD, substance use disorder, major depressive disorder, and anxiety/phobia).
Date: April 30, 2012
- Using Natural Language Processing to Evaluate Evidence-Based Treatment for Veterans with PTSD
Investigators analyzed the content of clinical notes using the automated retrieval console (ARC). ARC identified psychotherapy notes and classified the type of therapy performed in a treatment session as reliably as expert human raters. Evidence-based psychotherapies appear to be infrequently used as an initial treatment in VA outpatient PTSD clinics in New England. Of the Veterans in this study, ony 6% received at least one session of one of the evidence-based psychotherapies outlined in the VA/DOD guidelines for PTSD during the initial six months of treatment.
Date: April 26, 2012
- Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
Date: April 13, 2012
- Shorter Duration Group-Based Exposure Therapy Effective Treatment for Veterans with PTSD
Although future study is needed to directly compare the benefits of a 12-week vs. 16-week Group-Based Exposure Therapy (GBET) protocol, preliminary results show that the abbreviated 12-week GBET model was effective in reducing PTSD symptoms. Veterans’ PTSD symptom severity significantly decreased over the course of treatment, and 7 of the 10 Veterans no longer met criteria for PTSD at post-treatment. Overall, Veterans maintained improvements at 3-month follow-up. Participants indicated a high level of treatment satisfaction, and the group maintained a 100% retention rate. The authors suggest that these findings are particularly encouraging given that study participants were combat Veterans who reported histories of multiple traumatic events.
Date: April 1, 2012
- Meditation-Based Mantram Intervention Shows Potential as Adjunctive Therapy for Veterans with PTSD
The Mantram Repetition Program (MRP) shows potential when used as an adjunct to treatment as usual (TAU) for mitigating chronic PTSD symptoms in Veterans. In this study, twice as many Veterans in the MRP + TAU group had clinically meaningful reductions in PTSD symptoms compared to Veterans in the TAU alone group: 24% vs. 12%, respectively, and PTSD symptoms continued to improve in the MRP + TAU group at six-week follow-up. Compared to Veterans in the TAU alone group, Veterans in the MRP + TAU group also experienced significant reductions in depression and greater improvements in mental health-related quality of life and spiritual well-being. Reductions in anxiety were equivalent between groups. Of Veterans in the MRP + TAU group, 97% reported moderate or high satisfaction with MRP, and dropout rates were equivalent and low (7%) in both groups.
Date: March 12, 2012
- Use of Mental Health and Non-Mental Health Outpatient Care by OEF/OIF Veterans with Military Sexual Trauma
The most notable factor that influenced the receipt and intensity of MST-related care was gender. Male Veterans used less care than female Veterans and had a lower intensity of MST-related care compared to women, even after controlling for total number of healthcare visits. Other sociodemographic and military variables associated with less use and/or less intensity of MST-related care were younger age, unknown race/ethnicity, being in the Marines or Air Force, and being in the National Guard or Reserve. Among all Veterans who screened positive for MST, the majority (76%) received at least one MST-related care visit within a year of the positive screen. In examining diagnostic characteristics of MST-related care, the most common primary diagnoses related to a Veterans’ MST-related care were mental health diagnoses. Overall, more than half of all Veterans received MST-related care with an associated mental health primary diagnosis (57% of women and 50% of men); the most common diagnoses were PTSD, depression, and other anxiety disorders. The authors note that the high proportion of Veterans accessing MST-related care confirms the effectiveness of VA’s universal screening program to promote the use of mental health services for Veterans with positive MST screens.
Date: March 7, 2012
- Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
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
- PTSD Symptom Severity Predicts Aggression after Treatment
Post-treatment PTSD severity predicted aggression at the end of treatment and 4 months after treatment. Patients who experienced greater PTSD symptom severity at the end of treatment were more likely to be aggressive after treatment completion, regardless of their aggression history before treatment. Results suggest that severity of each PTSD symptom cluster is associated with aggression four months after treatment completion. Of the PTSD symptom clusters, hyper-arousal had the largest correlation with concurrent aggression before and after treatment. The authors suggest that this research could inform the development of aggression prevention and intervention efforts, as well as the development of clinical recommendations for post-treatment safety for patients with PTSD.
Date: March 1, 2012
- Increase in Proportion of Veterans with PTSD Prescribed Guideline-Concordant Medications
The number of Veterans being treated for PTSD in the VA healthcare system increased nearly 3-fold – from 170,685 in FY1999 to 498,081 in FY2009. The majority of these Veterans (80%) received one of the medications recommended in the clinical practice guideline (CPG) for the treatment of this disorder. The proportion of Veterans receiving either of the two CPG-recommended first-line pharmacotherapy treatments for PTSD – selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) – increased from 50% in 1999 to 59% in 2009. This increase represents more than 46,000 Veterans receiving first-line, guideline recommended medications. The overall frequency of antipsychotic use declined by 6% – from 20% in 1999 to 14% in 2009, and there also was a reduction in benzodiazepine prescriptions (the CPG cautions against prescribing benzodiazepines to manage core PTSD symptoms). However, non-benzodiazepine hypnotic drug prescribing tripled when zolpidem (Ambien) was added to the VA national formulary. Prazosin use increased more than 6-fold, from 1% in 1999 to 9% in 2009, suggesting that it is now more widely prescribed to Veterans with PTSD.
Date: March 1, 2012
- Gender Differences in Healthcare Utilization among Veterans with PTSD
Overall, female OEF/OIF Veterans with PTSD were more likely to have slightly higher mental health, primary care, and emergency care utilization compared to male Veterans with PTSD.
Women Veterans with comorbid PTSD and depression were 12.5 times more likely to have a mental health inpatient hospitalization compared to their female counterparts without depression, and they were twice as likely to have a mental health hospitalization compared to male Veterans with comorbid PTSD and depression. Diagnoses of comorbid PTSD and depression were present in 72% of women and 57% of men. Both men and women with PTSD and alcohol use disorders had more than double the mean number of mental health outpatient visits compared to their counterparts with PTSD but without alcohol use disorders. Comorbid PTSD and alcohol use disorders diagnoses were present in 8% of women and 29% of men. Regardless of gender, Veterans with comorbid PTSD and depression or comorbid PTSD and alcohol use disorders had higher healthcare utilization in all areas, as compared to their counterparts with PTSD but without these comorbid disorders.
Date: February 7, 2012
- 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
- 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 OEF/OIF Veterans
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
- Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
Date: December 1, 2011
- Decreased Use of Benzodiazepines among Veterans with PTSD
This study examined trends in benzodiazepine prescribing among Veterans with PTSD. Findings show that the overall proportion of Veterans receiving a benzodiazepine decreased from 37% in 1999 to 31% in 2009. In addition, the proportion of long-term users (>90 days) decreased from 69% to 64%, and the mean daily dose declined by nearly 15%. The likelihood of receiving benzodiazepines was influenced by time since first VA PTSD diagnosis. For example, in 2009, patients newly diagnosed with PTSD were the least likely to receive a benzodiazepine (21%) compared to patients with a history of three or more years of treatment (36%). Clonazepam was the most commonly prescribed benzodiazepine across all study years.Despite decreasing frequency of use, the absolute number of Veterans with PTSD who received benzodiazepines increased nearly 250% due to the increasing numbers of Veterans receiving care for PTSD in the VA healthcare system. Therefore, the authors suggest that minimizing benzodiazepine exposure will remain a vital policy issue.
Date: November 29, 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
- Low Rates of Screening for Intimate Partner Violence among Veterans with PTSD
This study sought to determine how many Veterans’ records showed documentation of screening for intimate partner violence (IPV) perpetration – and to assess the total number of screenings, and whether an initial screening affected future screenings. Findings show a low rate of screening and assessment for IPV perpetration in male, treatment-seeking Veterans with PTSD – a population believed to have high rates of relationship conflict. While most patient records did not show documentation of a screening or assessment for IPV perpetration, many provided rich descriptions of relationships, indicating that Veterans gave VA staff opportunities to ask about IPV. Authors suggest that documenting IPV screening and perpetration can alert other providers, offering an opportunity for further assessment of its impact on the Veteran and his family members.
Date: November 1, 2011
- Veterans Receiving PTSD Disability Benefits May Experience Fewer Symptoms, Less Poverty and Homelessness over Long Term
This study sought to examine long-term outcomes associated with receiving and not receiving VA disability benefits for PTSD. Findings showed that compared to Veterans not receiving VA PTSD disability benefits, Veterans receiving benefits continued to report more severe PTSD symptoms 10 years after applying for benefits, but were more likely to have had a clinically meaningful reduction in PTSD symptoms. Beneficiaries also had reduced odds of poverty and homelessness compared to denied claimants. Employment was low in both groups, and mortality was similar. On average, Veterans who had been awarded PTSD benefits and Veterans who had been denied them both experienced meaningful improvements of similar magnitude in work, role, and social functioning; however, overall functioning remained poor nonetheless. Findings counter common concerns that PTSD disability benefits impede recovery by incentivizing Veterans to remain ill, and suggest that such benefits may be helpful.
Date: October 1, 2011
- Cognitive Processing Therapy Improves PTSD Symptoms More than Usual Care among Veterans in Residential Rehabilitation Program
This study examined one VA PTSD Residential Rehabilitation Program and compared clinical outcomes for two cohorts of male Veterans with PTSD that were treated with either cognitive processing therapy (CPT) or trauma-focused group treatment as usual (TAU). Findings showed that Veterans treated with CPT experienced more improvement of PTSD and depression symptoms, psychological quality of life, coping, and psychological distress than Veterans who received TAU. In the CPT cohort, more Veterans reported PTSD symptoms that were classified as recovered or improved, compared to the TAU cohort.
Date: October 1, 2011
- Health of Gulf War Veterans Worsened in 10-Year Study
Since the 1991 Gulf War, initial concerns regarding health consequences of participation in the war have turned to requests for longitudinal evaluation of how the health of Gulf War Veterans has changed over time. To help in this evaluation, investigators conducted health surveys of deployed and non-deployed Gulf War-era Veterans in 1995 and again in 2005. Findings showed that the health of deployed Gulf War Veterans worsened during the 10-year period from 1995 to 2005 in comparison with non-deployed Gulf War Veterans. Perceived health of fair or poor was more likely to persist among deployed Veterans, and relatively more deployed Veterans reported that their health status had worsened over the 10-year follow-up. Deployed Veterans were less likely to recover from any prior functional impairment, limitation of activities, or PTSD that they had in 1995 – and were more likely to report new onset of these adverse health outcomes in 2005 compared with non-deployed Veterans. Authors note that the extent to which any of the health problems experienced by Gulf War Veterans were due to the effects of military service in the Gulf War is difficult to determine.
Date: October 1, 2011
- Treating Comorbid Substance Use Disorder and PTSD
This trial sought to determine whether male Veterans with a substance use disorder (SUD) and co-occurring PTSD symptoms in a VA outpatient SUD clinic would benefit from a specialized treatment program for these comorbid disorders. Findings show that Seeking Safety, a manualized treatment approach for substance use disorder, was well received and associated with better drug use outcomes than treatment as usual (TAU) in male Veterans with PTSD. Compared to TAU, Seeking Safety also was associated with increased treatment attendance, client satisfaction, and active coping through treatment. Although these factors may be beneficial for promoting recovery more broadly, neither they – nor reduction in PTSD severity that occurred during treatment – accounted for reductions in drug use among Veterans during the study.
Date: September 16, 2011
- Variation in Attitudes and Practices among VA Clinicians Conducting Disability Assessment for PTSD
This study examined the beliefs and practices of VA mental health professionals performing PTSD examinations as part of VA’s Compensation and Pension (C&P) Program. Findings showed that there was wide variation in the beliefs and practices of individuals conducting PTSD examinations, primarily in two areas: 1) preferences and practices related to psychological assessment, and 2) beliefs related to symptom under-reporting and exaggerating.
In a high percentage of cases, attitudes and practices conflicted with recommended best practices. For example, 59% of clinicians reported rarely or never using testing, and only 17% indicated routinely using standardized clinical interviews. Less than 1% of clinicians reported using functional assessment scales. [Note: VA does not require use of standardized testing; it is an option.] Standardized interviews were seldom employed, with 85% and 90% reporting that they “never” or “rarely” used the Clinician Administered PTSD Scale or the Structured Clinical Interview for DSM IV Axis I Disorders, respectively. Less than half of clinicians reported having received training in administering diagnostic interviews for PTSD. Nearly all clinicians (96%) believed that they were qualified in the skills needed to conduct a PTSD examination. On the other hand, clinicians held varying opinions about the authenticity of Veterans’ psychiatric conditions. For example, 25% of respondents reported that at least 15% of Veterans exaggerate PTSD symptoms, while 25% of respondents also reported that at least 15% of Veterans minimize or under-report their symptoms.
Date: September 12, 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
- Study Suggests PTSD Associated with Cognitive Impairment
This systematic review analyzed data from 21 articles published between 1968 and 2009 that examined memory and cognitive function in subjects with chronic PTSD compared to subjects who had been exposed to trauma but did not have PTSD. Eight of the studies that were analyzed included Veterans. Findings showed that chronic post-traumatic stress disorder is associated with cognitive impairment, particularly in Veterans, when compared to individuals with a history of trauma but no PTSD. The severity of PTSD is positively correlated with cognitive impairment. Strong evidence, especially in studies of Veterans, refugees, and war victims, suggests that individuals with PTSD have a poorer ability to sustain attention compared with individuals who have a history of exposure to trauma.
Date: September 1, 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
- Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
Date: August 1, 2011
- 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
- Women’s Health Issues Journal Focuses on Women Veterans
This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
Date: July 6, 2011
- 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
- Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
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
- Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
Date: May 1, 2011
- Intervention Targeting Trauma-Specific Sleep Disturbances Reduces PTSD Symptoms and Insomnia Severity among Veterans
This pilot study sought to determine whether or not the combined effects of cognitive behavioral therapy (CBT) for insomnia and imagery rehearsal therapy (IRT) for nightmares would produce significantly greater improvements in sleep disturbance than usual care alone. Findings show that the sleep intervention produced large short-term effects, including substantial reductions in PTSD symptoms, such as the frequency of nightmares and insomnia severity. In contrast, none of the participants in the usual care group responded or remitted from insomnia or PTSD, and did not improve from baseline on sleep quality.
Date: February 15, 2011
- Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
Date: February 14, 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
- Veterans who Commit Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
Date: December 1, 2010
- Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy.
The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
Date: December 1, 2010
- 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 OEF/OIF Veterans
This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
Date: October 21, 2010
- PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
Date: October 1, 2010
- 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
- Dementia More Prevalent among Older Veterans with PTSD
This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
Date: September 1, 2010
- Pain Screening Implementation for Veterans Falls Short
This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
Date: August 6, 2010
- 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
- Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
Date: July 1, 2010
- Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
Date: June 17, 2010
- Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
Date: June 9, 2010
- 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
- Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
Date: May 11, 2010
- Rates of Depression Rise among VA Nursing Home Residents
Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
Date: April 1, 2010
- Male 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
- Predictors Associated with Homelessness among Women Veterans
Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
Date: February 1, 2010
- 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
- Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
Date: January 26, 2010
- Veteran Minorities Equally Likely to Receive PTSD Treatment
This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
Date: December 1, 2009
- Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
Date: November 1, 2009
- Determinants of Veteran Treatment-Seeking for PTSD
This study explored determinants of PTSD treatment initiation among 21 treatment-seeking and 23 non-treatment-seeking Veterans who had served in Vietnam, or the current conflicts in Afghanistan and Iraq (14 of the 44 participants were women Veterans). Findings show that both Veterans who were and were not in treatment for PTSD described similar factors that hindered their help-seeking, including their own values and priorities (e.g., pride in self reliance), treatment-discouraging beliefs (e.g., providers would not believe them, or would treat them as if they were “crazy”), and trauma-related avoidance (e.g., avoiding discussion of the traumatic event). They also cited an invalidating post-trauma environment as a detriment to seeking treatment; for example, some women cited a military culture that silenced the reporting of sexual assault. But for some participants, facilitators located within the healthcare system and Veterans’ social networks led to help-seeking despite individual-level barriers. In some cases, it was a trusting relationship with the primary care provider that led the Veteran to follow the provider’s recommendation to seek mental health care. This suggests that factors outside the individual can promote mental health service use for PTSD, even when the Veteran is reluctant.
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 OEF/OIF Veterans
Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use).
The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
Date: August 5, 2009
- 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
- Review Suggests PTSD Negatively Impacts Physical Health but More Research Needed
In this systematic review, investigators searched case reports, comparative studies, meta-analyses, and review articles that examined the relationship between PTSD and specific physical-health diagnoses. Findings suggest that PTSD can have negative effects on physical health, but evidence regarding its association with specific physical disorders is lacking. Evidence suggests a significant association between PTSD and musculoskeletal disorders, especially participant report of arthritis, in the general population – but not in Veterans. There also was an association between PTSD and digestive disorders, particularly ulcers, among non-Veterans. The rest of the associations were either found in single studies or are conflicting, particularly in regard to diabetes, congestive heart failure, and stroke. Authors suggest that large, prospective epidemiological trials are needed to examine the relationship between PTSD and physical illness.
Date: June 1, 2009
- Diffusion of New Drug Therapy for PTSD Lessens with Distance
This study sought to evaluate the pace and reach of the passive dissemination of a novel, but as yet un-established treatment with the drug prazosin for post-traumatic stress disorder (PTSD) within the VA health care system. Investigators used geographic surveillance data to track the diffusion of prazosin to treat Veterans diagnosed with PTSD in the VA Puget Sound Healthcare System (where the treatment was developed), and at VAMCs ranging up to 2500 miles or farther from Puget Sound. Findings show that the passive diffusion of a new treatment can be rapid in the immediate area in which it is developed, but the geographic gradient of use seems to be steep and changed little during a two-year period, even when cost and organizational barriers were minimal. Veterans with PTSD treated in the area nearest to Puget Sound (<499 miles) were about 63% less likely in 2004 and about 49% less likely in 2006 to be prescribed prazosin than their counterparts treated within Puget Sound. These results suggest that if and when new treatments are definitively demonstrated to be effective, more active dissemination is likely to be needed, especially in geographically remote areas.
Date: April 1, 2009
- Assessing Healthcare Utilization among Veterans with Depression
Nearly half of VA primary care patients with significant depressive symptoms also used non-VA care. Among dual users, 94.9% used both VA and non-VA care for physical health problems, but only 20.3% used both for emotional health problems. Lower levels of alcohol use and the presence of PTSD were associated with the use of non-VA outpatient care for emotional health services. Authors suggest that care management strategies for Veterans with depression should include communication and coordination with non-VA providers.
Date: March 1, 2009
- Investigators Develop Diagnostic Guidelines for Post-Traumatic Stress Disorder
Diagnosing mental disorders is often challenging, but may be especially difficult in post-traumatic stress disorder (PTSD) due to the high rates of comorbidity between PTSD and other psychiatric disorders. As a result of this study, investigators offer guidelines for the differential diagnosis of Veterans with PTSD. Clinicians should be aware that those suffering from PTSD might present with symptoms that initially point to other diagnoses, and that mistaken diagnoses can have detrimental effects. Investigators believe that the guidelines they offer can lead to greater reliability in the diagnosis of PTSD and related comorbid conditions.
Date: February 1, 2009
- Successful Strategy that Engages Veterans and Families in Psychoeducation to Improve Treatment for Mental Illness
Recently, VA funded 19 initiatives to implement family psychoeducation, an evidence-based practice in the treatment of psychotic disorders that results in reduced risk of relapse, remission of residual psychotic symptoms, and enhanced social and family functioning, but the implementation of such programs requires engaging mental health clinicians, consumers, and families. This paper discusses the engagement strategies used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a 9-month family psychoeducation program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD). Findings show that REACH has had notable success in engaging Veterans and their families, with participation rates that are comparable to those for programs requiring a much shorter commitment than 9 months, and suggest that the REACH engagement strategy may be a promising tool in recruiting Veterans and their families into family psychoeducation.
Date: February 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
- Panic Control Treatment Proves Effective in Veterans with Panic Disorder and PTSD
Panic control treatment appeared to be superior in reducing the frequency, severity, and distress associated with panic disorder and suggests that brief cognitive-behavioral therapy for panic is effective for veterans with PTSD.
Date: August 1, 2008