Predicting costs of Veterans Affairs health care in Gulf War veterans with medically unexplained physical symptoms

Measures of post-traumatic stress disorder (PTSD) and depression were used to predict Veterans Affairs outpatient treatment costs among Persian Gulf War veterans with medically unexplained physical symptoms. Patients (N = 206) enrolled in a Veterans Affairs primary care clinic for Persian Gulf War veterans completed study assessments at the initial appointment or at a proximal follow-up visit. Costs of care for mental health, medical, and pharmacy services for these veterans were computed for the subsequent 6-month period. Depression and PTSD symptoms explained a significant share of variance in costs of mental health care and pharmacy services, after adjustment for covariates. None of the mental status measures was significantly related to costs of medical care. Models using global measures of mental health status were as robust as models using disorder-specific measures of PTSD and depression in predicting mental health care and pharmacy costs. The implications of these findings for anticipating costs of care for Persian Gulf War veterans are discussed.     

Does filing a post-traumatic stress disorder disability claim promote mental health care participation among veterans?

This study examined the impact of participation in the Department of Veterans Affairs (VA) disability system on health care use by veterans filing disability claims on the basis of post-traumatic stress disorder (PTSD). VA administrative databases were used to examine health care use in 3-month intervals before, during, and after veterans' filing of PTSD disability claims. Subjects were all veterans using some VA health care who filed PTSD claims between 1997 and 1999 in a large Midwestern region. PTSD claimants used more medical and mental health services after filing a disability claim, compared with the preapplication period. Continuation of elevated mental health care use after claim determination occurred only for those veterans whose claims were approved. Use of VA mental health care before the disability examination was associated with an increased likelihood of claim approval. For veterans with PTSD, disability system participation may both promote and be promoted by receipt of mental health care.     

Post-traumatic stress disorder claims from the viewpoint of veterans service officers

OBJECTIVE: To situate veterans' experience of the Department of Veterans Affairs claims process in a broader context, this study explored the beliefs of veterans service officers (VSOs) about the Department of Veterans Affairs disability claims process for post-traumatic stress disorder (PTSD). METHODS: A mail survey of the county and national VSOs working in Minnesota was performed. Questionnaires included a modified version of the Disability Application Appraisal Inventory. RESULTS: Most VSOs believe thatveterans value the Department of Veterans Affairs disability status for PTSD to obtain validation for what they experienced in the military and that veterans have negative reactions to the claims process for PTSD. VSOs' satisfaction with the claims process was associated with beliefs about its fairness. CONCLUSIONS: In general, VSOs' beliefs about the reasons veterans value service connection for PTSD parallel those veterans report. More work is needed to determine how VSOs influence veterans, to determine whether PTSD claimants have special or unique needs as they undergo the claims process, and to explore fairness concerns.     

Assessment of trauma exposure and post-traumatic stress in long-term care veterans: preliminary data on psychometrics and post-traumatic stress disorder prevalence

This article reports preliminary data on trauma and post-traumatic stress disorder (PTSD) prevalence, as well as test psychometrics, among 35 cognitively intact veterans residing in long-term care settings. Participants received a traumatic event screening, the Mini-Mental Status Examination, Combat Exposure Scale (CES), PTSD Checklist (PCL), and Mississippi Combat PTSD Scale (M-PTSD). Results demonstrated adequate reliability for the CES, PCL, and M-PTSD for use in these settings, with several significant intercorrelations. A high prevalence of trauma exposure was found, in particular combat. Based on the PCL and M-PTSD, although most veterans did not meet full PTSD diagnostic criteria, a moderate proportion met partial criteria. The need for assessment and treatment of trauma exposure and PTSD in Veterans Affairs long-term care settings is emphasized.     

The health status of Gulf War veterans: lessons learned from the Department of Veterans Affairs Health Registry.

OBJECTIVE: To describe the demographic characteristics and postwar health status of U.S. Gulf War veterans who participated in the Department of Veterans Affairs health examination registry program. DESIGN: Case records of 52,835 veterans who participated in a standardized health examination program were reviewed. SETTING: Participants volunteered for physical examinations at a Department of Veterans Affairs medical treatment facility from August 1992 to September 1996. SUBJECTS: U.S. Gulf War veterans deployed to southwest Asia between August 1990 and 1996. MAIN OUTCOME MEASURE: Demographic, military, symptom, and International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic categories. RESULTS: A wide variety of symptoms and diagnoses were reported without apparent internal variation by military characteristics (branch and service component). The frequency of symptoms (fatigue, skin rash, headache, muscle and joint pain, and memory loss) reported increased over time, whereas the proportion of individuals with physician-diagnosed illnesses remained fairly constant. No single category of disease increased or decreased substantially over time. CONCLUSIONS: Veterans have experienced a wide variety of health problems since their Gulf War service. These problems, in aggregate, are different from what has been seen in other armed conflicts. The Department of Veterans Affairs registry is a very large case series and has failed to identify a single, unique syndrome or new illness after Gulf War service. An epidemiologic study would better define the prevalence of specific symptoms and medical conditions among Gulf War veterans and to what extent any of the conditions identified are associated with Gulf War military service. The knowledge provided by such studies would be important to development of preventive measures and future deployment medical surveillance planning.     

Health and functioning among four war eras of U.S. veterans: examining the impact of war cohort membership,socioeconomic status,mental health,and disease prevalence

This analysis examines the self-rated health and functioning of World War II, Vietnam era, Korean Conflict, and Persian Gulf War veterans participating in the Veteran Identity Program Survey 2001. The results indicate that although World War II veterans are more likely to report poor health status and functioning, Vietnam-era veterans report more difficulty with specific activities of daily living and instrumental activities of daily living than any other era of veterans. These relationships remain when controlling for race/ethnicity, socioeconomic status, disease prevalence, and mental health status. These findings suggest that there are characteristics unique to the Vietnam experience that negatively affect this cohort of veterans. We suggest that further analysis examine the specific pathways through which the experience of being a Vietnam veteran affects health. In the meantime, health and social service planning within the Department of Veterans Affairs should explore the services that should be developed and targeted to this cohort of veterans so that they may remain independent in the community.     

Long-term effects of military service on mental health among veterans of the Vietnam War era

Comparing outcomes of veterans who served in Vietnam and those who served elsewhere, we examined treatment of post-traumatic stress disorder, treatment of other mental health conditions, psychiatric treatment location, and six mental health well-being measures. The analytic sample consisted of nationally representative data from the 2001 National Survey of Veterans. Analyses included multivariate logistic regression that controlled for sociodemographic characteristics. Of Vietnam War-era veterans in the National Survey of Veterans (N = 7,914), 3,937 served in Vietnam and 3,977 served elsewhere. These veterans were stratified into < 60 years of age (N = 6,141) and > or = 60 years of age (N = 1,766). Veterans who served in Vietnam had notably poorer mental health than did those who served elsewhere. There were striking mental health differences between younger and older veterans; younger veterans had substantially worse measures of mental health. These results suggest greater resource needs among younger Vietnam War veterans. Clinicians and the Department of Veterans Affairs should focus on mental health services for younger veterans.     

Incarceration and veterans of the first Gulf War

OBJECTIVE: This study investigated the prevalence of incarceration and the association with deployment among veterans of the first Persian Gulf War (GW). METHODS: A structured telephone interview of military personnel from Iowa deployed to the Persian Gulf and a comparison sample of nondeployed military personnel was conducted. The interview consisted of validated questions, validated instruments, and investigator-derived questions to assess relevant medical and psychiatric conditions. A total of 4,886 subjects were randomly drawn from one of four study domains, i.e., GW regular military, GW National Guard/Reserve, non-GW regular military, or non-GW National Guard/Reserve. Symptoms of medical conditions, psychiatric disorders, and health care utilization were the main outcome measures. RESULTS: Nearly one-quarter (845 of 3,695 subjects, 22.9%) had been incarcerated at some point before the interview ("ever incarcerated"). Ever incarcerated veterans had a higher frequency of psychiatric and medical comorbidity and higher rates of health care utilization. Ever incarcerated status was associated with male gender, enlisted rank, lower educational levels, low levels of military preparedness, discharge from service, cigarette smoking, antisocial traits, court martial and/or other military discipline, having seen a mental health professional, and having used illegal drugs. GW veterans who participated in combat had a modestly higher risk for incarceration after the GW than did noncombatants (odds ratio, 1.6; 95% confidence interval, 1.0-2.5). CONCLUSIONS: Military recruits with a history of incarceration more often displayed problematic behaviors, more often developed psychiatric/medical conditions, and had high rates of health care utilization. A history of incarceration may be a behavioral marker for substance abuse, antisocial behavior, and mental illness. Importantly, GW deployment carried no increased risk of subsequent incarceration overall.     

The millennium Cohort Study: a 21-year prospective cohort study of 140,000 military personnel

Does military service, in particular operational deployment, result in a higher risk of chronic illness among military personnel and veterans? The Millennium Cohort Study, the largest Department of Defense prospective cohort study ever conducted, will attempt to answer this question. The probability-based sample of 140,000 military personnel will be surveyed every 3 years during a 21-year period. The first questionnaire, scheduled for release in summer 2001, will be sent to 30,000 veterans who have been deployed to southwest Asia, Bosnia, or Kosovo since August 1997 and 70,000 veterans who have not been deployed to these conflict areas. Twenty thousand new participants will be added to the group in each of the years 2004 and 2007 to complete the study population of 140,000. The participants will have the option of completing the study questionnaire either on the paper copy received in the mail or through the World Wide Web-based version, which is available at www.MillenniumCohort.org. This will be one of the first prospective studies ever to offer such an option. The initial survey instrument will collect data regarding demographic characteristics, self-reported medical conditions and symptoms, and health-related behaviors. Validated instruments will be incorporated to capture self-assessed physical and mental functional status (Short Form for Veterans), psychosocial assessment (Patient Health Questionnaire), and post-traumatic stress disorder (Patient Checklist-17). Information obtained from the survey responses will be linked with other military databases, including data on deployment, occupation, vaccinations, health care utilization, and disability. In addition to revealing changes in veterans' health status over time, the Millennium Cohort Study will serve as a data repository, providing a solid foundation upon which additional epidemiological studies may be constructed.     

Declining access to alcohol and drug abuse services among veterans in the general population

Although the Veterans Health Administration has been committed to preserving its capacity to provide specialized substance abuse (SA) services, administrative data from the late 1990s point to reduced access. To explore the possible effects of reduced access to Veterans Affairs services on veterans in the general population, we examined data from the National Household Survey of Drug Abuse from 1994 to 2001. Although the data are not longitudinal at the level of individuals, the annual nature of these surveys makes it possible to chart aggregate changes in clinical needs and service use over time. The results indicate that, whereas veterans' needs for SA services remained high and were consistent across these years, the proportion of veterans in treatment decreased. The proportion of nonveterans receiving SA treatment also decreased but not as steeply as that of veterans. This trend parallels declining delivery of specialized alcohol and drug abuse services within the Veterans Health Administration, although they do not prove a causal relationship.     

A preliminary study of the effect of a diagnosis of concussion on PTSD symptoms and other psychiatric variables at the time of treatment seeking among veterans

The aim of this study was to assess whether a diagnosis of concussion given at a Veterans Healthcare Administration secondary traumatic brain injury assessment impacted either posttraumatic stress disorder (PTSD) symptomatology or other variables at the time veterans sought treatment for PTSD. This retrospective study compared 61 male veterans with a history of military-related concussion and military-related PTSD to 83 male veterans with military-related PTSD but without a diagnosis of military-related concussion. There were no significant between-group differences in PTSD symptomatology. However, the cohort with a history of military concussion endorsed decreased ability to cope with PTSD symptoms, increased problems with physical health, and more pain complaints. If replicated, these results may guide the design of more effective interventions for veterans who receive diagnoses of PTSD and concussion.     

Postdeployment health care for returning OEF/OIF military personnel and their social networks: a qualitative approach

Little is known regarding the health care needs of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) deployed veterans seeking care outside of Veterans Affairs facilities. Responding to this gap, we conducted a mixed methods study of postdeployment health among veterans and members of their social networks in six community-based primary care clinics. A total of 347 patients completed a survey dealing with deployment to Iraq/Afghanistan (whether their own or that of a family member, friend, or coworker), and subsequent psychosocial and health problems. A subset of 52 participants responded to an open-ended question requesting additional information about experiences during and postdeployment. Content analysis of these responses revealed five overarching themes: connectedness, perceptions of conflict, consequences of deployment, health and treatment concerns, and respect and concern for service members/veterans. These data point to significant deployment-related disruptions in the well-being of service members and those in their broader social networks, with implications for defining service needs in community health settings.     

The war-related illness and injury study centers: a resource for deployment-related health concerns

Combat veterans often return from deployment having experienced a wide range of exposures, symptoms, and medical conditions. The Department of Veterans Affairs established war-related illness and injury study centers to serve combat veterans with unexplained illnesses. We report the exposures, clinical status, and utilization of 53 combat veterans who participated in the National Referral Program (NRP) from January 2002 until March 2004. Participants were primarily male (81%) and served in the Persian Gulf War (79%). Common diagnoses were chronic fatigue syndrome (n = 23, 43%), neurotic depression (n = 21, 40%), and post-traumatic stress disorder (n = 20, 38%). Self-reported exposures related to weaponry, disease prophylaxis, environmental hazards, stress, and poor hygiene. A small increase in mean SF-36V mental component scores (2.8 points, p = 0.009) and use of rehabilitation therapies (1.6 additional visits, p = 0.018) followed the NRP referral. The small gain in mental function suggests that the NRP may benefit combat veterans with long and complex medical histories.     

Health care utilization by United Nations peacekeeping veterans with co-occurring, self-reported, post-traumatic stress disorder and depression symptoms versus those without

It remains to be determined whether patients with comorbid post-traumatic stress disorder (PTSD) and depression use more health care resources than do those without. United Nations peacekeeping veterans from Canada were divided into four groups, i.e., PTSD alone (n = 23), depression alone (n = 167), comorbid PTSD and depression (n = 119), and neither (n = 164), and compared with respect to total number of visits to any health care professional in the past year. Analysis of variance revealed that the groups significantly differed in total visits. Post hoc analyses indicated that veterans with co-occurring PTSD and depression symptoms had more visits than did those in the other groups and that veterans with PTSD symptoms alone and depression symptoms alone had more visits than did those with neither PTSD nor depression. Additional analyses revealed that veterans with co-occurring PTSD and depression symptoms made more visits to general practitioners, specialists, pharmacists, and mental health professionals than did the others. Future research directions and implications for treatment planning are discussed.     

Post-traumatic stress disorder (traumatic war neurosis) and concurrent psychiatric illness among Australian Vietnam veterans. A controlled study

Depression, anxiety, irritability with unpredictable explosions of aggressive behaviour, impulsivity, suicidal actions and substance abuse have been repeatedly observed among ex-servicemen from World War II in psychiatric treatment settings. In the most recent American Psychiatric Association classification of mental disorders the category of Post Traumatic Stress Disorder (PTSD) was introduced, replacing the earlier Traumatic War Neurosis and the above cluster of symptoms were included as associated features of this disorder. Two recent uncontrolled studies on U.S. Vietnam veterans receiving psychiatric care supported the linkage of PTSD with these abnormalities. However, the present controlled study found these associated features occurred with equal frequencies among one group of psychiatrically hospitalised Australian Vietnam veterans with PTSD and another group not so afflicted. Reservations, then, should be harboured about ascribing all the presented psychopathology and behavioural abnormalities of ex-servicemen to the stress of their war service.     

Concurrent psychiatric illness in inpatients with post-traumatic stress disorder

The discharge diagnoses of 374 inpatients on a VA Medical Center general psychiatry ward were reviewed. Sixty-three (16.8%) were diagnosed as having posttraumatic stress disorder (PTSD). The mean number of diagnoses was 2.9 for the PTSD group, compared with 1.4 for the non-PTSD patients. The most common comorbid conditions in the PTSD patients were alcohol abuse, unipolar major depression, substance abuse, atypical psychosis, and intermittent explosive disorder. All of these disorders except substance abuse occurred significantly more frequently in the PTSD patients than in those free of PTSD. Schizophrenia and organic mental disorders occurred significantly more frequently in the non-PTSD group. These results suggest a need for thorough psychiatric evaluation in patients with PTSD and the need to evaluate for PTSD when combat veterans present with one of several psychiatric syndromes mentioned above.     

Deployment risk factors and postdeployment health profiles associated with traumatic brain injury in heavy drinking veterans

Along with post-traumatic stress disorder (PTSD), mild traumatic brain injury (mTBI) is considered one of the "signature wounds" of combat operations in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]), but the role of mTBI in the clinical profiles of Veterans with other comorbid forms of post-deployment psychopathology is poorly understood. The current study explored the deployment risk and postdeployment health profiles of heavy drinking OIF and OEF Veterans as a function of mTBI. Sixty-nine heavy-drinking OIF/OEF Veterans were recruited through a Veterans' Affairs Medical Center and completed questionnaires and structured interviews assessing war-zone experiences, postdeployment drinking patterns, and PTSD symptoms. Veterans with positive mTBI screens and confirmed mTBI diagnoses endorsed higher rates of combat experiences, including direct and indirect killing, and met criteria for PTSD at a higher rate than Veterans without a history of mTBI. Both PTSD and combat experiences independently predicted screening positive for mTBI, whereas only combat experiences predicted receiving a confirmed mTBI diagnosis. mTBI was not associated with any dimension of alcohol use. These results support a growing body of literature linking mTBI with PTSD.     

The influence of military service on outpatient care use among racial/ethnic groups in Department of Veterans Affairs medical centers

This study examines race-specific military service effects on outpatient care utilization in the Department of Veterans Affairs (VA) using data from the 1992 National Survey of Veterans. The study population consisted of 4,791 male veterans. After controlling for predisposing, enabling, and need variables, black veterans were 3.7 times more likely than white veterans to use VA outpatient care. Veterans discharged from the military for medical release were less likely to use VA outpatient care (odds ratio = 0.76) than veterans discharged at the end of their normal terms. Hispanic veterans discharged for medical release were 5.3 times more likely than white veterans discharged for the same reason to use VA outpatient care. Korean conflict and mixed war period veterans were more likely to use VA outpatient care than World War II veterans. Racial/ethnic differences in military service characteristics influence the use of VA outpatient care and should be understood in delivering outpatient care to veterans.     

The Department of Defense's Persian Gulf War registry year 2000: an examination of veterans' health status

This study examined the health status of 46,633 Persian Gulf War theater veterans who received full clinical evaluations in the Department of Defense's Gulf War Comprehensive Clinical Evaluation Program (CCEP) as of spring 2000. Clinical data analyzed included demographic information, 15 health symptoms, 19 wartime exposures, and primary and secondary physician-determined medical diagnoses based on International Classification of Diseases, 9th Revision, Clinical Modification, criteria. Findings and discussions are arrayed, by gender, with comparative 1996 data from the Department of Veterans Affairs Health Examination Registry Program. Many veterans reported fewer physical symptoms now than during the time of the Gulf War. Many endorsed symptoms of joint pain, fatigue, weight change, and sleep disturbances. Most reported exposure to diesel fuel and the nerve agent antidote pyridostigmine bromide; far fewer female veterans reported combat involvement. The most frequent primary or secondary diagnosed medical conditions were musculoskeletal/connective tissue diseases, ill-defined conditions, and mental disorders. Female veterans were diagnosed more frequently with mental disorders. Symptom endorsement and diagnosis rates between the CCEP and the Department of Veterans Affairs registry were not dissimilar. Overall, the self-reported general health of veterans with symptoms was much poorer (females had higher rates of "fair to poor" health than males) than that of veterans with no reported symptoms.