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Post-9/11 Veterans' Mental Health

Below are some suggested studies and references that may assist you in working with trauma-affected veterans.  Wherever “($)” appears, the resource is available commercially at the link provided.  To access the study, click on the title and it will take you to the PDF (when available) or the site where the study may be reviewed or purchased.

This compilation of research and references is a work in progress -- suggestions for additions to this page are always welcome and may be sent to

Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. The New England Journal Of Medicine, 351(1), 13-22. doi:10.1056/NEJMoa040603

BACKGROUND The current combat operations in Iraq and Afghanistan have involved US military personnel in major ground combat and hazardous security duty. Studies are needed to systematically assess the mental health of members of the armed services who have participated in these operations and to inform policy with regard to the optimal delivery of mental health care to returning veterans. METHODS We studied members of 4 US combat infantry units (3 Army units and a Marine Corps unit) using an anonymous survey that was administered to the subjects either before their deployment to Iraq (n=2530) or 3 to 4 months after their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included major depression, generalized anxiety, and posttraumatic stress disorder (PTSD), which were evaluated on the basis of standardized, self-administered screening instruments. RESULTS Exposure to combat was significantly greater among those who were deployed to Iraq than among those deployed to Afghanistan. The percentage of study subjects whose responses met the screening criteria for major depression, generalized anxiety, or PTSD was significantly higher after duty in Iraq (15.6% to 17.1%) than after duty in Afghanistan (11.2%) or before deployment to Iraq (9.3%); the largest difference was in the rate of PTSD. Of those whose responses were positive for a mental disorder, only 23% to 40% sought mental health care. Those whose responses were positive for a mental disorder were twice as likely as those whose responses were negative to report concern about possible stigmatization and other barriers to seeking mental health care. CONCLUSIONS This study provides an initial look at the mental health of members of the Army and the Marine Corps who were involved in combat operations in Iraq and Afghanistan. Our findings indicate that among the study groups there was a significant risk of mental health problems and that the subjects reported important barriers to receiving mental health services, particularly the perception of stigma among those most in need of such care. [ABSTRACT FROM AUTHOR]



Prospective Prediction of Functional Difficulties Among Recently Separated Veterans

Larson, G. E., & Norman, S. B. (2014). Prospective prediction of functional difficulties among recently separated Veterans. Journal Of Rehabilitation Research & Development, 51(3), 415-427. doi:10.1682/JRRD.2013.06.0135

Reports of functional problems are common among Veterans who served post-9/11 (more than 25% report functional difficulties in at least one domain). However, little prospective work has examined the risk and protective factors for functional difficulties among Veterans. In a sample of recently separated Marines, we used stepwise logistic and multiple regressions to identify predictors of functional impairment, including work-related problems, financial problems, unlawful behavior, activity limitations due to mental health symptoms, and perceived difficulty reintegrating into civilian life. Posttraumatic stress disorder symptoms assessed both before and after military separation significantly predicted functional difficulties across all domains except unlawful behavior. Certain outcomes, such as unlawful behavior and activity limitations due to mental health symptoms, were predicted by other or additional predictors. Although several forms of functioning were examined, the list was not exhaustive. The results highlight a number of areas where targeted interventions may facilitate the reintegration of military servicemembers into civilian life. [ABSTRACT FROM AUTHOR]



Criminal Justice Involvement, Trauma, and Negative Affect in Iraq and Afghanistan War Era Veterans

Elbogen, E. B., Johnson, S. C., Newton, V. M., Straits-Troster, K., Vasterling, J. J., Wagner, H., & Beckham, J. C. (2012). Criminal justice involvement, trauma, and negative affect in Iraq and Afghanistan war era veterans. Journal Of Consulting And Clinical Psychology, 80(6), 1097-1102. doi:10.1037/a0029967

Objective: Although criminal behavior in veterans has been cited as a growing problem, little is known about why some veterans are at increased risk for arrest. Theories of criminal behavior postulate that people who have been exposed to stressful environments or traumatic events and who report negative affect such as anger and irritability are at increased risk of antisocial conduct. Method: We hypothesized veterans with posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) who report anger/irritability would show higher rates of criminal arrests. To test this, we examined data in a national survey of N = 1,388 Iraq and Afghanistan war era veterans. Results: We found that 9% of respondents reported arrests since returning home from military service. Most arrests were associated with nonviolent criminal behavior resulting in incarceration for less than 2 weeks. Unadjusted bivariate analyses revealed that veterans with probable PTSD or TBI who reported anger/irritability were more likely to be arrested than were other veterans. In multivariate analyses, arrests were 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 but were not significantly related to combat exposure or TBI. Conclusions: Findings show that a subset of veterans with PTSD and negative affect may be at increased risk of criminal arrest. Because arrests were more strongly linked to substance abuse and criminal history, clinicians should also consider non-PTSD factors when evaluating and treating veterans with criminal justice involvement. (PsycINFO Database Record (c) 2013 APA, all rights reserved) (journal abstract)



Internal Anger and External Expressions of Aggression in OEF/OIF Veterans

Renshaw, K. D., & Kiddie, N. S. (2012). Internal anger and external expressions of aggression in OEF/OIF veterans. Military Psychology, 24(3), 221-235. doi:10.1080/08995605.2012.678197

National Guard/Reserve service members (n = 143) deployed to Operations Enduring/Iraqi Freedom completed measures of anger/aggression, coping, and PTSD. Regressions and path analyses revealed that PTSD and avoidant coping both contributed to elevated anger. Furthermore, PTSD exerted indirect effects on verbal and physical aggression via anger, with direct effects only on physical aggression. Younger age was unrelated to anger but directly related to greater verbal and physical aggression. These results contribute to a more comprehensive understanding of risk for aggression in veterans of recent conflicts; however, the generalizability is limited by sample characteristics (all National Guard/Reserve, mostly White, married, religious). (PsycINFO Database Record (c) 2014 APA, all rights reserved) (journal abstract)



Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations


Ramchand, R., Schell, T. L., Karney, B. R., Osilla, K., Burns, R. M., & Caldarone, L. (2010). Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations. Journal Of Traumatic Stress, 23(1), 59-68. doi:10.1002/jts.20486

The authors reviewed 29 studies that provide prevalence estimates of posttraumatic stress disorder (PTSD) among service members previously deployed to Operations Enduring and Iraqi Freedom and their non-U.S. military counterparts. Studies vary widely, particularly in their representativeness and the way PTSD is defined. Among previously deployed personnel not seeking treatment, most prevalence estimates range from 5 to 20%. Prevalence estimates are generally higher among those seeking treatment: As many as 50% of veterans seeking treatment screen positive for PTSD, though much fewer receive a PTSD diagnosis. Combat exposure is the only correlate consistently associated with PTSD. When evaluating PTSD prevalence estimates among this population, researchers and policymakers should carefully consider the method used to define PTSD and the population the study sample represents.



Studies’ Estimates of PTSD Prevalence Rates for Returning Service Members Vary Widely

Rajeev Ramchand, Terry L. Schell, Benjamin R. Karney, Karen Chan Osilla, Rachel M. Burns, Leah B. Caldarone

RAND Corporation 2010

Summarizes analyses of existing posttraumatic stress disorder (PTSD) studies for war zone veterans, finding that the prevalence estimates vary widely and are linked to the use of different PTSD diagnostic definitions and divergent study samples.



Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq

Hoge, C. W., McGurk, D., Thomas, J. L., Cox, A. L., Engel, C. C., & Castro, C. A. (2008). Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. New England Journal Of Medicine, 358(5), 453-463. doi:10.1056/NEJMoa072972

BACKGROUND: An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood. METHODS: We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. RESULTS: Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. CONCLUSIONS: Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems. N Engl J Med 2008;358:453-63. [ABSTRACT FROM AUTHOR]



Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War

Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA: Journal Of The American Medical Association, 298(18), 2141-2148. doi:10.1001/jama.298.18.2141

Context: To promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden. Objective: To measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization. Design, Setting, and Participants: Population-based, longitudinal descriptive study of the initial large cohort of 88235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments. Main Outcome Measures: Screening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services. Results: Soldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement. Conclusions: Rescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain. (PsycINFO Database Record (c) 2012 APA, all rights reserved)



Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan

Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA: Journal Of The American Medical Association, 295(9), 1023-1032. doi:10.1001/jama.295.9.1023

CONTEXT The US military has conducted population-level screening for mental health problems among all service members returning from deployment to Afghanistan, Iraq, and other locations. To date, no systematic analysis of this program has been conducted, and studies have not assessed the impact of these deployments on mental health care utilization after deployment. OBJECTIVES To determine the relationship between combat deployment and mental health care use during the first year after return and to assess the lessons learned from the postdeployment mental health screening effort, particularly the correlation between the screening results, actual use of mental health services, and attrition from military service. DESIGN, SETTING, AND PARTICIPANTS Population-based descriptive study of all Army soldiers and Marines who completed the routine postdeployment health assessment between May 1, 2003, and April 30, 2004, on return from deployment to Operation Enduring Freedom in Afghanistan (n = 16 318), Operation Iraqi Freedom (n = 222 620), and other locations (n = 64 967). Health care utilization and occupational outcomes were measured for 1 year after deployment or until leaving the service if this occurred sooner. MAIN OUTCOME MEASURES Screening positive for posttraumatic stress disorder, major depression, or other mental health problems; referral for a mental health reason; use of mental health care services after returning from deployment; and attrition from military service. RESULTS The prevalence of reporting a mental health problem was 19.1% among service members returning from Iraq compared with 11.3% after returning from Afghanistan and 8.5% after returning from other locations (P<.001). Mental health problems reported on the postdeployment assessment were significantly associated with combat experiences, mental health care referral and utilization, and attrition from military service. Thirty-five percent of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. More than 50% of those referred for a mental health reason were documented to receive follow-up care although less than 10% of all service members who received mental health treatment were referred through the screening program. CONCLUSIONS Combat duty in Iraq was associated with high utilization of mental health services and attrition from military service after deployment. The deployment mental health screening program provided another indicator of the mental health impact of deployment on a population level but had limited utility in predicting the level of mental health services that were needed after deployment. The high rate of using mental health services among Operation Iraqi Freedom veterans after deployment highlights challenges in ensuring that there are adequate resources to meet the mental health needs of returning veterans.



Impact of Combat Duty in Iraq and Afghanistan on the Mental Health of U.S. Soldiers: Findings from the Walter Reed Army Institute of Research Land Combat Study

Hoge, C.W.; Castro, C.A. (2005) Impact of Combat Duty in Iraq and Afghanistan on the Mental Health of U.S. Soldiers: Findings from the Walter Reed Army Institute of Research Land Combat Study. In Strategies to Maintain Combat Readiness during Extended  Deployments – A Human Systems Approach (pp. 11-1 – 11-6). Meeting Proceedings RTO-MP-HFM-124, Paper 11.  Neuilly-sur-Seine, France: RTO.

BACKGROUND.  A recent study has shown that over 12% of U.S. Soldiers and Marines who returned from combat duty in Iraq met criteria for post-traumatic stress disorder, a rate significantly higher than before deployment, and that Soldiers reported significant stigma and barriers to receiving needed mental health care (Hoge, Castro, et. al. N Engl J Med 2004).  The study has continued to examine the effects of combat duty on U.S. Soldiers in near real time as the war has progressed, and this paper will present the latest findings from this landmark study.  METHODS.  Over 25,000 surveys have been obtained from U.S. Soldiers and Marines before deployment, during deployment, and up to one year post-deployment.   Outcomes include major depression, generalized anxiety, post-traumatic stress disorder (PTSD), alcohol misuse, health risk behaviors, and family functioning.  RESULTS.  Soldiers deployed to Iraq have experienced sustained high levels of combat exposure.  The rate of screening positive for a mental disorder at 3 months post-deployment was significantly higher after duty in Iraq (15-17%) compared with Afghanistan (11%) or before deployment (9%), with the largest difference due to PTSD.  Less than 40% of screen positives sought mental health care, and there was a high rate of concern about stigma / other barriers to care.  CONCLUSIONS.  Combat duty in Iraq is associated with a significant risk of mental health problems and there is an important unmet need for mental health services and barriers to care.  New data will be presented on the prevalence rates and risk factors for mental health problems up to one-year post-deployment.



PTSD Symptoms, Demographic Characteristics, and Functional Status Among Veterans Treated in VA Primary Care Clinics


Magruder, K. M., Frueh, B. C., Knapp, R. G., Johnson, M. R., Vaughan, J. A., Carson, T. C., Powell, D. A. and Hebert, R. (2004), PTSD symptoms, demographic characteristics, and functional status among veterans treated in VA primary care clinics. Journal of Traumatic Stress, 17: 293–301. doi: 10.1023/B:JOTS.0000038477.47249.c8

We hypothesized that PTSD symptomatology would have an inverse relationship with functional status and would vary as a function of sociodemographic variables. Primary care patients (N = 513) at two VA Medical Centers were randomly selected and recruited to participate. After adjustment for other demographic variables. PTSD symptom levels were significantly related to age (younger patients had more severe symptoms), employment status (disabled persons had higher symptom levels), war zone experience, and clinic location. PTSD symptomatology was inversely related to mental and physical functioning, even after control for potential confounding. These findings have implications for screening and service delivery in VA primary care clinics, and support the more general finding in the literature that PTSD is associated with impaired functioning.



Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment.


Brunello, N.; Davidson, J.; Deahl, M.; et al. 2001. Postraumatic Stress Disorder: Diagnostic and Epidemiology, Comorbidity and Social Consequences, Biology and Treatment. Neuropsychobiology 43:150–162.

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.