Mental Health Diagnoses and Utilization of VA Non-Mental Health Medical Services Among Returning Iraq and Afghanistan Veterans

Department of Veterans Affairs Medical Center, San Francisco VA Medical Center, Box 111A1, 4150 Clement Street, San Francisco, CA, 94121, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 09/2009; 25(1):18-24. DOI: 10.1007/s11606-009-1117-3
Source: PubMed


Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients' use of non-mental health medical services and the impact of mental disorders on utilization.
To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.
National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.
We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans' first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.
Veterans with mental disorders had 42-146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71-170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization.
Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs.


Available from: Charles Marmar, Oct 13, 2014
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    • "We found that patients with one or more mental health comorbidities were more likely to complete MAC for PTSD than patients with no comorbid mental health diagnoses. Other studies of utilization in OEF and OIF veterans with PTSD have found that comorbidities are associated with earlier initiation of mental health treatment (Cohen et al., 2010), as well as a greater likelihood of attending any follow-up mental health treatment and engaging in MAC (Seal et al., 2010). The presence of other psychiatric diagnoses in addition to PTSD may indicate greater clinical need and functional impairment, increasing the likelihood that patients will seek and complete adequate treatment. "
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    ABSTRACT: Female veterans of Operations Enduring and Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) represent a growing segment of Department of Veterans Affairs (VA) health care users. A retrospective analysis used national VA medical records to identify factors associated with female OEF/OIF/OND veterans' completion of minimally adequate care (MAC) for PTSD, defined as the completion of at least nine mental health outpatient visits within a 15-week period or at least twelve consecutive weeks of medication use. The sample included female OEF/OIF/OND veterans with PTSD who initiated VA health care between 2007-2013, and were seen in outpatient mental health (N=2183). Multivariable logistic regression models examined factors associated with completing MAC for PTSD, including PTSD symptom expression (represented by latent class analysis), sociodemographic, military, clinical, and VA access factors. Within one year of initiating mental health care, 48.3% of female veterans completed MAC. Race/ethnicity, age, PTSD symptom class, additional psychiatric diagnoses, and VA primary care use were significantly associated with completion of MAC for PTSD. Results suggest that veterans presenting for PTSD treatment should be comprehensively evaluated to identify factors associated with inadequate completion of care. Treatments that are tailored to PTSD symptom class may help to address potential barriers. Copyright © 2015. Published by Elsevier Ireland Ltd.
    08/2015; 230(1). DOI:10.1016/j.psychres.2015.08.028
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    • "in men and women separately . Analyses were conducted using SAS software ( version 9 . 3 ) . Because of our large sample size , we chose a cut off p - value of o0 . 001 to denote significant differences between the comparisons specified above , and there is precedent for doing so in several of our studies using these data ( Maguen et al . , 2010 ; Cohen et al . , 2010 ) ."
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    ABSTRACT: Veterans who served in Operation Enduring Freedom (OEF; predominantly in Afghanistan) and Operations Iraqi Freedom and New Dawn (OIF and OND; predominantly in Iraq) and are enrolled in the VA are comprised of a growing cohort of women and higher proportions of racial/ethnic minorities than civilians. To compare rates of mental health disorders by race/ethnicity and gender for this diverse cohort, we conducted a retrospective analysis of existing records from OEF/OIF/OND veterans who were seen at the VA 10/7/01-8/1/2013 (N=792,663). We found that race/ethnicity was related to diagnoses of mental health disorders. Asian/Pacific Islanders (A/PIs) were diagnosed with all disorders at lower rates than whites, and American Indian/Alaska Native (AI/AN) males were diagnosed with most disorders at higher rates than white males. Research is needed to identify contributing factors to differential rates of diagnoses based on race/ethnicity and gender. A/PIs and AI/ANs have unique patterns of mental health diagnoses indicating they should be considered separately to present a comprehensive picture of veteran mental health. Published by Elsevier Ireland Ltd.
    08/2015; 229(3):PSYD1401143. DOI:10.1016/j.psychres.2015.08.013
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    • "The societal costs of PTSD extend well beyond the specific symptoms of the disorder. For example, individuals with PTSD receive twice the non-mental health care as individuals without the disorder (Cohen et al., 2010). A recent report by the Congressional Budget Office estimates that the Veteran's Administration (VA) alone spent $2 billion in 2010 to treat veterans with PTSD (Office, 2012). "
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    ABSTRACT: Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can develop after experiencing traumatic events. A genome-wide association study (GWAS) design was used to identify genetic risk factors for PTSD within a multi-racial sample primarily composed of U.S. veterans. Participants were recruited at multiple medical centers, and structured interviews were used to establish diagnoses. Genotypes were generated using three Illumina platforms and imputed with global reference data to create a common set of SNPs. SNPs that increased risk for PTSD were identified with logistic regression, while controlling for gender, trauma severity, and population substructure. Analyses were run separately in non-Hispanic black (NHB; n=949) and non-Hispanic white (NHW; n=759) participants. Meta-analysis was used to combine results from the two subsets. SNPs within several interesting candidate genes were nominally significant. Within the NHB subset, the most significant genes were UNC13C and DSCAM. Within the NHW subset, the most significant genes were TBC1D2, SDC2 and PCDH7. In addition, PRKG1 and DDX60L were identified through meta-analysis. The top genes for the three analyses have been previously implicated in neurologic processes consistent with a role in PTSD. Pathway analysis of the top genes identified alternative splicing as the top GO term in all three analyses (FDR q<3.5×10(-5)). No individual SNPs met genome-wide significance in the analyses. This multi-racial PTSD GWAS identified biologically plausible candidate genes and suggests that post-transcriptional regulation may be important to the pathology of PTSD; however, replication of these findings is needed. Copyright © 2015 Elsevier B.V. All rights reserved.
    Journal of Affective Disorders 03/2015; in press. DOI:10.1016/j.jad.2015.03.049 · 3.38 Impact Factor
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