Association of Substance Use and VA Service-Connected Disability Benefits with Risk of Homelessness among Veterans
VA New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Avenue, West Haven, CT 06516, USA. American Journal on Addictions
(Impact Factor: 1.74).
09/2011; 20(5):412-9. DOI: 10.1111/j.1521-0391.2011.00166.x
Recent public attention on homelessness has shifted beyond emergency services and supportive housing to primary prevention. This study compares a national sample of homeless and nonhomeless Veterans Affairs (VA) mental health services users to determine risk and protective factors for homelessness. Using VA administrative data, veterans were identified as homeless (ie, used VA homeless services or received a diagnostic code for "lack of housing") or nonhomeless and compared using logistic regression. Additional analyses were conducted for two low-risk subgroups: veterans who served in current Middle East wars (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) and veterans with ≥50% service-connected disability. Among all VA mental health users, OEF/OIF (odds ratio [OR]) = 0.4) and ≥50% service-connected (OR = .3) veterans were less likely to be homeless. In the overall and subgroup analyses, illicit drug use (OR = 3.3-4.7) was by far the strongest predictor of homelessness, followed by pathological gambling (PG) (OR = 2.0-2.4), alcohol use disorder (OR = 1.8-2.0), and having a personality disorder (OR = 1.6-2.2). In both low-risk groups, severe mental illness (schizophrenia or bipolar disorder), along with substance use disorders, PG, and personality disorders, increased homelessness risk. Substance use, PG, and personality disorders confer the greatest modifiable risk of homelessness among veterans using VA services, while service-connected disability conferred reduced risk. Clinical prevention efforts could focus on these factors.
Available from: Heather Wardle
- "The first study analysed administrative data of US veterans and, after controlling for other confounding factors, found that problem gambling status was the second most important predictor of homelessness among this group (Edens et al, 2011). The second study analysed data from a longitudinal survey of adolescents who had self-reported experience of homelessness. "
Available from: Richard K Simons
- "In addition, there has been a lack of literature evaluating the clinical utility of routine screening for identifying ongoing life stressors that may impact mental health. This is a significant limitation because persons with mental health illnesses often do not receive treatment,  are less likely to see health care specialists  and experience emotional disabilities often in parallel with substantial physical, social, and economic disadvantages [14,15]. "
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Screening for acute stress is not part of routine trauma care owing in part to high variability of acute stress symptoms in identifying later onset of posttraumatic stress disorder (PTSD). The objective of this pilot study was to assess the sensitivity, specificity, and power to predict onset of PTSD symptoms at 1 and 4 months using a routine screening program in comparison to current ad hoc referral practice.
Prospective cross-sectional observational study of a sample of hospitalized trauma patients over a four-month period from a level-I hospital in Canada. Baseline assessments of acute stress (ASD) and subsyndromal ASD (SASD) were measured using the Stanford Acute Stress Reaction Questionnaire (SASRQ). In-hospital psychiatric consultations were identified from patient discharge summaries. PTSD symptoms were measured using the PTSD Checklist-Specific (PCL-S). Post-discharge health status and health services utilization surveys were also collected.
Routine screening using the ASD (0.43) and SASD (0.64) diagnoses were more sensitive to PTSD symptoms at one month in comparison to ad hoc referral (0.14) and also at four months (0.17, 0.33 versus 0.17). Ad hoc referral had greater positive predictive power in identifying PTSD caseness at 1 month (0.50) in comparison to the ASD (0.46) and SASD (0.43) diagnoses and also at 4 months (0.67 versus 0.25 and 0.29).
Ad hoc psychiatric referral process for acute stress is a more conservative approach than employing routine screening for identifying persons who are at risk of psychological morbidity following injury. Despite known limitations of available measures, routine patient screening would increase identification of trauma survivors at risk of mental health sequelae and better position trauma centers to respond to the circumstances that affect mental health during recovery.
Available from: Ellen Edens
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ABSTRACT: The rate and correlates of diagnosed pathological gambling (PG) among mental health patients in the Veterans Health Administration, the only national system of mental health care, have not been studied. Using fiscal year 2009 (FY2009) VA administrative data, a case-control study compared those with an ICD code of 312.31 (PG) versus those without. The analytic group was limited to 1,102,846 Veterans Affairs (VA) specialty mental health (MH) services users because 94.5% of all those diagnosed with PG in the U.S. VA health system received such services. Chi-square tests and logistic regression assessed associations between demographic and clinical factors and PG diagnosis. The past-year rate of PG diagnosis among veterans treated in specialty MH program was 0.2%, significantly lower than prevalence rates in other treatment samples and the general U.S population, suggesting under-diagnosis and/or a low-income sample. Being female, ages 40-74, and higher income increased the risk of PG diagnosis, as did past-year homelessness (Odds Ratio (OR) = 2.2), alcohol use disorders (OR = 2.8), bipolar disorder (OR = 2.1) and personality disorders (OR = 2.1). Depression, schizophrenia, and anxiety disorders other than PTSD, were also positively associated with PG diagnosis. Drug use disorder had no significant independent association with PG. PTSD, dementia, and living in isolated rural areas conferred reduced risk. More systematic screening and surveillance of PG among MH service users generally, and veterans with heavy alcohol use, severe mental illness, and homelessness specifically, appears warranted.
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