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VISN 1 New England MIRECC Past Health Services Research

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Analysis of the 2010 National Survey of Veterans
Contact: Jack Tsai, Ph.D. (

This study will analyze data from the 2010 National Survey of Veterans to examine predictors of disability, Internet use, and health service use. Data from the 2010 National Survey of Veterans contains information on 8,710 Veterans, their sociodemographic characteristics, Internet use, health status, health service use, and use of other Department of Veterans Affairs (VA) services. Regression analyses will be conducted to examine cross-sectional associations between these variables. The data will be weighted to represent the Veteran population and statistical analytic tests will be conducted. This study provides an opportunity to examine a representative, national survey of Veterans to guide future planning of VA health care services and highlight areas that may improve health care services for Veterans.
Findings: Studies conducted so far have shown that a substantial proportion of Veterans may have more health care options under the Affordable Care Act, that many Veterans use the Internet although few use My HealtheVet, and that high levels of disability compensation may create a disincentive for employment. Additional studies are planned.
Publications: (1) Tsai, J. & Rosenheck, R.A. (2014). Uninsured Veterans who will need to obtain insurance coverage under the Affordable Care Act. American Journal of Public Health, 104(3), e57-e62; (2) Tsai, J. & Rosenheck, R.A. (2013). Examination of Veterans Affairs disability compensation as a disincentive for employment in a population-based sample of Veterans under age 65. Journal of Occupational Rehabilitation, 23(4), 504-512; (3) Tsai, J. & Rosenheck, R.A. (2012). Use of the Internet and an online personal health record system by U.S. Veterans: Comparison of Veterans Affairs mental health service users and other Veterans nationally. Journal of the American Medical Informatics Association, 19(6), 1089-1094; (4) Tsai, J., Doran, K.M., & Rosenheck, R.A. (2013). When health insurance is not a factor: National comparison of homeless and nonhomeless US Veterans who use Veterans Affairs Emergency Departments. American Journal of Public Health, 103(Suppl 2), S225-S231; (5) Tsai, J., & Rosenheck, R. (2014). Uninsured Veterans who will need to obtain insurance coverage under the Affordable Care Act. American Journal of Public Health, 104(3), e57-e62; (6) Tsai, J., Whealin, J., & Pietrzak, R.H. (2014). Asian American and Pacific Islander military Veterans in the United States: Health service use and perceived barriers to mental health services. American Journal of Public Health, 104(Suppl 4), S538–S547; and (7) Tsai, J., Desai, M.U., Cheng, A.W., & Chang, J. (2014). The effects of race and other socioeconomic factors on health service use among American military Veterans. Psychiatric Quarterly, 85(1), 35-47.

Association of Substance Use and VA Service-Connected Disability Benefits with Risk of Homelessness among Veterans
Contact: Ellen L. Edens, M.D. (

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 non-homeless Department of Veterans Affairs (VA) mental health services users to determine risk and protective factors for homelessness. Using VA administrative data, Veterans were identified as homeless (i.e. used VA homeless services or received a diagnostic code for "lack of housing") or non-homeless and compared using logistic regression. Additional analyses were conducted for two low-risk subgroups: Veterans who served in Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) and Veterans with >=50% service-connected disability.
Findings: 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.
Collaborators: Robert A. Rosenheck, M.D. (, Wes Kasprow, Ph.D., MPH (, and Jack Tsai, Ph.D. (
Publications: (1) Edens, E., Kasprow, W., Tsai, J., & Rosenheck, R.A. (2011). Association of substance use and VA service-connected disability benefits with risk of homelessness among Veterans. American Journal on Addictions, 20(5), 412-419; and (2) Edens, E.L., Tsai, J., & Rosenheck, R.A. (2013). Does stimulant use impair housing outcomes in low‐demand supportive housing for chronically homeless adults? The American Journal on Addictions, 23(3), 243-248.

Comparison of Treatment Outcomes Among Chronically Homeless Adults Receiving Comprehensive Housing and Health Care Services vs. Usual Local Care
Contact: Robert Rosenheck, M.D. (

As the VA health care system develops programs to address homelessness, it is important to be aware of the types of services that are needed and can benefit homeless Veterans. In this project, service use and two-year treatment outcomes were compared between chronically homeless clients receiving services from comprehensive housing and health care services provided through the federal Collaborative Initiative on Chronic Homelessness (CICH)(n=281) in five communities (Chattanooga, TN; Los Angeles, CA; Martinez, CA; New York, NY; and Portland, OR) and cohorts from the same communities receiving usual care (n=104).
Findings: The findings suggest that a more comprehensive array of access to mental health and substance abuse treatment services and community-based case management was associated with improved housing outcomes and, to a modest extent, receipt of public assistance income. However, clinical status and community adjustment did not improve among the diverse population of chronically homeless adults.
Publications: (1) Tsai, J., Mares, A., & Rosenheck, R.A. (2010). A multi-site comparison of supported housing for chronically homeless adults: “Housing first” versus “residential treatment first.” Psychological Services, 7(4), 219-232; (2) Tsai, J. & Rosenheck, R.A. (2011). Religiosity among chronically homeless adults: Association with clinical and psychosocial outcomes. Psychiatric Services, 62(10), 1222-1224; (3) Tsai, J., Edens, E., & Rosenheck, R.A. (2011). A typology of childhood problems among chronically homeless adults and its association with housing and clinical outcomes in a supported housing program. Journal of Healthcare for the Poor and Underserved, 22(3), 853-870; (4) Tsai, J., Mares, A.S., & Rosenheck, R.A. (2012). Housing satisfaction among chronically homeless adults: Identification of its major domains, changes over time, and relation to subjective well-being and functional outcomes. Community Mental Health Journal, 48(3), 255-263; (5) Tsai, J. & Rosenheck, R.A. (2012). Smoking among chronically homeless adults: Prevalence and correlates. Psychiatric Services, 63(6), 569-576; (6) Tsai, J., Mares, A.S., & Rosenheck, R.A. (2012). Do homeless Veterans have the same needs and outcomes as non-Veterans? Military Medicine, 177(1), 27-31; and (7) Tsai, J., Mares, A.S., & Rosenheck, R.A. (2012). Does housing chronically homeless adults lead to social reintegration? Psychiatric Services, 63(5), 427-434.

Correlates of Military Sexual Trauma in Homeless Female Veterans
Contact: Rani Hoff, Ph.D., MPH (

This project examined the differences in demographics, clinical status, and outcomes of residential treatment in female Veterans who have experienced military sexual trauma (MST) compared to women who have experienced sexual assault outside of the military.
Findings: Women who experience MST have more severe psychiatric symptoms, lower self-esteem, smaller social networks, and more PTSD symptoms but do not differ on drug or alcohol use. Understanding the risks associated with MST will assist the VA health care system in planning appropriate clinical services for Veterans who have experienced MST.
Collaborator: Robert Rosenheck, M.D. (
Publication: Decker, S. E., Rosenheck, R.A., Tsai, J., Hoff, R., & Harpaz-Rotem, I. (2013). Military sexual assault and homeless women Veterans: Clinical correlates and treatment preferences. Women's Health Issues, 23(6), e373-e380. 

Effect of Heavy Substance Use Upon Housing Outcomes in Chronically Homeless Individuals Participating in a Low-Demand Housing Program
Contact: Ellen L. Edens, M.D. (

Recent clinical and policy trends have favored low-demand housing (provision of housing not contingent on alcohol and drug abstinence) in assisting chronically homeless people. This study compared housing, clinical, and service use outcomes of participants with high levels of substance use at time of housing entry and those who reported no substance use. Participants in the outcome evaluation of the 11-site Collaborative Initiative on Chronic Homelessness (n=756), who were housed within 12 months of program entry and received an assessment at time of housing and at least one follow-up (n=694, 92%), were classified as either high-frequency substance users (>15 days of using alcohol or >15 days of using marijuana or any other illicit drugs in the past 30 days; n=120, 16%) or abstainers (no days of use; n=290, 38%) on entry into supported community housing. An intermediate group reporting from one to 15 days of use (n=284, 38%) was excluded from the analysis. Mixed-model multivariate regression adjusted outcome findings for baseline group differences.
Findings: During a 24-month follow-up, the number of days housed increased dramatically for both groups, with no significant differences. High-frequency substance users maintained higher, though declining, rates of substance use throughout follow-up compared with abstainers. High frequency users continued to have more frequent or more severe psychiatric symptoms than the abstainers. Total health costs declined for both groups over time. Active-use substance users were successfully housed on the basis of a low-demand model. Compared with abstainers, substance users maintained the higher rates of substance use and poorer mental health outcomes that were observed at housing entry but without relative worsening. Some research suggests that not all drugs are equal with regards to effect upon housing outcomes. Therefore, the effect of heavy stimulant use, in particular, was further evaluated in this study of chronically homeless individuals.
Collaborators: Robert A. Rosenheck, M.D. ( and Jack Tsai, Ph.D. (
Publications: (1) Edens, E.L., Mares, A.S., Tsaj, J., & Rosenheck, R.A. (2011). Does active substance use at housing entry impair outcomes in supported housing for chronically homeless persons? Psychiatric Services, 62(2), 171-178; and (2) Edens, E.L., Tsai, J., & Rosenheck, R.A. (2013). Does stimulant use impair housing outcomes in low‐demand supportive housing for chronically homeless adults? The American Journal on Addictions, 23(3), 243-248.

Evaluation of Body Dysmorphic Disorder and its Clinical Correlates in a Veteran Sample
Contact: Megan M. Kelly, Ph.D. (

Body dysmorphic disorder (BDD) is a severe and relatively common mental health disorder characterized by preoccupations with imagined or slight defects in one’s physical appearance. Despite its severity, BDD is often underrecognized by health care providers. The primary objectives of this pilot study were to: (1) examine the prevalence of BDD in a VA medical center mental health setting; and (2) examine the clinical correlates of Veterans with BDD and without BDD. This study involved a retrospective chart review of Veterans in Primary Care Behavioral Health (PCBH) who were assessed for BDD as part of their mental health evaluation in the PCBH. Veterans were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDD-Q) and BDD diagnoses were confirmed with the Structured Clinical Interview for DSM-IV Patient Version (SCID-I/P) Module for BDD. Information about clinical correlates (e.g., age, gender, marital status, ethnicity, suicidality, psychiatric diagnoses) were obstained by a retrospective chart review.
Findings: 12% of Veterans (12/100; 2 women, 10 men) met criteria for a lifetime diagnosis of BDD, and 11% (11/100; 2 women, 9 men) had a current diagnosis of BDD. Only 8.3% (1/12) with a lifetime diagnosis of BDD had the BDD diagnosis documented in the medical record. The top two body areas of concern for Veterans with BDD were skin (33.3%) and body build (25.0%). 91.7% of Veterans with a lifetime diagnosis of BDD reported that BDD was associated with avoidance of activities, 83.3% of Veterans reported that BDD interfered with social activities, and 41.7% reported that BDD interfered with work activities. Veterans with BDD were more likely to be non-caucasian than Veterans without BDD, but there were no other differences in demographic variables. Veterans with BDD were more likely to have a lifetime history of attempted suicide (58.3% vs. 19.3%) and have lifetime diagnoses of major depressive disorder (MDD; 91.7% vs. 39.8%) and obsessive-compulsive disorder (OCD; 16.7% vs. 1.1%) than Veterans without a lifetime diagnosis of BDD. Veterans with and without BDD did not differ on marital status, Global Assessment of Functioning scores, a lifetime history of suicidal ideation, or a lifetime history of psychiatric hospitalizations. These preliminary results indicate that BDD is a prevalent diagnosis in a VA Primary Care Behavioral Health setting. However, it is underdiagnosed. BDD was associated with a higher lifetime risk of suicide attempts, MDD, and OCD. BDD appears to have a major impact on avoidance of activities, particularly work and social activities. These results suggest that there should be increased effort to assess and treat BDD in VA settings. Future research should focus on evaluating BDD in larger Veteran samples and developing methods of increasing awareness, assessment, and treatment of BDD in VA settings.
Publications: (1) Kelly, M.M., & Kent, M. (in press). Associations between body dysmorphic disorder and social anxiety disorder. In K.A. Phillips (Ed.), Oxford handbook of body dysmorphic disorder. New York: Oxford University Press; (2) Kelly, M.M., Zhang, J., & Phillips, K.A. (2015). The prevalence of body dysmorphic disorder in a VA Primary Care Behavioral Health Clinic. Psychiatry Research, 228, 162-165; and (3) Kelly, M.M., Brault, M., & Didie, E. R. (in press). Quality of life in body dysmorphic disorder. In K.A. Phillips (Ed.), Oxford handbook of body dysmorphic disorder. New York: Oxford University Press.

Impact of Current Alcohol and Drug Use on Outcomes Among Homeless Veterans Entering Supported Housing
Contact: Robert Rosenheck, M.D. (

Permanent supported housing has increasingly been identified as a central approach to helping homeless individuals with disabilities exit from homelessness. Given that one-third or more of homeless individuals actively use substances, it is important to determine the extent to which they benefit from such programs. The current study examined data from the evaluation of the U.S. Department of Housing and Urban Development (HUD) and the Department of Veterans Affairs (VA) established HUD-VA Supported Housing (HUD-VASH) program to determine differences in housing and clinical outcomes among Veteran participants with two different levels of active alcohol or drug use at time of housing entry.
Findings: While Veterans with 1-15 days of active use and 15-30 days of active use had significantly more days homeless albeit with small effect sizes (.06 and .19 respectively), there were no significant differences in days housed or days in institutions or other outcomes. Interaction analysis suggests that the highest frequency substance users who spent time in residential treatment prior to housing had the poorest housing outcomes. Higher frequency users who were not in residential treatment had outcomes comparable to abstainers. Although Veterans who actively use substances clearly benefit from supportive housing with small differences in outcomes from Veterans who abstain, Veteran high frequency substance users who were admitted to residential treatment before housing placement may be an especially vulnerable population.
Collaborator: Maria O’Connell, Ph.D.
Publications: (1) O’Connell, M.J., Kasprow, W.J., & Rosenheck, R.A. (2013). The impact of current alcohol and drug use on outcomes among homeless Veterans entering supported housing. Psychological Services, 10(2), 241-249; and (2) O’Connell, M., Kasprow, W., & Rosenheck, R. (2012). Differential impact of supported housing on selected subgroups of homeless Veterans with substance abuse histories. Psychiatric Services, 63(12), 1195-1205.

Implementation and Dissemination of Supported Employment in VA
Contacts: Sandra Resnick, Ph.D. ( and Robert Rosenheck, M.D. (

This implementation and dissemination project was done in phases. First, “mentor” sites at 21 VISNs received training on supported employment (SE) implementation. Then, the goal shifted to successful dissemination to the remaining 145 SE programs across the VA health care system. Efforts focused on teaching mentor sites to provide SE training, technical assistance, and conduct SE fidelity assessments in order for all sites to provide evidence-based supported employment. In other studies, fidelity to the SE model has been related to positive employment outcomes. The project hoped to indirectly improve Veteran outcomes through ongoing staff education, quality assurance procedures, and program evaluation.
Publications: (1) Resnick, S.G. & Rosenheck, R.A. (2007). Dissemination of supported employment in the Department of Veterans Affairs. Journal of Rehabilitation Research and Development, 44(6), 867-878; (2) Resnick, S.G. & Rosenheck, R.A. (2009). Scaling up the dissemination of evidence-based mental health practice to large systems and long-term timeframes. Psychiatric Services, 60, 682-685; and (3) Pogoda, T.K., Cramer, I.E., Rosenheck, R.A., & Resnick, S. (2011). Qualitative analysis of barriers to implementation of supported employment in the Department of Veterans Affairs. Psychiatric Services, 62(11), 1289-1295.

Is the Health Care for Reentry Veterans Program Effective?
Contact: Jack Tsai, Ph.D. (

The purpose of this study was to describe the characteristics and health needs of Veterans served by the Health Care for Reentry Veterans (HCRV) program, including sociodemographics and mental health diagnoses. Program data that was collected on Veterans served by the HCRV program was analyzed. Descriptive statistics were used to describe the characteristics and needs of Veterans served by the HCRV program, their psychosocial functioning, and health status. Multivariate analyses were conducted to examine the association between these variables. This project is complete.
Publications: (1) Tsai, J., Rosenheck, R.A., Kasprow, W.J., & McGuire, J.F. (2014). Homelessness in a national sample of incarcerated Veterans in state and federal prisons. Administration and Policy in Mental Health and Mental Health Services Research, 41(3), 360-367; (2) Tsai, J., Rosenheck, R.A., Kasprow, W.J., & McGuire, J.F. (2013). Risk of incarceration and clinical characteristics of incarcerated Veterans by race/ethnicity. Social Psychiatry and Psychiatric Epidemiology, 48(11), 1777-1786; and (3) Tsai, J., Rosenheck, R.A., Kasprow, W.J., & McGuire, J.F. (2013). Risk and characteristics of incarcerated Veterans in a national sample: Comparison between Veterans who served in Iraq and Afghanistan and other Veterans. Psychiatric Services, 64(1), 36-43.

Multidimensional Correlates of Frequent VA Emergency Department Use
Contact: Robert Rosenheck, M.D. (

There is widespread concern about the impact of frequent emergency department (ED) users on health care expenditures and ED overcrowding. A more comprehensive understanding of frequent ED users is needed to better design and target interventions. The purpose of this study was to identify socio-demographic and clinical factors most strongly associated with frequent ED use within a nationwide VA hospital sample. The study design included cross-sectional analyses of national Veterans Health Administration (VHA) databases including 5,531,379 VHA service users in 2010. The main outcome measure of interest was the number of VHA ED visits made during fiscal year (FY) 2010, categorized into 6 frequency levels.
Findings: In FY 2010, 4,600,667 (83.2%) VHA patients had no ED visit, while 493,391 (8.9%) had one visit, 356,258 (6.4%) had 2-4 visits, 70,741 (1.3%) had 5-10 visits, 9,705 (0.2%) had 11-25 visits, and 617 (0.01%) had greater than 25 visits. As levels of ED use rose, Veteran patients were more likely to: experience homelessness; have alcohol, substance use, and psychiatric diagnoses; have psychotropic and opiate prescriptions; have more serious medical illness; and have more frequent use of outpatient medical and mental health services. In multivariable analyses, factors most consistently and strongly associated with membership in each ED use group compared to those with no ED use were: schizophrenia (Odds Ratio [OR] range 1.44-6.86); homelessness (OR range 1.41-6.60); opiate prescriptions filled (OR range 2.09-5.08); and heart failure (OR range 1.64-3.53).
Conclusions: Frequent ED users have a high prevalence of medical and psychiatric illness, opiate and psychotropic medication use, non-ED service use, and social vulnerability reflected by disproportionate levels of homelessness. A heterogeneous set of Veteran patient traits representing severely compromised life circumstances with high levels of psychosocial dysfunction were the strongest correlates of frequent ED use. The predictors we identified for frequent ED use were consistent across five distinct levels of ED use which challenges the utility of defining a single “cut-point” for frequent use.
Collaborator: Doran Kelley, M.D.
Publications: (1) Doran, K.M., Raven, M.C., & Rosenheck, R.A. (2013). What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Annals of Emergency Medicine, 62(2), 151-159; (2) Tsai, J. & Rosenheck, R.A. (2013). Risk factors for ED use among homeless Veterans. American Journal of Emergency Medicine, 31(5), 855-858; and (3) Tsai, J., Doran, K.M., & Rosenheck, R.A. (2013). When health insurance is not a factor: National comparison of homeless and nonhomeless US Veterans who use Veterans Affairs Emergency Departments. American Journal of Public Health, 103(Suppl 2), S225-S231.

Pathways-to-Care in Vocational Rehabilitation (VR): Enhancing Entry and Retention
Contact: Charles Drebing, Ph.D. (

The purpose of this study was to identify predictors of referral, entry, and dropout of Veterans with serious mental illnesses (SMI) from VA vocational rehabilitation (VR) services and document the means by which these factors influence referral and participation. The results provide needed information for designing interventions to improve treatment entry by adults with both mental health and vocational problems. This multi-site study combined two common ‘pathways-to-care’ methodologies, the first focused on eligible treatment candidates who do not progress to treatment entry, and the second focused on those who do enter treatment, about half of whom fail to complete or continue in treatment. Part I of the study consisted of structured interviews that used an adapted version of the Pathways-To-Care Inventory to gain data from two subsamples: (1) adults identified as having serious mental illnesses (SMI) and were unemployed, but who had not been referred for VR services; and (2) adults identified within their VA medical record as having SMI, unemployment, and who had been referred to VA VR services between 3 and 12 months prior to the interview, but who have not entered VA VR services. In Part 2 of the study, a cohort of Veterans entering VA VR services were interviewed using the Pathways-To-Care Inventory to identify the process by which they reached entry and the barriers and supports to entry. 
Findings: Health service decision-making and utilization data were collected from 155 Veterans receiving some form of VA mental health care, and who had a “vocational problem” but were not currently enrolled in VR. Of the participants, 146 (94.2%) had recognized their vocational problem prior to the baseline evaluation, 125 (80.6%) reported that they or someone else had taken help-seeking steps to try and alleviate the problem, and 120 (77.4%) had entered some form of treatment for their vocational problem at some point prior to the evaluation. The mean length of participants’ vocational problem was more than seven years, and the mean length of time until treatment had first been entered was more than four years. The largest portion of the total delay to treatment entry was associated with the failure to recognize the problem (1.8 years). Filtering factors associated with a quicker recognition or higher likelihood of help-seeking and treatment entry include diagnosis, level of disability, type of vocational problem, and support from primary providers, family, and friends. 
Publications: (1) Drebing, C.E., Mueller, L., Van Ormer, E.A., Duffy, P., LePage, J., Rosenheck, R., Drake, R., Rose, G.S., King, K. & Penk, W. (2012). Pathways to vocational services: Factors affecting entry by Veterans enrolled in Veterans Health Administration mental health services. Psychological Services, 9(1), 49-63; (2) O’Connor, M., Mueller, L., Van Ormer, E.A., Drake, R.E., Penk, W.E., Rosenheck, R., Semiatin, A., & Drebing, C.E. (2011). Cognitive impairment as a barrier to engagement in vocational services among Veterans with severe mental illness. Journal of Rehabilitation Research & Development, 48(5), 597-608; (3) Drebing, C.E., Drake, R., Mueller, L., Van Ormer, E.A., Duffy, P., Rose, G.S., King, K., Desai, N., Penk, W., LePage, J., & Rosenheck, R. (2011). Help-seeking and entry into vocational services by adults enrolled in New Hampshire state mental health services: A pathways-to-care study. American Journal of Psychiatric Rehabilitation, 14(3), 181-197; and (4) Drebing, C.E., Mueller, L., Van Ormer, E.A., Duffy, P., LePage, J., Rosenheck, R., Drake, R., Rose, G.S., King, K. & Penk, W. (2012). Pathways to vocational services: Factors affecting entry by Veterans enrolled in VHA mental health services. Psychological Services, 9(1), 49-63.

Reasons for the Increase in Vietnam Era Veterans Diagnosed with PTSD
Contacts: Eric Hermes, M.D. ( or Robert Rosenheck, M.D. (

Reasons for the continued growth in the number of Vietnam era Veterans with post-traumatic stress disorder (PTSD) were examined.
Findings: The increase in Vietnam era Veterans with PTSD may be partially explained by a readiness of staff to diagnose PTSD among previous VHA users and the receipt of service connection.
Publication: Hermes, E.D., Hoff, R., & Rosenheck, R.A. (2014). Sources of the increasing number of Vietnam era Veterans with a diagnosis of PTSD using VHA services. Psychiatric Services, 65(6), 830-832.

Use of VA Services for PTSD by Veterans of the Current Middle East War
Contact: Robert Rosenheck, M.D. (

This study evaluated Veterans Health Administration (VHA) specialty mental health care workload for treating post-traumatic stress disorder (PTSD) and other mental disorders between 2005-2010 in comparison with results from 1997-2005. The 2005-2010 time frame represents a period of increased utilization of services by recently returning Veterans and of program expansion within VHA. VHA administrative databases were queried for all Veterans receiving specialty mental health treatment annually between 2005-2010. Veterans were categorized by military service era (World War II or Korea; Vietnam; post-Vietnam; Persian Gulf War [including operations in Iraq and Afghanistan]; and peacetime or other), diagnosis (PTSD or a non-PTSD mental disorder), and deployment to Iraq or Afghanistan. To the extent that workloads have increased, this project determined how accommodations were made for new cohorts of Veterans from Iraq and Afghanistan. Secondary objectives were to compare characteristics and service needs of Veterans of Iraq and Afghanistan to those of Gulf War I and Vietnam Veterans and to determine whether there have been changing mental health needs over the course of the GWOT.                                                                                                                           
Findings: Treating post-traumatic stress disorder (PTSD) among returning Iraq/Afghanistan Veterans is a high priority for the U.S. Department of Veterans Affairs (VA). The number of Persian Gulf-era Veterans diagnosed with PTSD grew by 8,000 Veterans per year from 2003-2005. Since 1997, however, the average annual growth in all users of VA specialty mental health services has averaged 37,000 Veterans per year, including 22,000 per year with PTSD. This expansion was associated with a 37% reduction in mental health visits per Veteran per year. The VA health care system has substantially increased funding for PTSD services. Nevertheless, the observed growth in demand requires continued monitoring to assure that the needs of returning Veterans are met.
Collaborator: Eric Hermes, M.D., MPH (
Publication: Hermes, E., Rosenheck, R.A., Desai, R., & Fontana, A. (2012). Recent trends in the treatment of post-traumatic stress disorder and other mental disorders in the VHA. Psychiatric Services, 63(5), 471-476.

Veterans’ Perceptions of Delayed Onset and Delayed Awareness of Post-Traumatic Stress Disorder
Contact: Robert Rosenheck, M.D. (

Recent studies have found that although 30 years have passed since the end of the war, demand for VA treatment services for post-traumatic stress disorder (PTSD) among Vietnam Veterans has increased steadily in the past decade. It is unclear to what extent this represents delayed help-seeking, delayed onset of illness, or delayed awareness of illness. Using data from two intensive studies of outpatient and inpatient Vietnam Veterans from the early 1990s, we examined Vietnam Veterans’ retrospective perceptions of the prevalence of delay in onset of PTSD symptoms and delay in the awareness of the connection between PTSD symptoms and war zone stress.
Findings: Delay of onset of symptoms was reported frequently in the studies’ samples: by 50% of outpatients and 35% of inpatients, with 90-95% of cases of delay occurring within 5-6 years after returning from the war zone. Delay of awareness of the connection of PTSD symptoms to war stress was even more prevalent and protracted: reported by 60% of outpatients and 65% of inpatients, with 90% of cases occurring within 17-20 years. Reported delays in onset were associated with more numerous negative life events occurring after military service but before the onset of PTSD symptoms. Reported delays of awareness were associated with both more numerous and more concentrated negative life events occurring after military service and before the onset of awareness.
Collaborators: Eric Hermes, M.D., MPH ( and Alan Fontana, Ph.D.
Publication: Hermes, E., Rosenheck, R.A., Desai, R., & Fontana, A. (2012). Recent trends in the treatment of post-traumatic stress disorder and other mental disorders in the VHA. Psychiatric Services, 63(5), 471-476.

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Mehmet Sofuoglu, M.D., Ph.D.

Patricia Sweeney, Psy.D., CPRP
Director for Education

Richard Carson, LCSW
Administrative Officer
203-932-5711 Ext. 4338

Ilan Harpaz-Rotem, Ph.D.
Co-Director for MIRECC Fellowship Program
203-932-5711 Ext. 2599

Suzanne Decker, Ph.D.
Co-Director for MIRECC Fellowship Program
203-932-5711 Ext. 7425