Female veterans' use of Department of Veterans Affairs health care services

OBJECTIVES: As access of women to mental health services has become increasingly important, empirical research has begun to examine the determinants of mental health care utilization across gender. This article examines the effect of being an extreme minority on utilization of Department of Veterans Affairs (VA) health services by female veterans. METHODS: Data were collected on a representative national sample of veterans in 1992 as part of the National Survey of Veterans. These data included information on sociodemographic variables, military service variables, physical health and disability, and health services utilization. The authors examined whether women who used health services in 1992, and who were eligible for VA care, differed from men on the likelihood of using any VA health services and on the likelihood of use of VA outpatient and inpatient health services. In addition, we compared VA health care utilization among subgroups of veterans with physical and mental disorders, and compared self-reported reasons for choice of health care provider, across gender. RESULTS: Results indicated that female veterans were less likely than male veterans to use VA health services. This difference was explained by lower utilization by women of VA outpatient services, since inpatient admission rates were the same across gender. The lower outpatient utilization was specific to women with self-reported mental disorders. Women with physical conditions did not differ from men with similar conditions in their VA outpatient utilization. Finally, men and women did not differ on their reasons for choosing VA or non-VA care. CONCLUSIONS: The authors conclude that extreme gender minority status appears to affect outpatient utilization rates at the VA among women with mental disorders, perhaps because of the more personal or sensitive nature of the services involved. Further research is needed to understand why certain women may be underutilizing VA outpatient services and on the consequences of minority gender status for health service utilization, more generally.     

Cognitive potentials in children with learning disabilities

This study investigated factors predicting help-seeking from the Department of Veterans' Affairs (DVA) by Vietnam veterans. Data used were from a national Australian survey of Vietnam veterans' health (n = 641) conducted between July 1990 and April 1993. The survey involved current clinical assessments and retrospective questionnaires, supplemented with health and service records retrieved from the DVA and Army personnel files. Measures included the 1989-90 Australian Bureau of Statistics Health Survey questionnaire, and mental health, sociodemographic and operational deployment history questionnaires. For both current and lifetime diagnoses of post-traumatic stress disorder, a third of the veterans with the disorder had never obtained any health care entitlement from the DVA. Other than physical and mental problems, which accounted for the greatest proportion of the help-seeking odds, significant factors predicting help-seeking included factors such as: predeployment personality, combat exposure, the veterans' own attitudes towards their deployment, experiences during deployment, experiences during repatriation and membership of ex-service organisations. These findings on how post-traumatic stress disorder and other health problems relate to help-seeking patterns could help in developing prevention and care programs for stress disorder.     

Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans.

Though the broader literature suggests that women may be more vulnerable to the effects of trauma exposure, most available studies on combat trauma have relied on samples in which women's combat exposure is limited and analyses that do not directly address gender differences in associations between combat exposure and postdeployment mental health. Female service members' increased exposure to combat in Afghanistan and Iraq provides a unique opportunity to evaluate gender differences in different dimensions of combat-related stress and associated consequence for postdeployment mental health. The current study addressed these research questions in a representative sample of female and male U.S. veterans who had returned from deployment to Afghanistan or Iraq within the previous year. As expected, women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). No gender differences were observed in reports of perceived threat in the war zone. Though it was hypothesized that combat-related stressors would demonstrate stronger negative associations with postdeployment mental health for women, only one of 16 stressor × gender interactions achieved statistical significance and an evaluation of the clinical significance of these interactions revealed that effects were trivial. Results suggest that female Operation Enduring Freedom/Operation Iraqi Freedom service members may be as resilient to combat-related stress as men. Future research is needed to evaluate gender differences in the longer-term effects of combat exposure. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The role of physical health functioning, mental health, and sociodemographic factors in determining the intensity of mental health care use among primary care medical patients.

The present study examined sociodemographic and attitudinal predisposing factors (gender, age, marital status, health insurance, household income, attitudes about mental health care), and need/illness variables (depression severity, physical and mental health functional status) as predictors of past-year mental health care use intensity (i.e., visit counts) and use/nonuse. The sample included 283 adult primary care patients from the Midwestern United States in a cross-sectional study. Nonlinear regression models demonstrated that past-year treatment use intensity was significantly associated with both married status and poorer physical health functioning, while the use (vs. nonuse) of treatment was associated with depression severity. A sociodemographic and attitudinal multivariate predictor model only explained 5% of the variance in treatment use intensity, but a need/illness model significantly contributed an additional 23% variance. Poorer physical health functioning was significant in predicting treatment use intensity, while depression severity was significant in predicting the use (vs. nonuse) of treatment. Results demonstrate the particular importance of physical health problems in determining the intensity of mental health care use, and depression severity in determining the use/nonuse of treatment, notwithstanding the restricted sociodemographic contour of the sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of PTSD, depression, and substance use disorders on disease burden and health care utilization among OEF/OIF veterans.

Growing evidence suggests that posttraumatic stress disorder (PTSD) is associated with poorer health status (e.g., more medical disease, physical symptoms, and sick visits to health care professionals) among veterans who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq. We investigated whether PTSD, depression, and substance use disorders independently predicted health status over time among OEF/OIF veterans. Information regarding psychiatric and medical conditions and health care utilization was culled for 4,463 OEF/OIF veterans enrolled in Veterans Administration primary care for a period of 6 years. Data were analyzed using multilevel modeling and generalized estimating equations. Results suggest that PTSD, depression, and substance use disorders are independently associated with increased medical disease burden and mental health care utilization but not increased medical health care utilization. The association between PTSD and medical disease burden strengthened over time. These data suggest that OEF/OIF veterans with PTSD may be at risk for increasingly poorer physical health in terms of medical disease burden over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Australian Vietnam Veterans Health Study: II. self-reported health of veterans compared with the Australian population

BACKGROUND: Self-reported physical health status of Australian Vietnam veterans was determined 20-25 years after the war and its relation to combat was investigated. METHOD: An epidemiological cohort study of a simple random sample of Army veterans posted to Vietnam between 1964 and 1972 was conducted with personal interviews using the Australian Bureau of Statistics Health Interview Survey questionnaire to compare veterans with the Australian population and a 21-item combat exposure index used to measure the relationship of combat to physical health. RESULTS: Veterans reported greater health service usage and more recent health actions than population expectations. They also reported excess health problems in almost all recent illness disease categories except endocrine conditions and cardiovascular conditions; only 6 of 37 chronic disease groups were not elevated compared to the population. Adjustment for non-response changed estimates only slightly. Combat exposure was significantly related to reports of recent and chronic mental disorders, recent hernia and chronic ulcer, recent eczema and chronic rash, deafness, chronic infective and parasitic disease, chronic back disorders and symptoms, signs and ill-defined conditions. CONCLUSION: Combat exposure may have significantly increased reports of only some health problems. A general position to complain as a result of psychological conditions due to combat is not consistent with the lack of relationship between combat and reports of physical conditions.     

Marital distress and mental health care service utilization.

Objective: This study was designed to evaluate the association between marital distress and mental health service utilization in a population-based sample of men and women (N = 1,601). Method: The association between marital distress and mental health care service utilization was evaluated for overall mental health service utilization and for specific sectors of treatment providers, including psychiatrist, other mental health provider, other medical provider, and religious services provider. Interviews were used to assess past-year service utilization and presence of anxiety, mood, and substance use disorders. Results: Approximately 12% of married individuals sought help for problems with their emotions, nerves, or substance use during the 12 months preceding the interview. Marital distress was significantly associated with (a) overall mental health service utilization and service utilization provided by each of the sectors of providers when controlling for demographic variables and (b) overall mental health service utilization and receiving treatment from a psychiatrist when additionally controlling for past-year anxiety, mood, or substance use disorders. There was little evidence that the associations between marital distress and service utilization were moderated by gender or presence of psychiatric disorders. Conclusion: The finding that marital distress is associated with greater mental health care service utilization suggests that clinicians should assess both individual and relationship factors among individuals presenting for treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans

A total of 641 randomly selected Australian veterans of the Vietnam War were interviewed about their use of health care in the previous two weeks to determine what factors contributed to health care consumption. Seventy-three variables were examined by univariate linear regression and then grouped into seven categories relating to age, physical and mental health, predisposition to posttraumatic stress disorder (PTSD), deployment and repatriation experiences, and membership in veterans groups. PTSD was associated with an additional cost of $79 in health care for the two-week period. Each physical diagnosis was associated with an additional $28. Alcohol consumption was not related to health care costs. Other important variables contributing to costs were depression, educational status, the quality of the repatriation experience, and social support.     

Vulnerability and resilience to combat exposure: Can stress have lifelong effects?

Examined whether appraisals of desirable and undesirable effects of military service mediated the effect of combat stress on posttraumatic stress disorder (PTSD) symptoms in later life in 1,287 male veterans (aged 44–91 yrs), 40% of whom had been in combat. The men reported more desirable effects of military service (e.g., mastery, self-esteem, and coping skills) than undesirable ones; both increased linearly with combat exposure. Path analysis revealed that the appraisals were independent and opposite mediators, with undesirable effects increasing and desirable effects decreasing the relationship between combat exposure and PTSD, even controlling for depression and response style. Although lifelong negative consequences of combat exposure were observed, perceiving positive benefits from this stressful experience mitigated the effect. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of help seeking for emotional distress among Chinese Americans: Family matters.

Using data from the Chinese American Psychiatric Epidemiological Study, the authors examined longitudinal predictors of help seeking for emotional distress in a community sample of 1,503 Chinese Americans. Specifically, they assessed the relative contribution of family relational variables (e.g., levels of family support and family conflict) in predicting help seeking for medical, mental health, and informal services. After traditional need, predisposing, and enabling factors were controlled for in hierarchical logistic regression analyses, family conflict predicted both mental health and medical service use, whereas family support was not predictive of help seeking. In addition to family conflict, mental health service use was predicted by negative life events, emotional distress, and insurance coverage. Implications of the findings for assessing and treating Asian American clients are explored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder

OBJECTIVE: A two-part study was conducted to examine the health status of Vietnam veterans with posttraumatic stress disorder (PTSD). In part 1, veterans with and without PTSD were compared on health behaviors and on self-reported and physician-rated health problems. Consistency of self-report with physician rating for health problems across the two groups was compared. In part 2, the association between health status and PTSD symptom severity, depression, somatization, and health behaviors in PTSD patients was evaluated. METHOD: In part 1, 276 combat veterans (225 with PTSD and 51 without PTSD) provided health status information, and medical records were reviewed. In part 2, 225 PTSD patients completed standardized PTSD severity, somatization, and depression measures. RESULTS: When analyses controlled for age, socioeconomic status, minority status, combat exposure, alcohol use, and pack-year history, veterans with PTSD reported and were rated as having a greater number of health problems than veterans without PTSD. Agreement between self-report and physician ratings for both groups ranged from low to moderate. Level of agreement between patient and physician was similar across groups. In the analysis of veterans with PTSD, somatization and PTSD symptom severity were significantly related to self-report of health problems, whereas only PTSD symptom severity was related to physician-rated health. Pack-year history was significantly related to self-reported health status in both groups. CONCLUSIONS: The presence and severity of PTSD in veterans were associated with greater physical health problems and conditions. Psychological variables (e.g., PTSD status, PTSD severity, somatization) and a behavioral variable (pack-year history) were related to health status.     

Improving Mental Health Service Utilization for Children and Adolescents.

Approximately 10% of children and adolescents have mental health problems necessitating intervention, but well below 50% of these children receive needed services, and far fewer receive the quality of care required to effectively reduce their impairments. Although system reform is needed to improve service utilization and quality of care for all children, preschoolers, girls, individuals of minority status, and the uninsured are most at risk for being underserved. Factors contributing to poor service utilization can be classified into two broad sets: sociopolitical factors referring to issues related to funding and access, and cultural/familial factors including beliefs about mental health services, providers, and treatments. This article describes the help-seeking process and focuses on cultural and familial factors that contribute to movement through these stages, with a particular focus on variables that are amenable to change by practitioners in the school and community, including school psychologists. Guidelines for understanding and changing the help-seeking behavior of families, including suggestions for creating service options, providing family education, and offering individualized family services, are described. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: Risk factors, war-zone stressors, and resilience-recovery variables.

Relationships among pretrauma risk factors (e.g., family instability, childhood antisocial behavior), war-zone stressors (e.g., combat, perceived threat), posttrauma resilience-recovery variables (e.g., hardiness, social support), and posttraumatic stress disorder (PTSD) symptom severity were examined. Data from a national sample of 432 female and 1,200 male veterans were analyzed using structural equation modeling. For both genders, direct links to PTSD from pretrauma, war-zone, and posttrauma variable categories were found; several direct associations between pretrauma and posttrauma variables were documented. Although war-zone stressors appeared preeminent for PTSD in men, posttrauma resilience-recovery variables were more salient for women. Researchers, policymakers, and clinicians are urged to take a broad view on trauma and its sequelae, especially regarding possible multiple exposures over time and the depletion and availability of important resources. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress disorder and war-zone exposure as correlates of perceived health in female Vietnam war veterans.

Previous studies have identified traumatic exposure and posttraumatic stress disorder (PTSD) as predictors of physical health complaints without considering the relationship between exposure and PTSD. This study examined the unique associations of war-zone exposure and PTSD with perceived physical health outcomes in a nontreatment-seeking sample of 109 female veterans of the Vietnam War who responded to a series of psychological, exposure, and health questionnaires. Both PTSD and exposure were associated with reports of negative health outcomes when each variable was not adjusted for the other. The effects associated with exposure decreased when PTSD was controlled for, whereas the effects associated with PTSD remained when exposure was controlled for. Results suggest that effects of traumatic exposure on perceived health are partially mediated by increases in PTSD after exposure, supporting studies on the effects of stress on health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological effects of military service in Vietnam: A meta-analysis.

To integrate research on the psychological status of Vietnam veterans, we conducted a meta-analysis of 67 studies appearing in the literature from 1972 through 1985. Mean effect size, representing the comparison between Vietnam veterans and others on a variety of mental health indicators, was a significant –0.53. There was a tendency for larger effect sizes in studies that appeared later, were published by researchers affiliated with the Veterans Administration, documented combat history, but did not incorporate a comparison group. Vietnam veterans were significantly different from both Vietnam-era veterans and nonveterans, with the pattern of differences indicating a "Vietnam effect." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An examination of family adjustment among Operation Desert Storm veterans.

This study examined interrelationships among combat exposure, symptoms of posttraumatic stress disorder (PTSD), and family adjustment in a sample of male and female Operation Desert Storm veterans (N = 1,512). In structural equation models for both male and female veterans, higher combat exposure was associated with higher PTSD symptoms, which in turn were associated with poorer family adjustment, although these indirect effects did not reach statistical significance. The model for female veterans evidenced a significant direct negative association between combat exposure and family adjustment when it statistically accounted for PTSD symptoms. When the relative impacts of separate PTSD symptom groupings were examined, those reflecting withdrawal/numbing symptoms and arousal/lack of control symptoms significantly and indirectly accounted for the negative effects of combat exposure on family adjustment. Study findings indicate a number of possible pathways through which war-zone deployments negatively impact military families and suggest several avenues for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: Findings and clinical implications.

Several clinical studies suggest that individuals with posttraumatic stress disorder (PTSD) experience neuroendocrine system alterations, resulting in significantly lower plasma cortisol. To test this hypothesis, morning serum cortisol was compared among a national sample of Vietnam "theater" veterans (n?=?2,490) and a sample of Vietnam "era" veterans (n?=?1,972) without service in Vietnam. Analysis of covariance was used to compare cortisol concentrations after adjusting for 9 covariates (education, income, race, age, smoking status, alcohol use, illicit drug use, medication use, and body mass index ). Adjusted cortisol was lower among theater veterans with current PTSD but not era or theater veterans with lifetime PTSD. Among theater veterans, cortisol was inversely related to combat exposure, with veterans exposed to heavy combat having the lowest concentrations. Analysis of plasma cortisol, together with other clinical data, may be instrumental in the future diagnosis and treatment of stress disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patterns and predictors of mental health service use and mental illness among older and younger adults in the United States.

The present study examined patterns of serious mental illness (SMI), specific mental health syndromes, and service use among older (65+) and younger (18-64) adults throughout the United States, and the extent to which various factors predict SMI and the use and magnitude of mental health treatment. Despite recent developments designed to improve mental healthcare access and treatment for older adults, older individuals were found to receive outpatient mental healthcare at very low rates. Compared to younger adults, older adults were three times less likely to report receiving treatment. Although prevalence estimates for SMI and specific syndromes were markedly lower among older than younger adults, older individuals most in need of care were highly unlikely to report receiving treatment. Findings point to the importance of perceived need in mental healthcare use. Significantly, however, those older adults that made it into services typically reported benefiting considerably from treatment, at least as much as all other age groups. Several predisposing, enabling, and need factors related to mental illness and service use were identified that have important implications for how we plan for, design, and deliver mental health services to older and younger Americans. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lipid lowering in a multidisciplinary clinic compared with primary physician management

OBJECTIVE: This study analyzed questionnaire items that address complaints about sleep from the National Vietnam Veterans Readjustment Study, a nationally representative sample of the 3.1 million men and women who served in Vietnam. This study compared the frequency of nightmares and difficulties with sleep onset and sleep maintenance in male Vietnam theater veterans with male Vietnam era veteran and male civilian comparison subjects. It focused on the role of combat exposure, nonsleep posttraumatic stress disorder (PTSD) symptoms, comorbid psychiatric and medical disorder, and substance abuse in accounting for different domains of sleep disturbance. METHOD: The authors undertook an archival analysis of the National Vietnam Veterans Readjustment Study database using correlations and linear statistical models. RESULTS: Frequent nightmares were found exclusively in subjects diagnosed with current PTSD at the time of the survey (15.0%). In the sample of veterans who served in Vietnam (N = 1,167), combat exposure was strongly correlated with frequency of nightmares, moderately correlated with sleep onset insomnia, and weakly correlated with disrupted sleep maintenance. A hierarchical multiple regression analysis showed that in Vietnam theater veterans, 57% of the variance in the frequency of nightmares was accounted for by war zone exposure and non-sleep-related PTSD symptoms. Alcohol abuse, chronic medical illnesses, panic disorder, major depression, and mania did not predict the frequency of nightmares after control for nonsleep PTSD symptoms. CONCLUSIONS: Frequent nightmares appear to be virtually specific for PTSD. The nightmare is the domain of sleep disturbance most related to exposure to war zone traumatic stress.