Criminogenic Needs and Legal Problem Severity Among Legal System Involved Veterans

BACKGROUND

Many veterans seeking behavioral health services have history of criminal-legal involvement. Research on criminogenic needs of legal system involved veterans is burgeoning. However, most research has relied on cross-sectional examinations and the vast majority of prior work has focused assessment on just one criminogenic need per study.

METHODS

The present study evaluated seven key criminogenic needs of legal system involved veterans (N = 341) enrolled in one of three U.S. Veterans Health Administration residential behavioral health treatment programs. Criminogenic needs and legal problem severity were assessed at baseline, and at 6 months and 12 months post-baseline. Directionality of associations between participants' criminogenic needs and legal problem severity was examined using latent change score models.

RESULTS

Results revealed having more antisocial associates at a previous timepoint was associated with greater subsequent improvements in legal problem severity ($\beta $=-0.01, P < 0.02) and greater improvements in legal problem severity predicted greater subsequent improvements in alcohol problem severity ($\beta $=0.13, P < 0.01).

CONCLUSIONS

In one of the most comprehensive single-study assessments of criminogenic needs among a sample of legal system involved veterans, results highlight links between antisocial associates and alcohol problem severity with legal problem severity.

Juvenile Violent Victimization and Adult Criminal Outcomes: The Role of Military Service as a Turning Point in Young Adulthood

Previous research has consistently shown that juvenile violent victimization is associated with an increased risk of future criminal involvement, a phenomenon commonly known as victim-offender overlap. Despite a growing interest in the factors underlying this overlap, potential roles of major life transitions and turning points that may interrupt and reshape the nature of this developmental association have garnered less academic attention. Analyzing nationally representative data from waves I, IV, and V of the National Longitudinal Study of Adolescent to Adult Health (Add Health; n = 10,205), this study investigates the association between juvenile violent victimization and adult criminal outcomes (i.e., violent offending, non-violent offending, arrest, and incarceration) and whether this association is moderated by military service with and without combat experience in young adulthood. Employing a series of logistic regression analyses and adjusting for a host of covariates, measures of selection, and criminogenic traits, we found that juvenile violent victimization was significantly associated with greater odds of violent offending, arrest, and incarceration in adulthood. Among individuals with violent victimization histories, military service with no combat experience was associated with a 16% decrease in the odds of incarceration in adulthood. Combat experience, however, was associated with over seven times greater odds of violent offending in adulthood for these individuals. These findings have important implications for theory, research, and practice, and highlight the relevance of life transitions and turning points in general, and military service in particular, in mitigating or perpetuating the criminogenic impacts of violent victimization in the life course.

Patterns of Psychiatric Medication Prescriptions for Veterans in Treatment Courts and Other Specialty Courts

Psychiatric medications can serve as important tools for addressing behavioral health issues among criminal justice-involved (CJI) veterans. This study used national data on 12,790 CJI veterans in the U.S. Department of Veterans Affairs (VA) Veterans Justice Outreach program from 2019 to 2020 to compare patterns of psychiatric medication prescriptions among veterans who entered a veterans treatment court (n = 6975), another specialty court (SC; n = 414), or no-SC (n = 5401). Different classes of medications were examined, including antidepressants, stimulants, antipsychotics, benzodiazepines, and medications for substance use disorders. The results showed that 60.2% of the total sample was prescribed a psychiatric medication within 1 year of entering the Veterans Justice Outreach program. There was no significant difference in overall psychiatric prescribing among veterans treatment court, other SC, and no-SC groups, but there were a few differences in certain classes of psychiatric medications. Moreover, about 7.8% of veterans who were in the no-SC group and were prescribed psychiatric medications did not have a psychiatric diagnosis. Veterans who were younger, non-Hispanic white, married, with a VA service-connected disability rating, had a diagnosis of mental and/or substance use disorder, and used more VA health care services were more likely to have been prescribed psychiatric medication. Together, these findings illustrate the essential role of psychiatric medications in courts and programs that serve CJI veterans, as well as the important link between VA service engagement and psychiatric prescriptions.

A Research Agenda for Criminal Justice Involvement Among U.S. Veterans

INTRODUCTION

A substantial proportion of adults in the U.S. criminal justice system are military veterans. Justice-involved veterans are of particular public concern given their service to the country and the high rates of health and social problems in the general veteran population. This article describes the development of a national research agenda for justice-involved veterans.

MATERIALS AND METHODS

In the summer of 2022, the VA National Center on Homelessness among Veterans in partnership with the VA Veterans Justice Programs Office convened a national group of subject matter experts and stakeholders across three listening sessions that included 40-63 attendees per session. These sessions were recorded, and transcriptions of all sessions and chats were synthesized to generate a preliminary list of 41 agenda items. The Delphi method involving two rounds of ratings from subject matter experts was used to develop consensus.

RESULTS

The final research agenda consists of 22 items covering five domains: Epidemiology and knowledge of the population, treatment and services, systems and systems interface, methodology and research resources, and policies.

CONCLUSIONS

The intent of sharing this research agenda is to spur stakeholders to conduct, collaborate, and support further study in these areas.

Exploring Reasons for Non-Engagement From a Peer-Led Diversionary Intervention for Veterans in Police Custody

UK veterans with complex needs arrested in police custody can access support through pre-charge diversion into treatment and ancillary services. We consider why veterans in police custody disengaged from a peer-led criminal justice diversionary support service in one UK region that adopted a continuous case management approach. Seven hundred and fifty-seven veterans were assessed to have high levels of comorbid health needs and socio-economic harms, with one-quarter (26.7%, n = 202) subsequently disengaging from the service. A logistic regression model using Multivariate Imputation by Chained Equations identified that veterans of a younger age, no-fixed-abode, a history of incarceration, and those from a Royal Navy background were likelier to disengage from the intervention. We conclude that this peer-based diversionary model has some efficacy in maintaining the engagement of a highly complex, comorbid segment of criminally-justice-exposed UK military veterans. The perceived benefits of an integrated peer-based model predicated on continuous case-management techniques are discussed.

Common mental disorders and associated factors among Ethiopian prisoners: a systematic review and meta-analysis

Background

Common mental disorders are a major public health concern in the world and negatively influence people's psychological, physical, economic, and overall well-being. Since prisoners live with restricted freedom and lack regular social interaction like communication with family and friends, the prevalence of common mental disorders is frequently found to be higher among prisoners compared to the general population. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of common mental disorders and their associated factors among prisoners in Ethiopia.

Methods

The primary published studies were searched by using different databases like PubMed, Google Scholar, CINHAL, and African Journal Online. A total of eight primary articles that assessed the prevalence and associated factors of common mental disorders among Ethiopian prisoners were included in this systematic review and meta-analysis. The data were extracted using the data extraction format in a Microsoft Excel spreadsheet and exported to Stata version 14 for further analysis. The statistical heterogeneity was assessed by the I² test. Due to the presence of heterogeneity among included studies, a random effect meta-analysis model was employed. Egger's weighted regression test and funnel plots were used to check the presence of publication bias.

Results

A total of 8 primary studies with 3,585 study participants were included in this systematic review and meta-analysis. The pooled prevalence of common mental disorders among Ethiopian prisoners was 62.29% with a 95% CI (50.94, 73.65). The subgroup analysis based on regional state revealed that the pooled prevalence of common mental disorders in Amhara, Oromia, and the other two regions (Addis Ababa and SNNPR) was 72.4, 50.23, and 54.25%, respectively. History of mental illness (AOR = 6.21, 95% CI: 3.27, 11.80), poor social support (AOR = 3.90, 95% CI: 1.45, 10.51), and traumatic life events (AOR = 3.63, 95% CI: 1.04, 12.73) were significantly associated with a common mental disorder in this review.

Conclusion

In this systematic review and meta-analysis, the pooled prevalence of common mental disorders among prisoners was high. Therefore, improving the delivery of mental health services in correctional institutions has a major contribution to the reduction of the disorder, and incarcerated people require more attention and early intervention for common mental disorders.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans

BACKGROUND

Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes.

OBJECTIVES

To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older.

RESEARCH DESIGN

Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions.

SUBJECTS

Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447).

METHODS

Mental illness, SUD, medical multimorbidity.

RESULTS

An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49).

CONCLUSIONS

Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

Military sexual trauma among Veterans using and not using VA justice-related programing: A national examination

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial.

Personality Disorder Diagnosis Among Justice-Involved Veterans: An Investigation of VA Using Veterans

ABSTRACT

Justice-involved veterans are more likely to experience myriad mental health sequelae. Nonetheless, examination of personality psychopathology among justice-involved veterans remains limited, with studies focused on males within correctional settings. We examined Department of Veterans Affairs (VA) electronic medical records for 1,534,108 (12.28% justice-involved) male and 127,230 (8.79% justice-involved) female veterans. Male and female veterans accessing VA justice-related services were both approximately three times more likely to have a personality disorder diagnosis relative to those with no history of using justice-related services. This effect persisted after accounting for VA use (both overall and mental health), age, race, and ethnicity. Augmenting and tailoring VA justice-related services to facilitate access to evidence-based psychotherapy for personality psychopathology may promote optimal recovery and rehabilitation among these veterans.

Suicide risk among veterans using VHA justice-involved services: a latent class analysis

BACKGROUND

Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited.

METHODS

We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018.

RESULTS

A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide.

CONCLUSIONS

Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.

Evaluation of the Strength at Home Group Intervention for Intimate Partner Violence in the Veterans Affairs Health System

Importance

Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH's effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined.

Objective

To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system.

Design, Setting, and Participants

This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion.

Intervention

Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships.

Main Outcomes and Measures

Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test.

Results

The study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, -0.17 [95% CI, -0.21 to -0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, -0.23 [95% CI, -0.27 to -0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, -0.18 [95% CI, -0.22 to -0.14), PTSD symptoms (mean change, -4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24).

Conclusions and Relevance

In this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

Common Mental Disorder and Its Associated Factors among Prisoners in North Wollo Zone Correctional Institutions, Northeastern Ethiopia

Background

Globally, about 450 million people suffer from mental disorders of which about 11% are assumed to be prisoners. The presence of mental illness among prisoners contributes to an increase in the risk of suicide, violence, morbidity, and mortality. In Ethiopia, there is a paucity of data particularly from resource-limited areas to assist policy maker's efforts in reforming mental health care.

Objective

This study is aimed at assessing common mental disorders and its associated factors among prisoners in North Wollo zone correctional institutions, Northeastern Ethiopia.

Method

Institution-based cross-sectional study was conducted on 401 study participants from January-February 2021. A simple random sampling technique was employed to enroll the study participants. Structured interviewer-administered Self Reporting Questionnaires-20 (SRQ-20) developed by the World Health Organization was used to collect the data. Data were checked for completeness, coded and entered into Epi data version 4.2, and transferred to SPSS version 23.0 for final analysis. Binary logistic regression analysis was carried out to identify factors associated with common mental disorders. Statistical significance was declared at p values < 0.05 in the final model.

Results

The prevalence of common mental disorders was found to be 63.6% (95% CI 58.9, 68.3). After adjusting for confounding factors using multiple logistic regression, having children (AOR = 3.7, 95% CI: 1.93, 7.36), poor social support (AOR = 6.6, 95% CI: 2.93, 14.93), history of mental illness (AOR = 6.5, 95% CI: 1.78, 24.3), one- to five-year prison stay (AOR = 2.6, 95% CI: 1.38, 5.04), greater than five-year prison stay (AOR = 5.7, 95% CI: 2.05, 16.27), experiencing one stressful life event (AOR = 5.2, 95% CI: 1.83, 15.01), experiencing two or more stressful life events (AOR = 7.3, 95% CI: 2.98, 17.9), unavailability of reading materials (AOR = 4.3, 95% CI: 1.63, 11.43), and greater than or equal to eleven years of sentences (AOR = 4.4, 95 CI: 1.82, 10.70) were factors significantly associated with common mental disorders.

Conclusion

Common mental disorders are highly prevalent among prisoners in this study area. The result of this study suggests the importance of screening and providing psychiatric counseling to this highly vulnerable population.

Correlates of Incarceration History Among Military Veterans

Veterans with histories of incarceration are at greater risk for poor physical and mental health outcomes, yet prior research in this population has focused on specific subsets of veterans or a narrow range of predictors. We utilized the Bronfenbrenner Socioecological Model as the framework to evaluate correlates of incarceration history in a large sample of Iraq and Afghanistan-era veterans at four levels: demographic, historical, clinical, and contextual. Participants were 2,904 veterans (76.9% male; 49.5% White and 46.5% Black; mean age 38.08, SD = 10.33), 700 of whom reported a history of incarceration. Four logistic regression models predicting history of incarceration were tested, adding demographic, historical, clinical, and contextual variables hierarchically. In the final model, younger age (OR=0.99, 95% CI=0.98-1.00), male gender (OR of being female =0.28, 95% CI=0.21-0.38), belonging to a historically marginalized group (OR of being White =0.69, 95% CI=0.56-0.84), family history of incarceration (OR=1.47, 95% CI=1.10-1.94), adult interpersonal trauma (OR=1.39, 95% CI=1.28-1.51), problematic alcohol use (OR=1.03, 95% CI=1.02-1.05), drug abuse (OR=1.15, 95% CI=1.11-1.19), and unemployment (OR for being employed=0.76, 95% CI=0.62-0.92) were significantly associated with a history of incarceration. Implications of these findings for developing interventions and supporting systems to effectively target this high-risk population of veterans are discussed.

A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality

BACKGROUND

Homeless Veterans are at substantially elevated risk for suicide mortality; however, understanding of drivers of suicide in this population remains limited.

METHOD

Building upon prior work, we conducted a retrospective chart review, comprised of a latent class analysis of 724,752 Veterans with use of Veterans Health Administration (VHA) homeless services 2005-2018.

RESULTS

A five-model class membership solution was identified. Among these classes, risk for suicide mortality was greatest among Veterans with the highest psychiatric burden and high VHA service use. Those experiencing moderate psychiatric burden or primarily experiencing substance use disorders also experienced elevated risk for suicide mortality relative to those with low burden and service use.

LIMITATIONS

Models were specific to Veterans accessing VHA homeless services and may not generalize to those not using such services outside VHA care.

CONCLUSIONS

Continued research and programing remain necessary to determine how to address mental health conditions and engage homeless Veterans in services to facilitate suicide prevention.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09-7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2-3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

Implementation Potential of Moral Reconation Therapy for Criminal Recidivism in Mental Health Residential Programs

OBJECTIVE

Criminal recidivism is common among patients in mental health residential treatment programs. Moral reconation therapy (MRT) has empirical support for reducing criminal recidivism by modifying antisocial cognitions and behaviors; however, its implementation potential in noncorrectional settings has been rarely studied. This potential was examined in a three-site effectiveness-implementation trial of MRT for justice-involved veterans receiving residential mental health treatment in the U.S. Veterans Health Administration.

METHODS

Semistructured interviews were conducted with 36 veterans who received MRT and 13 residential program staff who were involved in its implementation during the trial. Interviews were guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and a focus on patient engagement and context. Content analysis was used to identify facilitators of and barriers to MRT implementation in residential mental health treatment.

RESULTS

Participants viewed MRT as unique and complementary to usual residential care, with benefits beyond recidivism reduction. However, time intensity of the MRT curriculum, challenges in adapting its content and format, and long-term costs of maintaining MRT were viewed as barriers to implementation. To facilitate implementation, participants suggested streamlining the MRT curriculum, adding motivational components, and establishing partnerships in- and outside the health care system.

CONCLUSIONS

The findings suggest strategies and modifications to MRT, which, if shown to be effective, may facilitate its wider implementation in mental health residential treatment programs.

Drivers of County Engagement in Criminal Justice-Behavioral Health Initiatives

Several large, county-level initiatives are underway to improve behavioral health care for justice-involved clients. Unfortunately, only about a quarter of counties participate in these efforts, leaving justice-involved populations at risk of poor mental health, substance use, and judicial outcomes. This study examined characteristics of 2,922 U.S. counties and county equivalents by whether they participated in these initiatives and found that crime and socioeconomic characteristics were not associated with participation. Participating counties had significantly more robust mental health and substance use care delivery systems. Nonparticipating counties may lack the expertise and basic delivery system prerequisites needed for participation in most national initiatives, further driving geographic disparities.

Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans

Both homelessness and criminal justice involvement can impact mental health symptoms and increase risk for suicide. Despite this, few studies have examined their cumulative impact. Moreover, no studies to date have examined the impact of these social determinants of health on post-9/11 veterans, a population with high rates of housing insecurity and justice involvement. The current study sought to better understand the adverse impacts of homelessness and justice involvement on mental health symptoms and suicide risk among post-9/11 veterans. We carried this out by conducting a secondary analysis of cross-sectional data from a 2018 national survey of men and women post-9/11 veteran users and non-users of Veterans Health Administration (VHA) services (N = 15,067). Gender-stratified Poisson and multivariate regressions examined mental health symptoms and suicide risk based on history of homelessness and justice involvement. Models adjusted for sociodemographics, military-related variables, and trauma exposure. Homelessness and justice involvement were both independently associated with more severe posttraumatic, depressive, and substance use symptoms as well as increased rates of suicidal ideation and attempt relative to those with no history of homelessness or justice involvement. Veterans with a history of both homelessness and justice involvement reported the most severe mental health symptoms and suicide risk. This study found consistent positive associations with mental health symptoms for homelessness and justice-involved veterans. Enhancing and increasing access to services that address complex mental health presentation among those with histories of justice involvement and housing instability remain necessary.

Recidivism Treatment for Justice-Involved Veterans: Evaluating Adoption and Sustainment of Moral Reconation Therapy in the US Veterans Health Administration

Moral Reconation Therapy (MRT), an evidence-based intervention to reduce risk for criminal recidivism among justice-involved adults, was developed and primarily tested in correctional settings. Therefore, a better understanding of the implementation potential of MRT within non-correctional settings is needed. To address this gap in the literature, we evaluated the adoption and sustainment of MRT in the US Veterans Health Administration (VHA) following a national training initiative in fiscal years 2016 and 2017. In February 2019, surveys with 66 of the 78 VHA facilities that participated in the training were used to estimate the prevalence of MRT adoption and sustainment, and qualitative interviews with key informants from 20 facilities were used to identify factors associated with sustainment of MRT groups. Of the 66 facilities surveyed, the majority reported adopting (n = 52; 79%) and sustaining their MRT group until the time of the survey (n = 38; 58%). MRT sustainment was facilitated by strong intra-facility (e.g., between veterans justice and behavioral health services) and inter-agency collaborations (e.g., between VHA and criminal justice system stakeholders), which provided a reliable referral source to MRT groups, external incentives for patient engagement, and sufficient staffing to maintain groups. Additional facilitators of MRT sustainment were adaptations to the content and delivery of MRT for patients and screening of referrals to the groups. The findings provide guidance to clinics and healthcare systems that are seeking to implement MRT with justice-involved patient populations, and inform development of implementation strategies to be formally tested in future trials.

Substance Use Relapse Among Veterans at Termination of Treatment for Substance Use Disorders

INTRODUCTION

Military veterans continue to struggle with addiction even after receiving treatment for substance use disorders (SUDs). Identifying factors that may influence SUD relapse upon receiving treatment in veteran populations is crucial for intervention and prevention efforts. The purpose of this study was to examine risk factors that contribute to SUD relapse upon treatment completion in a sample of U.S. veterans using logistic regression and classification tree analysis.

MATERIALS AND METHODS

Data from the 2017 Treatment Episode Data Set-Discharge (TEDS-D) included 40,909 veteran episode observations. Descriptive statistics and multivariable logistic regression analysis were conducted to determine factors associated with SUD relapse after treatment discharge. Classification trees were constructed to identify high-risk subgroups for substance use after discharge from treatment for SUDs.

RESULTS

Approximately 94% of the veterans relapsed upon discharge from outpatient or residential SUD treatment. Veterans aged 18-34 years old were significantly less likely to relapse than the 35-64 age group (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.66, 0.82), while males were more likely than females to relapse (OR 1.55, 95% CI: 1.34, 1.79). Unemployed veterans (OR 1.92, 95% CI: 1.67, 2.22) or veterans not in the labor force (OR 1.29, 95% CI: 1.13, 1.47) were more likely to relapse than employed veterans. Homeless vs. independently housed veterans had 3.26 (95% CI: 2.55, 4.17) higher odds of relapse after treatment. Veterans with one arrest vs. none were more likely to relapse (OR 1.52, 95% CI: 1.19, 1.95). Treatment completion was critical to maintain sobriety, as every other type of discharge led to more than double the odds of relapse. Veterans who received care at 24-hour detox facilities were 1.49 (95% CI: 1.23, 1.80) times more likely to relapse than those at rehabilitative/residential treatment facilities. Classification tree analysis indicated that homelessness upon discharge was the most important predictor in SUD relapse among veterans.

CONCLUSION

Aside from numerous challenges that veterans face after leaving military service, SUD relapse is intensified by risk factors such as homelessness, unemployment, and insufficient SUD treatment. As treatment and preventive care for SUD relapse is an active field of study, further research on SUD relapse among homeless veterans is necessary to better understand the epidemiology of substance addiction among this vulnerable population. The findings of this study can inform healthcare policy and practices targeting veteran-tailored treatment programs to improve SUD treatment completion and lower substance use after treatment.

Increasing treatment-seeking intentions of US veterans in the Covid-19 era: A randomized controlled trial

BACKGROUND

Veterans have higher rates of anxiety, depression, and posttraumatic stress disorder (PTSD), and may be vulnerable to mental health consequences of the Covid-19 pandemic. More than half of veterans who meet mental illness criteria do not seek help. This study screened for clinical symptoms and evaluated the efficacy of a brief, online social-contact-based video intervention in increasing treatment-seeking intentions among veterans. We hypothesized that the video-based intervention would increase treatment-seeking intentions more than written vignette and control conditions.

METHODS

One hundred seventy-two veterans were randomized to either a (a) brief video-based intervention; (b) written vignette intervention, or (c) nonintervention control group. In the 3-min video, a veteran previously diagnosed with PTSD described his symptom reactivation by Covid-19, his barriers to care, and how therapy helped him to cope. Assessments were conducted at baseline, postintervention, and at 14- and 30-day follow-ups.

RESULTS

A total of 91 (53%) veterans reported high levels of clinical symptoms, especially those self-reporting Covid-19 exposure. The brief video-based intervention yielded greater increase in treatment-seeking intentions among veterans. Within the video group, women showed an increase in treatment-seeking intentions from baseline to postintervention only, whereas men showed a more sustained effect, from baseline to Day 14.

CONCLUSIONS

Surveyed veterans reported high symptoms levels. A brief video intervention increased treatment-seeking intention, likely through identification and emotional engagement with the video protagonist. This easily disseminable video-based intervention has the potential to increase likelihood of seeking care. Future research should examine longer term sustainability and changes in help-seeking behavior.

A Pilot Study of a Stress Management Program for Incarcerated Veterans

INTRODUCTION

Veterans involved in the justice system are an understudied population warranting attention given their higher risk of mental health concerns and psychosocial challenges. Thus, there is a need for programs to support the psychological health of incarcerated veterans. The present study sought to determine the acceptability and effectiveness of a mind-body stress reduction program for incarcerated veterans.

MATERIALS AND METHODS

Twenty-four incarcerated veterans (100% male; Mage = 44.87 (SD = 13.84)) completed a 6 week mind-body stress reduction course, or Resilient Warrior. Participants completed validated, self-report assessments of mood, functioning, mindfulness, and coping at pre- and post-program as well as having post-program qualitative feedback surveys.

RESULTS

Results showed improvement in depressive symptom severity, self-efficacy, and resilience over the study duration (P < .05), but not stress reactivity, mindfulness, sleep disturbance, or perceived stress. The intervention was reported as helpful by 96% of participants, with 86% of participants stating they would recommend the course to others.

CONCLUSIONS

The Resilient Warrior program is acceptable and well-tolerated for incarcerated veterans as well as may improve aspects of psychological health. Future studies could examine how stress reductions program might improve recidivism rates and quality of life after the release of incarcerated veterans.

Facilitating Successful Reentry Among Justice-involved Veterans: The Role of Veteran and Offender Identity

Reentry courts facilitate successful offender reintegration into the community following release from incarceration, and many justice-involved veterans may benefit from such services given their elevated risk for deleterious outcomes postrelease. However, effectively engaging court participants is a crucial foundation to achieve the goals of recidivism reduction and global psychosocial improvement. This conceptual article presents an overview of factors that may interfere with a veteran's engagement in reentry court through the lens of both veteran and offender identity. Recommendations for reentry court personnel based on justice-involved veterans' experiences, identity, and unique needs are presented. Careful consideration of these factors and associated practice adaptations may facilitate rapport between reentry court personnel and veteran participants, foster engagement, and ultimately improve outcomes among this unique, at-risk population.

Veterans behind bars: Examining criminogenic risk factors of Veteran incarceration

Introduction: Research on former military personnel incarcerated in Canada is limited. The objectives of this study were to determine the characteristics and criminogenic risk factors of Veterans using a convenience sample of 25 inmates at five Ontario detention centres from 2012 to 2015. This study builds on a pilot project of 19 former military personnel incarcerated at three Ontario detention centres between 2011 and 2012. Methods: Data on sociodemographic variables, military service, and history of physical and mental health problems was obtained through semi-structured interviews. Further data was gathered from institutional health care records. The official offence history and Level of Service Inventory–Ontario Revised (LSI–OR) scores of the inmates, if available, were obtained via client profiles. Results: Twenty-five male inmates self-identified as having been in the military and consented to participate in the study. Their mean age was 43.5 years. Participants indicated serving an average of six years in the military. Fifty-two percent of participants served in the Canadian Armed Forces and 24% in the United States Armed Forces. Other countries of service included Cuba, South Korea, former Yugoslavia, Portugal and Venezuela. Seventy-two percent had prior incarcerations, and 44% were convicted of criminal offences during their military service. For those on remand, 29.2% had been charged with homicide and related offences at the time of the study. A total of 48% of participants indicated involvement in war or operational missions during their military service. Seventy-two percent were diagnosed with a mental health condition during their lifetime. Discussion: This study provides valuable information about the unique characteristics, criminogenic risk factors, and mental health needs of incarcerated Veterans. If Veterans are identified on admission to a correctional facility, future care could be more appropriately directed to reduce criminal recidivism.

Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts

OBJECTIVES

Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users.

METHODS

Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators.

RESULTS

Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality.

CONCLUSIONS

Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Embedding a Co-occurring Disorders Rehabilitation Intervention in Veterans Courts: A Pilot Study with Male Veterans

Veterans treatment courts (VTCs) have expanded dramatically despite their limited empirical base. This pilot study examined MISSION-Criminal Justice (CJ), a co-occurring disorders wraparound intervention, delivered alongside two VTCs. Baseline data from 26 male veterans enrolled in two VTCs and MISSION-CJ, and 6-month follow-up data for 18 of the 26 veterans, are presented. Veterans on average were 37.5 years old, 85% Caucasian, had significant histories of criminal justice involvement (14.3 lifetime arrests), had an average of 14.7 years of alcohol use and 9.3 years of illicit drug use, and roughly three-quarters reported mental health symptomatology. At 6-month follow-up, veterans demonstrated improvements in behavioral health, substance use, and criminal justice outcomes. This study demonstrated promising preliminary outcomes of MISSION-CJ in VTCs. A randomized controlled trial is a critical next step to examine whether these outcomes remain consistent with a more rigorous design.

Criminal recidivism among justice-involved veterans following substance use disorder residential treatment

Veterans in treatment for substance use disorders (SUD) often report past criminal offending. However, the rate of criminal recidivism in this population is unknown. Further, prior research in veterans has not examined personality factors as predictors of recidivism, despite the prominence of such factors in leading models of recidivism risk management. We examined these issues in a secondary data analysis of 197 military veterans with a history of criminal offending who were enrolled in an SUD residential treatment program. Participants were interviewed using several measurement instruments at treatment entry, one month into treatment, treatment discharge, and 12 months post-discharge. Most veterans (94%) had a history of multiple charges, and 53% had recent involvement in the criminal justice system at the time of treatment entry. In the 12 months post-discharge, 22% reported reoffending. In addition, 30% of patients who had been recently involved in the criminal justice system at treatment entry reoffended during follow-up. Higher friend relationship quality (OR = 2.32, 95% CI [1.03, 5.21]) at treatment entry and higher staff ratings of patients' relationship quality with other residents during treatment (OR = 2.76, 95% CI [1.40, 5.41]) predicted lower odds of recidivism post-discharge. After accounting for these factors, smaller reductions during treatment in the personality trait of Negative Emotionality predicted an increased risk for criminal recidivism post-discharge (OR = 1.13, 95% CI [1.01, 1.26]). Results support augmenting the curriculum of SUD programs for veterans with services aimed at reducing risk for criminal recidivism, with a focus on interventions that directly target patients' social support networks and tendencies towards negative emotionality.

Systematic Review of Criminal and Legal Involvement After Substance Use and Mental Health Treatment Among Veterans: Building Toward Needed Research

Evidence indicates that substance use and mental health treatment is often associated with reduced criminal activity. The present systematic review examined this association among military veterans, and aimed to provide a comprehensive summary of needed research to further contribute to reduced criminal activity among veterans. This systematic review was derived from a scoping review that mapped existing research on justice-involved veterans' health. For the current systematic review, a subset of 20 publications was selected that addressed the question of whether criminal activity declines among veterans treated for substance use and mental health disorders. Generally, veterans improved on criminal outcomes from pre- to post-treatment for opioid use, other substance use, or mental health conditions, and more sustained treatment was associated with better outcomes. This occurred despite high rates of criminal involvement among veterans prior to entering treatment. Needed are substance use and mental health treatment studies that include women justice-involved veterans, follow criminally-active veterans for longer periods of time, and use validated and reliable measures of criminal activity with fully transparent statistical procedures. Future randomized trials should evaluate new treatments against evidence-based treatments (versus no-treatment control conditions). Subsequent studies should examine how to link veterans to effective treatments, facilitate sustained treatment engagement, and ensure the availability of effective treatments, and examine mechanisms (mediators and moderators) that explain the association of treatment with reduced criminal activity among veterans. Best practices are needed for reducing criminal activity among the minority of justice-involved veterans who do not have diagnosed substance use and/or mental health disorders.

Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders

BACKGROUND

Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs.

METHODS

We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS).

RESULTS

Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs.

CONCLUSIONS

Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.

Posttraumatic stress, panic disorder, violence, and recidivism among local jail detainees

PURPOSE

Most research on posttraumatic stress disorder (PTSD) and offending has been conducted with special populations (e.g. veterans and female inmates) and generally overlooks the additive effect of panic disorder (PD) in offending patterns. The purpose of this paper is to assess the prevalence of PTSD and PD among jail inmates, while simultaneously examining the relationships between these disorders, offending types and frequency.

DESIGN/METHODOLOGY/APPROACH

A random sample of adults recently booked into a local county jail participated in the Comprehensive Addictions and Psychological Evaluation-5 (CAAPE-5), a structured psychological assessment. The study sample was comprised of 200 male and 83 female inmates.

FINDINGS

Indications of PTSD were observed among 44.0 percent of male inmates and 57.8 percent of female inmates. Most male inmates (78.4 percent) with positive PTSD indications also met criteria for PD, with a similar proportion (78.1 percent) of female inmates also meeting criteria for both. The combination of PTSD and PD was not associated with offending frequency, but inmates presenting indications of both PTSD and PD were more likely to be charged with a violent offense relative to those with only PTSD.

PRACTICAL IMPLICATIONS

Inmates with PTSD who also have panic attacks may have a more severe condition with possible implications for other risks. Observations of these conditions among adults recently booked into local jails should coincide with each other.

ORIGINALITY/VALUE

Few studies have examined mental health conditions among local jail detainees, despite the ever-present need to address them. The current study considers this important population and investigates the prevalence of co-occurring conditions.

The prevalence and correlates of common mental disorders among prisoners in Addis Ababa: an institution based cross-sectional study

Objective

About one in seven prisoners is diagnosed with common mental disorders whose global prevalence ranges from 13 to 92.5%. The problem negatively affects the physical, psychological, and social well-being of prisoners. However, research into common mental disorders and associated factors among prisoners in low and middle-income countries has been limited. Therefore, this study aimed to explore the common mental disorders and associated factors among prisoners in Ethiopia to contribute the attempt to ensure optimal care for prisoners.

Results

The prevalence of common mental disorders among prisoners was found to be 58.4% [95% CI 53.70, 63.00]. In the multivariable logistic regression, poor social support [AOR = 2.4, 95% CI 1.16, 4.85], economic crisis [AOR = 3, 95% CI 1.84, 4.85], secondary school education [AOR = 2.3, 95% CI 1.04, 5.20], unemployment before arrest [AOR = 1.7, 95% CI 1.04, 2.80], and history of psychiatric illness [AOR = 4.3, 95% CI 1.21, 15.56] were factors significantly associated with the problem.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4425-7) contains supplementary material, which is available to authorized users.

A scoping review of military veterans involved in the criminal justice system and their health and healthcare

BACKGROUND

In the criminal justice system, special populations, such as older adults or patients with infectious diseases, have been identified as particularly vulnerable to poor health outcomes. Military veterans involved in the criminal justice system are also a vulnerable population warranting attention because of their unique healthcare needs. This review aims to provide an overview of existing literature on justice-involved veterans' health and healthcare to identify research gaps and inform policy and practice.

METHODS

A systematic search was conducted to identify research articles related to justice-involved veterans' health and healthcare that were published prior to December 2017. Study characteristics including healthcare category, study design, sample size, and funding source were extracted and summarized with the aim of providing an overview of extant literature.

RESULTS

The search strategy initially identified 1830 unique abstracts with 1387 abstracts then excluded. Full-text review of 443 articles was conducted with 252 excluded. There were 191 articles included, most related to veterans' mental health (130/191, 68%) or homelessness (24/191, 13%). Most studies used an observational design (173/191, 91%).

CONCLUSIONS

Knowledge gaps identified from the review provide guidance on future areas of research. Studies on different sociodemographic groups, medical conditions, and the management of multiple conditions and psychosocial challenges are needed. Developing and testing interventions, especially randomized trials, to address justice-involved veterans care needs will help to improve their health and healthcare. Finally, an integrated conceptual framework that draws from diverse disciplines, such as criminology, health services, psychology, and implementation science is needed to inform research, policy and practice focused on justice-involved veterans.

Posttraumatic Stress Disorder Symptoms and Criminal Behavior in U.S. Army Populations: The Mediating Role of Psychopathy and Suicidal Ideation

Whereas past research has demonstrated the relationship between posttraumatic stress disorder (PTSD) and criminal behavior, the present study examines the underlying mechanisms driving this association. The primary objective was to determine the role of psychopathy and suicidal ideation as mediating factors in the relationship between military PTSD symptoms and criminal behavior (defined as incarceration status). A correlational study using archival data from the U.S. Disciplinary Barracks (USDB) and a control population of U.S. Army soldiers was conducted. The USDB provided data from 310 incarcerated male U.S. Army soldiers. Data were also collected from 310 nonincarcerated, male U.S. Army soldiers in the greater Fort Rucker, Alabama area. Data validity checks eliminated some cases, thus yielding a final dataset of 246 USDB and 252 control participants. The results suggested partial mediation, in that PTSD symptoms had a direct effect on incarceration status, and significant indirect effects through suicidal ideation and psychopathy while controlling for intelligence and warmth. In furnishing evidence of how psychopathy and suicidal ideation mediate the relationship between PTSD and incarceration status in military personnel, this research highlights specific internalization and externalization mechanisms that may increase the tendencies of people with greater PTSD symptoms to engage in criminal behaviors. By adding to the small amount of prior research on why PTSD sometimes leads people to engage in criminal behaviors, our research provides specific, observable symptoms that clinicians may use to identify, treat, and possibly ameliorate facets of PTSD that can lead affected people to engage in criminal behaviors.

Characteristics, needs, and experiences of U.S. veterans on a specialized prison unit

The Veterans Service Unit (VSU) in Connecticut is one of several all-veterans prison units that are being created throughout the United States. This study examined the characteristics, needs, and experiences of veterans on the Connecticut VSU. This study utilized data from a quality improvement survey that was completed by 87 of the 110 veterans on the Connecticut VSU (79% response rate). The majority of veterans on the VSU were white, aged 41-56, never married, and had an honorable or general military discharge making them potentially eligible for Veterans Affairs (VA) healthcare upon release. The most common psychiatric diagnoses reported by veterans were substance use disorders and 29% reported posttraumatic stress disorder. Veterans on the unit reported a variety of needs related to legal, housing, basic needs, health, income, and community re-entry. The majority of veterans reported positive experiences on the VSU with 61% reporting the VSU was better than other units they have been on. Together, these findings illustrate how regional partnerships between state Departments of Corrections and VA medical centers may benefit veterans. More rigorous evaluation of the VSU model is needed to inform innovations to address the needs of incarcerated veterans and prepare them for successful community reintegration.

Antecedents, Behaviours, and Court Case Characteristics and Their Effects on Case Outcomes in Litigation for Persons with Schizophrenia

A 10% random sample of 3543 cases litigated in the United States' civil and criminal courts were analysed using logistic regression to develop a model that can predict case outcomes for litigants with schizophrenia. Most predictors are related to case characteristics and not to the litigants' antecedents, behaviours or medication issues. Only the psychologist as an expert witness was found to be related to case outcome, but the concern is expressed that inadequate weight is given to expert testimony. Other significant findings include being represented by counsel, atypical medication and malingering.

Does trauma exposure predict prescription drug problems beyond the contribution of post-traumatic stress disorder and depression? An analysis of the Mind Your Heart cohort study

It is not clear from prior studies whether trauma exposure predicts substance use problems independent of psychiatric comorbidities. Most prior studies were cross-sectional in nature, and none focused on prescription drug problems. To address this gap in the literature, the current article is a secondary analysis of veterans from the Mind Your Heart prospective cohort study. The primary research question is whether trauma exposure predicts prescription drug problems even after controlling for major psychiatric symptoms, such as post-traumatic stress disorder and depression. Multinomial logistic regression was used to assess whether the 10-item lifetime Brief Trauma Questionnaire (e.g., serious car accidents, war traumas, life-threatening illness, natural disasters, physical, or sexual abuse) predicts prescription drug problems as determined by a self-report categorical question (three answer choices) over a 4-year follow-up time period (n = 661 [100%] at year 1; 83.4% at year 2; 85.9% at year 3; and 78.2% at year 4). Trauma exposure was positively associated with prescription drug problems in unadjusted and age-, sex-, and race-adjusted analyses at follow-up. After accounting for post-traumatic stress disorder (PTSD Checklist-17 Civilian Version) and depression (Patient Health Questionnaire-9) symptoms, trauma exposure was no longer associated with prescription drug problems at all time points (relative risk ratios range 0.91-1.47). These results were robust to different missing data strategies. Trauma exposure was not associated with prescription drug problems over a 4-year follow-up in a prospective cohort study of veterans. Future directions include detailed measures of prescription drug problems and recruitment from community sites.