Psychiatric disorder in male veterans and nonveterans

Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8^TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

Women at war: The crucible of Vietnam

Relatively little has been written about the military women who served in Vietnam, and there is virtually no literature on deployed civilian women (non-military). We examined the experiences of 1285 American women, military and civilian, who served in Vietnam during the war and responded to a mail survey conducted approximately 25 years later in which they were asked to report and reflect upon their experiences and social and health histories.

We compare civilian women, primarily American Red Cross workers, to military women stratified by length of service, describe their demographic characteristics and warzone experiences (including working conditions, exposure to casualties and sexual harassment), and their homecoming following Vietnam. We assess current health and well-being and also compare the sample to age- and temporally-comparable women in the General Social Survey (GSS), with which our survey shared some measures.

Short-term (<10 years) military service women (28%) were more likely to report their Vietnam experience as “highly stressful” than were career (>20 years; 12%) and civilian women (13%). Additional differences regarding warzone experiences, homecoming support, and health outcomes were found among groups. All military and civilian women who served in Vietnam were less likely to have married or have had children than women from the general population, χ² (8) = 643.72, p < .001. Career military women were happier than women in the general population (48% were “very happy”, as compared to 38%). Civilian women who served in Vietnam reported better health than women in the other groups. Regression analyses indicated that long-term physical health was mainly influenced by demographic characteristics, and that mental health and PTSD symptoms were influenced by warzone and homecoming experiences. Overall, this paper provides insight into the experiences of the understudied women who served in Vietnam, and sheds light on subgroup differences within the sample.

•

Physical health of women deployed to Vietnam was influenced by warzone experiences.

•

Career military women Vietnam veterans are happier than women in general population.

•

Military and non-military Vietnam service women less likely to marry or have kids.

•

Paper provides insight to mostly unstudied lives of American women of Vietnam War.

Can social policy influence socioeconomic disparities? Korean War GI Bill eligibility and markers of depression

PURPOSE

The Korean War GI Bill provided socioeconomic benefits to veterans; however, its association with health is unclear; we hypothesize GI Bill eligibility is associated with fewer depressive symptoms and smaller disparities.

METHODS

Data from 246 Korean War GI Bill eligible veterans and 240 nonveterans from the Health and Retirement Study were matched on birth year, southern birth, race, height, and childhood health using coarsened exact matching. Number of depressive symptoms in 2010 (average age = 78 years) was assessed using a modified, validated Center for Epidemiologic Studies-Depression Scale, dichotomized to reflect elevated depressive symptoms. Regression analyses were stratified into low (at least one parent < 8 years schooling/missing data, n = 167) or high (both parents ≥ 8 years schooling, n = 319) childhood socioeconomic status (cSES) groups.

RESULTS

Korean War GI Bill eligibility predicted fewer depressive symptoms among individuals from low cSES backgrounds [β = -0.64, 95% confidence interval (CI) = (-1.18, -0.09), P = .022]. Socioeconomic disparities were smaller among veterans than nonveterans for number of depressive symptoms [β = -0.76, 95% CI = (-1.33, -0.18), P = .010] and elevated depressive symptoms [β = -11.7, 95% CI = (-8.2, -22.6), P = .035].

CONCLUSIONS

Korean War GI Bill eligibility predicted smaller socioeconomic disparities in depression markers.

Explaining differences in hepatitis C between U.S. veterans and nonveterans in treatment for substance abuse: results from a regression decomposition

Hepatitis C virus (HCV) infection is common among people with substance abuse histories and a burden for U.S. veterans in particular. This study compares self-reported HCV between 1,652 veterans and 48,013 nonveterans who received public-sector substance abuse treatment in Los Angeles between 2006 and 2010. A higher percentage of veterans than nonveterans reported HCV (6.5% vs. 3.8%, p < .0001). Homelessness and mental illness explained, respectively, 8.6% and 7.1% of the difference in HCV between the two groups, adjusting for other variables. Reducing homelessness and mental illness among veterans may also help reduce the excess burden of HCV in this population.

Alcohol problems as a risk factor for postdisaster depressed mood among U.S. veterans

Alcohol problems may impede adaptive, proactive responses to disaster-related injury and loss, thus prolonging the adverse impact of disasters on mental health. Previous work suggests that veterans of the U.S. armed forces have a relatively high prevalence of alcohol misuse and other psychiatric disorders. This is the first study to estimate the impact of predisaster alcohol problems on postdisaster depressed mood among veterans, using data that were collected before and after the 1994 Northridge, CA, earthquake. The authors assessed the impact of alcohol problems on postdisaster depressed mood in an existing clinical cohort of veterans who experienced the 6.7-magnitude earthquake that struck Northridge in January 1994. One to 3 months after the disaster, interviewers contacted participants by telephone to administer a follow-up questionnaire based on a survey that had been done preearthquake. Postearthquake data were obtained on 1,144 male veterans for whom there were preearthquake data. We tested a predictive path model of the relationships between latent variables for predisaster alcohol problems, functional limitations, and depressed mood on latent variables representing postdisaster "quake impact" and depressive mood. Results showed that veterans who had more alcohol problems before the earthquake experienced more earthquake-related harms and severely depressed mood after the earthquake, compared with those who had fewer alcohol problems. Programs serving veterans with a high prevalence of alcohol problems should consider designing disaster response protocols to locate and assist these patients in the aftermath of disasters.

Incarceration among male veterans: relative risk of imprisonment and differences between veteran and nonveteran inmates

Using data from national surveys of jail and prison inmates conducted in 2002 and 2004, the authors found that male veterans in the age group that entered military service in the early years of the All Volunteer Force (AVF) were at greater risk of incarceration than nonveterans of similar age and ethnicity, whereas veterans who enlisted in later years of the AVF had less risk of incarceration than nonveterans. Although White veterans tend to have greater risk of incarceration than nonveteran Whites, Black and Hispanic veterans were at less risk than their nonveteran peers, although they are at greater risk than White veterans. These patterns are best explained by changes over time and in differential effects across racial/ethnic groups of recruiting practices, accession standards, and in civilian employment opportunities rather than combat trauma or other adverse experiences in the military. For example, reductions in the relative risk for incarceration of veterans during the AVF appear to generally result from increases in recruit qualifications and socioeconomic status due to greater military pay, improved skill in recruiting, and higher accession standards.

Health of national service veterans: an analysis of a community-based sample using data from the 2007 Adult Psychiatric Morbidity Survey of England

PURPOSE

In the context of increasing concerns for the health of UK armed forces veterans, this study aims to compare the prevalence of current mental, physical and behavioural difficulties in conscripted national service veterans with population controls, and to assess the impact of length of service in the military. The compulsory nature of national service sets these veterans apart from younger veterans.

METHOD

Data are drawn from a nationally representative community-dwelling sample of England. We compared 484 male national service veterans to 301 male non-veterans aged 65+ years.

RESULTS

There were no differences in mental, behavioural or physical outcomes, except that veterans were less likely to have "any mental disorder" than non-veterans (age adjusted OR = 0.56, 95% CI 0.31, 0.99). Longer serving veterans were older but were not different in terms of mental, behavioural or physical outcomes.

CONCLUSIONS

Community-dwelling national service veterans are at no greater risk of current adverse mental, physical or behavioural health than population controls.

Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England

BACKGROUND

There is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.

METHOD

Data from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16-64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (<4 years service) were compared with longer serving veterans.

RESULTS

Male veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01-2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13-7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08-16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21-4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61-94.68) than longer serving veterans.

CONCLUSIONS

The findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

The effect of perceived racial discrimination on bodily pain among older African American men

OBJECTIVES

We examined the extent to which experiences of racial discrimination are associated with bodily pain reported by African American men.

METHODS

The study sample consisted of 393 African American male veterans who responded to a national survey of patients aged 50-75 who received care from the Veterans Health Administration (VHA). Veterans were surveyed by mail, with a telephone follow-up. The response rate for African Americans in the sample was 60.5%. Pain (assessed using the bodily pain subscale of the 36-item short-form health survey), experiences of discrimination, employment, education, and income were obtained through the survey. Age, race, and mental health comorbidities were obtained from VA administrative data. Multiple regression analysis adjusting for item non-response (via imputation) and unit non-response (via propensity scores and weighting) was used to assess the association between racial discrimination and likelihood of experiencing moderate or severe pain over the past 4 weeks.

RESULTS

Experiences of racial discrimination were associated with greater bodily pain (beta = -0.25, P < 0.0001), even after controlling for socioeconomic and health-related characteristics.

CONCLUSION

Perceived racial discrimination was associated with greater pain among a sample of older African American male patients in the VA. Additional research is needed to replicate this finding among other populations of African Americans.

Hypnotic analgesia for combat-related spinal cord injury pain: a case study

A U.S. Army soldier stationed in Iraq developed myriad pain problems after sustaining a high-level spinal cord injury (SCI) from a gunshot wound. These problems were negatively impacting his ability to participate fully in his physical rehabilitation and care. Ten sessions of self-hypnosis training were administered to the patient over a 5-week period to help him address these problems. Both the patient and his occupational therapist reported a substantial reduction in pain over the course of treatment, which allowed the patient to actively engage in his therapies. Six months post treatment, the patient reported continued use of the hypnosis strategies taught, which effectively reduced his experience of pain. This case study demonstrates the efficacy of hypnotic analgesia treatment for U.S. military veterans who are experiencing pain problems due to traumatic or combat-related SCIs.

Development and Validation of a Psychiatric Case-Mix System

BACKGROUND

Although difficulties in applying risk-adjustment measures to mental health populations are increasingly evident, a model designed specifically for patients with psychiatric disorders has never been developed.

OBJECTIVE

Our objective was to develop and validate a case-mix classification system, the "PsyCMS," for predicting concurrent and future mental health (MH) and substance abuse (SA) healthcare costs and utilization.

SUBJECTS

Subjects included 914,225 veterans who used Veterans Administration (VA) healthcare services during fiscal year 1999 (FY99) with any MH/SA diagnosis (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 290.00-312.99, 316.00-316.99).

METHODS

We derived diagnostic categories from ICD-CM codes using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition definitions, clinical input, and empiric analyses. Weighted least-squares regression models were developed for concurrent (FY99) and prospective (FY00) MH/SA costs and utilization. We compared the predictive ability of the PsyCMS with several case-mix systems, including adjusted clinical groups, diagnostic cost groups, and the chronic illness and disability payment system. Model performance was evaluated using R-squares and mean absolute prediction errors (MAPEs).

RESULTS

Patients with MH/SA diagnoses comprised 29.6% of individuals seen in the VA during FY99. The PsyCMS accounted for a distinct proportion of the variance in concurrent and prospective MH/SA costs (R=0.11 and 0.06, respectively), outpatient MH/SA utilization (R=0.25 and 0.07), and inpatient MH/SA utilization (R=0.13 and 0.05). The PsyCMS performed better than other case-mix systems examined with slightly higher R-squares and lower MAPEs.

CONCLUSIONS

The PsyCMS has clinically meaningful categories, demonstrates good predictive ability for modeling concurrent and prospective MH/SA costs and utilization, and thus represents a useful method for predicting mental health costs and utilization.

Process of care and outcome after acute myocardial infarction for patients with mental illness in the VA health care system: are there disparities?

OBJECTIVE

To compare process of care and outcome after acute myocardial infarction, for patients with and without mental illness, cared for in the Veterans Health Administration (VA) health care system.

DATA SOURCES/SETTING

Primary clinical data from 81 VA hospitals.

STUDY DESIGN

This was a retrospective cohort study of 4,340 veterans discharged with clinically confirmed acute myocardial infarction. Of these, 859 (19.8 percent) met the definition of mental illness. Measures were age-adjusted in-hospital and 90-day cardiac procedure use; age-adjusted relative risks (RE) of use of thrombolytic therapy, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, or aspirin at discharge; risk-adjusted 30-day and one-year mortality.

RESULTS

Patients with mental illness were marginally less likely than those without mental illness to undergo in-hospital angiography (age-adjusted RR 0.90 [95 percent confidence interval: 0.83, 0.98]), but there was no significant difference in the age-adjusted RR of coronary artery bypass graft surgery in the 90 days after admission (0.85 [0.69, 1.05]), or in the receipt of medications of known benefit. For example, ideal candidates with and without mental illness were equally likely to receive beta-blockers at the time of discharge (age-adjusted RR 0.92 [0.82, 1.02]). The risk-adjusted odds ratio (OR) for death in patients with mental illness versus those without mental illness within 30 days was 1.00 (0.75, 1.32), and for death within one year was 1.25 (1.00, 1.53).

CONCLUSIONS

Veterans Health Administration patients with mental illness were marginally less likely than those without mental illness to receive diagnostic angiography, and no less likely to receive revascularization or medications of known benefit after acute myocardial infarction. Mortality at one year may have been higher, although this finding did not reach statistical significance. These findings are consistent with other studies showing reduced health care disparities in the VA for other vulnerable groups, and suggest that an integrated health care system with few financial barriers to health care access may attenuate some health care disparities. Further work should address how health care organizational features might narrow disparities in health care for vulnerable groups.

A twin study of the association between pathological gambling and antisocial personality disorder

Many individuals with a history of pathological gambling (PG) also have a history of engaging in antisocial behaviors, and this has often been interpreted as a result of the former causing the latter. In a sample of 7,869 men in 4,497 twin pairs from the Vietnam Era Twin Registry, the authors examined (a) the association between PG and antisocial personality disorder (ASPD), (b) the extent to which PG might be differentially associated with childhood conduct disorder (CD) and adult antisocial behavior (AAB), and (c) the contribution of genetic and environmental factors to the association of PG with ASPD, CD, and AAB. PG was significantly associated with all 3 antisocial behavior disorders, and the association of PG with ASPD, CD, and AAB was predominantly explained by genetic factors. The results of this study suggest that the greater-than-chance co-occurrence of PG and antisocial behavior disorders is partially due to their sharing a common genetic vulnerability. The antisocial behavior observed among many individuals with PG probably cannot be interpreted as being simply a consequence of the PG.

Persistence of impaired functioning and psychological distress after medical hospitalization for men with co-occurring psychiatric and substance use disorders

OBJECTIVE

To measure the persistence of impaired health-related quality of life (HRQL) and psychological distress associated with co-occurring psychiatric and substance use disorders in a longitudinal sample of medically hospitalized male veterans.

DESIGN

A random sample followed observationally for 1 year after study enrollment.

SETTING

Inpatient medical and surgical wards at 3 university-affiliated Department of Veterans Affairs Medical Centers.

PATIENTS/PARTICIPANTS

A random sample of 1,007 admissions to medical and surgical inpatient services, excluding women and admissions for psychiatric reasons. A subset of participants (n = 736) was designated for longitudinal follow-up assessments at 3 and 12 months after study enrollment. This subset was selected to include all possible participants with study-administered psychiatric diagnoses (52%) frequency-matched by date of study enrollment to approximately equivalent numbers of participants without psychiatric diagnoses (48%).

MEASUREMENTS AND MAIN RESULTS

All participants were administered a computerized structured psychiatric diagnostic interview for 13 psychiatric (include substance use) disorders and received longitudinal assessments at 3 and 12months on a multidimensional measure of HRQL, the SF-36, and a measure of psychological distress, the Symptom Checklist, 90-item version. On average, HRQL declined and psychological distress increased over time (P <.05). Psychiatric disorders were associated with significantly greater impairments in functioning and increased distress on all measures (P <.001) except physical functioning (P <.05). These results were replicated in the patients (n = 130) who received inpatient or outpatient mental health or substance abuse services.

CONCLUSIONS

General medical physicians need to evaluate the mental health status of their hospitalized and seriously ill patients. Effective mental health interventions can be initiated posthospitalization, either immediately in primary care or through referral to appropriate specialty care, and should improve health functioning over time.

The heritability of alcoholism symptoms: "indicators of genetic and environmental influence in alcohol-dependent individuals" revisited

There is consistent evidence from twin and adoption studies implicating genetic factors in the etiology of alcoholism, yet few studies have examined the role of genetic influences on individual symptoms of alcoholism. In a previous study of 113 male twins, Johnson et al. (1996a) identified 7 alcoholism symptoms that were more "genetic" and 14 that were more "environmental" (that is, non-genetic) in their etiology by examining symptom concordances among monozygotic and dizygotic twin pairs. The present study represents an attempt to replicate the results of this previous study and extend them by estimating the contribution of genetic factors to the variation in liability for different alcoholism symptoms. Subjects were 3356 male twin pairs from the Vietnam Era Twin Registry. Lifetime histories of alcoholism symptoms were assessed by a structured psychiatric telephone interview. The results of the previous study were not replicated. The correlations between symptom classifications as genetic and non-genetic in the present and previous study were nonsignificant and ranged from -0.27 to 0.11. However, within the present study the correlation between symptom classifications as genetic and non-genetic was statistically significant across random split-half subsamples (r = 0.59); nine alcoholism symptoms were consistently classified as genetic and six symptoms as non-genetic in their etiology. Model-fitting analyses applied to different alcoholism symptoms yielded heritability estimates ranging from 0.03 to 0.53 with broad and overlapping confidence intervals around these estimates, ranging from 0.00 to 0.65. The results of this study highlight the difficulty of identifying more or less heritable phenotypes in twin research, and suggest that it may not be possible to identify specific alcoholism symptoms that are more genetic in their etiology than others. Nevertheless, there appears to be potentially important variation in the relative magnitude of genetic influences for individual alcoholism symptoms, and exploring these differences may lead to further insights into the nosology and etiology of alcohol-related problems.

Multifacility utilization by the chronically mentally ill in the Department of Veterans Affairs

The objectives of this research are (1) to quantify the multifacility utilization patterns ("shared care") for a selected subset of patients with a chronic mental disorder, (2) to examine the patient characteristics correlated with several observed utilization patterns, and (3) to determine facility groups through cluster analysis, based on multifacility readmissions. Patients were identified from the VA's hospital discharge abstract system based on a diagnosis of schizophrenia in any discharge during the two-year study period. All discharges for this cohort during the period were analyzed. Essentially, three different groups of patients from this cohort were found. The vast majority have one or two hospitalizations and in the process are seen at one or maybe two facilities. However, two small minorities are hospitalized many times. One small group confines these hospitalizations to relatively few facilities while the other travels from facility to facility around the country. These two groups present very different clinical management problems from each other as well as from the majority. Since the distribution of travel distance between facilities remained similar for all types of patients (median distance was about 120 miles), facilities were clustered based on the number of linkages they shared. By use of six different measures of the disjointedness of shared care, clustering produced a reasonable number of meaningful groups which account for a majority of possibly uncoordinated shared care. We feel that these results and this approach can be useful for administrators, policymakers, and researchers. By looking simultaneously at the utilization patterns of its clients and their characteristics (e.g., age) as well as the utilization patterns within groups of facilities, any multifacility health system can characterize its shared care and identify those clients and facilities most in need of intervention, resources, and future study.

Self-reported symptoms of social anxiety in a sample of combat veterans with posttraumatic stress disorder

The relationship between posttraumatic stress disorder (PTSD) and self-reported levels of social anxiety among combat veterans was assessed using the Social Phobia and Anxiety inventory (SPAI). Participants were 45 veterans with combat-related PTSD assessed using a multimeasure assessment package. The veterans reported a high level of social anxiety and agoraphobia-like symptoms. Agoraphobia scores were predicted by PTSD severity and elevated by Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scales of acute distress and psychopathology. Social phobia scores were predicted by severity of depression. The relationship between social anxiety, depression, and PTSD is discussed. Implications for the assessment and treatment of PTSD are also discussed.

Mental disorder as a risk factor for human immunodeficiency virus infection in a sample of veterans

People who suffer from mental disorders are at increased risk for becoming infected with HIV. There have been no studies that show whether particular psychiatric disorders present an increased risk for HIV infection in samples of nonpatients. This article uses data from the 1992 National Survey of Veterans to determine if veterans with posttraumatic stress disorder (PTSD), or with other mental or emotional problems, are at increased risk for HIV infection. The results indicate that the combination of PTSD and substance abuse increased the risk of HIV infection by almost 12 times over those without either. This is evidence of a particular psychiatric disorder increasing risk for HIV. Although cross-sectional, these data allow some conjecture about the timing of the onset of PTSD in relation to HIV infection. These results present powerful evidence that mentally ill persons such as those with PTSD, who may be underserved for health services including AIDS prevention efforts, should be targeted as an at-risk group.

The influence of familial and non-familial factors on the association between major depression and substance abuse/dependence in 1874 monozygotic male twin pairs

The co-occurrence of major depression (MD) with alcohol and illicit substance abuse/dependence (A/D) has been repeatedly observed. However, prior research has been unable to determine whether or not the co-occurrence is a result of familial vulnerability or non-familial influences. The present study examines the association of the lifetime diagnosis of MD with alcohol, cannabis, amphetamine, cocaine, and sedative A/D (DSM-III-R criteria) before and after controlling for familial factors in a non-clinical sample of 1874 middle aged, monozygotic male twin pairs. A lifetime diagnosis of MD was significantly associated with lifetime diagnosis of alcohol and illicit substance A/D prior to accounting for familial factors (odds ratios: 1.8-4.5). After employing a co-twin analytical technique to control for familial factors, a lifetime diagnosis of MD remained significantly associated only with lifetime diagnoses of cannabis, amphetamine and sedative A/D (odds ratios: 2.3-10.9). These results suggest that the association between MD and alcohol A/D is influenced by familial factors. In contrast, the association between MD and illicit substances of A/D is largely explained by non-familial factors.