“Give us respect,support and understanding”: Women veterans of Iraq and Afghanistan recommend strategies for improving their mental health care

Although women veterans of Iraq and Afghanistan have experienced war-related mental health challenges, they underutilize Veterans Affairs (VA) health care relative to men. Quantitative studies have identified barriers that limit women veterans’ use of health care, but there is a dearth of research asking recent women veterans to volunteer their own recommendations for improving their mental health care. The current qualitative study sought to increase representation of the client voice by asking 29 women veterans of the recent wars to recommend strategies for improving VA and community-based mental health services. 16 strategies were identified in three thematic areas, including the therapeutic relationship, clinical care environment, and health care system. Implications of the findings for enhancing access, use, and quality of mental health services for this cohort of women veterans are discussed.     

Rates and Correlates of Pathological Gambling Among VA Mental Health Service Users

The rate and correlates of diagnosed pathological gambling (PG) among mental health patients in the Veterans Health Administration, the only national system of mental health care, have not been studied. Using fiscal year 2009 (FY2009) VA administrative data, a case–control study compared those with an ICD code of 312.31 (PG) versus those without. The analytic group was limited to 1,102,846 Veterans Affairs (VA) specialty mental health (MH) services users because 94.5% of all those diagnosed with PG in the U.S. VA health system received such services. Chi-square tests and logistic regression assessed associations between demographic and clinical factors and PG diagnosis. The past-year rate of PG diagnosis among veterans treated in specialty MH program was 0.2%, significantly lower than prevalence rates in other treatment samples and the general U.S population, suggesting under-diagnosis and/or a low-income sample. Being female, ages 40–74, and higher income increased the risk of PG diagnosis, as did past-year homelessness (Odds Ratio (OR) = 2.2), alcohol use disorders (OR = 2.8), bipolar disorder (OR = 2.1) and personality disorders (OR = 2.1). Depression, schizophrenia, and anxiety disorders other than PTSD, were also positively associated with PG diagnosis. Drug use disorder had no significant independent association with PG. PTSD, dementia, and living in isolated rural areas conferred reduced risk. More systematic screening and surveillance of PG among MH service users generally, and veterans with heavy alcohol use, severe mental illness, and homelessness specifically, appears warranted.     

Considering child care and parenting needs in Veterans Affairs mental health services

Child care and parenting needs of adults with mental illness are of growing concern, especially among those seeking Department of Veterans Affairs (VA) mental health services. One area of interest concerns the possible benefits that on-site child care could have for improving veterans’ access to VA mental health care. Child care programs are currently being piloted at the VA for the first time, although the need for them has not been evaluated. We conducted a brief survey of a convenience sample of 147 veterans (132 men, 15 women) seeking mental health care at outpatient clinics and/or at a psychiatric rehabilitation center at one VA. Participants were asked about their attitudes and experiences regarding child care and parenting support at the VA. Of the 52 (35.4%) participants who responded and had children under 18, the majority of both men and women surveyed agreed that the VA should offer child care services and that they would use child care services at the VA if it were available. These results are based on a small sample of participants, but they may contribute to ongoing discussion and efforts to develop “family-friendly” mental health services.     

A qualitative investigation into military veterans’ experiences in a problem-solving court: Factors that impact graduation rates

Veterans treatment courts (VTCs) are designed to offer a rehabilitative approach to criminal justice, focusing on treatment for mental health and substance use disorders. This qualitative study develops an in-depth understanding of a Midwestern VTC by asking participants (n = 15) their views on the most helpful aspects of the program and how the program could be more helpful. Three themes emerged from the data. 1) Military veterans felt that they were treated in a compassionate and caring manner, while also being held accountable for their behaviors. 2) Military veterans felt that they were not labeled by their mental health diagnoses, but that their identities as people and military veterans were more fully recognized. 3) Military veterans were dissatisfied with some of the services they received from the local VA. These findings are discussed in the context of problem-solving courts and military veterans’ experiences of services.     

Analyzing free-text survey responses: An accessible strategy for developing patient-centered programs and program evaluation

Despite widespread availability of yoga in the Veterans Health Administration (VA), it remains unclear how to best evaluate yoga programs. This is particularly problematic for programs aimed at veterans with mental health concerns, as evaluation typically focuses narrowly upon mental health symptom severity, even though program participants may have other health-related priorities. We analyzed responses to free-text questions on 237 surveys completed by veterans with mental health concerns enrolled in a yoga program at six VA clinics in Louisiana to characterize veteran participants’ experiences with yoga. Qualitative analysis resulted in 15 domains reflecting veterans’ individual health-related values and priorities. We use results to illustrate the potential for analysis of free-text responses to reveal valuable insights into patient experiences, demonstrating how these data can inform patient-centered program evaluation. The approach we present is more accessible to those responsible for decision-making about local programs than conventional methods of analyzing qualitive evaluation data.     

Associations Between Psychological,Physical, and Sexual Intimate Partner Violence and Health Outcomes Among Women Veteran VA Patients

Women veterans experience high rates of lifetime intimate partner violence (IPV) and suffer a variety of trauma-related health conditions. The purpose of this study was to identify health status and health risk behaviors associated with experiences of psychological, physical, or sexual IPV among women veterans receiving care at a Veterans Affairs (VA) medical center. We conducted surveys with 249 women veteran patients and examined health factors associated with each form of violence. Sexual IPV victimization had the most pronounced associations with adverse health. In multivariate analysis, controlling for age, race, and income, women veterans who experienced sexual violence victimization were close to or more than three times as likely as those who experienced no IPV to report poor or fair overall health, a diagnosis of post-traumatic stress disorder or depression, bipolar disorder, or anxiety, difficulty sleeping, cigarette smoking, and problem drinking. Those who reported psychological violence only (without physical or sexual violence) also reported greater odds of self-rated poor or fair health. These findings are consistent with findings from studies with non-veteran populations and serve to further identify the unique contributions of sexual IPV to health outcomes. The integrated VA health care system offers opportunities for IPV identification and response including a coordinated team-based care model with social work integrated within primary care.     

Suffering in the Shadows: Interviews with Wives of Combat Veterans Suffering from Post-Traumatic Stress Disorder and/or Traumatic Brain Injury

The body of research examining issues confronting combat veterans of the Afghanistan and Iraq wars continues to grow. However, this research focuses primarily upon veterans with very less attention given to the challenges confronting their spouses. Using a semi-structured interview methodology and a feminist perspective, this study examines what it means to be a wife of a combat veteran who suffers from post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). Our findings indicate these women—who experience tremendous emotional, financial, and social challenges that arise from being the caregiver for their husbands—feel isolated from and abandoned by both the military community and the civilian community. Furthermore, the social and emotional disconnection of these women experience amplify the stresses they confront in daily life—stresses that are unique to their relationship to being with a combat veteran spouse who has PTSD and/or TBI. We argue future research should build upon this exploratory study to better understand how both the military community and the civilian community impact the subjectivity of these women and their efforts to reintegrate themselves and their families into civilian life.     

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg–Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N?=?126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including “equal access to services,” “enhancing economic stability,” “providing safe and affordable housing with trauma-informed services,” and “training service social workers to deliver well-informed linkages and services” are discussed.     

Providing mental health care to veterans in rural areas: using telehealth in mobile clinics

The purpose of this article is to provide information to improve the quality of care of veterans living in geographically isolated areas who require treatment for mental health issues. Because interactive care solutions are currently hot topics in the health care community, they should be viewed as possible strategies to meet the needs of this specialty group of veterans. An intervention using a mobile clinic and clinical video telehealth reduces distance barriers by making it possible for mental health specialists to come to rural veterans instead of the veteran attempting to find a way to get to the practitioner, who may be located in a clinic or hospital many miles away. This article focuses on an alternate strategy-telehealth in mobile clinics-as a possible solution to the mental health crisis of veterans in rural areas.     

THE SAIGON OF THE FAMILY'S MIND: FAMILY THERAPY WITH FAMILIES OF VIETNAM VETERANS

Unlike other wars, Vietnam was America's first teenage war. This has caused unique problems in dealing with the Vietnam veteran, as exemplified by the Post-Traumatic Stress Disorder (PTSD). Although the bulk of the work done on PTSD has indicated the likelihood of veterans establishing disengaged families, it has been the author's experience that the families of Vietnam veterans often have enmeshed parent-child ties between the veteran and his children. When the children become adolescents, their quest for individualization throws the family into turmoil which has its genesis in the father's own foreclosed identity. A five-stage method of treatment (Intake, Ventilation, Bridging, Education and Hiking the Therapy Home) is proposed by the author as being a sound method of family treatment in this growing family problem.     

Differential association between unemployment status and mental health among veterans and civilians

This study aims to examine the negative effect of unemployment on mental health among 2,762 veterans and 45,095 civilians aged 18 to 50 years. The data were from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. We used ordinary least squares regression to test the interaction association between employment status and veteran/civilian status with mental health status. Findings revealed that long-term unemployed veterans had a significantly greater number of days with poor mental health than long-term unemployed civilians. The study highlights the need for future research concerning the negative effects of long-term unemployment on veterans’ mental health as well as the reciprocal relationships between mental health and occupational functioning for veterans. The findings challenge researchers to question the meanings that are associated with employment status for veterans as compared to those of their civilian peers. In addition to this, the study raises the need for further exploration into the topics of identity, self-perception, and the notion often present in the military/veteran culture that there is “dignity in labor.”     

Health disparities in military veterans with PTSD: influential sociocultural factors

Health disparities based on sociocultural factors such as gender, race and ethnicity, socioeconomic status, culture, and access to health care can potentially complicate the early diagnosis and effective management of posttraumatic stress disorder (PTSD). Research indicates that among those individuals affected by health disparities, there is a greater burden of illness and disability, higher morbidity and mortality rates, and increased behavioral risk factors. The purpose of this article is to highlight the sociocultural factors that affect the development of PTSD and to publicize health disparities in military combat veterans.     

Characteristics of urban male homeless veterans and non-veterans in Omaha,Nebraska

The current study examined differences between urban homeless veterans and non-veterans on sociodemographics, housing, clinical characteristics, and psychosocial factors. We recruited a sample of 196 homeless men (101 veterans, 95 non-veterans) from the Omaha, Nebraska metropolitan area. Structured interviews were conducted by research staff. The results showed that the two groups were similar in most respects, though there were several notable differences. Homeless veterans were found to be older and more educated than non-veterans, more likely to have married, and reported having fewer non-adult children. Multivariable models controlling for age further showed that veterans reported a higher number of medical problems and were more likely to report being diagnosed with major depression or PTSD than non-veterans. Comparison with previous studies suggests changes in certain characteristics of homeless veterans over the past few decades that may reflect the growing proportion of veterans from the all-volunteer force, initiated after the draft ended in 1975. Findings from this study were consistent with previous comparative studies suggesting limited changes in recent decades in the characteristics of homeless veterans as compared to non-veterans, although the high prevalence of major depression and PTSD merit special treatment for these disorders.     

How does discharge status impact suicide risk in military veterans?

Little is known about over 125,000 veterans who received non-honorable military discharges since 2001, even though these veterans face substantial barriers to obtaining services and are likely to be at high risk for negative mental and behavioral health outcomes including suicide. Seven-hundred twenty-two veterans living the in the San Francisco Bay Area participated in the study. The sample comprised honorably discharged (n = 508) and non-honorably discharged veterans (n = 214). T-tests were used to compare means on predictors of suicide risk including Posttraumatic Stress Disorder (PTSD), depression, alcohol use, somatic symptoms, and physical disability. A series of regression models tested relationships between predictors, discharge status, and suicide risk. Non-honorably discharged veterans demonstrated higher mean scores than honorably discharged veterans on all predictors. In regression models, somatic symptoms (β = 0.22, p < 0.001), physical disability (β = 0.16, p < 0.05), and discharge status (β = 0.33, p < 0.001) were associated with suicide risk. The final model showed an interaction effect for discharge status on the relationship between somatic symptoms and suicide risk (β = 0.16, p < 0.05). Non-honorably discharged veterans showed higher rates of mental and physical health problems and suicide risk compared to honorably discharged veterans. The magnitude of the relationship between somatic symptoms and suicide risk was significantly greater in non-honorably discharged veterans.     

The Trauma Trifecta of Military Sexual Trauma: A Case Study Illustrating the Integration of Mind and Body in Clinical Work with Survivors of MST

Military sexual trauma (MST) has recently received much attention from the media in contemporary society. With the ever-increasing population of United States service members returning from the Iraq and Afghanistan wars, it is vital for any mental health practitioner to be aware of the epidemic that is sexual assault in the military, the unique trauma experiences of the MST survivor, and treatment implications incorporating multiple psychological theories. This article explores three factors, referred to as the trauma trifecta, in which the effects of MST are exacerbated: the loss of professional and personal identity, the regulatory functions of self harm behaviors, and the retraumatization that many service members endure as a result of the distinctive characteristics of the military culture and its service to veterans. A case study with clinical interventions will be utilized to demonstrate this concept of “the trauma trifecta” and the unique challenges in treating the PTSD symptoms that can result from MST in clinical therapy. Drawing from multiple theories in clinical treatment, this paper illustrates the strengths and limitations of cognitive-behavioral techniques, highlights the integration of feminist theory to illustrate the obstacles of power structures, and mind–body interventions, bridging the gap between talk therapy and body therapy. Through this unique integration of multiple therapies, the case study illustrates the veteran’s reengagement with her body and the reformulation of her identity post MST.     

Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy

Domestic violence rates among veterans with posttraumatic stress disorder (PTSD) are higher than those of the general population. Individuals who have been diagnosed with PTSD who seek couples therapy with their partners constitute an understudied population. Self-report measures of domestic violence, relationship satisfaction, and intimacy were administered at intake to 179 couples seeking relationship therapy at a Veterans Affairs clinic. Couples in which the veteran was diagnosed with combat-related PTSD were compared with two other groups based on the veteran's primary diagnosis (depression, adjustment disorder/V-code). Both the PTSD- and depression-diagnosed veterans perpetrated more violence than did those with adjustment/V-code diagnoses. Domestic violence rates among depressed and PTSD-diagnosed veterans were much higher than those found in previous research. Implications for assessment and treatment are discussed.     

Sleep disturbances and suicide—New battles for veterans of U.S. wars in Afghanistan and Iraq: A retrospective review

In this article, we systematically reviewed 116 veterans’ medical records to explore the mitigating factors in sleep disturbance, polytrauma clinical triad (PCT), and suicide. We discovered that a particular nonaction (i.e., no standardized completion of sleep-disturbance screenings) had strong implications for resulting suicides among veterans with reported sleep disturbances, PCT, and suicidal ideations. This study provides strong propositions for the further study of this veteran cohort—Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND)—with regard to the impact of sleep disturbance on PCT and its relationship with suicide symptoms, ideation, and completion. The purpose of this study was to examine the outcomes of sleep disturbances on complex relationships among the three primary diagnoses—posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and chronic pain—that establish the PCT cluster. We identified that those diagnosed with sleep disturbances had increased suicidal ideations and rates of completed suicides. We analyzed these factors in veterans returning from the current wars in Afghanistan and Iraq. We hypothesized that (a) clinicians were not completing sleep-disturbance screenings as a standard practice for the OEF/OIF/OND veterans diagnosed with PCT who reported sleep disturbance concerns within the U.S. Department of Veterans Affairs; (b) if no sleep-disturbance screening instruments were used by clinicians, veterans would be at a greater risk of suicide completion.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

Female Veterans: Navigating Two Identities

Female veterans differ from their male veteran counterparts in terms of ratio of men to women, minority status, economic status, and age. In 2014, female veterans totaled over 2 million; roughly 10% of the veteran population. In addition to balancing personal and professional responsibilities, many female veterans also have to adjust to and cope with the physical and/or mental health conditions they experience post-deployment. The extent to which female veterans succeed in transitioning back to civilian life post-deployment may be determined by biological, psychological, and social factors within their home and community. Circumstances that can support or hinder female veterans’ reintegration process include: (a) availability of gender-specific Veterans Affairs policies and services; (b) access to education and employment; (c) supports specific to mental health and/or military sexual trauma; and (d) social stigmas associated with being a female veteran. Along with other healthcare professionals, social workers have an obligation to promote social justice, and to empower underprivileged populations, including female veterans, whose needs may differ from male veterans and require specific expertise and knowledge.