Posttraumatic stress disorder and insomnia in US military veterans: Prevalence, correlates, and psychiatric and functional burden.

Military veterans have high rates of psychiatric conditions such as posttraumatic stress disorder, which can complicate the clinical management of insomnia. Population-based data are lacking on the prevalence, characteristics and mental health burden of veterans with co-occurring posttraumatic stress disorder and insomnia. The current cross-sectional study analysed data from a nationally representative sample of 4069 US veterans examining the prevalence and comorbidity between posttraumatic stress disorder and insomnia, and their associations with psychiatric and medical comorbidities, suicidality, and psychosocial functioning. Results revealed that 4.0% of US veterans screened positive for posttraumatic stress disorder + insomnia, 7.4% for insomnia only, and 3.2% for posttraumatic stress disorder only. Compared with controls, higher odds of major depressive disorder and generalized anxiety disorder were observed in the posttraumatic stress disorder + insomnia and posttraumatic stress disorder only groups. Moreover, compared with the control group, posttraumatic stress disorder + insomnia and posttraumatic stress disorder only groups had higher odds of current suicidal ideation, while the posttraumatic stress disorder + insomnia group had also higher odds of attempting suicide. Relative to the posttraumatic stress disorder only group, the posttraumatic stress disorder + insomnia group scored substantially lower on measures of cognitive, emotional and social functioning (d = 1.05, 1.04 and 0.87, respectively). This study provides contemporary data regarding current prevalence, correlates, and psychiatric and functional burden of posttraumatic stress disorder + insomnia among US veterans. The results underscore the importance of assessing, monitoring and treating posttraumatic stress disorder and insomnia as part of the efforts to mitigate suicide risk and promote multi-domain functioning in this population.

New-onset and exacerbated insomnia symptoms during the COVID-19 pandemic in US military veterans: A nationally representative, prospective cohort study.

The COVID-19 pandemic has had a negative impact on physical and mental health worldwide. While pandemic-related stress has also been linked to increased insomnia, scarce research has examined this association in nationally representative samples of high-risk populations, such as military veterans. We evaluated pre- and pandemic-related factors associated with new-onset and exacerbated insomnia symptoms in a nationally representative sample of 3,078 US military veterans who participated in the National Health and Resilience in Veterans Study. Veterans were surveyed in the USA in 11/2019 (pre-pandemic) and again in 11/2020 (peri-pandemic). The Insomnia Severity Index was used to assess severity of insomnia symptoms at the pre- and peri-pandemic assessments. Among veterans without clinical or subthreshold insomnia symptoms pre-pandemic (n = 2,548), 11.5% developed subthreshold (10.9%) or clinical insomnia symptoms (0.6%) during the pandemic; among those with subthreshold insomnia symptoms pre-pandemic (n = 1,058; 26.0%), 8.0% developed clinical insomnia symptoms. Pre-pandemic social support (21.9% relative variance explained), pandemic-related stress related to changes in family relationships (20.5% relative variance explained), pre-pandemic chest pain (18.5% relative variance explained) and weakness (11.1% relative variance explained), and posttraumatic stress disorder (8.2% relative variance explained) explained the majority of the variance in new-onset subthreshold or clinical insomnia symptoms during the pandemic. Among veterans with pre-pandemic subthreshold insomnia, pandemic-related home isolation restrictions (59.1% relative variance explained) and financial difficulties (25.1% relative variance explained) explained the majority of variance in incident clinical insomnia symptoms. Taken together, the results of this study suggest that nearly one in five US veterans developed new-onset or exacerbated insomnia symptoms during the pandemic, and identify potential targets for prevention and treatment efforts.

Self-rated sleep quality predicts incident suicide ideation in US military veterans: Results from a 7-year, nationally representative, prospective cohort study.

Sleep disturbance is a risk factor for future suicidal behaviours (e.g. suicidal ideation, suicide attempt, death by suicide), and military veterans are at increased risk for both poor sleep and death by suicide relative to civilians. The purpose of this study was to evaluate whether self-reported sleep quality was associated with risk of new-onset suicidal ideation in a 7-year prospective nationally representative cohort study of US military veterans. Multivariable logistic regression analyses were conducted to identify the relation between self-rated sleep quality and incident suicidal ideation in 2,059 veterans without current suicidal ideation or lifetime suicide attempt history at baseline. Relative importance analyses were then conducted to identify the relative variance explained by sleep quality and other significant determinants of incident suicidal ideation. A total of 169 (weighted 8.9%, 95% confidence interval =7.7%-10.3%) veterans developed suicidal ideation over the 7-year study period. Poor self-rated sleep quality was associated with a more than 60% greater likelihood of developing suicidal ideation (relative risk ratio = 1.62, 95% confidence interval = 1.11-2.36), even after adjustment for well-known suicide risk factors such as major depressive disorder. Relative importance analysis revealed that poor self-rated sleep quality accounted for 44.0% of the explained variance in predicting incident suicidal ideation. These results underscore the importance of assessing, monitoring and treating sleep difficulties as part of suicide prevention efforts in military veterans.

Randomized clinical trial pilot study of prolonged exposure versus present centred affect regulation therapy for PTSD and anger problems with male military combat veterans.

A randomized controlled trial pilot study (www.ClinicalTrials.org; NCT01228539) with N = 31 U.S. male military recent combat veterans with PTSD and severe anger problems was conducted comparing 10-session individual therapy versions of Trauma Affect Regulation: Guide for Education and Therapy (TARGET) versus prolonged exposure (PE). TARGET had fewer drop-outs than PE (i.e., 29% vs. 64%). At post-test, improvements were found for both interventions in increased emotion regulation and hope, and reduced PTSD symptoms, hostility, experiential avoidance, and mental health problems. At a four-month follow-up, comparable proportions (approximately 40%) of recipients in each therapy maintained clinically significant gains. Self-rated expectancy of therapeutic outcome and working alliance was comparable for both PE and TARGET early in therapy, at mid-treatment, and at the end of treatment. While preliminary, these results suggest that TARGET may be a viable therapeutic option for male military veterans with PTSD and anger problems.

Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia.

STUDY OBJECTIVES: The goal of this study was to examine the phenotypic expression of posttraumatic stress disorder (PTSD) symptoms in veterans with probable PTSD and clinical insomnia relative to those with probable PTSD alone. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4,069 US military veterans. RESULTS: A total of 3.9% of the full sample screened positive for probable PTSD and clinical insomnia and 3.2% for probable PTSD alone. Relative to veterans with probable PTSD alone, those with probable PTSD and clinical insomnia reported significantly greater severity of intrusions, avoidance, and anxious and dysphoric arousal symptoms. Post hoc analyses of individual symptoms revealed that trauma-related nightmares; flashbacks; trauma-related emotional and physiological reactivity; avoidance of trauma-related thoughts, feelings, and external reminders; exaggerated startle response; concentration difficulties; and trauma-related sleep difficulties differed between groups. A multivariable logistic regression analysis further revealed that trauma-related sleep difficulties, trauma-related physiological reactivity, and exaggerated startle response independently predicted probable PTSD and clinical insomnia relative to PTSD alone. CONCLUSIONS: Results of this study suggest that trauma-related reactivity and arousal symptoms differentiate veterans with probable PTSD and clinical insomnia from those with probable PTSD alone. They further underscore the importance of utilizing nuanced models of PTSD symptom expression as part of assessment and treatment planning efforts in this population. CITATION: DeViva JC, McCarthy E, Fischer I, Pietrzak RH. Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia. J Clin Sleep Med. 2024;20(3):345-351.

Electronic Health Record Concordance with Survey-Reported Military Sexual Trauma Among Younger Veterans: Associations with Health Care Utilization and Mental Health Diagnoses.

Introduction: Military sexual trauma (MST) is more common among post-9/11 Veterans and women versus older Veterans and men. Despite mandatory screening, the concordance of electronic health record (EHR) documentation and survey-reported MST, and associations with health care utilization and mental health diagnoses, are unknown for this younger group. Materials and Methods: Veterans' Health Administration (VHA) EHR (2001-2021) were merged with data from the observational, nationwide WomenVeterans Cohort Study (collected 2016-2020, n = 1058; 51% women). Experiencing MST was defined as positive endorsement of sexual harassment and/or assault. From the EHR, we derived Veterans' number of primary care and mental health visits in the initial two years of VHA care and diagnoses of posttraumatic stress disorder (PTSD), depression, and anxiety. First, the concordance of EHR MST screening and survey-reported MST was compared. Next, multivariate analyses tested the cross-sectional associations of EHR screening and survey-reported MST with Veterans' health care utilization, and compared the likelihood of PTSD, depression, and anxiety diagnoses by MST group, while covarying demographics and service-related characteristics. With few MST cases among men, multivariate analyses were only pursued for women. Results: Overall, 29% of women and 2% of men screened positive for MST in the EHR, but 64% of women and 9% of men had survey-reported MST. Primary care utilization was similar between women with concordant, positive MST reports in the EHR and survey versus those with survey-reported MST only. Women with survey-reported MST only were less likely to have a PTSD or depression diagnosis than those with concordant, positive MST reports. There was no group difference in women's likelihood of anxiety. Conclusions: EHR MST documentation is discordant for many post-9/11 Veterans-both for men and women. Improving MST screening and better supporting MST disclosure are each critical to provide appropriate and timely care for younger Veterans, particularly women.

Differences in sleep apnea among veterans with PTSD and other mental health conditions.

The current study compared polysomnography results of 200 consecutive VA sleep clinic referrals with PTSD, other mental health diagnoses (OTHMH), and no mental health diagnoses (NOMH). There were 59 (29.5%) NOMH cases, 62 (31.0%) PTSD cases, and 79 (39.5%) OTHMH cases. SA was diagnosed in 105 cases (52.5%), and rates of SA diagnosis did not differ by MH diagnosis. PTSD SA cases were younger than NOMH cases. NOMH cases had less sleep and higher apnea-hypopnea index than OTHMH cases. PTSD cases were not different on any sleep variable, hypertension frequency, or body-mass index.

Resilience to traumatic stress in U.S. military veterans: Application of a novel classification approach in a nationally representative sample.

Resilience has been of particular interest to researchers and clinicians focused on response to trauma. In the current study, we employed a novel, discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalizing resilience and examined its relation to potentially protective psychosocial factors in a nationally representative sample of U.S. veterans (N = 2704). Cumulative lifetime trauma burden, severity of PTSD symptoms, and protective factors such as personality characteristics (e.g., conscientiousness), protective psychosocial characteristics (e.g., purpose in life), and social connectedness (e.g., secure attachment style) were assessed. PTSD Checklist (PCL) scores were regressed onto cumulative trauma burden for the entire sample and a predicted PCL score was generated for each veteran. Resilience was operationalized as a lower actual relative to predicted PCL score. Results of a relative importance analysis revealed that somatic symptoms (22.5% relative variance explained [RVE]), emotional stability (22.4% RVE), and a secure attachment style (14.1%) explained the majority of the variance in resilience scores. These results demonstrate the utility of a DBPR approach to operationalizing resilience in U.S. military veterans. They also identify potentially modifiable psychosocial factors that may be bolstered in prevention and treatment efforts designed to mitigate the negative effects of trauma and promote resilience in this population.

The impact of sleep quality on the incidence of PTSD: Results from a 7-Year, Nationally Representative, Prospective Cohort of U.S. Military Veterans.

Sleep and posttraumatic stress disorder (PTSD) have a complex relationship, with some studies showing that disrupted sleep is associated with subsequent development of PTSD. The purpose of the current study was to examine the relationship between sleep quality and the development of probable PTSD in U.S. veterans surveyed as part of the National Health and Resilience in Veterans Study, a 7-year, nationally representative, prospective cohort study with four waves of data collection. Sociodemographic, military, trauma, and clinical variables were entered into a multivariate analysis to examine independent determinants of new-onset PTSD. A total of 142 (7.3 %) veterans developed PTSD over the 7-year study period. Poor/fair sleep quality at Wave 1 was associated with 60 % greater likelihood of developing PTSD, with more than twice as many veterans who developed PTSD reporting poor sleep quality at Wave 1 (47.8 % vs. 20.7 %). Younger age, using the VA as a primary source of healthcare, greater traumas since Wave, and lifetime depression were additionally associated with this outcome. Results of this study underscore the importance of self-reported sleep quality as a potential risk factor for the development of PTSD in the U.S. veteran population.

Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study.

STUDY OBJECTIVES: Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans. METHODS: A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning. RESULTS: A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively). CONCLUSIONS: Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

Ecological momentary assessment of sleep and PTSD symptoms in a veteran sample.

OBJECTIVE: Disturbed sleep is common among individuals with posttraumatic stress disorder (PTSD), but there has been limited research on the momentary relationships between daytime PTSD symptoms and nighttime sleep. The goal of this study was to examine the relationships between daytime peak PTSD symptoms and sleep duration that night and between sleep duration and peak PTSD symptoms the next day. METHOD: The study sample was 42 American post-2001 veterans recruited for a study of risky sexual behavior who completed a baseline PTSD Checklist-5 For 28 days, PTSD symptoms were assessed 3 times per day using a version of the PTSD Checklist-5 modified to ask about the previous 2 hours. Each morning, participants rated the previous night's sleep duration. Two multilevel models were estimated, 1 modeling a given day's peak PTSD symptoms and the other modeling a given night's sleep duration. RESULTS: In the first model, peak PTSD symptoms on a given day were significantly related to mean peak daily PTSD symptoms, estimate = 1.003, p < .001; previous night's sleep duration, estimate = -1.799, p < .001; and previous day's peak PTSD symptoms, estimate = .159, p < .05. In the second model, sleep duration on a given night was associated with mean sleep duration, estimate = 1.032, p < .001, but not with peak PTSD symptoms during that day, estimate = -.001, ns. CONCLUSIONS: This study adds to research indicating that a poorer-than-usual night's sleep is associated with higher peak PTSD symptoms the next day but higher peak PTSD symptoms in the day are not associated with worse sleep that night. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Self-assessed sleep quality partially mediates the relationship between PTSD symptoms and functioning and quality of life in U.S. veterans: Results from the National Health and Resilience in Veterans Study.

OBJECTIVE: Sleep difficulties are among the most common symptoms reported by trauma survivors with posttraumatic stress disorder (PTSD). Problems with sleep have been associated with a wide range of physical, mental, cognitive difficulties, as well as reduced quality of life (QOL). The purpose of this study was to evaluate whether self-assessed sleep quality mediated the relationship between PTSD symptoms and functioning and QOL in a nationally representative sample of U.S. military veterans. METHOD: Data were analyzed from a population-based sample of 3,157 U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). Path analyses were conducted to assess whether sleep quality mediated the relationship between PTSD symptoms and measures of functioning and QOL. RESULTS: A total of 714 veterans (weighted 27.6%) reported poor sleep quality. The prevalence of poor sleep quality was significantly higher among veterans who screened positive for probable PTSD compared with those who did not (84.2% vs. 24.7%). Path analyses revealed significant associations between greater severity of PTSD symptoms and sleep quality, ß = 0.42, as well as significant associations between greater severity of PTSD symptoms and scores on measures of cognitive functioning, ß = -0.54, mental health functioning, ß = -0.57, physical functioning, ß = -0.19, and overall QOL, ß = -0.40. Poorer sleep quality partially mediated these associations, with the strongest effects observed for physical functioning, ß = -0.28, and QOL, ß = -0.27. CONCLUSIONS: Results of this study extend prior research on the relationship between PTSD symptoms, sleep, and functioning and QOL in a nationally representative sample of U.S. veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trauma treatment for veterans in buprenorphine maintenance treatment for opioid use disorder.

INTRODUCTION: Opioid use disorder (OUD) rates are high among veterans. PTSD is also prevalent among veterans; those with comorbidity have worse outcomes than those without comorbidity. This study assessed buprenorphine retention rates in veterans initiating OUD treatment, comparing veterans without PTSD to veterans with PTSD who were receiving versus not receiving concurrent trauma treatment. METHODS: This retrospective chart review examined consecutive referrals to buprenorphine maintenance (N = 140). PTSD diagnosis was identified by chart review and retention was defined as continuous buprenorphine maintenance 6-months post-admission. Logistic regression analyses compared buprenorphine retention for veterans without PTSD and PTSD-diagnosed veterans who received concurrent trauma treatment to a reference group of PTSD-diagnosed veterans who did not receive trauma treatment. Models adjusted for opioid type, age, and service-connected status. RESULTS: Sixty-seven (47.9%) buprenorphine-seeking veterans carried a PTSD diagnosis; only 31.3% (n = 21) received trauma treatment while in buprenorphine maintenance, with 11.9% (n = 8) receiving evidence-based psychotherapy for PTSD. Among PTSD-diagnosed veterans who received trauma treatment, 90.5% (n = 19/21) were in buprenorphine maintenance at 6-months, compared to 23.9% (n = 11/46) of PTSD-diagnosed veterans without trauma treatment, and 46.6% (n = 34/73) of veterans without PTSD. In the full model, veterans with trauma treatment had 43.36 times greater odds of remaining in buprenorphine treatment than the reference group. CONCLUSIONS: Most PTSD-diagnosed veterans in buprenorphine treatment were not receiving trauma treatment. Those receiving concurrent trauma treatment had better retention, suggesting OUD and trauma can be simultaneously addressed. Future clinical trials should investigate trauma-focused treatment for veterans with comorbid PTSD who are seeking buprenorphine for OUD.

Counseling Veterans Applying for Service Connection Status for Mental Health Conditions.

Veterans with mental health conditions that were either caused or aggravated by their military service are eligible to receive service-connected disability benefits from the Department of Veterans Affairs. The process of applying for service connection status is complex, and it is not surprising that veterans frequently develop beliefs about service connection that may not be accurate and that could interfere with treatment. The authors describe some of these beliefs and offer suggestions to clinicians for addressing them. Veterans may believe that their clinician is directly involved in service connection determination or that therapy notes will determine the outcome of the claim. Veterans may not understand the basis for award of service connection and may interpret rejection of their claim as reflecting disrespect for their service or degree of distress. The authors argue that discussing these beliefs with veterans might enhance therapy by demonstrating familiarity with an important aspect of veterans' experience and by helping veterans address a significant and distressing issue.

Effects of a brief education and treatment-planning group on evidence-based PTSD treatment utilization and completion among veterans.

OBJECTIVE: Veterans with posttraumatic stress disorder (PTSD) presenting for care with Veterans Affairs Health Care System (VA) tend not to engage in evidence-based psychotherapies (EBPs) despite widespread availability of these treatments. Though there is little evidence that "readiness for treatment" affects treatment choice, many VA providers believe that interventions to increase readiness would be helpful. This naturalistic study examined the effects of a 4-session education/treatment-planning group on treatment choice among veterans in a VA outpatient PTSD treatment program. METHOD: Treatment choices and completion rates of 114 veterans who received at least 1 session of the group (EG) were compared with those of 68 veterans who did not receive the group and received PTSD program treatment as usual (TAU). TAU and EG cases were matched on gender and service era. RESULTS: Of 114 EG cases, 52 (45.6%) chose to receive EBPs, compared with 10 of 68 TAU cases (14.7%). These rates were significantly different, χ2(1) = 18.1, p < .0001. Among cases choosing EBPs, 52.2% of EG cases completed the EBPs as planned, compared with 60% of TAU cases. These percentages were not significantly different. Among EG cases choosing EBPs, lower likelihood of treatment completion was related to psychiatric medication prescription, presence of PTSD service connection, and higher overall service-connection level. CONCLUSION: The education/treatment-planning group was associated with higher likelihood of selecting but not completing EBPs for PTSD. The decision to engage in trauma-focused treatment may be a different process from the decision to complete such treatment. (PsycINFO Database Record

Correlates of VA mental health treatment utilization among OEF/OIF/OND veterans: Resilience, stigma, social support, personality, and beliefs about treatment.

Veterans of Operations Iraqi Freedom/Enduring Freedom/New Dawn (OEF/OIF/OND) tend not to engage in mental health care. Identifying modifiable factors related to mental health service utilization could facilitate development of interventions to increase utilization. The current study examined the relationship between mental health care utilization and measures of PTSD symptoms, resilience, stigma, beliefs about mental health care, perceived barriers to mental health care, posttraumatic growth and meaning, social support, and personality factors in a sample of 100 OEF/OIF/OND veterans with PTSD symptoms referred to VA mental health care. Participants who received psychotherapy and pharmacotherapy (PP) scored higher on measures of PTSD symptoms, stigma, and adaptive beliefs about mental health treatment, and lower on measures of resilience, postdeployment social support, emotional stability, and conscientiousness, than participants who received no treatment (NT). Participants who received psychotherapy only (PT) scored higher on a measure of PTSD symptoms than NT participants. PT participants scored higher on an emotional stability measure and lower on measures of PTSD symptoms and stigma than PP participants. Multinomial logistic regression including all variables significantly related to treatment utilization indicated that PTSD symptoms and adaptive beliefs about psychotherapy and pharmacotherapy were higher in the PT and PP groups than in the NT group, and concerns about discrimination were higher in the PP group than the NT group. Interventions targeting beliefs about mental health care could increase mental health treatment utilization among OEF/OIF/OND veterans. Concerns about stigma may affect the utilization process differently at different decision points. (PsycINFO Database Record

Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment.

This exploratory study investigated the relationship between anxiety disorders, anxiety comorbidity, and eating disorder (ED) symptoms in clinical practice, and examined the naturalistic detection of ED when diagnoses were based on the Anxiety Disorders Interview Schedule (ADIS). Two hundred and fifty-seven female patients completed an ED questionnaire and were assessed with the ADIS. Although ED frequency did not differ among anxiety disorder diagnoses, regression analyses revealed that social phobia (SP) and posttraumatic stress disorder (PTSD) accounted for unique variance in eating pathology. Questionnaire results indicated that almost 12% of patients met criteria for a possible ED. Clinicians using the ADIS evidenced good specificity but were not sensitive to detecting ED, missing 80% of possible cases. Results support possible links between ED, social phobia and PTSD and highlight the importance of assessing anxiety comorbidity when examining the relationship between ED and anxiety disorders. Results also suggest that formal screening for ED among female anxiety patients may be warranted.

Treatment utilization among OEF/OIF veterans referred for psychotherapy for PTSD.

Despite high levels of positive screening for mental health complaints, research indicates that veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) seek mental health care at low rates. The purpose of this study was to examine treatment utilization in 200 consecutive OEF/OIF referrals to a PTSD specialist for psychotherapy. This study also examined the relationships between treatment engagement/completion and numerous demographic and clinical variables. This chart-review study identified whether referrals were seen at all and whether they completed psychotherapy (as defined by documented mutual agreement between therapist and referral). Chi-square analyses and t tests were performed to determine whether engagement and completion were related to gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Of 200 consecutively referred OEF/OIF veterans, 75 were never seen, 86 were seen at least once without completing, and 24 completed psychotherapy. Being married and employed and older age were associated with higher likelihood of completing therapy. Completers received significantly more sessions of psychotherapy than those who were seen without completing, but the 2 groups did not differ in the types of therapy received.