Gambling and Substance Use Disorders in U.S. Military Veterans: Prevalence, Clinical Characteristics, and Suicide Risk.

Gambling and substance use disorders (SUDs) are prevalent among U.S. military veterans and often co-occur. However, little is known about the clinical and behavioral correlates and suicidal risk of SUDs and gambling among veterans that can help inform targeted interventions for their co-occurrence. In the current study, we analyzed data from a nationally representative sample of 4069 veterans who participated in the National Health and Resilience in Veterans Study. Self-reported measures of lifetime SUDs and past-year gambling (Brief Problem Gambling Screen) were administered. A multinomial logistic regression analysis was conducted to examine differences between four groups: non-SUD/non-gambling, 40.3%; SUD-only 27.3%; Gambling-only 16.3%; and SUD + Gambling, 16.1%. The Gambling-only, SUD-only, and SUD + Gambling groups reported more adverse childhood experiences relative to the non-SUD/non-gambling group. The SUD-only and SUD + Gambling groups had higher odds for all lifetime and current clinical and trauma variables relative to the non-SUD/non-gambling group. The SUD + Gambling group had higher odds of suicidality, non-suicidal self-injury, nicotine dependence and mental health treatment relative to the SUD-only group and all assessed clinical measures relative to the Gambling-only group. Results suggest that SUDs and gambling are associated with substantial trauma and mental health burden among U.S. veterans, with co-occurring SUDs and gambling linked particularly to suicidality/self-harm and mental health treatment. The findings underscore the importance of multicomponent assessments and interventions targeting SUDs, gambling, and related concerns, such as trauma-related mental health difficulties, in this population.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis.

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans-399,125 homeless and 5,729,796 non-homeless-followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

Transportation As A Determinant Of Health: Evaluating The Veterans Affairs Rideshare Program For Homeless Patients.

From 2020 to 2023, the Department of Veterans Affairs (VA) conducted a national pilot of a rideshare program to support homeless patients' transportation needs to obtain critical resources and attend medical appointments. This study linked Lyft rideshare data in 2022 to VA administrative data to examine characteristics and changes in service use among VA homeless service users. The results showed that VA homeless service users who used the VA Rideshare program were more likely to have psychiatric diagnoses and urgent care visits than those who did not use the program. When we controlled for past VA service use, use of the VA Rideshare program was associated with greater use of VA outpatient and inpatient services and fewer no-show medical appointments six months after the veterans' index date. VA Rideshare users had three to eight more program visits over the course of six months than non-Rideshare users. These findings indicate benefits associated with providing transportation assistance to vulnerable patients in a nationwide health system.

Why some homeless individuals are unsheltered: A narrative review of self-reported reasons.

The rising rate of unsheltered homelessness is a troubling and important public health issue. This narrative review sought to answer the question: What are the reasons that homeless individuals report for being unsheltered? To identify studies, systematic search methods were applied to PubMed, Google Scholar, and PsycINFO databases using the following eligibility criteria: English-written, peer-reviewed studies published from 2000 to 2023 that reported qualitative or quantitative data related to reasons why homeless individuals in a Western country were unsheltered. After duplicates were removed, 14,690 studies were screened and filtered to 10 final studies that fit all eligibility criteria and were included in the review. Eight of the 10 studies reported qualitative data from interviews and focus groups; the two quantitative studies reported data from interviewer-administered surveys. Across studies, eight thematic categories were identified as barriers to staying in shelters or other sheltered locations: lack of safety, triggers for substance use, strict shelter rules, triggers for substance use, perceived inadequate care, unsanitary conditions, required treatment to participate in housing program, no pet or family accommodations, and lack of accessibility for individuals with disabilities. Together, these findings indicate the delicate balance needed in homeless shelters to have both an inclusive/permissive and structured/safe environment for homeless individuals. Attention to the design and operation of homeless shelters, as well as staff training and accommodation for clients with special needs may improve some of these issues.

Digital access among a national sample of currently and formerly homeless veterans in 2022.

Background: Digital technologies are essential for connecting to the Internet and communicating with others. Methods: This study used data from the 2022 Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) survey, which surveyed a national sample of 1992 homeless-experienced veterans (HEV) about use of cell phones, smart phones, computers, laptops, and the Internet. Data were analyzed to compare currently and formerly homeless veterans on digital access and to identify characteristics associated with never using the Internet. Results: Over 75% of HEV reported having a cellphone and over 65% reported having a smartphone. Internet use was common among HEV as 74% of currently homeless veterans and 77% of formerly homeless veterans reported using the Internet. Among HEV who used the Internet, over 70% used the Internet at least weekly. There was no significant difference between currently and formerly homeless veterans on their Internet use in the total sample and subsamples of only black and only Hispanic veterans. Overall, HEV who were older, black non-Hispanic, and living in the Southeast were more likely to never use the Internet. Conclusions: These findings highlight the potential for technology-based interventions among HEV, and suggest a digital divide based on age, race, and geography.

Socioeconomic Correlates of Suicidal Ideation in Military Veterans: Examining the Interaction Between Homelessness and Financial Debt.

Studies in veterans have yet to examine interconnections between homelessness, financial debt, and suicidal ideation. We analyzed data from a nationally-representative study conducted in 2021 of low-income U.S. veterans (N = 1,004). Analyses revealed veterans who were younger, male, had a history of criminal arrests, met criteria for posttraumatic stress disorder (PTSD), reported greater loneliness, or had both a history of homelessness and higher debt were more likely to endorse suicidal ideation. We found an interaction between a history of homelessness and current debt: 40% of veterans with both past homelessness and higher debt reported suicidal ideation, whereas only 10% of veterans with either past homelessness or higher debt reported suicidal ideation. As past homelessness and current debt interacted to increase the odds of suicidal ideation in a national sample of veterans, these results inform policy and clinical decision-making for suicide prevention and in programs serving veterans experiencing homelessness.

Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study.

Screening for viral hepatitis is considered a high-priority area in the Veterans Health Administration (VHA). Yet, few studies have examined viral hepatitis screening test use among low-income veterans who are considered high-risk with limited healthcare access. Using cross-sectional data from 933 participants in the 2021-2022 National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, we examined rates and correlates of lifetime screening for hepatitis B (HBV) and hepatitis C (HCV) infections. Multivariable logistic regression models evaluated characteristics associated with HBV/HCV screening. Nearly 16% and 21% reported lifetime HBV and HCV screening, respectively. These rates are considerably lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records. In the NV-HOPE data, veterans 50-79 years were more likely than those ≥80 years of age to ever-screen for HBV/HCV. Whereas, household income was inversely related to lifetime screening behaviours, veterans reporting 'other' employment types (vs. full-time/part-time employment) were more likely to ever-screen for HBV/HCV. Ever-screening for HBV was more likely among veterans reporting non-Hispanic 'other' (vs. non-Hispanic 'white') race, housing instability, Medicaid insurance, as well as drug use and cognitive disorder histories. Living with ≥5 members (vs. alone), histories of alcohol use, cancer, and liver disorders were also correlated with ever-screening for HCV. HIV/AIDS history correlated with ever-screening for HBV/HCV. In conclusion, fewer than one-third of low-income US veterans ever-screened for HBV/HCV, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment and vaccinations for HBV/HCV.

Small Observational Study of Battlefield Acupuncture for Homeless-Experienced Veterans.

Background: Homeless-experienced veterans (HEVs) are an important but challenging group to care for in the U.S. Department of Veterans Affairs health care system, and there are opportunities to examine the potential of integrative and complementary medicine approaches. Methods: This observational study enrolled 33 HEVs in a one-group observational, prospective study of Battlefield Acupuncture (BFA) with a monthly follow-up for 3 months after initiating BFA. Results: Linear growth curve analyses revealed a significant improvement in overall pain scores and scores on the effects of pain on activity level, mood, and stress. Conclusions: These preliminary findings suggest the potential of BFA to improve pain among HEVs as an area for further research.

Prevalence of Four Types of Social Support and Their Relation to Mental Health among low-income U.S. Veterans: Implications for Community Health.

To provide a comprehensive examination of different types of social support and associations with mental health among U.S. military veterans, a group vulnerable to psychosocial dysfunction. Using a nationally representative sample of 1,004 low-income U.S. veterans, this study examined the prevalence and mental health correlates of emotional, informational/tangible, positive social interaction, and affectionate social support. In the sample, 49-60% of participants perceived the four types of social support "most of the time" with the lowest prevalence being positive social interaction and the highest being affectionate support. Multivariable analyses found higher levels of all four types of social support were significantly associated with being married and greater mental health functioning. Some types of social support were uniquely associated with income level and positive screens for specific psychiatric disorders. Low social support is common among low-income U.S. veterans, and there is a need for community health interventions that target different types of social support to improve mental health and community integration.

Performance of the Elixhauser Comorbidity Index in Predicting Mortality Among a National US Sample of Hospitalized Homeless Adults.

BACKGROUND: The Elixhauser Comorbidity Index (ECI) is widely used, but its performance in homeless populations has not been evaluated. OBJECTIVES: Using a national sample of inpatients, this study compared homeless and nonhomeless inpatients on common clinical diagnoses and evaluated ECI performance in predicting mortality among homeless inpatients. RESEARCH DESIGN: A retrospective study was conducted using 2019 National Inpatient Sample (NIS) data, the largest publicly available all-payer inpatient health care database in the United States. SUBJECTS: Among 4,347,959 hospitalizations, 78,819 (weighted 1.8%) were identified as homeless. MEASURES: The ECI consists of 38 medical conditions; homelessness was defined using the International Classification of Diseases Tenth Revision Clinical Modification (ICD-10-CM) diagnostic code, and clinical conditions were based on the Clinical Classifications Software Refined (CCSR) for ICD-10-CM. RESULTS: Leading clinical diagnoses for homeless inpatients included schizophrenia and other psychotic disorders (13.3%), depressive disorders (9.4%), and alcohol-related disorders (7.2%); leading diagnoses for nonhomeless inpatients were septicemia (10.2%), heart failure (5.2%), and acute myocardial infarction (3.0%). Metastatic cancer and liver disease were the most common ECI diagnoses for both homeless and nonhomeless inpatients. ECI indicators and summary scores were predictive of in-hospital mortality for homeless and nonhomeless inpatients, with all models yielding concordance statistics above 0.80, with better performance found among homeless inpatients. CONCLUSIONS: These findings underlie the high rates of behavioral health conditions among homeless inpatients and the strong performance of the ECI in predicting in-hospital mortality among homeless inpatients, supporting its continued use as a case-mix control method and predictor of hospital readmissions.

Is the Risk of Alzheimer's Disease and Related Dementias Among U.S. Veterans Influenced by the Intersectionality of Housing Status, HIV/AIDS, Hepatitis C, and Psychiatric Disorders?

BACKGROUND: Homelessness and housing instability disproportionately affect U.S. veterans with psychiatric disorders, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), hepatitis C, and Alzheimer's disease and related disorders (ADRD). We examined housing status and/or HIV/AIDS in relation to ADRD risk and evaluated hepatitis C, substance use, and mental health disorders as mediators and/or moderators of hypothesized relationships, among U.S. veterans ≥50 years of age seeking Department of Veterans Affairs (VA) healthcare services. METHODS: A retrospective cohort study was conducted using linked VA Homeless Operations Management and Evaluation System and Corporate Data Warehouse databases (2017-2023) on 3 275 098 eligible veterans yielding 133 388 ADRD cases over 5 years of follow-up. Multivariable regression and causal mediation analyses were performed, controlling for demographic and clinical characteristics. RESULTS: Taking stably housed veterans without HIV/AIDS as referent, ADRD risk was higher among veterans with homelessness/housing instability alone (adjusted hazard ratio [aHR] = 1.67, 95% confidence interval [CI]: 1.63,1.72), lower among veterans with HIV/AIDS alone (aHR = 0.65, 95% CI: 0.58,0.73), but similar to veterans with homelessness/housing instability and HIV/AIDS (aHR = 1.01, 95% CI: 0.79,1.29). In adjusted models, hepatitis C and psychiatric disorders were positively related to homelessness/housing instability and ADRD risk, but negatively related to HIV/AIDS. Statistically significant mediation and/or moderation of hepatitis C and psychiatric disorders were observed, although <10% of total effects were explained by these characteristics, controlling for confounders. CONCLUSIONS: Among older veterans, ADRD diagnoses over 5 years were less among those with HIV/AIDS, but more among those with homelessness/housing instability, and these relationships were partly explained by hepatitis C and psychiatric disorders.

Shallow Subsidies for Veterans Facing Housing Barriers in the VA Supportive Services for Veteran Families Program.

The Department of Veterans Affairs provides a shallow subsidy (i.e., subsidizing 50% of an individual's rent for two years) to Veterans experiencing housing instability. We sought to describe the characteristics of Veterans who received these subsidies. Methods. We conducted a retrospective cohort study of Veterans between 10/2019-9/2021. We identified Veteran-level characteristics associated with receiving a shallow subsidy using a multivariable two-part regression model. We also conducted qualitative interviews to identify how shallow subsidies are allocated. Results Black race, higher income, more education, and older age were positively associated with receiving a shallow subsidy; previous homelessness, prior VA outpatient cost, and participating in permanent supportive housing were negatively associated with receiving a shallow subsidy. Interviews revealed that income was the most influential determinant of whether to give shallow subsidies. Discussion Our mixed methods findings were consistent, indicating that socioeconomic stability is an important driver of shallow subsidy allocation decisions.

Barriers to Mental Health Care in US Military Veterans.

BACKGROUND: Military veterans often encounter multiple obstacles to mental health care, such as stigma, practical barriers (e.g., high cost), and negative beliefs about mental health care. To date, however, nationally representative data on the prevalence and key correlates of these barriers to care are lacking. Such data are critical to informing population-based efforts to reduce barriers and promote engagement in mental health treatment in this population. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed 4,069 US veterans, 531 (weighted 15.0%) of whom screened positive for a mental disorder but never received mental health treatment. Multivariable logistic regression and relative importance analyses were conducted to identify key predisposing, enabling, and need-based factors associated with endorsement of stigma, instrumental barriers, and negative beliefs about mental health care. RESULTS: A total 47.1% of veterans endorsed any barrier to care, with 38.7% endorsing instrumental barriers to care, 28.8% perceived stigma, and 22.0% negative beliefs about mental health care. Lower purpose in life, grit, and received social support were most consistently associated with these barriers to care. CONCLUSIONS: Nearly half of US veterans with psychiatric need and no history of mental health treatment report barriers to care. Modifiable characteristics such as a low purpose in life, grit, and received support were associated with endorsement of these barriers. Results may help inform resource allocation, as well as prevention, psychoeducation, and treatment efforts to help reduce barriers and promote engagement with mental health services in this population.

Disproportionate Increases in Numbers and Rates of Homelessness Among Women in the United States, 2018-2022.

OBJECTIVES: Information about homelessness among women is conflicting. We examined changes in the number and rate of various types of homelessness among females in multiple population groups from 2018 through 2022. METHODS: We used 5 years of population data (2018-2022) from the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA). We performed descriptive analyses to examine changes in rates of homelessness over time and differences in rates of homelessness between general and veteran populations. RESULTS: From 2018 through 2022, there were major increases in rates of unsheltered homelessness among females (25.1%) and males (17.3%) in the general population, which outpaced increases in general population birth rates. Although the percentage change in the proportion of females among all people experiencing unsheltered homelessness grew by 4.0%, the proportion of females among all veterans experiencing unsheltered homelessness grew by 26.3%. CONCLUSIONS: These findings highlight the growing problem of unsheltered homelessness in the general population. Prevention efforts should be focused particularly on the female, especially veteran female, population.

Addressing racial and ethnic disparities in premature exits from permanent supportive housing among residents with substance use disorders.

Background: Permanent supportive housing (PSH) is an evidence-based practice for reducing homelessness that subsidizes permanent, independent housing and provides case management-including linkages to health services. Substance use disorders (SUDs) are common contributing factors towards premature, unwanted ("negative") PSH exits; little is known about racial/ethnic differences in negative PSH exits among residents with SUDs. Within the nation's largest PSH program at the Department of Veterans Affairs (VA), we examined relationships among SUDs and negative PSH exits (for up to five years post-PSH move-in) across racial/ethnic subgroups. Methods: We used VA administrative data to identify a cohort of homeless-experienced Veterans (HEVs) (n = 2,712) who were housed through VA Greater Los Angeles' PSH program from 2016-2019. We analyzed negative PSH exits by HEVs with and without SUDs across racial/ethnic subgroups (i.e., African American/Black, Non-Hispanic White, Hispanic/Latino, and Other/Mixed [Asian, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander, and multi-race]) in controlled models and accounting for competing risk of death. Results: In competing risk models, HEVs with at least one SUD had 1.3 times the hazard of negative PSH exits compared to those without SUDs (95% CI: 1.00, 1.61). When stratifying by race/ethnicity, Other/Mixed race residents with at least one SUD had 6.4 times the hazard of negative PSH exits compared to their peers without SUDs (95% CI: 1.61-25.50). Hispanic/Latino residents with at least one SUD had 1.9 times the hazard compared to those without SUDs, also indicating a strong relationship with negative PSH exits; however, this association was not statistically significant (95% CI: 0.85-4.37). Black residents with at least one SUD had 1.2 times the hazard compared to those without SUDs (95% CI: 0.85-1.64), indicating no evidence of an association with negative PSH exits. Similarly, Non-Hispanic White residents with at least one SUD had 1.1 times the hazard compared to those without SUDs (95% CI: 0.75-1.66). Conclusions: These findings suggest relationships between SUDs and negative PSH exits differ between race/ethnic groups and suggest there may be value in culturally specific tailoring and implementation of SUD services for these subgroups.

Lifetime prevalence and correlates of colorectal cancer screening among low-income U.S. Veterans.

PURPOSE: The Veterans Health Administration (VHA) is the largest integrated healthcare system in the U.S. While preventive healthcare services are high priority in the VHA, low-income U.S. Veterans experience adverse life circumstances that may negatively impact their access to these services. This study examined lifetime prevalence as well as demographic, socioeconomic, military-specific, and clinical correlates of colorectal cancer (CRC) screening among low-income U.S. Veterans ≥ 50 years of age. METHODS: Cross-sectional data on 862 participants were analyzed from the 2021-2022 National Veteran Homeless and Other Poverty Experiences study. RESULTS: Overall, 55.3% (95% confidence interval [CI] 51.3-59.3%) reported ever-receiving CRC-screening services. In a multivariable logistic regression model, never-receivers of CRC screening were twice as likely to reside outside of the Northeast, and more likely to be married (odds ratio [OR] = 1.86, 95% CI 1.02, 3.37), have BMI < 25 kg/m2 [vs. 25- < 30 kg/m2] (OR = 1.75, 95% CI 1.19, 2.58), or ≥ 1 chronic condition (OR = 1.46, 95% CI 1.06, 2.02). Never-receivers of CRC screening were less likely to be female (OR = 0.53, 95% CI 0.29, 0.96), aged 65-79y [vs. ≥ 80y] (OR = 0.61, 95% CI 0.40, 0.92), live in 5 + member households (OR = 0.33, 95% CI 0.13, 0.86), disabled (OR = 0.45, 0.22, 0.92), with purchased health insurance (OR = 0.56, 95% CI 0.33, 0.98), or report alcohol-use disorder (OR = 0.10, 95% CI 0.02, 0.49) and/or HIV/AIDS (OR = 0.28, 95% CI 0.12, 0.68). CONCLUSION: Nearly 55% of low-income U.S. Veterans reported ever screening for CRC. Variations in CRC-screening behaviors according to veteran characteristics highlight potential disparities as well as opportunities for targeted behavioral interventions.

First Decade of Supportive Services for Veteran Families Program and Homelessness, 2012-2022.

As homelessness remains an urgent public health crisis in the United States, specific programs in the US Department of Veterans Affairs (VA) system may serve as a roadmap for addressing it. We examine lessons learned from the first decade (2012-2022) of the Supportive Services for Veteran Families (SSVF) program, a cornerstone in the VA continuum of homeless services aimed at both preventing homelessness among those at risk and providing rapid rehousing for veterans and their families who are currently experiencing homelessness. Drawing on information from annual reports and other relevant literature, we have identified 3 themes of SSVF that emerged as features to comprehensively deliver support for homeless veterans and their families: (1) responsiveness and flexibility, (2) coordination and integration, and (3) social resource engagement. Using these strategies, SSVF reached nearly three quarters of a million veterans and their families in its first decade, thereby becoming one of the VA's most substantial programmatic efforts designed to address homelessness. We discuss how each feature might apply to addressing homelessness in the general population as well as future research directions. (Am J Public Health. 2024;114(6):610-618. https://doi.org/10.2105/AJPH.2024.307625).

Geographic and psychosocial correlates of homelessness or unstable housing among US veterans in the Midwest.

The purpose of this study was to explore (1) the prevalence of physical and mental health conditions among veterans stratified by homelessness and unstable housing (HUH) in several Midwestern states, and (2) the correlation between HUH and sociodemographic, military, financial, risky behavior, health, and geographical characteristics. The study cohort consisted of 7260 HUH veterans and stably housed veterans in 2018-2022 in Veterans Integrated Service Network (VISN) 23. A multivariate logistic regression analysis was performed which revealed the strongest associations with HUH were any incarceration experience (adjusted odds ratio [AOR] = 0.21) and rural location (AOR = 0.33). Frontier and remote location scores (AOR = 1.23) were associated with increased risk of HUH among veterans. Our results suggest potential differences in risk for HUH among veterans living in rural versus frontier and remote locations, which may be important to consider to provide care to the many veterans in these areas.