Combat exposure and mental health: the long-term effects among US Vietnam and Gulf War veterans.

Using a random sample of more than 4000 veterans, we test the effects of combat exposure on mental health. We focus on two cohorts of veterans: those who served in Vietnam (1964-1975) and the Gulf War (1990-1991). Combat exposure differed between these groups in intensity, duration and elapsed time since exposure. We find that combat exposure generally, and exposure to dead, dying, or wounded people, specifically, is a significant predictor of mental health declines as measured by an individual's Mental Component Summary score. Under our general specifications, the negative effects of combat on mental health were larger for Gulf war veterans than for Vietnam veterans as of 2001. These effects persist after controlling for demographic characteristics, insurance coverage, income and assets. Using discrete factor, nonparametric maximum likelihood (DFML) estimation we controlled for unobserved heterogeneity as well as the factors above. In the DFML specifications we find a negative impact of exposure to dead, wounded or dying people for both Gulf and Vietnam veterans, but find no statistically significant effect for combat exposure overall for Vietnam veterans as of 2001. Based on our Gulf war parameters, we estimate that the costs of mental health declines to be between $87 and $318 per year for each soldier with combat service and exposure to dead, dying and wounded people.

Equity in Veterans Affairs disability claims adjudication in a national sample of veterans.

OBJECTIVES: To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims. METHODS: Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework. RESULTS: Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects. CONCLUSIONS: Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

Compensation and wellness: a conflict for veterans' health.

In Australia greater attention is being given to health determinants, and the dominance of treatment in health policy and budgets is giving away some ground to prevention, health promotion, rehabilitation and disability management. This creates a dilemma for compensation systems: should the inclusion criteria be broadened to match the new thinking or should a narrower definition of "disease, injury or death" be retained? This issue is explored in the context of war syndromes among veterans. While veterans experience symptoms more frequently and more severely than military and community controls, their patterns of symptoms are not unique. Current compensation and benefit programs can create iatrogenic effects. It is concluded that compensation systems should be kept as safety nets while resources are provided to improve the capacity of primary health care caregivers, community organisations and veterans with war syndromes and their families to better deal with these problems. Adapting compensation systems to promote wellness through self-management health partnerships is one way of directing resources to individuals and their families. Action research at the community level with veterans, their families, their organisations, primary health care organisations, policy makers and researchers would allow this sector to work out the best way to apply existing efficacious tools to these modern health problems.

US Department of Veterans Affairs disability policies for posttraumatic stress disorder: administrative trends and implications for treatment, rehabilitation, and research.

An accumulating body of empirical data suggests that current Department of Veterans Affairs (VA) psychiatric disability and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD) are problematic. In combination, recent administrative trends and data from epidemiological and clinical studies suggest theses policies are countertherapeutic and hinder research efforts to advance our knowledge regarding PTSD. Current VA disability policies require fundamental reform to bring them into line with modern science and medicine, including current empirically supported concepts of resilience and psychiatric rehabilitation.

A randomized trial of self-management and psychoeducational group therapies for comorbid chronic posttraumatic stress disorder and depressive disorder.

The authors randomized 101 male veterans with chronic combat-related posttraumatic stress disorder (PTSD) and depressive disorder to an evidence-based depression treatment (self-management therapy; n = 51) or active-control therapy (n = 50). Main outcome measures for efficacy, using intention-to-treat analyses, were subjective and objective PTSD and depression scales at pretest, posttest, and 3-, 6-, and 12-month follow-up. Other measures included treatment compliance, satisfaction, treatment-targeted constructs, functioning, service utilization, and costs. Self-management therapy's modestly greater improvement on depression symptoms at treatment completion disappeared on follow-up. No other differences on symptoms or functioning appeared, although psychiatric outpatient utilization and overall outpatient costs were lower with self-management therapy. Despite success in other depressed populations, self-management therapy produced no clinically significant effect in depression with chronic PTSD.

Change of diagnosis of post-traumatic stress disorder related to compensation-seeking.

AIM: To explore the change in the diagnosis of posttraumatic stress disorder (PTSD) related to the implementation of the new national regulation on compensation-seeking by war veterans in Croatia. METHODS: The study included 225 compensation-seeking war veterans who were psychiatrically assessed and diagnosed on three different occasions. The first diagnosis was made by a local psychiatrist when a veteran sought psychiatric help for the first time. The second psychiatric diagnosis was established during the veteran's psychiatric treatment, and the third one was made by an independent expert team in charge of the psychiatric assessment for compensation purposes. The expert examination included structured diagnostic procedure and analysis of military service data. The diagnoses established on three different points were compared. RESULTS: There were significant differences between the diagnoses of mental disorders made at three different occasions in compensation-seeking war veterans. Six different diagnostic categories of mental disorders were confirmed. The diagnosis changed in 134 (59.5%) out of 225 veterans, mainly in the categories of PTSD and personality changes due to catastrophic experience, during their psychiatric treatment in the 2000-2002 period, when the new regulation for compensation was implemented. PTSD diagnosis remained unchanged at all three psychiatric assessments in only 7.5% of the veterans, whereas the diagnosis of a mental disorder remained unchanged in 37 (16.4%) veterans. Experts' confirmation of PTSD or PTSD comorbid with other mental disorders positively correlated with the number of hospitalizations. CONCLUSION: Inconsistencies in the diagnosis of PTSD could be related to the different diagnostic criteria and the course of illness. Psychiatric examination for compensation purposes should be independent and integrate all relevant data for making a complete assessment. Compensation-seeking policy, represented by new regulations, could be a source of bias in diagnostic outcome.

War pensions (1900-1945): changing models of psychological understanding.

BACKGROUND: War pensions are used to examine different models of psychological understanding. The First World War is said to have been the first conflict for which pensions were widely granted for psychological disorders as distinct from functional, somatic syndromes. In 1939 official attitudes hardened and it is commonly stated that few pensions were awarded for post-combat syndromes. AIMS: To re-evaluate the recognition of psychiatric disorders by the war pension authorities. METHOD: Official statistics were compared with samples of war pension files from the Boer War and the First and Second World Wars. RESULTS: Official reports tended to overestimate the number of awards. Although government figures suggested that the proportion of neurological and psychiatric pensions was higher after the Second World War, our analysis suggests that the rates may not have been significantly different. CONCLUSIONS: The acceptance of psychological disorders was a response to cultural shifts, advances in psychiatric knowledge and the exigencies of war. Changing explanations were both a consequence of these forces and themselves agents of change.

Medical-care costs associated with posttraumatic stress disorder in Vietnam veterans.

OBJECTIVE: This study examined the relationship between medical-care costs of Vietnam veterans and predictor factors, including posttraumatic stress disorder (PTSD). METHOD: We merged medical-care cost data from the Department of Veterans' Affairs and the Health Insurance Commission with data from an epidemiological study of 641 Australian Vietnam veterans. Posttraumatic stress disorder and other factors were examined as predictors of medical-care cost using regression analysis. RESULTS: We found that a diagnosis of PTSD was associated with medical costs 60% higher than average. Those costs appeared to be partly associated with higher treatment costs for physical conditions in those with PTSD and also related mental health comorbidities. Major predictors of medical-care cost were age ($137 per year for each 5-year increase in age) and number of diagnoses reported ($81 to $112 per year for each diagnosis). Mental health factors such as depression ($14 per year for each symptom reported) and anxiety ($27 per year for each symptom reported) were also important predictors. CONCLUSIONS: The findings indicate that, however they are incurred, high healthcare and, presumably, also economic and personal costs are associated with PTSD. There is an important social obligation as well as substantial economic reasons to deal with these problems. From both perspectives, continued efforts to identify and implement effective prevention and treatment programs are warranted.

Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans.

A total of 641 randomly selected Australian veterans of the Vietnam War were interviewed about their use of health care in the previous two weeks to determine what factors contributed to health care consumption. Seventy-three variables were examined by univariate linear regression and then grouped into seven categories relating to age, physical and mental health, predisposition to posttraumatic stress disorder (PTSD), deployment and repatriation experiences, and membership in veterans groups. PTSD was associated with an additional cost of $79 in health care for the two-week period. Each physical diagnosis was associated with an additional $28. Alcohol consumption was not related to health care costs. Other important variables contributing to costs were depression, educational status, the quality of the repatriation experience, and social support.

Inpatient treatment of war-related posttraumatic stress disorder: a 20-year perspective.

These papers show that long-stay inpatient PTSD programs provide treatment that is quite different from other programs but that they are neither as effective, from a psychometric perspective, nor as helpful, from the veterans' subjective perspective, as has been expected. VA treatment of PTSD is changing its focus and is being influenced by three distinct societal forces, in addition to data from studies like these: (1) the continuing effort of American society to come to terms with its Vietnam War experience; (2) the crisis of U.S. health care costs; and (3) the emergence of a movement to "re-invent" government and to increase public accountability through performance data.

Compensation for certain undiagnosed illnesses--VA. Final rule.

This document amends the Department of Veterans Affairs (VA) adjudication regulations to authorize compensation for disabilities resulting from the undiagnosed illnesses of Persian Gulf veterans. This amendment provides the necessary regulatory framework to allow the Secretary to pay compensation under the authority granted by the Persian Gulf War.

Scheduled brief admissions: patient "tuneups".

1. Incorporating brief, planned admissions into the treatment plan of chronically mentally disabled patients has demonstrated positive outcomes related to health care services, as well as to the patients' perceptions of their own health status. 2. A comparison of the "Tuneup" program before and since its inception showed that, while the number of patient hospitalizations increased, the patients' length of stay, amount of unplanned hospitalizations, and cost decreased significantly during this period. 3. The chronically mentally ill are a population at risk for a variety of hardships, including rehospitalization, social isolation, homelessness, and even death. Psychiatric nurses who understand the needs of these persons can serve as a vital force in mental health care reform.