Suicide, PTSD, and Substance Use Among
OEF/OIF Veterans Using VA Health Care:
Facts and Figures
Erin Bagalman
Analyst in Health Policy
July 18, 2011
Congressional Research Service
7-5700
www.crs.gov
R41921
CRS Report for Congress
P
repared for Members and Committees of Congress
Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care
Contents
OEF/OIF Veterans Using VA Health Care.................................................................................... 1
Suicide........................................................................................................................................ 2
Suicide Prevention in the VA Health Care System ................................................................. 2
Posttraumatic Stress Disorder (PTSD)......................................................................................... 3
PTSD Treatment in the VA Health Care System..................................................................... 3
Substance Use Disorders ............................................................................................................. 4
Substance Use Disorder Treatment in the VA Health Care System ......................................... 5
Figures
Figure 1. Annual Suicides per 100,000 OEF/OIF Veterans Using VA Health Care,
FY2002-FY2008...................................................................................................................... 2
Figure 2. Prevalence of PTSD Among OEF/OIF Veterans Using VA Health Care,
FY2002-FY2010...................................................................................................................... 3
Figure 3. Prevalence of Drug Abuse and Dependence Among OEF/OIF Veterans Using
VA Health Care, FY2002-FY2010............................................................................................ 4
Tables
Table B-1. Selected Evaluations of VA Mental Health Services Since 2008.................................. 7
Appendixes
Appendix A. Data Limitations ..................................................................................................... 6
Appendix B. Selected Evaluations of VA Services ....................................................................... 7
Contacts
Author Contact Information ........................................................................................................ 8
Congressional Research Service
Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care
n May 10, 2011, the Ninth Circuit Court of Appeals ruled against the Department of
Veterans Affairs (VA) in a case brought by two nonprofit veterans advocacy groups,
O Veterans for Common Sense and Veterans United for Truth.1 The ruling criticized the
VA’s mental health services, among other things.2 This has intensified interest in veterans’ mental
health, already a topic of ongoing concern to Members of Congress and their constituents.
This brief report addresses three relevant topics: suicide, posttraumatic stress disorder (PTSD),
and substance use disorders. Using data from the VA, it answers two questions about each topic:
(1) How many veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF)3 are
affected? and (2) What is the VA doing, in terms of screening, prevention, and treatment?
OEF/OIF Veterans Using VA Health Care
In general, veterans must enroll with the VA in order to receive VA health care services. All
enrolled veterans are offered a standard medical benefits package that covers, among other things,
mental health care, including substance abuse treatment; additional benefits may be available,
based on service-connected disabilities, income, or other factors.4
The VA offers OEF/OIF veterans enhanced enrollment eligibility for five years following
separation.5 From FY2002 through FY2010, a total of 1,250,663 OEF/OIF veterans separated
from service. Approximately half of them (625,384) used VA health care at some point during that
time.6
The VA has provided Congressional Research Service (CRS) with data on these veterans. The
data include suicide rates (annual through FY2008), prevalence of PTSD (cumulative across
years), and prevalence of substance use disorders (cumulative across years).7
The VA uses electronic medical records, which include reminders for required screenings.
Providers at the VA can also access electronic records for care provided by the Department of
Defense (DOD), including mental health assessments conducted prior to separation.8
1 Veterans for Common Sense v. Shinseki, No. 08-16728 6 (U.S. 9th Circuit Court of Appeals 2011).
2 The suit also addressed VA’s handling of disability benefits claims and medical services.
3 Operation Enduring Freedom (OEF) began on October 7, 2001, and continues today. Operation Iraqi Freedom (OIF)
began on March 20, 2003. On September 1, 2010, OIF was redesignated Operation New Dawn, which continues today.
The beginning dates of these operations are not defined in statute; the dates presented are commonly accepted. In this
report, the abbreviation OEF/OIF refers to Operation Enduring Freedom and Operation Iraqi Freedom, including
Operation New Dawn.
4 Summary of CRS Report R41343, Veterans Medical Care: FY2011 Appropriations, by Sidath Viranga Panangala.
5 Under the National Defense Authorization Act for Fiscal Year 2008 (P.L. 110-181), OEF/OIF veterans discharged or
released from active service on or after January 28, 2003, are eligible to enroll in the VA health care system for five
years from the date of discharge or release. They continue to be enrolled after the five-year eligibility period ends.
6 Department of Veterans Affairs, Office of Public Health and Environmental Hazards, Analysis of VA Health Care
Utilization among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, Cumulative
from 1st Quarter FY2002 through 4th Quarter FY2010, December 2010.
7 Prevalence is the percentage of a specified population experiencing a condition within a given timeframe.
8 Using the Federal Health and Bi-directional Health Information Exchange (FHIE/BHIE), VA and DOD share most
essential health information that is available in electronic form.
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Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care
Systematic information regarding veterans who do not use VA health care is not available. Data
about OEF/OIF veterans using VA health care should not be extrapolated to the rest of the
OEF/OIF veteran population, or to the broader veteran population. Limitations of the VA’s data
are discussed in Appendix A.
Suicide
The VA identifies veteran suicides by matching suicides from the National Death Index9 with the
roster of veterans in VA administrative data. Figure 1 presents annual suicide rates (i.e., not the
number of suicides) among male and female OEF/OIF veterans, separately and combined. Rates
are presented per 100,000 OEF/OIF veterans enrolled in VA health care; for example, in FY2008,
the rate of suicides was 38 per 100,000 OEF/OIF veterans (male and female combined) enrolled
in VA health care.10 The figure represents only completed (i.e., fatal) suicides; it does not include
attempted (i.e., nonfatal) suicides. Data limitations are discussed in Appendix A.
Figure 1. Annual Suicides per 100,000 OEF/OIF Veterans Using VA Health Care,
FY2002-FY2008
All
Male
Female
47
43
s
r
n
e
ra
30
30
p
te
28
40
s
e
e
26
38
id
V
0
ic
0
28
26
u
,0
24
S
24
100
17
8
6
FY02
FY03
FY04
FY05
FY06
FY07
FY08
Source: CRS analysis of data provided by the VA on March 8, 2011, pursuant to a CRS inquiry.
Note: Rates are presented per 100,000 OEF/OIF veterans enrolled in VA health care; for example, in FY2008,
the rate of suicides was 38 per 100,000 OEF/OIF veterans (male and female) enrolled in VA health care.
Suicide Prevention in the VA Health Care System
Department policy requires an annual depression screening for veterans using VA health care. For
each veteran identified as at high risk for suicide, a suicide prevention safety plan is developed,
and the veteran’s medical record is flagged. The VA has established a center of excellence in
suicide prevention, and every VA Medical Center is staffed with a suicide prevention
9 For more information, see Centers for Disease Control and Prevention, National Center for Health Statistics, About
the National Death Index, http://www.cdc.gov/nchs/data_access/ndi/about_ndi.htm.
10 The suicide rate is the ratio of the number of OEF/OIF veterans enrolled in VA health care who are identified as
suicides in the NDI during the year to the total number of OEF/OIF veterans enrolled in VA health care (whether in
active treatment or not). The result is then multiplied by 100,000 to create a rate per 100,000 OEF/OIF veterans.
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Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care
coordinator.11 All veterans, regardless of enrollment, may use the department’s suicide hotline (1-
800-273-8255, option 1), an online chat service (www.VeteransCrisisLine.net/chat), and an online
suicide prevention resource center (www.suicideoutreach.org) maintained jointly with the DOD.
Several reports that have evaluated the department’s suicide prevention efforts, and offered
recommendations, are listed in Appendix B.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD) is a
Figure 2. Prevalence of PTSD Among
psychological response to a traumatic event;
OEF/OIF Veterans Using VA Health Care,
however, a history of trauma is not enough to
FY2002-FY2010
establish a diagnosis of PTSD. The diagnosis
requires a minimum number of symptoms in
each of three categories: reexperiencing (e.g.,
recurring nightmares about the traumatic
PTSD
event); avoidance (e.g., avoiding
27%
conversations about the traumatic event); and
arousal (e.g., difficulty sleeping). Symptoms
No
must persist for at least one month and must
PTSD
73%
result in clinically significant distress or
impairment in functioning.12
Figure 2 shows the prevalence of PTSD
Source: U.S. Department of Veterans Affairs, Office
among OEF/OIF veterans receiving VA health
of Public Health and Environmental Hazards, Analysis
care in FY2002-FY2010.13 This percentage is
of VA Health Care Utilization Among Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF)
subject to important data limitations discussed
Veterans, Cumulative from 1st Quarter FY2002 Through
in Appendix A.
4th Quarter FY2010, December 2010.
PTSD Treatment in the VA Health Care System
Department policy requires that veterans new to VA health care receive a PTSD screening, which
is repeated every year for the first five years and every five years thereafter, unless there is a
clinical need to screen earlier. Department policy also requires that new patients requesting or
referred for mental health services receive an initial assessment within 24 hours and a full
evaluation appointment within 14 days; follow-up appointments for established patients must
occur within 30 days.14 Congressional testimony has raised questions about the extent to which
these policies are implemented in practice.15
11 Department of Veterans Affairs, Suicide Prevention, http://www.mentalhealth.va.gov/suicide_prevention/.
12 CRS summary of American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (Washington, DC: American Psychiatric Association, 2000), pp. 467-468.
13 Prevalence is the ratio of the number of OEF/OIF veterans with a diagnosis code indicating PTSD in FY2002-
FY2010 to the number of OEF/OIF veterans enrolled in VA health care in FY2002-FY2010.
14 Department of Veterans Affairs, Veterans Health Administration, Programs for Veterans with Post-Traumatic Stress
Disorder (PTSD), VHA Handbook 1160.03, March 12, 2010.
15 U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care: Closing the Gaps, 112th Cong., 1st
sess., July 14, 2011.
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PTSD treatment provided by the VA includes both medication and cognitive-behavioral therapy
(a category of talk therapy).16 Every VA Medical Center has specialists in PTSD treatment. Some
facilities offer specialized PTSD treatment programs of varying intensity and duration, including
(among others) PTSD day hospitals (four to eight hours per day, several days per week);
evaluation and brief treatment PTSD units (14-28 days); specialized inpatient PTSD units (28-90
days); and PTSD residential rehabilitation programs (28-90 days living in a supportive
environment while receiving treatment). Veterans may also receive PTSD treatment at VA
community-based outpatient clinics (CBOCs)17 or at Vet Centers18 (which are subject to different
policies than VA health care facilities).19 Several reports that have evaluated the VA’s PTSD
screening and treatment efforts, and offered recommendations, are listed in Appendix B.
Substance Use Disorders
Substance use disorders include dependence
Figure 3. Prevalence of Drug Abuse and
on and abuse of drugs, alcohol, or other
Dependence Among OEF/OIF Veterans
substances (e.g., nicotine). A diagnosis of
Using VA Health Care, FY2002-FY2010
dependence requires at least three symptoms
(e.g., tolerance or withdrawal); substance use
that does not meet criteria for dependence,
Drug
but leads to clinically significant distress or
3%
Dependence
impairment, is called abuse.20 Each diagnosis
is specific to the substance, so an individual
may have multiple diagnoses of abuse or
dependence—one for each substance (e.g.,
Drug Abuse
4%
marijuana dependence and cocaine abuse).
Figure 3 shows the prevalence of drug
dependence and abuse among OEF/OIF
Source: U.S. Department of Veterans Affairs, Office
of Public Health and Environmental Hazards, Analysis
veterans using VA health care during
of VA Health Care Utilization Among Operation Enduring
FY2002-FY2010.21 Alcohol dependence (7%)
Freedom (OEF) and Operation Iraqi Freedom (OIF)
is more common than either drug dependence
Veterans, Cumulative from 1st Quarter FY2002 Through
or abuse; the prevalence of alcohol abuse was
4th Quarter FY2010, December 2010.
not provided. These percentages are subject to
important data limitations discussed in Appendix A.
16 Jessica Hamblen, Treatment of PTSD, Department of Veterans Affairs, National Center for PTSD, 2010.
17 For more information on CBOCs see CRS Report R41044, Veterans Health Administration: Community-Based
Outpatient Clinics, by Sidath Viranga Panangala.
18 Readjustment Counseling Centers (Vet Centers) provide veterans and their families with services such as screening
and counseling for PTSD or substance use disorders, employment/educational counseling, bereavement counseling,
military sexual trauma counseling, and marital and family counseling.
19 Department of Veterans Affairs, National Center for PTSD, PTSD Treatment Programs in the U.S. Department of
Veterans Affairs, http://www.ptsd.va.gov/public/pages/va-ptsd-treatment-programs.asp.
20 CRS summary of American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (Washington, DC: American Psychiatric Association, 2000), pp. 191-199.
21 Prevalence is the ratio of the number of OEF/OIF veterans with a diagnosis code indicating abuse/dependence in
FY2002-FY2010 to the number of OEF/OIF veterans enrolled in VA health care in FY2002-FY2010.
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Substance Use Disorder Treatment in the VA Health Care System
Given the comparatively low rates of drug abuse and dependence (relative to PTSD or alcohol
dependence), VA policy does not require routine drug use screening. Department policy does
require an annual alcohol screening, which is waived for veterans who drank no alcohol in the
prior year.22
The VA offers medication and psychosocial interventions for substance use disorders, as well as
acute detoxification care when necessary. Medication may be used to reduce cravings or to
substitute for the drug of abuse (e.g., methadone for heroin users). Psychosocial interventions
include (among others) brief counseling to enhance motivation to change; intensive outpatient
treatment (i.e., at least nine hours of treatment per week); residential care (i.e., living in a
supportive environment while receiving treatment); long-term relapse prevention; and referral to
outside programs such as Alcoholics Anonymous.23
Several reports that have evaluated the department’s alcohol screening and substance use disorder
treatment efforts, and offered recommendations, are listed in Appendix B.
22 Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice Guideline for the
Management of Substance Use Disorders, August 2009.
23 Department of Veterans Affairs, Summary of VA Treatment Programs for Substance Use Problems, May 20, 2010,
http://www.mentalhealth.va.gov/res-vatreatmentprograms.asp.
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Appendix A. Data Limitations
In order to understand the limitations of the data presented in this report, it is helpful to
understand their sources. As noted previously, the VA identifies veteran suicides by matching
suicides from the National Death Index with the roster of veterans in VA administrative data. The
VA identifies PTSD and substance use disorders by searching VA administrative data for
diagnosis codes associated with specific conditions (e.g., 309.81 for PTSD). These codes are
entered into veterans’ electronic medical records by clinicians, in the normal course of evaluation
and treatment.
The data provided by the VA should be interpreted in light of at least four limitations, each of
which is discussed below.
First, suicides may be understated, because cause of death might not always be accurately
identified in the National Death Index, particularly where intent is involved. For example, it may
not be known whether a car crash or drug overdose is intentional, which may be the determining
factor in identifying suicide.
Second, some conditions may be overstated, because veterans with diagnosis codes for a
condition might not have the condition, as a result of provisional diagnoses or noncurrent
diagnoses. A provisional diagnosis code may be entered into a veteran’s electronic medical record
when further evaluation is required to confirm the diagnosis. A diagnosis may be noncurrent
when a veteran who had a condition in the past no longer has it. In either case, the code remains
in the veteran’s electronic medical record.
Third, some conditions may be understated, because veterans who have a condition might not be
diagnosed (and therefore might not have the diagnosis code in their records), if they choose not to
disclose their symptoms. Veterans might not want to disclose information that would lead to a
diagnosis of mental illness. Veterans have reported not wanting to disclose trauma for fear that
that they will not be believed, that others will think less of them, that they will be institutionalized
or stigmatized, or that their careers will be jeopardized, among other reasons.24 Also, veterans
using VA health care services may receive additional services outside the VA, without the
knowledge of the department.
Fourth, the numbers provided by the VA should not be extrapolated to all OEF/OIF veterans, or to
the broader veteran population, because OEF/OIF veterans using VA health care are not
representative of all OEF/OIF veterans or the broader veteran population. Veterans who use VA
health care may differ from those who do not, in ways that are not known. Potential differences
include (among other characteristics) disability status, employment status, and distance from a VA
medical facility.
24 Matthew D Jeffreys, Ruth Q Leibowitz, Erin Finley, et al., “Trauma Disclosure to Health Care Professionals by
Veterans: Clinical Implications,” Military Medicine, vol. 175, no. 10 (October 2010), pp. 719-724.
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Appendix B. Selected Evaluations of VA Services
Table B-1 lists selected reports published since 2008 that evaluate VA’s efforts to address suicide,
PTSD, and substance use disorders. In some cases, the focus of the evaluation was broader than
the specific topics addressed in this report (e.g., mental health services generally).
Table B-1. Selected Evaluations of VA Mental Health Services Since 2008
Report
Full Citation and Link
Suicide
PTSD
Substance
Use
Department of Veterans Affairs, Office of Inspector General, Healthcare
Inspection: Post Traumatic Stress Disorder Counseling Services at Vet Centers,
Report No. 10-00628-170, May 17, 2011, http://www.va.gov/oig/54/
√
reports/VAOIG-10-00628-170.pdf
Department of Veterans Affairs, Office of Inspector General, Combined
Assessment Program Summary Report Re-Evaluation of Suicide
Prevention Safety Plan Practices in Veterans Health Administration
√
Facilities, Report Number 11-01380-128, March 22, 2011,
http://www.va.gov/oig/CAP/VAOIG-11-01380-128.pdf
Department of Veterans Affairs, Office of Inspector General, Healthcare
Inspection: Progress in Implementing the Veterans Health Administration’s
Uniform Mental Health Services Handbook, Report No. 08-02917-145, May
√
√
√
4, 2010, http://www.va.gov/oig/54/reports/VAOIG-08-02917-145.pdf
U.S. Government Accountability Office, VA Faces Challenges in Providing
Substance Use Disorder Services and Is Taking Steps to Improve These Services
for Veterans, GAO-10-294R, March 10, 2010, http://www.gao.gov/
√
new.items/d10294r.pdf
Department of Veterans Affairs, Office of Inspector General, Healthcare
Inspection: Evaluation of Suicide Prevention Program Implementation in
Veterans Health Administration Facilities January–June, 2009, Report
√
Number 09-00326-223, September 22, 2009, http://www.va.gov/oig/54/
reports/VAOIG-09-00326-223.pdf
Department of Veterans Affairs, Office of Inspector General, Healthcare
Inspection: Review of Veterans Health Administration Residential Mental Health
Care Facilities, Report No. 08-00038-152, June 25, 2009,
√
√
http://www.va.gov/oig/54/reports/VAOIG-08-00038-152.pdf
Blue Ribbon Work Group on Suicide Prevention in the Veteran
Population, Report to James B. Peake, MD, Secretary of Veterans Affairs, June
√
30, 2008, http://www.mentalhealth.va.gov/suicide_prevention/
Blue_Ribbon_Report-FINAL_June-30-08.pdf
Source: CRS search for evaluations of VA services related to suicide, PTSD, and substance use, since 2008.
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Suicide, PTSD, and Substance Use Among OEF/OIF Veterans Using VA Health Care
Author Contact Information
Erin Bagalman
Analyst in Health Policy
ebagalman@crs.loc.gov, 7-5345
Congressional Research Service
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