Mental Disorders Among OEF/OIF Veterans
Using VA Health Care: Facts and Figures
Erin Bagalman
Analyst in Health Policy
January 11, 2013
Congressional Research Service
7-5700
www.crs.gov
R41921
CRS Report for Congress
Pr
epared for Members and Committees of Congress
Mental Disorders Among OEF/OIF Veterans Using VA Health Care: Facts and Figures
Summary
The mental health of veterans—and particularly veterans of Operations Enduring Freedom and
Iraqi Freedom (OEF/OIF)—has been a topic of ongoing concern to Members of Congress and
their constituents, as evidenced by hearings and legislation. Knowing the number of veterans
affected by various mental disorders and actions the Department of Veterans Affairs (VA) is
taking to address mental disorders can help Congress determine where to focus attention and
resources.
Using data from the VA, this brief report addresses the number of veterans with (1) depression or
bipolar disorder, (2) posttraumatic stress disorder (PTSD), and (3) substance use disorders. For
each topic, this report also briefly describes what the VA is doing in terms of screening and
treatment.
From FY2002 through FY2011, 1.4 million OEF/OIF veterans (including members of the
Reserve and National Guard) left active duty and became eligible for VA health care; by the end
of FY2011, 53% of them had enrolled and obtained VA health care. The VA publishes the
cumulative prevalence of selected mental disorders among OEF/OIF veterans using VA health
care, based on information in the VA’s electronic health records.
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.
Reports that have evaluated VA’s efforts and offered recommendations are listed in Appendix B.
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Mental Disorders Among OEF/OIF Veterans Using VA Health Care: Facts and Figures
Contents
Introduction ...................................................................................................................................... 1
OEF/OIF Veterans Using VA Health Care ....................................................................................... 1
Depression or Bipolar Disorder ....................................................................................................... 2
Prevalence Among OEF/OIF Veterans Using VA Health Care ................................................. 2
Treatment in the VA Health Care System .................................................................................. 3
Posttraumatic Stress Disorder (PTSD) ............................................................................................. 4
Prevalence Among OEF/OIF Veterans Using VA Health Care ................................................. 4
Treatment in the VA Health Care System .................................................................................. 5
Substance Use Disorders ................................................................................................................. 5
Prevalence Among OEF/OIF Veterans Using VA Health Care ................................................. 5
Treatment in the VA Health Care System .................................................................................. 6
Figures
Figure 1. Prevalence of Affective Psychoses Among OEF/OIF Veterans Using VA Health
Care, FY2002–FY2011 ................................................................................................................. 3
Figure 2. Prevalence of Depressive Disorder NEC Among OEF/OIF Veterans Using VA
Health Care, FY2002–FY2011 ..................................................................................................... 3
Figure 3. Prevalence of PTSD Among OEF/OIF Veterans Using VA Health Care,
FY2002–FY2011 .......................................................................................................................... 4
Figure 4. Prevalence of Drug Dependence Among OEF/OIF Veterans Using VA Health
Care, FY2002–FY2011 ................................................................................................................. 6
Figure 5. Prevalence of Drug Abuse Among OEF/OIF Veterans Using VA Health Care,
FY2002–FY2011 .......................................................................................................................... 6
Tables
Table B-1. Selected Evaluations of VA Mental Health Services Since 2008 ................................... 9
Appendixes
Appendix A. Data Limitations ......................................................................................................... 8
Appendix B. Selected Evaluations of VA Services .......................................................................... 9
Contacts
Author Contact Information............................................................................................................. 9
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Mental Disorders Among OEF/OIF Veterans Using VA Health Care: Facts and Figures
Introduction
The mental health of veterans—and particularly veterans of Operations Enduring Freedom and
Iraqi Freedom (OEF/OIF)1—has been a topic of ongoing concern to Members of Congress and
their constituents, as evidenced by hearings2 and legislation.3 Knowing the number of veterans
affected by various mental disorders and actions the Department of Veterans Affairs (VA) is
taking to address mental disorders can help Congress determine where to focus attention and
resources.
Using data from the VA, this brief report addresses the number of veterans with (1) depression or
bipolar disorder, (2) posttraumatic stress disorder (PTSD), and (3) substance use disorders;
Appendix A discusses important data limitations. For each topic, this report also briefly describes
what the VA is doing in terms of screening and treatment; Appendix B lists reports evaluating the
VA’s efforts.
OEF/OIF Veterans Using VA Health Care
Veterans generally must enroll in the VA health care system to receive medical care; for
information about enrollment, health benefits, and cost-sharing, see CRS Report R42747, Health
Care for Veterans: Answers to Frequently Asked Questions, by Sidath Viranga Panangala and Erin
Bagalman. From FY2002 through FY2011, 1.4 million OEF/OIF veterans (including members of
the Reserve and National Guard) left active duty and became eligible for VA health care; by the
end of FY2011, 53% of them had enrolled and obtained VA health care.4
The VA publishes the cumulative prevalence5 of selected mental disorders among OEF/OIF
veterans using VA health care, based on information in the VA’s electronic health records.
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
1 Operation Enduring Freedom (OEF) began on October 7, 2001; Operation Iraqi Freedom (OIF) began on March 20,
2003 and was redesignated Operation New Dawn on September 1, 2010. These operations are not defined in statute;
the dates presented here are commonly accepted. The abbreviation OEF/OIF is used throughout this report to refer to
Operation Enduring Freedom and Operation Iraqi Freedom (including Operation New Dawn).
2 See, for example, U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care: Closing the Gaps,
112th Cong., 1st sess., July 14, 2011; U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care:
Addressing Wait Times and Access to Care, 112th Cong., 1st sess., November 30, 2011; U.S. Congress, House
Committee on Veterans’ Affairs, Subcommittee on Health, Understanding and Preventing Veteran Suicide, 112th
Cong., 1st sess., December 2, 2011.
3 A search of the Legislative Information System for legislation introduced during the 112th and 113th Congresses, with
Topic = “Mental Health” and Keyword = “veteran” yields more than 50 results.
4 U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Analysis of VA Health Care
Utilization among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn
(OND) Veterans: Cumulative from 1st Quarter FY2002 through 4th Quarter FY2011, November 2011. (Full-year data
for FY2012 have not yet been published.) The VA reports that, during the specified time frame, 1,396,477 OEF/OIF
veterans left active duty and became eligible for VA health care; of these, 741,954 (53%) used VA health care.
5 Prevalence is the proportion of a specified population experiencing a condition within a given timeframe; cumulative
prevalence represents the proportion of a population (e.g., OEF/OIF veterans using VA health care services)
experiencing a condition at any point in an extended time period (e.g., FY2002 – FY2011).
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Mental Disorders Among OEF/OIF Veterans Using VA Health Care: Facts and Figures
OEF/OIF veteran population, or to the broader veteran population. Limitations of the VA’s data
are discussed in Appendix A.
Depression or Bipolar Disorder
Depression and bipolar disorder are both mood disorders; bipolar disorder includes episodes of
both depressed mood (which characterizes depression) and mania (elevated mood or irritability)
or hypomania (a milder form of mania).6
Prevalence Among OEF/OIF Veterans Using VA Health Care
The VA does not present separate prevalence figures for depression and bipolar disorder, nor does
it provide the prevalence of depression and bipolar disorder combined; instead, the VA presents
the prevalence of
• affective psychoses,7 a range of diagnoses including major depressive disorder
and bipolar disorder, among others (13%); and
• depressive disorder not elsewhere classified (NEC),8 a diagnosis assigned when a
patient reports depressive symptoms that do not meet criteria for other depressive
disorders (e.g., major depressive disorder) (21%).9
The percentages are presented in Figure 1 and Figure 2.Neither of these categories includes
dysthymic disorder (a form of depression), which falls in a category of neurotic disorders10 (a
broad category that also includes panic disorder and generalized anxiety disorder, among others).
It is possible that a patient with a diagnosis of one mood disorder reflected in the electronic health
record might also have a diagnosis of another mood disorder in the electronic health record; for
this reason, the prevalence of affective psychoses (13%) and the prevalence of depressive
disorder NEC (21%) should not be summed. These percentages are subject to other important
data limitations discussed in Appendix A.
6 CRS summary of American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (Washington, DC: American Psychiatric Association, 2000), pp. 345-428.
7 This category is also referred to as episodic mood disorders.
8 This condition is also referred to as depressive disorder not otherwise specified (NOS).
9 Prevalence is the ratio of the number of OEF/OIF veterans with a diagnosis code indicating one of these disorders in
FY2002-FY2011 to the number of OEF/OIF veterans enrolled in VA health care in FY2002-FY2011.
10 This category is also referred to as anxiety, dissociative, and somatoform disorders.
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Figure 1. Prevalence of Affective
Figure 2. Prevalence of Depressive
Psychoses Among OEF/OIF Veterans
Disorder NEC Among OEF/OIF Veterans
Using VA Health Care, FY2002–FY2011
Using VA Health Care, FY2002–FY2011
Affective
Depressive
Psychosis
Disorder
13%
NEC
21%
No
No
Affective Psychosis
Depressive Disorder NEC
87%
79%
Source: U.S. Department of Veterans Affairs,
Source: U.S. Department of Veterans Affairs,
Analysis of VA Health Care Utilization among Operation
Analysis of VA Health Care Utilization among Operation
Enduring Freedom (OEF), Operation Iraqi Freedom
Enduring Freedom (OEF), Operation Iraqi Freedom
(OIF), and Operation New Dawn (OND) Veterans:
(OIF), and Operation New Dawn (OND) Veterans:
Cumulative from 1st Quarter FY2002 through 4th
Cumulative from 1st Quarter FY2002 through 4th
Quarter FY2011.
Quarter FY2011.
Note: Affective psychoses include a range of
Note: Depressive disorder not elsewhere classified
diagnoses such as major depressive disorder and
(NEC) is a diagnosis assigned when depressive
bipolar disorder, among others.
symptoms do not meet criteria for other depressive
disorders (e.g., major depressive disorder).
Treatment in the VA Health Care System
Department policy requires an annual depression screening for veterans using VA health care.11
Depression and bipolar disorder may be treated with medication, psychosocial interventions, or
both.12 The VA’s suicide prevention efforts, which are relevant to patients with mood disorders (as
well as other veterans), are described in CRS Report R42340, Suicide Prevention Efforts of the
Veterans Health Administration, by Erin Bagalman. 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 Department of Defense (DOD). Several
11 For an overview of VA mental health services, see VA, Mental Health: About VA Mental Health, October 25, 2012,
http://www.mentalhealth.va.gov/VAMentalHealthGroup.asp.
12 For depression treatment, see VA, Mental Health: Depression, updated May 18, 2012,
http://www.mentalhealth.va.gov/depression.asp (see the tab labeled “VA Programs & Services”). For Bipolar Disorder
treatment, see VA, Mental Health: Bipolar Disorder, updated October 11, 2012, http://www.mentalhealth.va.gov/
bipolar.asp (see the tab labeled “VA Programs & Services”). For suicide prevention, see VA Suicide Prevention,
updated January 3, 2013, http://www.mentalhealth.va.gov/suicide_prevention/ .
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reports that have evaluated the department’s mental health programs (including treatment for
mood disorders and suicide prevention) and offered recommendations are listed in Appendix B.
Posttraumatic Stress Disorder (PTSD)
Posttraumatic stress disorder (PTSD)—one of the “signature injuries” of OEF/OIF13—is a
psychological response to a traumatic event; however, a history of trauma is not enough to
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 event);
avoidance (e.g., avoiding conversations about the traumatic event); and arousal (e.g., difficulty
sleeping). Symptoms must persist for at least one month and must result in clinically significant
distress or impairment in functioning.14
Prevalence Among OEF/OIF Veterans Using VA Health Care
As illustrated in Figure 3, the VA reports the
Figure 3. Prevalence of PTSD Among
prevalence of PTSD among OEF/OIF
OEF/OIF Veterans Using VA Health Care,
veterans receiving VA health care in FY2002-
FY2002–FY2011
FY2011 to be 28%. This percentage is subject
to important data limitations discussed in
Appendix A.
Given the attention on PTSD, it is worth
noting that prevalence estimates from other
sources (generally not limited to users of VA
health care) vary widely. A 2010 RAND
analysis of 29 relevant studies found
prevalence estimates for PTSD ranging from
around 1% to 60% among OEF/OIF
servicemembers; variation was attributed in
part to the use of different samples and
different methods of identifying PTSD.15 A
Source: U.S. Department of Veterans Affairs, Analysis
2012 report by the Institute of Medicine
of VA Health Care Utilization among Operation Enduring
indicates that recent estimates of PTSD
Freedom (OEF), Operation Iraqi Freedom (OIF), and
prevalence among OEF/OIF servicemembers
Operation New Dawn (OND) Veterans: Cumulative from
1st Quarter FY2002 through 4th Quarter FY2011.
and veterans range from 13% to 20%.16
13 Institute of Medicine (IOM), “Preface,” in Treatment for Posttraumatic Stress Disorder in Military and Veteran
Populations: Initial Assessment (Washington, DC: The National Academies Press, 2012), p. xiii.
14 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.
15 Rajeev Ramchand et al., “Disparate Prevalence Estimates of PTSD Among Service Members who Served in Iraq and
Afghanistan: Possible Explanations,” Journal of Traumatic Stress, February 2010.
16 Institute of Medicine (IOM), “Preface,” in Treatment for Posttraumatic Stress Disorder in Military and Veteran
Populations: Initial Assessment (Washington, DC: The National Academies Press, 2012), p. xiii
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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.17 Congressional testimony has raised questions about the extent to which
these policies are implemented in practice.18
PTSD treatment provided by the VA includes both medication and cognitive-behavioral therapy
(a category of talk therapy).19 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) or at Vet Centers20 (which are subject to different
policies than VA health care facilities).21 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 on and abuse of drugs, alcohol, or other substances
(e.g., nicotine). A diagnosis of dependence requires at least three symptoms (e.g., tolerance or
withdrawal); substance use that does not meet criteria for dependence, but leads to clinically
significant distress or impairment, is called abuse.22 Each diagnosis is specific to the substance, so
an individual may have multiple diagnoses of abuse or dependence—one for each substance (e.g.,
marijuana dependence and cocaine abuse).
Prevalence Among OEF/OIF Veterans Using VA Health Care
Figure 4 and Figure 5 show the prevalence of drug dependence and abuse (respectively) among
OEF/OIF veterans using VA health care during FY2002–FY2011.23 Alcohol dependence (7%) is
17 VA, VHA, Programs for Veterans with Post-Traumatic Stress Disorder (PTSD), VHA Handbook 1160.03, March
12, 2010.
18 U.S. Congress, Senate Committee on Veterans’ Affairs, VA Mental Health Care: Closing the Gaps, 112th Cong., 1st
sess., July 14, 2011.
19 Jessica Hamblen, Treatment of PTSD, Department of Veterans Affairs, National Center for PTSD, 2010.
20 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.
21 VA, 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.
22 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.
23 Prevalence is the ratio of the number of OEF/OIF veterans with a diagnosis code indicating abuse/dependence in
(continued...)
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more common than either drug dependence (3%) or abuse (4%); the prevalence of alcohol abuse
was not provided. These percentages are subject to important data limitations discussed in
Appendix A.
Figure 4. Prevalence of Drug
Figure 5. Prevalence of Drug Abuse
Dependence Among OEF/OIF Veterans
Among OEF/OIF Veterans Using VA
Using VA Health Care, FY2002–FY2011
Health Care, FY2002–FY2011
Drug
Dependence
Drug Abuse
3%
4%
No Drug
No Drug Abuse
Dependence
96%
97%
Source: U.S. Department of Veterans Affairs,
Source: U.S. Department of Veterans Affairs,
Analysis of VA Health Care Utilization among Operation
Analysis of VA Health Care Utilization among
Enduring Freedom (OEF), Operation Iraqi Freedom
Operation Enduring Freedom (OEF), Operation
(OIF), and Operation New Dawn (OND) Veterans:
Iraqi Freedom (OIF), and Operation New Dawn
Cumulative from 1st Quarter FY2002 through 4th
(OND) Veterans: Cumulative from 1st Quarter
Quarter FY2011.
FY2002 through 4th Quarter FY2011.
Treatment in the VA Health Care System
Given the comparatively low rates of drug abuse and dependence (relative to other disorders
presented in this report), 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.24
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
(...continued)
FY2002-FY2011 to the number of OEF/OIF veterans enrolled in VA health care in FY2002-FY2011.
24 Department of Veterans Affairs and Department of Defense, VA/DOD Clinical Practice Guideline for the
Management of Substance Use Disorders, August 2009.
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supportive environment while receiving treatment); long-term relapse prevention; and referral to
outside programs such as Alcoholics Anonymous.25
Several reports that have evaluated the department’s alcohol screening and substance use disorder
treatment efforts and offered recommendations are listed in Appendix B.
25 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. 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 three limitations, each of
which is discussed below.
First, 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.
Second, 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.26
Also, veterans using VA health care services may receive additional services outside the VA,
without the knowledge of the department.
Third, 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.
26 Matthew D Jeffreys 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
veterans’ mental health:
Table B-1. Selected Evaluations of VA Mental Health Services Since 2008
Institute of Medicine (IOM), Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment
(Washington, DC: The National Academies Press, 2012),
Katherine E. Watkins and Harold Alan Pincus, Veterans Health Administration Mental Health Program Evaluation: Capstone
Report, Altarum Institute and RAND Health, 2011.
U.S. Government Accountability Office, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to
Increase Access, GAO-12-12, October 14, 2011.
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.
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.
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.
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.
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.
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.
Blue Ribbon Work Group on Suicide Prevention in the Veteran Population, Report to James B. Peake, MD, Secretary of
Veterans Affairs, June 30, 2008.
Source: CRS search for evaluations of VA services related to mental health since 2008.
Author Contact Information
Erin Bagalman
Analyst in Health Policy
ebagalman@crs.loc.gov, 7-5345
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