veterans mental health essay

Post-Traumatic Stress Disorder

The crisis in veterans' mental health and new solutions, veteran suicides increase 10-fold from 2006 to 2020..

Posted November 10, 2023 | Reviewed by Davia Sills

• What Is PTSD?
• Find a therapist to heal from trauma
• Veterans suffer from high rates of mental health conditions, including PTSD, depression, and substance use.
• Suicides among veterans increased 10-fold from 2006 to 2020.
• New treatment strategies are desperately needed.
• Addressing mental and metabolic health simultaneously may lead to better outcomes.

Every year on Veterans Day, we celebrate the brave individuals who have served our country. The mental health challenges that veterans face are both unique and profound. As they transition from service to civilian life, many carry the weight of experiences that significantly impact their well-being. Conventional treatment approaches for conditions such as PTSD , anxiety , depression , and substance abuse are invaluable, yet some veterans continue to struggle with symptoms.

A recent research study published in JAMA Neurology has unearthed a deeply troubling trend: a greater than 10-fold increase in suicide rates among U.S. veterans from 2006 to 2020. Clearly, our current treatment strategies are failing far too many veterans. This is where innovative perspectives, such as the brain energy theory of mental illness, offer fresh hope and understanding.

The brain energy theory, as outlined in this post , posits that mental health conditions are intricately linked with the brain's energy dynamics. A brain with balanced and optimal energy is crucial for mental wellness. For veterans, whose brains are often taxed by the rigors of service and the scars of trauma , ensuring adequate brain energy could be particularly transformative.

Brain energy is, in essence, the currency that powers every thought, emotion , and reaction. This energy stems from the complex interplay of nutrients, hormones , neurotransmitters, and mitochondrial function. For veterans, exposure to stressful environments, trauma, sleep disruption, and physical exertion can lead to a mismatch in energy supply and demand within the brain, potentially exacerbating mental health symptoms.

Research has demonstrated that PTSD, for example, is not just a manifestation of psychological distress but may also be linked to altered metabolism . This can affect the way the brain processes information and responds to stress. By targeting these metabolic processes, we might be able to offer veterans more effective interventions.

How, then, can the brain energy theory guide novel treatment strategies?

• Nutritional Interventions: Tailored nutritional counseling aimed at optimizing brain energy production can be a powerful addition to veterans' treatment plans.
• Exercise and Stress Reduction: Interventions such as targeted exercise regimens may not only enhance overall energy but also improve brain plasticity, resilience , and the regulation of stress hormones. Mind-body practices like yoga and meditation could further aid in rebalancing the brain's energy utilization and emotion regulation mechanisms.
• Specialized Brain Energy Interventions: One promising area is the exploration of supplements, medications, and even light therapy that specifically support mitochondrial function and, consequently, brain energy. While still in the early stages of research, these interventions may offer relief for veterans whose mental health symptoms have been resistant to other treatments. One example is the application of red or near-infrared light to the scalp (transcranial photobiomodulation). In a pilot trial , this intervention was found to improve brain metabolism and reduce symptoms of traumatic brain injury and PTSD.
• Enhanced Psychotherapy : Integrating brain energy optimization into behavioral therapies could amplify their effectiveness. By ensuring the brain is energetically equipped to engage with and benefit from therapy, we can enhance learning, neural growth, and the consolidation of therapeutic gains.
• Comprehensive Care Teams: Coordinated care teams can ensure that veterans receive holistic support, addressing both mental and metabolic health.

The journey toward healing and mental wellness for veterans is both a collective and individual endeavor. By harnessing the principles of brain energy, we can open new avenues for treatment that honor the complexity of the brain and the diversity of experiences among veterans. With continued research and clinical application, this perspective holds the promise of not only alleviating symptoms but also restoring a sense of vitality and hope to those who have served.

As we move forward, it is essential to continue advocating for and investing in research that elucidates the intricate connections between metabolism and mental health. By doing so, we not only pay homage to the sacrifices of our veterans but also elevate our approach to mental health care for all.

Christopher M. Palmer, M.D. , is a Harvard psychiatrist and researcher working at the interface of metabolism and mental health. He is the director of the Department of Postgraduate and Continuing Education at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School.

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Veterans Mental Health Care

How it works

Mental health disparities affect a large amount of population across the United States. However, nobody is more affected by unstable mental health than those members of the military and their families. With the increase in the need for security in different areas of the world, military soldiers are deployed to assist in securing and protecting those areas. Often, these soldiers see combat and are affected in their mental state. Not only are the soldiers affected by the deployment, their families are often affected as well.

Spouses and children left at home have adjustment problems due to the absence of the other parent. Post Traumatic Stress Disorder can develop, not only in the soldier, but also the family members as well. Soldiers are less accepting of mental health services upon return to civilian life (Hoge, et.al., 2014). By providing advocation and services to the soldiers and their families, before, during, and after deployment, mental health for both the soldier and families can be improved.

• 1 Population Health Issue and Population Affected
• 2 Advocacy Programs Researched in this Area
• 3 Effective Attributes of the Programs
• 4 Health Advocacy Plan
• 5 Objectives for the Policy Implemented
• 6 Data and Evidence to Substantiate Proposed Need
• 7 References

Population Health Issue and Population Affected

Military personnel and their families are affected by the deployment of a soldier. These soldiers are away from home for a minimum of six months and can stay deployed for up to eighteen months. If the soldier has seen combat, their percentage of developing Post Traumatic Stress Disorder increases (Nasveld, et.al., 2018). And there is also the risk for injury that will affect the soldier’s self-image. Deployment also means added stress for the family members. The spouse is left to maintain finances, household, and children’s lives while the soldier is deployed (James & Countryman, 2012). Not only are those chores difficult, the spouse worries about the soldier and what may happen to him/her. Children of military families are also affected by the soldier and their deployment. According to the Veteran’s Administration, reactions to deployment of the parent depends on the child’s age. The age at which sees the most behavior issues are that of the younger children from age 3-5 (V.A. 2018).

Advocacy Programs Researched in this Area

Due to the backlog of veteran’s services through the Veteran’s Administration, other programs were created to help create other resources for veterans to obtain mental health care. The Veteran’s Choice Program was initiated by Congress to relieve congestion in the V.A. mental health department. This allows veterans to seek mental health services from providers within their community. This initiative also proposes more training to the mental health providers in the aspects of the military culture and prevention of suicide. This program, which was due to run out of funding in May 2018, has received new funding and revitalization for the next year.

Another program initiated by the Veteran’s Administration for veterans to help with the backlog of patients in the healthcare system is called VETS, also known as Veterans E-health & Telemedicine support Act of 2017. This program allows veterans to receive medical and mental health services within their home. By creating a familiar and confidential environment for the veterans, they are less resistant to mental health services.

In researching these programs, most of the population is not aware they exist. The veterans themselves may not have received these programs as their options for health care through the Veterans Administration. By educating military personnel and the public of the programs that are available for the veterans, there would be a greater increase in the participation of these services by military personnel and veterans. Both programs are free as they are part of the military medical benefit.

Effective Attributes of the Programs

In the First Choice Program, the veteran and their families are able to receive mental health services that are provided in their communities. This alleviates the need for the veteran to travel long distances to seek treatment at a V.A. run facility. This also helps the veteran to receive mental health treatment in a timely manner, which will decrease the chance of violent outbursts and possible suicide.

The VETS program will create more access to mental health, as well as, medical health care treatment. By allowing the veteran to remain in their home and receive mental health care in the comfort of their home, they are able to receive confidential mental health care treatment without the stigma of being seen at a mental health facility. This also allows for family members to speak with the mental health professionals to gain information regarding interventions that may be performed to help the veteran in crisis.

Health Advocacy Plan

I propose to initiate informative meetings in my local area on the mental health care opportunities for the veterans that reside in my area. These meetings will be provided at the local American Legion and V.F.W. posts in the surrounding area. This information will also be provided to the local health care organizations that participate in mental health care, including hospitals, and counseling centers.

Objectives for the Policy Implemented

I perceive that more mental health professionals will receive training in counseling of veterans that have mental health issues. I also perceive that their will be an increase in mental health care sought by veterans that have seen combat during deployment. With the increase in mental health counseling, there will be a decrease in Post Traumatic Stress Disorder symptoms among those participating in counseling.

Data and Evidence to Substantiate Proposed Need

According to statistics obtained in research regarding mental health in veterans. According to the National Veterans Foundation, 20 percent of veterans returning from the Gulf war areas have major depression or Post Traumatic Stress Disorder. Of those soldiers that have returned from the Gulf area, 20% have PTSD (SAMHSA, 2018). Of those that return, only 50% will seek treatment for mental health conditions. And of those that receive treatment, half will not receive adequate treatment for their condition. Substance abuse is also high among military with 39% suffering from alcohol abuse (“”Veterans PTSD Statistics | Statistics: Depression, TBI and Suicide””, 2018).

Do Something. (2108). 11 facts about military families. Retrieved from https://www.dosomething.org/facts/11-facts-about-military-families

Hoge, C., Grossman, S., Auchterlonie, J., Riviere, L., Milliken, C., & Wilk, J. (2014). PTSD Treatment for Soldiers After Combat Deployment: Low Utilization of Mental Health Care and Reasons for Dropout. Psychiatric Services, 65(8), 997-1004. doi: 10.1176/appi.ps.201300307

James, T., & Countryman, J. (2012). Psychiatric Effects of Military Deployment on Children and Families: The Use of Play Therapy for Assessment and Treatment. Innovations in Clinical Neuroscience, 9(2), 16-20.

Lifeline For Vets. (2016). Troubling Veteran Mental Health Facts and Statistics that Need to be Addressed. Retrieved from https://nvf.org/veteran-mental-health-facts-statistics/

Nasveld, P., Cotea, C., Pullman, S., & Pietrzak, E. (2018). Effects of deployment on mental health in modern military forces: A review of longitudinal studies. Journal Of MilitaryAnd Veteran’s Health, 20(3).

Sharp, M., Fear, N., Rona, R., Wessely, S., Greenberg, N., Jones, N., & Goodwin, L. (2015). Stigma as a Barrier to Seeking Health Care Among Military Personnel With Mental Health Problems. Epidemiologic Reviews, 37(1), 144-162. doi: 10.1093/epirev/mxu012

Veterans and Military Families | SAMHSA – Substance Abuse and Mental Health Services Administration. (2018). Retrieved from https://www.samhsa.gov/veterans-military-families

Veterans PTSD Statistics | Statistics: Depression, TBI and Suicide. (2015).

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• April 01, 2024 | VOL. 75, NO. 4 CURRENT ISSUE pp.307-398
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Mental Health Care Use Among U.S. Military Veterans: Results From the 2019–2020 National Health and Resilience in Veterans Study

• Alexander C. Kline , Ph.D. ,
• Kaitlyn E. Panza , Ph.D. ,
• Brandon Nichter , Ph.D. ,
• Jack Tsai , Ph.D. ,
• Ilan Harpaz-Rotem , Ph.D. ,
• Sonya B. Norman , Ph.D. ,
• Robert H. Pietrzak , Ph.D., M.P.H.

https://orcid.org/0000-0001-7420-7547

Search for more papers by this author

https://orcid.org/0000-0002-6066-9406

Psychiatric and substance use disorders are prevalent among U.S. military veterans, yet many veterans do not engage in treatment. The authors examined characteristics associated with use of mental health care in a nationally representative veteran sample.

Using 2019–2020 data from the National Health and Resilience in Veterans Study (N=4,069), the authors examined predisposing, enabling, and need factors and perceived barriers to care as correlates of mental health care utilization (psychotherapy, counseling, or pharmacotherapy). Hierarchical logistic regression and relative importance analyses were used.

Among all veterans, 433 (weighted prevalence, 12%) reported current use of mental health care. Among 924 (26%) veterans with a probable mental or substance use disorder, less than a third (weighted prevalence, 27%) reported care utilization. Mental dysfunction (24%), posttraumatic stress disorder symptom severity (18%), using the U.S. Department of Veterans Affairs as primary health care provider (14%), sleep disorder (12%), and grit (i.e., trait perseverance including decision and commitment to address one’s needs on one’s own; 7%) explained most of the variance in mental health care utilization in this subsample. Grit moderated the relationship between mental dysfunction and use of care; among veterans with high mental dysfunction, those with high grit (23%) were less likely to use services than were those with low grit (53%).

Conclusions:

A minority of U.S. veterans engaged in mental health care. Less stigmatized need factors (e.g., functioning and sleep difficulties) may facilitate engagement. The relationship between protective and need factors may help inform understanding of veterans’ decision making regarding treatment seeking and outreach efforts.

Only 12% of all veterans in the full sample and 27% of those who screened positive for mental or substance use disorder reported current mental health treatment utilization.

Need factors, such as mental and cognitive functioning, posttraumatic stress disorder symptoms, and sleep-related difficulties, were most predictive of utilization.

Perceived stigma and barriers to care explained minimal variance in use of mental health care but were endorsed by a meaningful number of veterans.

Among veterans with lower mental functioning, those with high grit were substantially less likely to use services than were those with low grit, suggesting that protective factors may influence the relationship between need factors and care utilization.

Among U.S. military veterans, mental and substance use disorders are prevalent, impairing, and often chronic without treatment ( 1 , 2 ). Although evidence-based interventions are often effective ( 3 – 6 ), up to one-third of veterans with mental disorders do not receive treatment ( 7 , 8 ). Further, even when veterans ultimately engage in services, delayed treatment initiation is common, with one nationally representative study estimating median times of 16 and 2.5 years for pre- and post-9/11 veterans, respectively, between onset of diagnosis and treatment for posttraumatic stress disorder (PTSD) ( 9 ). To engage more veterans in treatment in a timely manner, it is critical to identify determinants and correlates of mental health care utilization.

Treatment utilization research among veterans has primarily focused on psychotherapy for PTSD ( 10 ). Less is known about other disorders, such as depression, anxiety, and substance use disorders, which frequently co-occur with PTSD and each other ( 2 , 11 , 12 ). Additionally, research has primarily examined veterans in the Veterans Health Administration (VHA) ( 10 ), yet most veterans receive health care outside the VHA ( 13 ). Only one in five veterans use the U.S. Department of Veterans Affairs (VA) for primary health care ( 2 , 13 , 14 ), and many maintain other health care coverage ( 15 ). Consequently, the prevalence and correlates of mental health care utilization in the population of U.S. veterans remain unknown.

A widely used model to understand use of health care is the behavioral model of health service utilization (BMHSU) ( 16 ), positing that use is determined by predisposing, enabling, and need factors. Predisposing characteristics, such as nonminority ethnic-racial status ( 17 , 18 ) and trauma or combat exposure ( 18 , 19 ), have been linked to higher rates of health care utilization among veterans. Enabling factors, such as unemployment ( 19 ) or closer proximity to services ( 20 ), may also facilitate use. Need factors have been most robustly associated with use ( 19 , 20 ), particularly greater severity of PTSD or depressive symptoms ( 17 , 20 – 23 ), medical conditions ( 19 ), and screening positive for mental or substance use disorders and comorbid psychiatric conditions ( 20 , 24 , 25 ). Researchers have also frequently studied factors related to perceived barriers to care, such as stigma, pragmatic barriers, and treatment-related beliefs. Among veterans, more positive treatment beliefs ( 21 , 24 , 26 , 27 ) and lower perceived stigma ( 14 , 24 , 26 ) have been linked to greater likelihood of mental health care utilization.

Although studies of need factors have often emphasized psychological distress and impairment, we have also examined medical conditions and insomnia, given their associations with mental health ( 28 ), possible links to health care utilization ( 24 , 29 ), and the older age of the veteran population. Further, we have considered the role of protective psychosocial characteristics (e.g., grit, defined as trait perseverance that extends to one’s decision or commitment to address mental health needs on one’s own; dispositional optimism; and purpose in life) as possible need factors, because these factors could inhibit or facilitate use by affecting an individual’s perceived need for services. Given the links of these factors to lower psychological distress ( 30 ), individuals scoring higher on these characteristics may perceive an ability to manage distress on their own, in turn dissuading them from seeking care ( 21 ). Furthermore, these traits may moderate the relation between need-based correlates and mental health care utilization; for example, among individuals with high distress, those with higher grit may be less likely to engage in treatment.

In this study, we applied a BMHSU-informed model of health care utilization that included predisposing, enabling, and need factors and perceived barriers to care to examine the prevalence and correlates of current use of mental health care (i.e., counseling, psychotherapy, or medication) in a nationally representative sample of veterans and a subsample of those with a probable current mental disorder (e.g., PTSD, major depressive disorder, or generalized anxiety disorder [GAD]) or substance use disorder (e.g., alcohol use or drug use disorder). Veterans with a probable mental or substance use disorder were grouped together, given high diagnostic overlap among these disorders and because they frequently co-occur among U.S. veterans ( 28 , 31 ). We examined correlates of care utilization in the full sample given that functional impairment or distress occur in subclinical or subthreshold conditions ( 32 , 33 ) and to adhere to previous methods in utilization literature ( 24 ). We hypothesized that need factors ( 10 , 17 , 20 – 22 , 24 , 25 ) and fewer barriers to care ( 14 , 21 , 24 , 27 ) would be most strongly associated with use.

Participants, Procedures, and Variables

Data were drawn from the 2019–2020 National Health and Resilience Veterans Study, a nationally representative survey of 4,069 U.S. military veterans. The human subjects subcommittee of the VA Connecticut Healthcare System approved the study protocol, and all participants provided informed consent. Table S1 in an online supplement to this article describes the study variables, which included predisposing, enabling, and need characteristics and perceived barriers to care.

Data Analyses

Analyses proceeded in five steps. First, exploratory factor analyses combined variables assessing common constructs into one variable (e.g., functional difficulties). Second, in the full sample and a subsample of veterans with a probable mental or substance use disorder (N=924), independent-samples t tests and chi-square analyses compared characteristics of veterans who were engaged in mental health care with those of veterans who were not engaged. Third, hierarchical logistic regression analyses identified independent correlates of care utilization; we entered variables into sequential blocks by using the BMHSU-informed model of health care to determine specific variance explained by each variable cluster. After identifying significant correlates, we incorporated an interaction term to evaluate whether the strongest protective factor moderated the association between the strongest negative correlate and use of health care. Statistics from the final, comprehensive models with each block of variables are reported in Results. Fourth, post hoc analyses of multicomponent variables (e.g., psychological distress and functional difficulties) were conducted to specify features that drove associations with use. Fifth, relative importance analyses ( 34 ) determined relative contributions of each significant variable in predicting use after accounting for intercorrelations among independent variables.

The mean±SD age of the participants was 62±16 years (range 22–99), and 90% (N=3,564) were male (percentages were calculated with poststratification weighting). Most participants were non-Hispanic White (N=3,318, 78%), with 11% (N=296) being non-Hispanic Black, 7% (N=307) Hispanic, and 4% (N=148) other or mixed race. Veterans of all branches were represented (Army, 47% [N=2,707]; Navy, 20% [N=879]; Air Force, 19% [N=955]; Marines, 6% [N=260]; and National Guard, Reserves, or Coast Guard, 8% [N=409]). Overall, 35% (N=1,353) were combat veterans, and 36% (N=1,476) had served for ≥10 years. Nearly all (N=3,989, 98%) reported having health insurance such as Medicare (N=2,399, 47%) or through a current or former employer (N=1,447, 41%) or the VA (N=1,336, 33%); 21% (N=790) reported the VA as their primary source of health care. (Details regarding data collection are presented in the online supplement .)

In the full sample (N=4,069), 433 veterans (weighted prevalence, 12%, 95% confidence interval [CI]=11%–13%) reported current engagement in mental health care, including psychotherapy or counseling (N=243, weighted prevalence, 7%, 95% CI=6%–8%), pharmacotherapy (N=383, weighted prevalence, 10%, 95% CI=9%–11%), or both (N=193, weighted prevalence, 6%, 95% CI=5%–6%). In total, 924 (26%) veterans screened positive on one or more of the respective self-report measures of PTSD, major depressive disorder, GAD, alcohol use disorder, or drug use disorder. Most of these veterans (N=685, weighted prevalence, 73%, 95% CI=71%–76%) reported no current engagement in treatment, and 157 (weighted prevalence, 19%, 95% CI=17%–21%) reported receiving psychotherapy or counseling, 211 (weighted prevalence, 23%, 95% CI=21%–26%) pharmacotherapy, and 129 (weighted prevalence, 16%, 95% CI=13%–18%) both types of treatments.

In the full sample, 10% (N=359) had alcohol use disorder, 9% (N=291) major depressive disorder, 9% (N=313) drug use disorder, 8% (N=229) GAD, and 7% (N=214) PTSD. In the subsample of veterans with a probable mental or substance use disorder (N=924), 40% (N=360) had alcohol use disorder, 37% (N=314) drug use disorder, 33% (N=292) major depressive disorder, 30% (N=232) GAD, and 25% (N=217) PTSD; 62% (N=612) had one probable disorder, 21% (N=190) had two, 10% (N=81) had three, 6% (N=34) had four, and 1% (N=7) had all five.

Bivariate analyses for the two samples are shown in Tables S2 and S3 in the online supplement . Tables 1 and 2 present results of multivariable regression analyses examining correlates of current health care utilization in the full sample and in the subsample with a probable mental or substance use disorder, respectively. Collinearity diagnostics did not reveal multicollinearity in either model, with variance inflation factors for all variables <5. Results from parallel analyses in a subset of veterans (N=3,007, 74%) unlikely to have a mental or substance use disorder per screening measures are available in the online supplement .

a ACES, Adverse Childhood Experiences Scale; ADL, activities of daily living; IADL, instrumental activities of daily living; VA, U.S. Department of Veterans Affairs.

b Cumulative variance is explained in the full multivariable model (Nagelkerke R 2 =0.44).

c Post hoc analyses indicated that the association between psychological distress and mental health treatment use was driven by posttraumatic stress disorder symptoms (odds ratio [OR]=1.02, 95% confidence interval [CI]=1.01–1.04, p<0.001) but not by depression or generalized anxiety disorder symptoms (p>0.11).

d Post hoc analyses indicated that the association between medical conditions and mental health treatment use was driven by sleep disorder (OR=2.51, 95% CI=1.88–3.35, p<0.001), high cholesterol (OR=1.95, 95% CI=1.46–2.60, p<0.001), chronic pain (OR=1.61, 95% CI=1.22–2.14, p=0.001), hypertension (OR=1.38, 95% CI=1.02–1.86, p=0.037), and no previous heart attack (OR=0.36, 95% CI=0.19–0.68, p=0.002) but not by any other conditions (p>0.08).

e Post hoc analyses indicated that the association between functioning and mental health treatment use was driven by worse mental (OR=0.93, 95% CI=0.91–0.96, p<0.001) and cognitive (OR=0.89, 95% CI=0.97–0.99, p=0.009) functioning and better physical functioning (OR=1.02, 95% CI=1.01–1.03, p=0.044) but not by psychosocial functioning (p=0.20).

TABLE 1. Associations between current mental health care utilization and predisposing, enabling, and need factors and barriers to care among U.S. military veterans (N=4,069) a

a Veterans in his subgroup had screened positive for current posttraumatic stress, major depressive, generalized anxiety, alcohol use, or drug use disorder. ACES, Adverse Childhood Experiences Scale; ADL, activities of daily living; IADL, instrumental activities of daily living; VA, U.S. Department of Veterans Affairs.

c Post hoc analyses indicated that the association between psychological distress and mental health treatment utilization was driven by PTSD symptoms (odds ratio [OR]=1.01, 95% confidence interval [CI]=1.01–1.03, p=0.048) but not by depression or generalized anxiety disorder symptoms (p>0.06).

d Post hoc analyses indicated that the association between number of medical conditions and mental health treatment utilization was primarily driven by sleep disorder (OR=2.50, 95% CI=1.63–3.83, p<0.001), previous concussion or mild traumatic brain injury (OR=2.03, 95% CI=1.16–3.58, p<0.001), high cholesterol (OR=2.20, 95% CI=1.44–3.36, p<0.001), and no previous heart attack (OR=0.28, 95% CI=0.11–0.72, p=0.008) but not by any other conditions (p>0.10).

e Post hoc analyses indicated that the association between functioning and mental health treatment use was driven by worse mental functioning (OR=0.93, 95% CI=0.90–0.95, p<0.001) and better physical functioning (OR=1.02, 95% CI=1.01–1.05, p=0.030) but not by changes in cognitive or psychosocial functioning (p>0.19).

TABLE 2. Associations between current mental health care utilization and predisposing, enabling, and need factors and barriers to care among U.S. military veterans who screened positive for a mental or substance use disorder (N=924) a

Relative importance analysis in the full sample revealed that mental dysfunction (i.e., emotional difficulties, such as anxiety and depression and their impact on social and occupational functioning; 19% relative variance explained [RVE]) and cognitive dysfunction (12% RVE), PTSD symptom severity (12% RVE), chronic pain (9% RVE), and grit (6% RVE) accounted for most of the explained variance in health care utilization. In the subsample, mental dysfunction (24% RVE), PTSD symptom severity (18% RVE), the VA as primary source of health care (14% RVE), sleep disorder (12% RVE), grit (7% RVE), and history of suicide attempt (6% RVE) accounted for most of the explained variance (see Figures S1 and S2 in the online supplement ).

To examine whether the strongest protective correlate—grit—moderated the effect of the strongest need correlate—mental dysfunction—on use of care, we incorporated a mental functioning × grit interaction term into regression models. This interaction was statistically significant in both the full sample (Wald χ 2 =4.82, p=0.028; odds ratio [OR]=0.88, 95% CI=0.78–0.99) and the subsample (Wald χ 2 =7.94, p=0.005; OR=0.80, 95% CI=0.68–0.93). Among veterans with high mental dysfunction, those with high grit (23%) were significantly less likely to use services than were those with low grit (53%) ( Figure 1 ).

FIGURE 1. Probability of mental health treatment among veterans, by mental functioning tertile and level of grit a

a A: full sample of veterans (N=4,069); B: subsample of veterans screening positive for mental or substance use disorder (N=924). Mental functioning tertiles were computed with mental component summary scores from the Short Form–8 Health Survey. The score range for tertile 1 was 8–52 (median=46); tertile 2, 53–58 (median=55); and tertile 3, 59–68 (median=59). Possible scores range from 0 to 100, with higher scores indicating better functioning. A median split procedure was used to stratify groups into low- and high-grit groups; the score range was 1.1–3.7 (median=3.4) for the low-grit group and 3.9–5.0 (median=4.1) for the high-grit group. Error bars show 95% confidence intervals. −1 SD and +1 SD refer to one standard deviation below and above the mean for grit, respectively.

In line with literature indicating underuse of mental health care among veterans ( 24 ), we found that only 27% of U.S. veterans with a probable mental or substance use disorder and 12% of U.S. veterans in general were currently engaged in mental health treatment. A key implication of this finding is that available treatments—although often effective—may not be reaching most veterans who could benefit from them. Correlates were generally consistent with literature reporting that need factors are most robustly associated with mental health care utilization ( 10 , 17 , 19 – 22 , 24 , 25 ). However, previous studies have rarely examined need factors that may be protective. This study therefore extends this literature, showing that protective psychosocial factors and their interaction with more commonly studied need characteristics may shed additional light on veterans’ health services use and could help inform strategies to engage veterans in treatment.

As hypothesized, need factors emerged as the strongest correlates of mental health care utilization among veterans. Psychological distress—indexed with a composite variable of depressive, anxiety, and PTSD symptoms—was strongly associated with use of care, primarily driven by PTSD symptoms. Indices of cognitive dysfunction and mental dysfunction were also salient contributors, accounting for nearly a third of the explained variance in care utilization. Previous findings suggest that functional impairment accompanying psychological distress may motivate use of mental health services ( 35 ) and underscore the importance of assessing functioning in addition to psychiatric symptoms to most accurately gauge veterans’ mental health care needs. In the full sample, a diagnosis of a substance use disorder was not associated with mental health care utilization, suggesting that the reasons underlying treatment seeking may differ between individuals with mental or substance use disorders. It is also possible that individuals with a substance use disorder sought treatment through 12-step programs rather than psychotherapy, counseling, or medication.

The relationship between functioning and use of health care was further clarified when considered in the context of protective psychosocial factors. Specifically, grit was negatively associated with use and also moderated the relationship between mental functioning and utilization. Grit is positively correlated with constructs such as self-efficacy and conscientiousness ( 36 , 37 ), suggesting that this factor may reflect individuals’ self-efficacy and belief in their ability to handle mental health difficulties on their own. These traits are often considered assets or strengths (e.g., self-reliance and perseverance), but in the context of help seeking could also be a barrier (e.g., reluctance to seek help). Protective factors were included as need factors within the BMHSU framework, given that they may affect perceived need for services. Our results suggest nuanced relationships between service use and need and protective factors that merit attention.

Veterans who reported higher levels of mental dysfunction and scored lower on a measure of grit were particularly likely to be engaged in treatment, suggesting that these individuals may reflect a particularly distressed subgroup of veterans. Conversely, veterans reporting similar levels of mental dysfunction who scored highly on grit were less likely to be engaged in treatment. This pattern suggests that higher levels of grit among veterans may reduce their likelihood of seeking treatment, even in the presence of clinically meaningful distress. Clinically, our results highlight the potential utility of promoting grit once veterans begin treatment (i.e., leveraging grit to bolster treatment motivation and engagement and emphasizing goal setting). For veterans reporting greater functional impairment and lower protective factors, interventions designed to cultivate personal strengths ( 38 )—in addition to mitigating symptoms and functional difficulties—may be beneficial for boosting treatment engagement and response. Notably, of the four protective factors examined (i.e., resilience, purpose in life, grit, and optimism), only grit was strongly associated with mental health care utilization in the subsample. Our findings therefore need replication, and additional research is needed regarding protective factors, their links to distress, and how these factors affect treatment engagement.

Other need factors linked to greater likelihood of use in both samples included a history of attempted suicide, sleep-related difficulties, and medical burden. Although it is encouraging that veterans with suicide attempt histories were more likely to be engaged in treatment, continued efforts in suicide prevention ( 39 ) are critically needed. Suicide rates among veterans have increased in the past two decades ( 40 ), and 60% of veterans endorsing suicidal ideation are not engaged in mental health treatment ( 26 ). Regarding sleep-related difficulties and medical burden, screening veterans for mental health and substance use and connecting them with needed treatment via integration with primary care and nonmental health clinics are effective methods for increasing care access and boosting use ( 41 , 42 ) and have been increasingly adopted by the VA and other health care settings ( 43 , 44 ). Results suggest that health care systems should continue to leverage this overlap between medical, sleep, and mental health difficulties, because assessment of less stigmatized need factors (i.e., sleep and general medical health) may help identify veterans in need of mental health care. Insomnia treatment, for example, is preferred to PTSD or depression interventions among veterans ( 45 ) and has been theorized as a possible gateway for connecting veterans with needed mental health services ( 45 , 46 ). The broad array of need factors also highlights the significance of interdisciplinary, integrative care, which has been increasingly adopted within the VA and has effectively increased veterans’ mental health care utilization ( 47 ).

Enabling factors were generally unrelated to use of mental health care, a result that aligns with literature indicating that need factors are more consistent and stronger correlates of use. Aside from use of the VA as primary source of health care, only unemployment was linked to use in the full sample, and no other enabling characteristics emerged as correlates in the subsample of veterans with a probable current mental or substance use disorder. Employment was negatively associated with use, possibly because employed veterans have less functional or occupational impairment, have less distress due to financial problems, or have work schedules that interfere with treatment. In both samples, health care users were more likely than nonusers to report the VA as their primary source of health care. Veterans who use the VA tend to have higher rates of psychiatric symptoms, suicidality, trauma exposure, and functional impairment ( 13 ); however, the link between primary VA use and care utilization remained significant even when these factors were controlled for. Primary VA care may thus reflect an enabling factor that facilitates access to mental health care services and increases veterans’ likelihood of using them. Further research should examine specific facets of VA care that may promote mental health care engagement (e.g., no or minimal treatment cost, integrated primary and mental health care, routine mental health screenings, and increased telehealth availability), which may also promote mental health care engagement in non-VA systems.

Predisposing characteristics associated with health care utilization were female sex and deployments and, in the full sample, younger age. This finding highlights the potential importance of tailoring strategies to promote utilization among symptomatic veterans who are male, combat-exposed, and older. Outside the BMHSU framework, perceived stigma and barriers to care explained relatively little variance in utilization. Nevertheless, in the symptomatic subsample, endorsement of “it would be embarrassing to seek treatment” was associated with a highly reduced odds of use, whereas in the full sample, endorsements of “it would harm my reputation” and “mental health care does not work” also were associated with significantly reduced odds of use. Although stigma related to mental health treatment has decreased among U.S. military members in recent years ( 48 ), these findings suggest that continued efforts to combat stigma, such as psychoeducation and promotion of mental health literacy, may help motivate treatment engagement. Fortunately, beliefs regarding stigma are modifiable and unrelated to use once veterans have attended even a single mental health visit ( 22 ).

The results of this study should be interpreted in light of several limitations. First, its cross-sectional design precluded examining how changes in correlates over time may affect use of care. Second, screening instruments, rather than semistructured clinical interviews, were used to identify probable mental and substance use disorders. Although the results obtained with the scales we used are known to correlate strongly with results from gold-standard diagnostic interviews ( 49 , 50 ), screening via self-report measures may have inflated estimates of disorder prevalence. Third, because the sample comprised primarily older White male veterans, it is important to understand whether the results generalize to younger, more diverse veterans. Relatedly, although the sample was nationally representative, the participation rate from the larger panel of veterans was only 52%. Although poststratification weights enhanced generalizability of our results to the broader U.S. veteran population, it is possible that more symptomatic veterans may have been less represented in this sample, and homeless and institutionalized veterans were excluded altogether. Fourth, psychotherapy and medication categories were combined because only a small number of veterans engaged in psychotherapy only. This data handling may have limited the specificity of our findings, because correlates of medication and psychotherapy use may differ. Fifth, although we adhered to established theory and literature in classifying variables, some variables could have been placed in more than one cluster (e.g., activities of daily living could be an enabling or need factor). Finally, programs such as Alcoholics Anonymous and Narcotics Anonymous were not formally assessed and may affect utilization estimates.

Notwithstanding these limitations, strengths of this study included examination of a broad constellation of variables associated with mental health care utilization in a contemporary, nationally representative sample of U.S. veterans. Additionally, correlates examined in this study, including novel indicators of use (i.e., protective factors), explained 44%−50% of the variance in care utilization, thus providing insight into key correlates of use in this population.

Conclusions

Mental health treatments are often not reaching veterans who need them, a deficiency that may be especially pronounced among veterans who are distressed but also have high numbers of protective factors. Our findings underscore the importance for continued research on strategies to reduce stigma and negative beliefs and promote mental health literacy among veterans, particularly regarding the availability of evidence-based mental health interventions. Future work should also more precisely ascertain the impact of protective factors among veterans with mental and substance use disorders; specifically, our understanding of treatment seeking among veterans will be improved by deciphering whether protective factors reflect veterans’ self-reliance and capacity to manage distress on their own or whether they reflect a barrier to seeking help. Better understanding protective factors and their links to distress and impairment may help identify additional veterans who could benefit from care. Another future direction is to evaluate and disseminate self-help tools such as mobile apps and online programs (e.g., PTSD Coach, Virtual Hope Box, and VetChange), which may be treatment options ideal for veterans with high levels of both distress and protective factors and who want to manage mental health and substance use difficulties on their own.

The National Health and Resilience in Veterans Study is supported by the VA National Center for Posttraumatic Stress Disorder.

The authors report no financial relationships with commercial interests.

The authors thank the veterans who participated in the National Health and Resilience in Veterans Study and Steven M. Southwick, M.D., and John H. Krystal, M.D., for their critical input into the design of this study.

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• Smaller rostral cingulate volume and psychosocial correlates in veterans at risk for suicide Psychiatry Research, Vol. 320

• Veterans issues
• Care utilization patterns
• Mental illness
• Alcohol abuse
• Substance use disorder

Military Veterans’ Mental Health Needs

The topic of the study concerns the mental health needs of veterans who suffer different types of disorders as the result of their military service. This issue has a significant influence on my practice because this population constitutes a relatively large number of people in the USA. Many individuals encounter such difficulties as mental disorders, substance abuse, “homelessness, and involvement in the criminal justice system” (Blodgett et al., 2015, p. 163). Such a wide range of issues that need to be addressed in the psychotherapeutic context implies the importance of the investigation of the challenges this population experiences.

Despite cultural and ethnic diversity of the target population, the common psychological issues are characterized by similar symptoms. However, it is relevant to apply culture-sensitive interventions to amplify the efficacy of psychotherapy. It is essential to retrieve and use the information about the cultural particularities of a patient to help him or her deal with the issues within a comfortable spectrum of beliefs. Religious and family history background might be helpful at this point.

The community provides both private and public services to ensure veterans’ accessibility to the facilities and information. Multiple brochures, scholarly research publications, websites, and counseling advertisement are available to increase the scope of services for vets. However, there are some gaps in the addressing of the possible ways how this population might seek for help. This issue might be complicated due to the reluctance of traumatized individuals to face the problem and acknowledge their disability and attempts to resolve it on their own. To address the gaps, the ways to facilitate the accessibility of mental health institutions for veterans should be found.

To understand the needs of veterans better and to introduce effective psychotherapeutic services, it would be useful to study the scope of literature addressing the particular aspects with which they deal, such as substance use, communicational issues, depression. Also, it is important to investigate the mental health problems that veterans’ family members might experience and provide relevant services for them as well. I will need to find and study an explicit description of practical interventions applicable to this particular population.

The relevance of the research to the target population might be explained by the common occurrence of the mental health problems of veterans after their combat service. More importantly, the unresolved psychological issues in veterans might lead to severe complications in both their health conditions and their social behavior. According to Blodgett et al. (2015), about “10% of incarcerated adults (i.e., those in jail or prison) have served in the military” which includes approximately 210,000 veterans (p. 164).

Also, alcohol misuse and the behavioral threats that follow are prevalent among veterans (Osilla et al., 2018). Thus, a great number of those involved in military service have a high rate of exposure to substance abuse and criminal activities. It is vital to apply timely mental health for those who need it to prevent adverse outcomes for both, the veterans and the society.

To succeed at timely identification of a problem, it is essential to raise awareness and attract family members to therapeutic interventions. The research explicitly addressed the involvement of veterans’ families in mental health treatment. One of the most widely spread problems related to military experience is a post-traumatic stress disorder that is best treated with the participation of family members (Fisher et al., 2015). It is essential to identify the most effective interventions for veterans and their families to eliminate the threats emerging as the result of combat experience.

This research will greatly influence my practice as a psychiatric-mental health nurse practitioner (PMHNP) because it will contribute specific knowledge about the mental health needs of veterans related to their military experiences. According to American Psychological Association (n.d.), the majority of veterans returning home after their service fail to find relevant public institutions due to the lack of workforce in the field. As a result of this research, the information and its analysis will facilitate in increasing of the scope of service and providing more opportunities for the deployed military service members to find psychotherapeutic help and be adequately treated.

The particular findings of the most commonly found disorders including alcohol and drug use, criminal behavior, depression, or post-traumatic stress disorder will contribute to the practical side of my work.

Being acknowledged about the various mental health problems, it will be more useful to apply basic methodology and interventions to treat veterans. The implementation of the family-oriented method will amplify the positive outcomes of therapy for both vets and their family members who might also experience challenges in the adjustment to a non-military environment (Osilla et al., 2018). Thus, the research will broaden the scope of my theoretical and practical skills and will contribute to the efficacy of my work.

To improve care for veterans, I aim to investigate the relations between the type of service and mental health disorders. It will contribute to the understanding of the roots of problems and, from a long-term perspective, will facilitate the interventions. Also, it would be appropriate to find more information about positive therapeutic experiences in care for veterans. Such practical implications will be the basis for improvement of session interventions aimed at dealing with different mental health problems specific for this population group.

American Psychological Association. (n.d.). The mental health needs of veterans, service members and their families . Web.

Blodgett, J. C., Avoundjian, T., Finlay, A. K., Rosenthal, J., Asch, S. M., Maisel, N. C., & Midboe, A. M. (2015). Prevalence of mental health disorders among justice-involved veterans. Epidemiologic Reviews, 37 (1), 163–176.

Fischer, E. P., Sherman, M. D., McSweeney, J. C., Pyne, J. M., Owen, R. R., and Dixon, L. B. (2015). Perspectives of family and veterans on family programs to support reintegration of returning veterans with posttraumatic stress disorder. Psychological Services, 12 (3), 187-198

Osilla, K. C., Pedersen, E. R., Tolpadi, A., Howard, S. S., Phillips, J. L., and Gore, K. L. (2018). The feasibility of a web-intervention for military and veteran spouses concerned about their partner’s alcohol misuse. The Journal of Behavioral Health Services and Research, 45 (1), 57-73.

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Veteran and Military Mental Health Issues

Affiliations.

• 1 1st Special Operations Medical Group
• 2 Uniformed Services University of the Health Sciences
• 3 Hurlburt Field Air Force Base
• 4 Uniformed Services University
• 5 University of Texas Health Science Center at San Antonio
• PMID: 34283458
• Bookshelf ID: NBK572092

As the United States endures 2 decades of ongoing warfare, both the media and individuals with personal military connections have raised significant public and professional concerns about the mental health of veterans and service members. The most widely publicized mental health challenges veterans and service members encounter are posttraumatic stress disorder (PTSD) and depression. Research indicates that approximately 14% to 16% of the US service members deployed to Afghanistan and Iraq have been affected by PTSD or depression. Although these mental health concerns are prominently highlighted, it is crucial to acknowledge that other issues, such as suicide, traumatic brain injury (TBI), substance use disorder (SUD), and interpersonal violence, can be equally detrimental in this population. These challenges can have far-reaching consequences, significantly affecting service members and their families. Although combat and deployments are known to be associated with increased risks for these mental health conditions, general military service can also give rise to challenges. The presentation of these mental health concerns may not follow a specific timeline. However, there are particularly stressful periods for individuals and families, especially during periods of close proximity to combat or when transitioning from active military service.

As per the recent reports released by the U.S. Census Bureau, there are around 18 million veterans and 2.1 million active-duty and reserve service members (https://www.census.gov/newsroom/press-releases/2020/veterans-report.html) in the United States. Since September 11, 2001, the deployment of 2.8 million active-duty American military personnel to Iraq, Afghanistan, and other areas has resulted in a growing number of combat veterans within the population. Over 6% of the US population has served or is currently serving in the military. Notably, this number also does not consider the significant number of relatives affected by military service. Healthcare providers can enhance the quality of care they provide patients and potentially save their lives by comprehending the relationship between military service and a patient's physical and mental well-being.

Posttraumatic Stress Disorder

PTSD was officially recognized and codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-3 in 1980, driven partly by the sociopolitical aftermath of the Vietnam War. However, its manifestations have been alluded to in different forms throughout history, with terms such as "soldier's heart" during the Civil War, "shell shock" in the First World War, and "combat fatigue" around the Vietnam War. The DSM criteria have remained primarily unchanged until the latest update in 2013. However, there is still ongoing debate regarding its classification. As a complex and constantly evolving combination of biological, psychological, and social factors, studying and diagnosing PTSD poses significant challenges. Although PTSD is commonly studied in individuals who have experienced war or natural disasters, its impact is not limited to specific groups and can affect anyone, including children. This disorder is commonly observed in individuals who have survived violent events such as assaults, disasters, terror attacks, and war. However, even secondhand exposure, such as learning that a close friend or family member experienced a violent threat or accident, can also lead to PTSD. Although many individuals may experience transient numbness or heightened emotions, nightmares, anxiety, and hypervigilance after exposure to trauma, these symptoms resolve within 1 month. However, in approximately 10% to 20% of cases, the symptoms may worsen and become persistent, causing significant impairment. PTSD is characterized by intrusive thoughts, flashbacks, and nightmares related to past trauma, leading to avoidance of reminders, hypervigilance, and sleep difficulties. Frequently, reliving the event can evoke a sense of threat as intense as the original trauma. PTSD symptoms can significantly disrupt interpersonal and occupational functioning and manifest in various ways, affecting psychological, emotional, physical, behavioral, and cognitive aspects. Military personnel can be exposed to an array of potentially traumatizing experiences. Military personnel deployed during wartime may witness severe injuries or violent deaths, which can occur suddenly and unpredictably. These events can impact not only intended targets but also others in the vicinity. Active-duty military members risk non-military-related traumas beyond the challenging deployment environment, such as interpersonal violence and physical or sexual abuse. Symptoms related to these traumas may be exacerbated in the deployed environment.

As a result of 2 decades of ongoing warfare in Afghanistan, there is a rising population of veterans seeking mental health treatment, with a significant portion having experienced combat and deployment. While caring for veterans, healthcare providers should consider the physical injuries they may have sustained during their service period and the emotional wounds they may be experiencing presently, including PTSD, acute stress disorder, and depression. Although depression does not garner the same level of attention as PTSD, this condition remains a prevalent mental health condition in the military. Research shows that depression is responsible for up to 9% of all ambulatory military health network appointments. The military environment can serve as a catalyst for the development and progression of depression. Factors such as separation from loved ones and support systems, the stressors of combat, and the experience of witnessing oneself and others in harm's way all contribute to an increased risk of depression in both active-duty and veteran populations. After deployments to Iraq or Afghanistan, military medical facilities witnessed an increase in diagnosed depression cases, rising from a baseline of 11.4% of members to a rate of 15%. Given this high prevalence, providers have a critical responsibility to identify active-duty and veteran patients who may be suffering from depression.

Major depression manifests through various symptoms, encompassing a depressed mood, loss of interest in activities, insomnia, weight loss or gain, psychomotor retardation, fatigue, reduced ability to concentrate, feelings of worthlessness, and thoughts of suicide. These symptoms dramatically affect the patient's capacity to operate at full potential. Although the array of symptoms is evident on paper, a patient's presentation can often be ambiguous. Surprisingly, it has been found that half of all patients suffering from depression are not correctly diagnosed by their general practitioner. Therefore, accurate screening, identifying, and following through with appropriate treatments is paramount, especially in the active-duty and veteran military population.

Veteran suicide rates have reached their highest level in recorded history, with over 6000 veterans dying by suicide annually. Furthermore, overall suicide rates within the United States have increased by 30% between 1999 and 2016. According to a study conducted in 27 US states, it was estimated that veterans committed 17.8% of reported suicide cases. Data published by the U.S. Department of Veterans Affairs (VA) in 2016 indicated that veteran suicide rates were 1.5 times higher than those of non-veterans. Research has shown that veterans are at significantly increased risk of suicide during their first year after leaving the military service. In 2018, a Presidential Executive Order was signed to improve suicide prevention services for veterans during their transition to civilian life. Moreover, the Department of Defense (DoD) and VA have placed significant emphasis on suicide prevention due to the observed rise in fatal and non-fatal suicide attempts during the wars in Iraq and Afghanistan. The suicide rates in the U.S. Armed Forces doubled between 2000 and 2012. However, since then, there has not been any significant change in the annual rate of suicides, with approximately 19.74 deaths per 100,000 service members occurring each year.

Substance Use Disorders

Despite receiving public attention over recent decades, SUDs, including alcohol use, continue to be a problem among veterans and military members. In these populations, alcohol use is prevalent and is frequently utilized for stress relief and socializing. SUDs are associated with significant adverse medical, psychiatric, interpersonal, and occupational outcomes. A study conducted on military personnel revealed that approximately 30% of completed suicides and around 20% of deaths resulting from high-risk behavior were attributed to alcohol or drug use. In the general US population, alcohol is the fourth leading cause of preventable death, contributing to 31% of driving-related fatalities involving alcohol intoxication. According to the DSM-5, SUD is a group of behaviors that involve compulsive drug-seeking, which includes impaired control over drug use, dysfunctional social functioning due to drug use, and physiological changes resulting from drug consumption. Addiction represents the most severe stage of SUD in individuals, characterized by a loss of self-control that leads to compulsive drug-seeking behavior despite a desire to quit. Substances encompass various categories, including legal drugs such as caffeine, nicotine, and alcohol; prescription medications such as opioids, sedatives or hypnotics, and stimulants; and illicit drugs such as marijuana, cocaine, methamphetamines, heroin, hallucinogens, and inhalants.

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The National Health and Resilience in Veterans Study: A Narrative Review and Future Directions

Brienna m. fogle.

1 U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, United States

2 Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States

Natalie Mota

Ilan harpaz-rotem, john h. krystal, steven m. southwick, robert h. pietrzak.

3 Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States

United States (U.S.) veterans are substantially older than their non-veteran counterparts. However, nationally representative, population-based data on the unique health needs of this population are lacking. Such data are critical to informing the design of large-scale outreach initiatives, and to ensure the effectiveness of service care delivery both within and outside of the Veterans Affairs healthcare system. The National Health and Resilience in Veterans Study (NHRVS) is a contemporary, nationally representative, prospective study of two independent cohorts ( n = 3,157 and n = 1,484) of U.S. veterans, which is examining longitudinal changes, and key risk and protective factors for several health outcomes. In this narrative review, we summarize the main findings of all NHRVS studies ( n = 82) published as of June 2020, and discuss the clinical implications, limitations, and future directions of this study. Review of these articles was organized into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics and epigenetics. Collectively, results of these studies suggest that while a significant minority of veterans screen positive for mental disorders, the majority are psychologically resilient. They further suggest that prevention and treatment efforts designed to promote protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life), and social connectedness (i.e., secure attachment, community integration, social engagement) help mitigate risk for mental disorders, and promote psychological resilience and post-traumatic growth in this population.

Introduction

Nationally representative epidemiological studies of United States (U.S.) military veterans conducted outside of the Veterans Affairs (VA) healthcare system are sparse, yet highly valuable, given that only about half (48%) of veterans utilize any VA healthcare services ( 1 ), and even fewer (~20%) utilize VA care as their primary source of health care ( 2 ). Moreover, utilization of VA healthcare services is driven by many factors, such as sex, race, income, marital status, and physical and mental health conditions ( 1 , 2 ). Thus, it is critical to understand the unique needs of veterans at a broader population level to better inform the design of large-scale outreach initiatives and to help ensure the effectiveness of service care delivery.

Further, while a substantial body of research on veterans has focused on risk factors for prevalent mental and physical health conditions, few studies have assessed potentially modifiable factors that may help mitigate risk for these conditions, such as gratitude, social support, optimism, community integration, and purpose in life ( 3 , 4 ). Accordingly, the overarching goal of the National Health and Resilience in Veterans Study (NHRVS) is to characterize the longitudinal trajectories of mental and physical health outcomes in U.S. veterans, and to study genetic and environmental risk and protective factors that contribute to these trajectories. The NHRVS is a large, nationally representative prospective study which consists of two separate cohorts of 3,157 and 1,484 U.S. military veterans. Additionally, the NHRVS utilizes well-validated measures to examine longitudinal changes of mental and physical health outcomes in this population.

Since the NHRVS began in 2011, it has yielded a total of 82 publications. In this review, we summarize the main findings of all NHRVS studies published as of June 2020, and discuss the broader clinical implications, limitations and future directions of this study. To thematically organize the content, the 82 articles were sorted into six major topic areas: post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics.

Methodology for National Health and Resilience in Veterans Study

The NHRVS cohorts were recruited to complete a 60-min online survey from a research panel of over 50,000 households that was developed and maintained by GfK Knowledge Networks, Inc. (now Ipsos). GfK Knowledge Networks, Inc. recruited panel members through national random samples by telephone and postal mail. Internet and computer hardware access are provided if needed. GfK Knowledge Networks, Inc. uses dual sampling frames to recruit participants and offers coverage of ~98% of U.S. households. These sampling procedures are different from Internet convenience panels (i.e., “opt in” panels) as it included listed and unlisted telephone numbers, telephone and non-telephone households, cell-phone-only households, and households with and without Internet access. Only individuals sampled through these probability-based techniques are eligible to participate in the survey. To promote generalizability of results to the entire population of U.S. veterans, post-stratification weights based on demographic distributions of US veterans from concurrent US Census data ( 5 ) were applied. Of the 4,750 veterans who were in the survey panel at the time the first cohort (Cohort one; C1) was fielded, 3,408 (71.7%) completed a screening question to confirm their study eligibility (current or past active military status). Of these veterans who completed the screening question, 3,188 (93.5%) confirmed their current or past active military status, and 3,157 (92.6%) completed the survey.

C1 completed a baseline survey in 2011, which included comprehensive measures of demographics and military history, medical and psychiatric status, and psychosocial functioning. Following the baseline survey, 2-, 4-, and 7-year follow-ups were conducted. Wave 2 ( n = 2,157; 68.3%) data were collected in 2013, Wave 3 ( n = 1,538; 48.7%) in 2015, and Wave 4 ( n = 1,310; 41.5%) in 2018. Additional saliva samples were collected from 500 veterans in Wave 3 for epigenetic and telomere length assays. At baseline, C1 was 90.6% male, 76.2% White, 9.6% Black, 8.2% Hispanic, 1.5% mixed races, and the mean age was 60.3 ( SD = 15.0, range = 21–96), with 57.3% aged 60 years or older. Two-thirds of participants (66.7%) had completed at least some college education, 75.6% were married/cohabitating, 44.0% reported a household income of $60,000 or greater, 43.5% were retired, and 40.7% reported working part-time and/or full-time. The majority of did not serve in a combat or war zone (65.2%), and 19.3% reported using VA healthcare as their main source of health care.

Cohort 2 (C2) completed a baseline survey in 2013 and a follow-up survey 3 years later. A total of 1,602 individuals responded “Yes” to an initial screening question that confirmed veteran status and 1,484 participated, resulting in a response rate of 92.6%. C2 consists of 1,484 veterans who completed a baseline survey and 713 (48.0%) who completed a 3-year follow-up survey. Veterans in C2 were demographically similar to C1, with 89.7% male, 75.4% White, 9.7% Black, 9.1% Hispanic, and 1.4% mixed races, with a mean age of 60.4 ( SD = 15.3, range 20–94) at baseline. The majority of C2 veterans were married/cohabitating (70.1%), 44.2% were retired, and 41.6% were working part-time and/or full-time, and had household incomes of $60,000 or greater (43.4%); two-thirds (66.9%) had completed at least some college education. The majority of C2 veterans did not serve in a combat or war zone (61.6%), and 21.3% reported using VA as their main source of healthcare. Saliva samples were also obtained from both NHRVS cohorts, with genetic data (PsychChip) available for 2,827 veterans.

Review Methodology

A search of Pubmed and Scopus was conducted with the terms, “National Health and Resilience in Veterans Study”; “NHRVS”; “nationally representative sample of U.S. veterans”; “U.S. veteran population”; and the author/principal investigator “Pietrzak, R.H.” Non-NHRVS studies were excluded if “residential treatment”; “National Epidemiologic Survey on Alcohol and Related Conditions”; “Million Veteran Program”; or “VA cooperative study 504” were in the title/abstract. This search revealed 90 studies, 8 of which were excluded for not utilizing NHRVS data upon further review. The final review included 82 original research studies.

Post-traumatic Stress Disorder

Eighteen studies (see Table 1 ) utilized data from the NHRVS to examine the prevalence and risk factors for PTSD and co-occurring conditions in veterans, as well as the factor and network structure of PTSD symptomatology. Below, we summarize results of these studies.

Post-traumatic stress disorder.

PTSD is one of the most prevalent mental disorders among U.S. veterans. Prevalence estimates of this disorder among veterans ranging widely ( 23 , 24 ), partly due to most studies being conducted in non-representative samples (e.g., convenience sample of Vietnam-era veterans or veterans deployed to Iraq or Afghanistan). Using data from the NHRVS, which surveyed a nationally representative sample of U.S. veterans, Wisco et al. ( 6 , 14 ) found that estimates of lifetime DSM-IV and DSM-5 PTSD were 8.0 and 8.1%, respectively, and past-month PTSD were 4.8 and 4.7%, respectively. Further, to understand the burden of subthreshold manifestations of PTSD, Mota et al. ( 13 ) analyzed NHRVS data and found that the prevalence of lifetime and current subthreshold DSM-5 PTSD was 22.1 and 13.5%, respectively. These prevalences were markedly higher than prevalences of lifetime and current PTSD (8.0 and 4.5%, respectively) ( 13 ).

Exacerbation/Re-emergence of PTSD in Late-Life

Research on older veterans has also suggested that PTSD symptoms may re-emerge or become exacerbated in older age among trauma-exposed veterans ( 25 ). Using NHRVS data, Mota et al. ( 12 ) found that nearly 10% of older U.S. veterans experienced exacerbated PTSD symptoms an average of nearly 3 decades after their worst trauma. Cognitive difficulties, particularly perceived deficits in executive function, were the sole determinant of late-life exacerbation of PTSD symptoms. These findings suggest that late-life exacerbation of PTSD symptoms affects a substantial minority of older veterans in the U.S., and that reductions in executive control may increase risk for this phenomenon.

Longitudinal Trajectories of PTSD Symptoms

A recent study ( 26 ) utilized all four waves of data from C1 and found evidence of three predominant courses of PTSD symptoms over a 7-year period: low/no (89.2%), moderate (7.6%), and severe (3.2%). Relative to veterans in the no/low symptom course, those in the moderate and severe courses endured a significantly greater number of lifetime traumatic events, reported greater physical health difficulties, were more likely to have lifetime psychiatric histories; and reported lower social connectedness. Importantly, more than 10% veterans evidenced a symptomatic elevation of PTSD symptoms that steadily declined over a 7-year period. Results suggested that interventions to help bolster social connectedness may help mitigate risk for symptomatic trajectories of PTSD in U.S. veterans.

DSM-5 vs. ICD-11 Classification of PTSD

The Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) are the two major diagnostic systems commonly used worldwide and, historically, the two have defined PTSD using similar criteria. However, in the recent publication of the ICD-11 ( 27 ), a definition of PTSD was proposed that diverges substantially from DSM-5 and reduces the total number of symptoms to 6, compared to 20 in DSM-5. Therefore, it is important to compare how using different diagnostic definitions of PTSD may impact reported prevalence of the disorder. To evaluate this possibility, Wisco et al. ( 16 ) found that using the ICD-11 diagnostic criteria yielded significantly lower estimates of lifetime (6.9 vs. 5.0%) and past-month (4.0 vs. 2.7%) PTSD than DSM-5 criteria, without reducing associations with psychiatric comorbidities. Importantly, among individuals excluded under ICD-11, all endorsed clinically significant distress or functional impairment related to their PTSD symptoms, suggesting that the ICD-11 criteria may underestimate clinically meaningful distress and impairment related to PTSD symptoms ( 16 ).

Dissociative Subtype of PTSD

The DSM-5 formally introduced a dissociative subtype of PTSD, which includes symptoms of depersonalization (i.e., “the experience of being an outside observer of or detached from oneself”) and/or derealization [i.e., “the experience of unreality, distance, or distortion; ( 28 )]. Tsai et al. ( 9 ) evaluated the prevalence and correlates of this subtype of PTSD in the NHRVS. They found that 19.2 and 16.1% of veterans with a positive screen for lifetime and past-month DSM-5 PTSD, respectively, also screened positive for the dissociative subtype. In 2017, Wolf et al. ( 17 ) developed and evaluated the Dissociative Subtype of PTSD Scale (DSPS) using a resampled subset of C1 from the NHRVS, and found that nearly 40% of those who screened positive for lifetime PTSD met criteria for the dissociative subtype. Importantly, dissociative symptoms may not exclusively occur in the context of a PTSD diagnosis. A recent NHRVS study ( 22 ) found that 20.8% of trauma-exposed veterans experience dissociative symptoms, even if they do not screen positive for this disorder. Results of this study suggest that dissociative symptoms, independent of a PTSD diagnosis, may be a transdiagnostic risk factor for mental health disorders and poor functioning in veterans ( 22 ).

PTSD Symptoms and Functioning

PTSD deleteriously affects various aspects of functioning, including physical health, quality of life (QOL), and psychosocial functioning. Given that there is considerable variability in PTSD symptom presentation among trauma survivors, analysis of individual symptoms that are associated with measures functioning may provide more nuanced insight into how this heterogeneous syndrome may impact these outcomes. Using NHRVS data, Kachadourian et al. ( 20 ) employed a novel “symptomics” approach to identify specific PTSD symptoms linked to functional difficulties in trauma-exposed veterans. They found that the non-specific symptoms of this disorder (e.g., difficulty experiencing positive affect, sleep difficulties, loss of interest) were the strongest correlates of poor functioning and suicidal thinking. Furthermore, McCarthy et al. ( 21 ) found that sleep difficulties may partially mediate the relationship between PTSD symptoms, and functioning and QOL.

Symptom Structure of PTSD

The DSM-5 criteria for PTSD include four symptom clusters of intrusions, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity ( 28 ). Tsai et al. ( 10 ) found that a 5-factor dysphoric arousal model and a 6-factor externalizing behavior model provided a better fit than the 4-factor model of DSM-5 PTSD symptom clusters in C2 of the NHRVS, with the externalizing behavior model providing the best dimensional representation of the symptom clusters. Expanding on this work, a novel 7-factor hybrid model ( 7 ) of PTSD was proposed utilizing NHRVS data. This model incorporated unique features of the 6-factor externalizing behavior model ( 10 ) with those of another 6-factor ( 29 ) to suggest a 7-factor model of intrusions, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal (i.e., hypervigilance, exaggerated startle response), and dysphoric arousal (i.e., sleep and concentration difficulties) symptoms. This more nuanced structural model was found to be the best-fitting structural model of DSM-5 PTSD symptoms in veterans and a sample of university students ( 7 ). Since the publication of this 7-factor model of DSM-5 PTSD symptoms, several additional studies in various trauma-exposed samples have found support for this structural model of PTSD [e.g., ( 30 – 34 )].

Evaluating the underlying structure of PTSD symptoms allows researchers to determine specific sets of symptoms that account for comorbidity of PTSD with other disorders and aspects of functioning. Using NHRVS data, Pietrzak et al. ( 8 ) examined the functional significance of the 7-factor hybrid model with comorbid psychopathology (e.g., depression, anxiety, suicide ideation, hostility) and found differential patterns of associations between PTSD symptom clusters and comorbidities. Specifically, anhedonia symptoms were most strongly related to current depression, reduced mental functioning, and quality of life. Externalizing behaviors were most strongly related to hostility. Further, dysphoric arousal, negative affect, and anhedonia symptom clusters were most strongly associated with past-year alcohol consequences ( 35 ).

Data from the NHRVS have also been used to examine latent profiles of DSM-5 PTSD symptoms. One study ( 19 ) found a three-class solution, described as Dysphoric (i.e., high probabilities of negative affect and anhedonia symptoms), Threat (i.e., high probabilities of intrusive and avoidance symptoms), and High Symptom (i.e., high probabilities of all PTSD symptoms). A related study ( 11 ) found evidence of a 5-class PTSD-personality typology solution, which differed with respect to DSM-5 PTSD symptom cluster severity and several of the “Big Five” personality dimensions. Both studies found that these typologies were differentially related to clinical and trauma characteristics, thus underscoring the importance of considering differential “person-based” manifestations of PTSD symptomatology in personalized approaches to the assessment and treatment of this disorder.

Network Structure of PTSD Symptoms

Exposure to traumatic events in veterans often involves life-threatening combat, injuries, accidents, loss, or interpersonal violence, such as sexual trauma ( 6 ). While initial symptoms, such as trouble sleeping, are considered to be a normal reaction to stress in the short term and many veterans manage to overcome these symptoms over time ( 36 ), more persistent symptoms can be debilitating. PTSD is a characterized by heterogeneous constellation of symptoms, including intrusive memories related to the trauma, hypervigilance to and avoidance of trauma-related situations and memories, and negative cognitions and mood ( 28 ). Network theory suggests that symptoms are correlated in a syndrome because they directly activate and dynamically interact with each other, rather than because they have a shared origin ( 15 ). However, until recently little was known about the network structure of PTSD symptoms.

To address this gap, a network analysis of DSM-5 PTSD symptoms was conducted in participants from C2 of the NHRVS with subthreshold or greater PTSD symptoms. Results revealed that negative emotions related to the trauma, detachment, flashbacks, and physiological reactivity were most central and interconnected within the PTSD symptom network ( 37 ). Strong connections were observed between flashbacks and nightmares related to the trauma, hypervigilance and exaggerated startle response, and detachment and restricted affect ( 37 ). A follow-up study ( 18 ) evaluated the temporal stability of this network structure over a 3-year period to help identify symptoms that contribute to the chronicity of PTSD. Results indicated that the network structure for DSM-5 PTSD was stable over the 3-year period with respect to both network structure and global strength ( 18 ). Similar to prior research, avoidance, intrusive, and negative cognition and mood symptoms were among the more central nodes, suggesting these symptoms may contribute to the chronicity of PTSD in symptomatic veterans.

Clinical Implications

Results of NHRVS studies focused on PTSD suggest that veterans report exposure to a wide range of potentially traumatic events from military and non-military experiences, and a strikingly high proportion of veterans—approximately one in three—experience clinically significant PTSD symptoms in their lifetime, with a significant minority screening positive for PTSD ( 6 , 13 , 14 ). Collectively, these results suggest that sleep, avoidance, intrusive, and dysphoric symptoms may contribute to the chronicity of PTSD symptoms in veterans, and may thus represent important targets in prevention, treatment, and risk reduction efforts ( 18 , 20 , 21 , 37 ). Utilizing a 7-factor hybrid model of PTSD symptoms may also provide greater specificity in understanding how PTSD symptoms relate to mental health, functioning, and QOL in U.S. veterans ( 7 , 8 ). Furthermore, resilience, social support, secure attachment, and community integration are potentially modifiable factors that are linked to decreases in PTSD symptoms and may be targeted in prevention and treatment efforts ( 6 , 26 ).

Suicidality

Suicide has been a significant public health problem among veterans for over a decade and is a top clinical priority for the VA. In 2016, the rate of deaths by suicide was 1.5 times greater for veterans than for non-veteran adults, after adjusting for age and gender ( 38 ). Numerous studies have examined potential mental and physical health risk factors for suicide in veterans, but less research has sought to identify modifiable protective factors ( 39 ). To date, seven studies (see Table 2 ) from the NHRVS have examined the prevalence and correlates of suicidality and identified potential protective factors in the U.S. veteran population.

Suicidality.

Prevalence and Longitudinal Courses of Suicidality

Suicidal ideation (SI) is often a precursor to a suicide attempt or death by suicide. Thus, there is a great need to systematically understand the nature and prevalence of SI over time among veterans. This may provide insight into the predominant patterns and causes of SI, which can help determine targets for prevention and treatment. In 2017, Smith et al. ( 40 ) analyzed data from C1 of the NHRVS and found that 13.7% of veterans had chronic, new-onset, or remitted SI over a 2-year period. A key finding was that while mental and physical health problems were risk factors for chronic and onset SI, greater social connectedness (e.g., secure attachment style and perceived social support), was negatively related to these outcomes. Building on this work using 4-year prospective data from C1 of the NHRVS, Pietrzak et al. ( 41 ) conducted a prospective cohort study of U.S. veterans without SI at baseline to identify the incidence and baseline determinants of new-onset SI. Results revealed that greater age, higher loneliness, disability in instrumental activities of daily living, PTSD, alcohol use problems, and somatic symptoms, and use of denial-based coping were associated with increased risk for SI. After controlling for these risk factors, greater perceived social support, curiosity, resilience, and acceptance-based coping emerged as significant protective factors for SI, accounting for more than 40% of the total variance in predicting SI risk. These findings underscore the importance of considering both risk and protective factors in population-based suicide risk prevention efforts in veterans.

The risk of suicide is even greater in veterans who have been diagnosed with PTSD and/or major depressive disorder (MDD). A recently published NHRVS study ( 45 ) found that 29.4% of veterans with PTSD and/or MDD reported current SI and that 28.0% reported a lifetime suicide attempt. Greater purpose in life, curiosity, and optimism were inversely associated with SI. Subsequently, another study ( 46 ) used NHRVS data to prospectively examine how a broad range of risk and protective factors contributed to the development of SI over 7 years in this high-risk subpopulation. Importantly, 27.1% of veterans with PTSD and/or MDD who did not endorse SI at baseline developed SI during the course of 7 years of the study. Lower levels of purpose in life, conscientiousness, and frequency of religious service attendance were most strongly associated with developing SI. These findings help to characterize potential targets for population-based prevention and treatment efforts that may help mitigate suicidality in high-risk veterans.

Combat-Related Moral Injury and Suicidality

Another military-related stressor that has been associated with elevated risk for suicide is moral injury. Moral injury is defined as “the psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” [( 47 ), p. 698], and often includes feelings of guilt and shame ( 47 ). Moral injury can occur by transgressions by self (e.g., killing a child), transgressions by others (e.g., witnessing torture committed by others), and betrayal experiences (e.g., perceived failures by leadership or fellow service members). Using NHRVS data, Wisco et al. ( 42 ) found that 10.8–25.5% of U.S. combat veterans reported being exposed to potentially morally injurious experiences. In particular, transgressions by self were found to be associated with current mental disorders and SI, and betrayal with post-deployment suicide attempts, even after adjustment for severity of combat exposure. Building upon this work, Corona et al. ( 44 ) investigated whether global purpose and meaning in life moderated the relationship between potentially morally injurious experiences and SI in combat veterans. Results revealed that greater global purpose and meaning in life was associated with significantly lower likelihood of experiencing SI among veterans who reported higher levels of transgression by others and betrayal experiences.

Military Sexual Trauma and Suicidality

Effectively responding to suicide risk among veterans involves further understanding reactions to military-related stressors, including military sexual trauma (MST). Veterans with a history of MST (i.e., sexual assault and/or sexual harassment during service) are at elevated risk for suicide. Accordingly, Monteith et al. ( 43 ) sought to identify psychiatric and interpersonal correlates of suicidal ideation and suicide attempt among NHRVS veterans with a history of MST. The study found MST survivors who reported more severe alcohol use problems and perceived general disapproval from others in relation to their worst traumatic event were significantly more likely to report current SI and a lifetime suicide attempt; psychological distress was additionally linked to current SI.

Collectively, results of NHRVS studies on suicidality conducted to date indicate that a considerable proportion of U.S. veterans experience SI, and that SI courses may fluctuate over time. These findings underscore the importance of periodic monitoring of suicidal thoughts and behaviors in this population ( 40 ). Further, prevention and treatment efforts designed to mitigate psychiatric and physical health comorbidities, loneliness, and disability in instrumental activities of daily living, and bolster social connectedness (i.e., secure attachment style and perceived social support) and protective psychosocial characteristics (i.e., curiosity, resilience, acceptance-based coping) may help mitigate risk for SI in veterans ( 40 , 41 ). In high-risk veterans with comorbid PTSD/MDD, higher levels of purpose in life, curiosity, conscientiousness, and optimism were associated with decreased risk of SI ( 45 , 46 ). Finally, results of these studies highlight the important of routine assessment of MST and potentially morally injurious experiences in the assessment, monitoring, and treatment of suicidality in veterans.

More than half (65%) of veterans are currently aged 55 or older ( 48 ) and it is projected that this proportion of aged veterans will increase over the next two decades ( 49 ). There is an new focus potentially modifiable protective psychosocial characteristics in veterans, such as resilience, optimism, and religiosity, which may help older persons adapt to negative life events such as medical and psychiatric illness and promote successful aging ( 50 ). To date, twelve studies (see Table 3 ) focusing on aging-related topics have been published utilizing NHRVS data. The majority of these studies have examined characteristics that may help promote successful aging in veterans.

Successful Aging

Using data from C1 of the NHRVS, Pietrzak et al. ( 56 ) found that the majority (82%) of 60–96 year old veterans rated themselves as aging successfully, and that physical and mental health difficulties were most strongly negatively related to successful aging. Additionally, after adjustment for these risk factors, resilience, gratitude, purpose in life, and community integration were strongly positively related to successful aging. Subsequently, Rozanova et al. ( 58 ) qualitatively evaluated veterans' perceptions of factors important to successful aging. Results of this study resonated with those of the quantitative study, suggesting that older veterans emphasize health behaviors, social engagement, and dispositional characteristics as key determinants of successful aging.

Purpose in Life and Physical Disability

Physical disability is an important aspect of aging that may negatively affect functioning and quality of life in older veterans. Accordingly, elucidation of modifiable factors that may help buffer against the development of physical disability are critical to further understanding determinants of successful aging. Mota et al. ( 59 ) found that over 2 years, the incidence of new-onset physical disability among veterans aged 55 years and older was 11.5%. Importantly, purpose in life, which may be modified using adjunctive intervention strategies such as logotherapy, was found to be protective against the development of physical disability. Retirement, which may lead to a reduced sense of purpose and meaning in life, was found to be a risk factor for this outcome.

Caregiving in Veterans

Employment may play a role in fostering a greater sense of purpose in life, and with the aging veteran population reaching retirement age, understanding the roles that veterans maintain later in life could be a useful mechanism for promoting successful aging. Indeed, older veterans may transition to providing care to their family members as they reach retirement or face other challenges, as it is estimated that one in 10 of all caregivers in the U.S. have served in the military ( 63 ). Monin et al. ( 55 ) found that greater perceived resilience was negatively associated with veteran caregiver physical strain. Depressive symptoms were positively associated with emotional strain ( 55 ). Additionally, gratitude, happiness, and social support were associated with greater perceived rewards related to caregiving ( 55 ).

Social Connectedness and Psychological Resilience

Social connectedness recurrently appears as an important factor in successful aging and resilience among older veterans who participated in the NHRVS. Fanning and Pietrzak ( 51 ) found that social connectedness was negatively related to SI in older veterans. Weiner et al. ( 60 ) investigated the effects of different types of social engagement in older veterans, and found that community integration, but not perceived social support, was associated with fewer mental health difficulties in older veterans. In a study of sexual minority veterans [i.e., lesbian, gay, bisexual; Monin et al. ( 61 )] found that, relative to younger veterans, older veterans had lower levels of mental health problems, but they reported the smallest social support networks. Finally, Kuwert et al. ( 53 ) found that 44.0% of veterans reporting feeling lonely at least some of the time, with 10.4% reporting often feeling lonely. While depressive symptoms were strongly related to loneliness in this study, greater, perceived social support and having a attachment style were negatively related to this outcome.

Psychological Resilience in Late-Life

Significant changes and losses are common in older adulthood and include retirement, erosion of social networks, and reductions in functioning and mobility. It has been proposed that experiencing trauma and stressors before late adulthood may “inoculate” and help enhance coping skills in older adults ( 52 , 64 ). It has been hypothesized that experiencing trauma or stressors earlier in life may promote psychological resilience to future traumas and stressors ( 52 , 64 ). Using data from the NHRVS, Pietrzak and Cook ( 52 ) found that among older veterans who endured a high number of traumas in their lifetimes, nearly 70% were psychologically resilient in later life. Relative to distressed veterans, resilient veterans were younger, more likely to be White, less likely to have physical health difficulties and psychiatric histories. Resilient veterans also endorsed higher levels of emotional stability, prosocial behaviors (e.g., altruism), gratitude, purpose in life, and lower levels of openness to experiences ( 52 ). These findings suggest that prevention and treatment efforts designed to enhance gratitude, sense of purpose, and altruism may help promote resilience in trauma-exposed veterans.

Negative age stereotypes, defined as deprecating beliefs about older people as a category, have been linked to a broad range of negative health outcomes, including cardiovascular disease, cognitive decline, and mortality ( 65 ). Using NHRVS data, Levy et al. ( 54 ) evaluated whether negative age stereotypes may also be linked to risk for mental disorders in older veterans who participated in the NHRVS. They found that the prevalence of SI (5.0 vs. 30.1%), anxiety (3.6 vs. 34.9%), and PTSD (2.0 vs. 18.5%) was significantly lower among older veterans who fully resisted negative age stereotypes, compared to those who fully accepted them. A 4-year prospective cohort study of this cohort further revealed that greater resistance of negative age stereotypes was linked to significantly lower incidence of these outcomes and that engagement in active coping moderated this association ( 62 ); specifically, among veterans with more negative age stereotypes, those who engaged in active coping strategies to manage stress were less likely to develop mental health problems relative to those who did not engage in these strategies. Collectively, these results suggest that strategies to promote positive age stereotypes ( 66 ) and engagement in active coping may help mitigate risk for mental illness in older veterans.

Barriers to Mental Healthcare

Between 41 and 79% of older persons with psychiatric disorders do not receive mental health care ( 67 , 68 ). Perceived barriers to care, including stigma, negative beliefs about mental health care, and logistical barriers to care, may also affect utilization of mental health services among older veterans ( 57 ). Blais et al. ( 57 ) analyzed NHRVS data to identify correlates of current mental health care utilization and perceived barriers to care in older veterans. Only 6% of older veterans reported current mental health care utilization, and among veterans who screened positive for a current psychiatric disorder 25% were currently utilizing services. Utilization was also associated with several medical and psychiatric disorders, most notably PTSD (odds ratio = 5.9). Notably, greater perceptions of stigma and negative beliefs about mental health care were related to decreased likelihood of utilizing care. Collectively, these results suggest that efforts to identify veterans with mental health distress, and to reduce stigma and negative beliefs about mental health care may help promote mental health service utilization among symptomatic older U.S. veterans.

A majority of veterans with a high lifetime trauma burden are psychologically resilient in later life ( 52 ). However, a significant minority of older veterans may experience a clinically significant exacerbation of PTSD symptoms in late life ( 12 ). Prevention and treatment efforts designed to promote health behaviors, protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life), social connectedness (i.e., secure attachment, community integration, social engagement), and cognitive functioning may help promote successful aging in older veterans and mitigate risk for mental disorders ( 12 , 51 – 53 , 56 , 58 , 60 ). Further, since physical disability is prevalent among older veterans, promoting a greater sense of purpose in life may help preserve physical functioning in aging veterans ( 59 ). Efforts to identify distressed older veterans and reduce stigma and negative beliefs about mental health care may help increase mental health service utilization ( 57 ). In sum, results of these studies suggest that interventions designed to mitigate psychological and physical struggles in older veterans, and to promote social connectedness and protective psychosocial characteristics, may help foster successful aging in veterans.

Special Topics Relevant to Veterans

Twenty-five (see Table 4 ) studies from the NHRVS have examined a myriad of special topics relevant to veterans, including military sexual trauma, combat exposure, positive and negative effects of military service, homelessness, and psychiatric and physical morbidities/comorbidities.

Special topics relevant to veterans.

Military Sexual Trauma and Combat Exposure

Certain trauma exposures are unique to veterans, including military sexual trauma and combat exposure. While the prevalence of MST is highest in female veterans, the VA reports that almost half of VA users who screen positive for MST are men ( 93 ). Furthermore, MST is also thought to be largely underreported, particularly in men, among whom there may be a higher burden of stigma. Using NHRVS data, Klingensmith et al. ( 69 ) found that 7.6% of U.S. military veterans reported MST, and that the prevalence was significantly higher among female than male veterans (32.4 vs. 4.8%) and younger than older veterans (22.8% among 18–29 year-olds vs. 4.5% among 60+ year-olds). In a model adjusted for sociodemographic and military characteristics, MST was associated with elevated rates of several psychiatric morbidities and suicidality (adjusted odds ratio range = 2.2–3.1), reduced functioning and QOL, as well as increased mental health treatment utilization (adjusted odds ratios range = 2.4–3.7) ( 69 ). A follow-up study by Averill et al. ( 86 ) found that, relative to female MST survivors, male MST survivors have greater trauma burden, hostility, and higher rates of drug use disorder, but lower severity of PTSD symptoms. Taken together, these findings suggest that screening for MST and the consideration of sex differences are critical to informing risk for a broad range of mental health problems in U.S. veterans.

Similar to MST, combat exposure is linked to increased risk for mental health problems, including psychiatric disorders such as PTSD, generalized anxiety disorder, MDD, and substance use ( 94 , 95 ). A NHRVS study ( 76 ) found 38% of veterans reported being exposed to combat, and that, relative to non-combat veterans, combat veterans had 2 to 3-fold elevated rates of PTSD and generalized anxiety disorder. Further, combat veterans had 68% greater odds of a suicide attempt and 85% and 38% greater odds of a stroke and chronic pain, respectively. Among combat veterans, age was associated with differential risk for certain health conditions, with younger veterans more likely to screen positive for PTSD, SI, and migraine headaches, while older veterans were more likely to reported having heart disease and a heart attack. Results of this study suggest that combat exposure may independently contribute to risk for mental and physical health issues in U.S. veterans, and that age may moderate the effect of combat exposure on health outcomes.

Perceived Effects of Military Service

In addition to combat exposure, other military-related factors, such as perceived threat during deployment, and difficult living and working environments, have been linked to depression, anxiety, and PTSD ( 96 ). Using NHRVS data, Campbell et al. ( 78 ) examined the relationship between perceptions of desirable (e.g., military service helped one learn to cope with adversity) and undesirable effects of service (e.g., military service caused misery and discomfort), and mental health problems. The study found desirable effects of service were more frequently endorsed than undesirable effects (54–86% vs. 9–48%), and that combat-exposed veterans were more likely to endorse undesirable than desirable effects of service (11–60% vs. 4–41%). Of note, after adjustment for possible confounding variables, undesirable effects of service predicted significantly greater odds of probable current mental health disorders and current SI (both odds ratios = 1.1), while desirable effects of military service were linked to lower odds of current SI (odds ratio = 0.96). Taken together, results of this study suggest that perceptions of military service may be linked to risk for mental disorders and suicidality, and that desirable effects of effects of military service may help counteract risk for suicidal thinking associated with undesirable effects of service. Clinically, they suggest that assessment of perceptions of military service may help identify at-risk veterans who may benefit from mental health treatment.

Major Depressive Disorder

MDD is prevalent disorder that often co-occurs with PTSD. Using data from the NHRVS, Nichter et al. ( 84 ) estimated the prevalence of current PTSD/MDD in the U.S. veterans population at 3.4%. Compared to veterans with PTSD only and MDD only, those with comorbid PTSD/MDD were significantly more likely to screen positive for current SI, lifetime suicide attempts, and anxiety disorders, and they scored substantially lower on measures of mental health and cognitive functioning, and QOL. Furthermore, a follow-up study ( 85 ) found that veterans with comorbid PTSD/MDD had a substantially greater burden of physical illness than veterans with either disorder alone. Specifically, veterans with comorbid PTSD/MDD had higher rates of heart disease, migraine, fibromyalgia, and rheumatoid arthritis compared to veterans with MDD alone, and higher rates of hypercholesterolemia and hypertension compare to veterans with PTSD alone ( 85 ). Taken together, these findings highlight the importance of screening, monitoring, and treatment comorbid PTSD/MDD in veterans. They also suggest that veterans with comorbid PTSD/MDD should be closely monitored for physical health problems, particularly cardiovascular risk factors and disease, and inflammatory and pain-related conditions. Finally, emerging NHRVS research on PTSD/MDD comorbidity ( 89 ) has revealed that greater dispositional optimism and community integration were associated with lower likelihood of having comorbid PTSD/MDD relative to either disorder alone, thus highlighting the potential importance of targeting these psychosocial factors in prevention and treatment efforts.

Alcohol Use Disorder

Although PTSD is one of the most prevalent and intensively studied psychiatric disorders among veterans, other disorders are also prevalent among veterans. With regard to alcohol use disorder (AUD), Fuehrlein et al. ( 71 ) found the lifetime and past-year prevalence of AUD was 42.2 and 14.8%, respectively in the NHRVS. Results further revealed that veterans with lifetime AUD were approximately four times more likely to have a lifetime history of PTSD, MDD, and SI ( 78 ). When considering racial/ethnic differences in veterans associated with AUD, a recent study found that Black and Hispanic veterans with lifetime AUD experience a greater disease burden relative to White veterans, which underscores the importance of race/ethnicity-sensitive approaches to the assessment, monitoring, and treatment of AUD in veterans ( 88 ).

Building on these cross-sectional findings of AUD in veterans, a 4-year prospective cohort study ( 79 ) was conducted to identify predominant trajectories of alcohol consumption and baseline determinants of these trajectories, where four predominant trajectories were identified. The majority (65.3%) of veterans were rare drinkers, 30.2% were moderate drinkers, 2.6% were excessive drinkers (2.6%), and 1.9% were recovering drinkers. Lifetime MDD was linked to an excessive drinking trajectory, while fewer medical conditions and lower social support were linked to a moderate drinking trajectory. Absence of lifetime MDD, having a secure attachment style, and greater social support were linked to the recovering drinking trajectory ( 84 ). Another prospective study ( 90 ) found that ~6% of veterans without AUD at baseline developed AUD over 7-year follow-up. Adult sexual trauma in adulthood, higher anxious arousal symptoms of PTSD, lifetime history of drug and nicotine use disorders, and higher alcohol consumption at baseline predicted the development of AUD. Collectively, these results suggest that targeting MDD, other substance use, and trauma exposure in population-based prevention and treatment initiatives may help prevent, mitigate, and promote recovery from AUD in veterans.

Given that AUD and PTSD are among the most prevalent disorders in veterans and often co-occur, it is important to determine the burden associated with AUD/PTSD comorbidity relative to either disorder alone. Using NHRVS data, Norman et al. ( 80 ) found that one of every five veterans with AUD also screened positive for PTSD. Veterans with comorbid PTSD/AUD, comparted to AUD only veterans, were more likely to screen positive for MDD, GAD, and reported strikingly higher rates of current SI (39.1 vs. 7.0%) and lifetime suicide attempt(s) (46.0 vs. 4.1%); they also scored lower on measures of cognitive, mental, and physical health functioning, and QOL ( 80 ). Building on this study, Straus et al. ( 83 ) examined social (e.g., social connectedness) and psychosocial characteristics in veterans with PTSD, AUD, and comorbid PTSD/AUD. The study found veterans with comorbid PTSD/AUD had lower on social connectedness and protective psychosocial characteristics relative to those with AUD alone, but not PTSD alone. While both social and psychosocial protective factors partially mediated the relation between PTSD and current SI, only psychosocial protective characteristics partially mediated the relation between PTSD and lifetime suicide attempt(s) ( 83 ). Collectively, these findings highlight the burden of comorbid PTSD/AUD in veterans and suggest that treatment of PTSD in veterans with PTSD/AUD, and promotion of social connectedness and psychosocial protective factors, may help mitigate risk for and promote recovery from these disorders.

Nicotine Dependence

Another commonly used substance in veterans is nicotine. Baldassarri et al. ( 87 ) found that almost one in five U.S. veterans met criteria for lifetime nicotine dependence. The strongest correlates of lifetime nicotine dependence were lifetime alcohol use disorder, lifetime drug use disorder, current alcohol use disorder, kidney disease, and heart disease. Given that nicotine dependence often presents as part of a complex set of conditions that includes psychiatric and medical comorbidities, trauma history, reduced overall physical functioning, and an increase in somatic complaints, veterans with nicotine dependence may require a comprehensive and integrated approach to care.

Problem Gambling

PTSD has also been associated with problem gambling ( 97 ) and 40% of veterans seeking treatment for gambling problems have reported prior suicide attempts, with 64% of those who attempted suicide reported gambling-related attempts ( 98 ). Using NHRVS data, Stefanovics et al. ( 75 ) examined the prevalence, risk factors, and mental health correlates of recreational and problem gambling in U.S. veterans. They found 35.1% of U.S. veterans gambled recreationally and 2.2% screened positive for problem gambling. Younger age, self-identifying as Black and being retired were associated with increased likelihood of screening positive for problem gambling. Veterans with problem gambling also had higher rates of substance use, anxiety, depressive disorders, a history of physical trauma or sexual trauma, and greater lifetime trauma burden. Results of this study suggest that a significant minority of U.S. veterans screen positive for problem gambling, which is associated with greater mental health burden. They further suggest that routine screening and monitoring of gambling severity may help identify at-risk veterans, and that trauma burden may contribute to risk for problem gambling in this population.

Physical Health Morbidities

The relationship between trauma, PTSD, and physical health has been well-documented ( 99 ). Given that the clinical presentation of PTSD is often heterogeneous, examining the relation between PTSD and subthreshold PTSD, and a range of physical conditions may elucidate potential mechanisms driving comorbidity with physical health conditions. Using data from the NHRVS, El-Gabalawy et al. ( 82 ) found that PTSD and subthreshold PTSD were associated with increased risk of sleep disorder and respiratory conditions. PTSD was additionally associated with increased risk of osteoporosis or osteopenia and migraine, while subthreshold PTSD was associated with increased odds of diabetes. Results also demonstrated the importance of dysphoric arousal symptoms of PTSD, which are characterized by sleep disturbance, concentration difficulties, and irritability and anger, in risk models of certain physical conditions in veterans with PTSD symptoms.

NHRVS investigators have also examined the prevalence and health burden of obesity in U.S. veterans. A recent study found that 32.7% of NHRVS veterans were obese, which is higher than previously reported estimates in the U.S. veteran population ( 81 ). The prevalence of obesity was particularly elevated among veterans who were younger, racial/ethnic minorities, and who utilized VA healthcare services as their main source of healthcare. Notably, obesity was associated with greater trauma burden, as well as elevated rates of a broad range of mental health conditions, including PTSD and nicotine dependence ( 81 ). Further NHRVS studies have revealed that 5.8% of veterans have co-occurring PTSD and obesity and 5.4% of veterans have co-occurring nicotine dependence and obesity ( 91 , 92 ). Obesity was also associated with a range of physical health conditions, such as diabetes, arthritis, and heart disease, in addition to poor physical and mental health-related functioning and overall QOL ( 91 ). Collectively, these findings underscore the burden of obesity—independently and in combination with smoking and PTSD—on multiple aspects of health, functioning, and QOL in veterans.

Gender Differences

Gender differences have also been reported among veterans for specific health conditions. Risk for exposure to various types of traumatic events differs by gender ( 6 ) and the association of trauma with adverse health outcomes may vary by traumatic event type ( 69 ). Thus, it is important to consider the possibility that assaultive trauma may be differentially associated with health outcomes in male and female veterans. A recent study ( 77 ) found that female veterans had significantly higher prevalence of lifetime PTSD, MDD, arthritis, migraine headaches, and osteoporosis, but lower prevalence estimates of lifetime nicotine dependence, drug use, diabetes, heart attack, and high blood pressure. With more women joining the military, consideration of their unique health needs is critical to informing care delivery models and developing gender-sensitive interventions ( 77 ).

Hostility and Anger

Understanding the burden and clinical features of hostility and anger is particularly relevant to veterans given evidence of elevated rates of hostility-related health issues such as PTSD, depression, and heart disease relative to non-veterans ( 100 , 101 ). Using data from the NHRVS, Sippel et al. ( 72 ) examined the prevalence and longitudinal course of hostility over a 2-year period. They found that 61.2% of veterans reported experiencing difficulties controlling anger and that nearly a fourth reported having aggressive urges ( 72 ). Psychological distress and alcohol misuse were associated with symptomatic courses of hostility, while greater dispositional optimism and a secure attachment style were negatively associated with these courses ( 72 ). These findings underscore the burden of hostility and anger in the U.S. veterans, and suggest potential targets for prevention and treatment efforts designed to mitigate hostility and anger in this population.

Homelessness

Studies from the NHRVS have also contributed to the literature on homelessness and employment, which may help inform allocation of governmental resources and services for veterans. A 2016 study by Tsai et al. ( 73 ) found that 8.5% of veterans reported ever being homeless in their adult life, but only 17.2% of those reported ever using VA homeless services. Findings further revealed that low income, being middle-aged ( 15 , 18 , 37 – 41 , 45 – 47 ), and having poor mental and physical health were independently associated with lifetime homelessness. Additionally, veterans who were White or lived in rural areas were significantly less likely to have used ever VA homeless services.

Self-Employment

Efforts to support self-employment may help mitigate unemployment among veterans. Results from Heinz et al. ( 74 ) demonstrated that veteran entrepreneurs experienced a higher number of traumas compared to non-entrepreneurs, but veterans entrepreneurs did not report higher levels of PTSD or other psychopathology. These results suggest that higher trait levels of optimism, extraversion, gratitude, curiosity (i.e., need for autonomy), and openness may contribute to resilience in veteran entrepreneurs. Combined with elevated sense of purpose in life, there trains may help these individuals be more “gritty” and pursue entrepreneurial employment.

Veterans face a wide array of mental and physical health struggles, many of which commonly co-occur, and may result in functional difficulties, and chronicity and exacerbation of symptoms. Results of the NHRVS studies reviewed above help to characterize the population-based burden of a wide range of mental and physical health conditions that are prevalent among veterans, which may help inform outreach efforts, resource allocation, and program development within VA and non-VA settings to better serve this population. They also highlight the need for screening initiatives and specialty services targeting homelessness, employment, and PTSD and co-occurring health disorders. Specifically, veterans with histories of MST and combat-exposure, as well as common co-occurring physical and mental health conditions may have heightened need for screening, monitoring, and treatment efforts. Increasing access to information about mental health care, which may serve to decrease stigma, may also help veterans navigate barriers to initiation and engagement in care.

Resilience and Post-Traumatic Growth

Although most studies on trauma focus on psychopathology and other negative consequences, a new concentration in trauma literature is to characterize the prevalence and correlates of psychological resilience in veterans. Psychological resilience is defined as “the ability to adapt in the aftermath of trauma or extreme stress and maintain a high level of psychological functioning” ( 3 ). There are several personality and behavioral constructs associated with stress resilience, including hardiness, mental toughness, and grit ( 102 ). Though these constructs have nuanced differences, they represent the positive psychological traits that may help foster psychological resilience. Additionally, positive psychological changes, or PTG, can occur as a consequence of exposure to traumatic and stressful life events, and may include developing an increased appreciation of life, greater sense of personal strength, renewed appreciation for intimate relationships, and positive spiritual changes ( 103 ). Longitudinal studies of resilience and PTG can help elucidate the nature and determinants of heterogeneous courses of reactions to stressful or traumatic events and help inform strategies for promoting positive psychological changes in the face of adversity ( 104 ). To date, eight NHRVS studies (see Table 5 ) have focused on resilience and post-traumatic growth.

Resilience and post-traumatic growth.

Psychological Resilience

As described above, studies from the NHRVS have found that the majority of veterans with a large number of traumatic experiences are psychologically resilient in later life and that prosocial behaviors and purpose in life may help promote psychological resilience ( 52 ). Although many cross-sectional studies have examined the correlates of veteran resilience, scarce longitudinal studies have identified longitudinal determinants of resilience in this population. Longitudinal data are important, as they can help inform population-based treatment and prevention initiatives geared toward the promotion of psychological resilience in trauma-exposed individuals such as veterans.

Toward this end, Isaacs et al. ( 107 ) conducted a 2-year prospective cohort study and found that among veterans endured a high number of traumas over the course of their lifetimes, 67.7% reported minimal-to-no current psychological distress (i.e., current PTSD, depression, and anxiety symptoms). Baseline determinants of resilience included younger age, White race/ethnicity, better physical health, lower rates of psychiatric and substance use disorders, and greater levels of emotional stability, extraversion, purpose in life, dispositional gratitude, and altruism, and lower openness to experiences ( 107 ). Cross-sectionally, research using the NHRVS has also found high levels of religiosity/spirituality is associated with decreased risk for PTSD, MDD, alcohol use disorder, and SI ( 108 ). Importantly, higher levels of religiosity/spirituality were also strongly linked with greater PTG and other protective factors, such as increased purpose in life and dispositional gratitude, thus underscoring the potential importance of religiosity/spirituality in contributing to psychological resilience in U.S. veterans.

Post-traumatic Growth

A growing body of literature has found that individuals who experience a wide range of traumatic life events (e.g., prisoners of war, refugees, assault survivors, combat veterans) often report experiencing PTG. However, the relationship between PTSD symptoms and PTG is less clear. In the first known nationally representative study of PTG in veterans, Tsai et al. ( 105 ) found that nearly three-quarters of veterans who screened positive for PTSD reported at least moderate levels of PTG. Several psychosocial factors, such as greater social connectedness, intrinsic religiosity and purpose in life, were also independently related to greater PTG ( 105 ). Furthermore, they observed a curvilinear (i.e., inverted U-shaped) relationship between PTSD symptoms and PTG, with veterans with a moderate level of PTSD symptoms reporting the greatest levels of PTG. A follow-up prospective study ( 106 ) examined whether PTG may predict greater resilience to subsequent traumatic stress. Results indicated that greater scores on the personal strength domain of PTG, which assesses one's perception of their ability to handle difficulties, was associated with reduced severity and incidence of PTSD at a 2-year follow-up ( 106 ). Other research on PTG using NHRVS data has found that greater PTG moderates the influence of PTSD on perceived QOL in veterans with life-threatening illness or injury, with higher levels of PTG associated with higher QOL among veterans with greater severity of PTSD symptoms ( 110 ).

To date, the vast majority of studies of PTG have been cross-sectional in nature, thus little is known about the longitudinal course or predictors of PTG. Consistent with the cross-sectional studies, a recent prospective study ( 111 ) of the dynamic interplay between PTSD symptoms and perceived PTG found that the relationship between PTSD and PTG over time was optimally characterized by a non-linear, “inverted U” shaped association, and that greater severity of PTSD symptoms, particularly avoidance and hyperarousal, were associated with greater PTG over time, but not vice versa. Another study of PTG in the NHRVS found that over a 2-year period, PTSD symptoms, particularly re-experiencing symptoms, greater number of medical conditions, stronger purpose in life, altruism, and an active lifestyle predicted a maintenance or increase in PTG over time ( 104 ). Using 4-year prospective data, Tsai and Pietrzak ( 109 ) identified three predominant PTG trajectories (i.e., low and decreasing, consistently moderate, and high and increasing) among veterans in hopes of better understanding the temporal course of PTG. Veterans who reported experiencing greater severity of PTSD symptoms, particularly re-experiencing and avoidance symptoms, were more likely to have consistently moderate or high and increasing PTG ( 109 ).

In clinical settings, individuals with trauma-exposure generally receive treatments designed to reduce negative symptoms; however, a growing body of research suggests the potential importance of additionally considering interventions designed to foster resilience and PTG ( 110 ). Specifically, prevention and treatment efforts designed to enhance modifiable factors such as sense of purpose and meaning in life, dispositional gratitude, and altruism may help promote resilience and PTG in trauma-exposed veterans ( 104 , 107 , 109 ). Further, promoting positive health behaviors (e.g., regular physical activity), and screening and treating medical and mental health conditions may also help bolster psychological resilience and PTG. Furthermore, since re-traumatization is common in trauma-exposed individuals, fostering PTG in clinical settings may help promote psychological resilience in response to subsequent traumatic life events.

Genetics and Epigenetics

Many major psychiatric disorders have high heritability. To date, twelve studies (see Table 6 ) have investigated genetic factors associated with major psychiatric disorders such as PTSD and MDD in the NHRVS sample. These studies provide preliminary insight into how genetic factors may increase risk for lifetime PTSD and related disorders in European-American veterans, as well as how environmental factors such as trauma burden and social support may exacerbate or moderate risk for these disorders. Of note, however, results of these studies should be interpreted with caution for the following reasons: first, they primarily focused on candidate genes previously found to be associated with PTSD and related disorders that have not emerged as statistically significant in recent genome-wide association studies; second, they included only European-Americans; and third, they were based on relatively small samples, which were underpowered for genome-wide association studies.

Genetics and epigenetics.

In addition to genetic and gene-by-environment studies, we examined how psychological factors may be linked to markers of biological aging, such as telomere length and DNA methylation age, in veterans. As with candidate gene findings, these findings should be interpreted with caution, as they may be tissue-specific (i.e., derived from cells present in saliva).

FK506 Binding Protein 5

Examining the interactive effects of candidate genes and environmental factors on risk for mental disorders such as PTSD, rather than investigating independent genetic or environmental influences, may help advance understanding of the etiology of these conditions. Common single nucleotide polymorphisms (SNPs) in the FK506 Binding Protein 5 ( FKBP5 ) gene may interact with childhood abuse to increase risk of developing PTSD ( 123 – 125 ). Results from Watkins et al. ( 113 ) suggested that the main effects of four FKBP5 SNPs (rs9296158, rs3800373, rs1360780, rs9470080) were associated with lifetime severity of PTSD symptoms in veterans from C1 and C2 of the NHRVS. Results of this study further revealed that FKBP5 polymorphisms, directly and interactively with childhood abuse, predicted greater severity of lifetime PTSD symptoms, specifically hyperarousal symptoms.

Building upon these findings, Tamman et al. ( 122 ) examined attachment style as a potentially modifiable environmental moderator of this association. A majority of individuals that experience abuse during childhood endorse insecure attachment styles ( 126 ), which has in turn been linked to increased risk for PTSD ( 127 ). Attachment style is also clinically relevant given that an insecure attachment style has been linked to reduced treatment response among veterans with PTSD ( 128 ). This study found that FKBP5 SNPs, childhood abuse, and insecure attachment style were associated with greater PTSD symptoms ( 122 ). Importantly, FKBP5 homozygous minor allele carriage and history of childhood abuse was associated with greater PTSD symptoms, but these effects were fully counteracted by secure attachment style ( 122 ).

Neuropeptide Y

Another gene of relevance to traumatic stress and resilience is the neuropeptide Y ( NPY ) gene, which is expressed in a number of brain regions and plays a key role in the regulation of fear, stress, anxiety, learning, and memory ( 129 ). Previous studies have found that the rs16147 SNP, which is located in the promoter region of the NPY gene and accounts for more than half of the in vivo plasma expression of NPY, may interact with traumatic or stressful experiences to predict PTSD symptoms ( 130 ). Watkins et al. ( 117 ) examined whether polymorphisms in this gene may be linked to resilience to traumatic stress and PTSD symptoms in the C1 genetic subcohort of the NHRVS. Results of this study suggested that the T allele of NPY rs16147 was associated with greater resilience to PTSD symptoms, particularly re-experiencing/intrusive symptoms, even in veterans exposed to very high levels of trauma. Further research is need to evaluate whether interventions designed to enhance NPY expression levels, such as intranasal NPY ( 131 , 132 ) may help promote stress resilience in trauma-exposed individuals ( 117 ).

Apolipoprotein E

The apolipoprotein E ( APOE ) gene has also been implicated in PTSD risk. This gene is active in neuronal repair via cholesterol metabolism and transportation ( 133 ). This gene has also been associated with greater probability of developing neurologic and psychiatric disorders ( 133 ). Previous research examining the association between APOE gene polymorphism and PTSD risk has been mixed due to small and select samples. Accordingly, Mota et al. ( 118 ) used data from the genetic subcohorts of C1 and C2 of the NHRVS, and examined the relation between APOE genotype and PTSD symptoms. In both C1 and C2 of the NHRVS, the interaction of APOE ε4 carrier status and cumulative trauma burden was associated with higher PTSD symptoms, particularly re-experiencing/intrusion symptoms. Notably, they also observed an environmental moderation effect of social support, with greater social support associated with lower severity of PTSD symptoms among APOE ε4 allele carriers with greater cumulative trauma burden.

The ε4 allele of the APOE gene may also increase risk of cognitive dysfunction among normal aging veterans ( 134 ), especially given PTSD is associated with cognitive decline and difficulties ( 135 ). Accordingly, Averill et al. ( 119 ) examined the effects of APOE ε4 genotype and PTSD on cognitive functioning in veterans from C1 and C2 of the NHRVS, as well as a younger, predominantly civilian, replication sample from the Yale–Penn Study. Results revealed that APOE ε4 allele carrier status and PTSD were independently associated with lower cognitive functioning in the NHRVS samples ( 119 ). Specifically, veterans with PTSD who were ε4 carriers scored lower than those without PTSD, and the most pronounced differences were observed in executive function and attention/concentration. The significant interaction of ε4 and PTSD in predicting executive function was also replicated in the Yale–Penn cohort, but the main effects of ε4 and PTSD were not. Results of these studies suggest that APOE ε4 allele carrier status may contribute to the genetic etiology of PTSD symptoms and cognitive difficulties in U.S. veterans. They further highlight the role of trauma burden and social support in moderating the effect of ε4 on PTSD symptoms, and of PTSD in moderating the effect of ε4 on cognitive difficulties.

Oxytocin Receptor

Polymorphisms in the oxytocin receptor gene ( OXTR ) may also interact with attachment style to predict PTSD, as the oxytocin system plays a key role in social behavior and stress regulation ( 136 ). Results from Sippel et al. ( 116 ) revealed that insecure attachment style and the interaction of the OXTR SNP rs53576, which has been implicated in empathy, loneliness, and parental sensitivity, and attachment style were associated with probable lifetime PTSD. Specifically, veterans with an insecure attachment style were at significantly increased risk of screening positive for PTSD if they had at least one rs53576 A allele, which has been linked to reduced empathy. However, the OXTR rs53576 genotype was not associated with PTSD when tested using a GWAS approach in a civilian sample. However, this GWAS did detect a new associated SNP (rs2300549), which was then tested in the veteran NHRVS sample, and while the main effect was null, there was preliminary evidence that it also interacted with attachment style to predict PTSD. Taken together, results of this study indicated that polymorphisms in the OXTR gene and attachment style may contribute to vulnerability to PTSD in veterans.

Brain-Derived Neurotrophic Factor

Genetic studies from the NHRVS have also implicated a specific polymorphism in the brain-derived neurotrophic factor ( BDNF ) gene as a potential risk factor for PTSD ( 137 , 138 ). BDNF is also know to influence synaptic plasticity, differentiation, and neuronal function. Prior research has found that Met allele of the Val66Met polymorphism of the BDNF gene is associated with impaired fear extinction, as well as reduced hippocampal volume and function, in individuals with PTSD ( 139 , 140 ). Physical exercise has been linked to increased memory function, plasma BDNF levels, and hippocampal neurogenesis ( 120 , 141 ). Physical exercise has also been linked to reduced depressive and PTSD symptoms ( 120 , 141 ). To evaluate if physical exercise moderates the effect of the Val66Met SNP on risk of PTSD, Pitts et al. ( 141 ) examined the relationship between BDNF Val66Met Met allele carrier status, physical exercise, and PTSD symptoms in the NHRVS genetics subcohort. The authors found that relative to Val/Val homozygotes, Met allele carriers reported greater severity of lifetime PTSD symptoms and Met allele carriers with a higher number of traumas reported greater severity of PTSD symptoms ( 141 ). Greater engagement in physical exercise moderated this association where, among veterans with high trauma burden, Met allele carriers who engaged in regular physical exercise had significantly lower severity of PTSD symptoms relative to those who did not exercise ( 141 ). Another study examined the direct and interactive effect of the BDNF Val66Met polymorphism, depression, and physical exercise in predicting cognitive functioning in the NHRVS genetics subcohort ( 120 ). Pitts et al. ( 120 ) found that depression was associated with moderate decrements in cognitive functioning and this association was moderated by the BDNF Val66Met genotype and physical exercise. Jointly, results of these studies suggest that physical exercise interventions may help mitigate PTSD symptoms in trauma-exposed veterans and cognitive dysfunction in depressed veterans who are Met allele carriers.

Genome-Wide Association Study of Depression and Alcohol Dependence

Alcohol-related problems, such as alcohol dependence, and MDD are other mental health disorders that are common in genetics research, as it is hypothesized that shared genetic factors may predispose individuals to both alcohol dependence and MDD. Using four genome-wide association study (GWAS) data sets, including C1 from the NHRVS, Andersen et al. ( 115 ) examined whether alcohol dependence and MDD have genetic overlap using polygenic risk scores. Polygenetic risk scores quantitatively measure the cumulative effects of common genetic variations across the genome in consideration of risk for a disorder. Results of this study revealed that higher MDD polygenic risk scores were associated with an increased risk for alcohol dependence ( 115 ). Results also suggested that there are common genetic factors which contribute to comorbid MDD-alcohol dependence, and that some individuals carry a genetic predisposition for both disorders ( 115 ). Findings from this study add a significant contribution to better understanding co-occurring disorders in veterans.

Telomere Length and DNA Methylation Age

In addition to characterization of genetic risk factors for PTSD, alcohol dependence, and MDD, characterization of factors that may accelerate biological aging is important. Telomeres are nucleoprotein structures that cover the ends of chromosomes and protect from damage ( 142 ). Importantly, telomere length is associated with aging-related medical conditions and mortality, in addition to being an indicator of an individual's biological age ( 142 ). Hostility is characterized by aggressive urges/impulses and difficulties controlling anger ( 143 ). Research has established that hostility is prevalent among veterans ( 72 ) and is associated with aging-related disorders and telomere shortening ( 144 ). Using data from the NHRVS, Watkins et al. ( 114 ) found that greater severity of hostility, particularly difficulties controlling anger, was associated with peripheral telomere shortening in veterans.

Another study ( 112 ) evaluated whether negative age stereotypes, which have been linked to increased rates of physical decline, cognitive decline, and mortality in older adults ( 65 , 145 ), are associated with shorter telomere length in veterans from the NHRVS and an independent sample of civilian older adults who recently experienced an acute myocardial infarction. In both samples, negative age stereotypes were associated with shorter telomere length, independent of sociodemographic characteristics and physical and mental-health indicators.

Aging has also been associated with predictable changes in DNA methylation. Genome-wide methylation research has established algorithms that estimate chronological age and serve as an “epigenetic clock” ( 146 ). These estimates, called DNA methylation (DNAm) age, can be used to quantify if DNAm aging is accelerated within an individual, which can predict detrimental health outcomes and is associated with sociodemographic, health, and psychosocial characteristics ( 121 ). Specifically, Tamman et al. ( 121 ) found that three physical health variables—diabetes, hypertension, and body mass index—were associated with accelerated DNAm aging. Cumulative trauma burden, child sexual trauma, and negative beliefs about aging were additionally associated with accelerated DNAm aging. Notably, child sexual abuse explained nearly the same amount of variance in accelerated DNAm age as diabetes (33.2 vs. 35.9%), thus underscoring the importance of trauma exposure in the acceleration of DNAm age. These results suggest that prevention and treatment efforts to mitigate deleterious effects of trauma exposure and negative beliefs about aging, which are modifiable, may help forestall accelerated DNA methylation aging in veterans.

Collectively, results of NHRVS genetic and epigenetic studies underscore the utility of assessing, monitoring, and treating trauma-exposure, specifically childhood abuse and cumulative trauma burden, in veterans with certain genetic polymorphisms ( 113 , 118 – 120 , 122 ). They further suggest that therapeutic enhancement of modifiable protective factors, such as social support networks (e.g., one-to-one mentorship programs, peer support groups, social/relationship skills interventions, Vet-to-Vet programs), attachment style, and physical exercise among trauma-exposed veterans at elevated genetic risk for PTSD and related disorders may be an important aspect of prevention initiatives ( 116 , 120 , 122 ). Further, prevention and treatment efforts designed to reduce implicit negative age stereotypes, and anger and hostility may help mitigate acceleration of biological aging, and ultimately help reduce risk for age-related disorders among veterans ( 112 , 114 ). As noted above, however, these findings must be interpreted with caution and require replication in larger, more diverse samples, as well as in tissues other than saliva.

Conclusions and Future Directions

This narrative review summarized results of 82 original research studies that have been published to date using data from the NHRVS. These studies have covered six major topic areas, including post-traumatic stress disorder, suicidality, aging, resilience and post-traumatic growth, special topics relevant to veterans, and genetics. Collectively, the results of these studies underscore the need to develop and test prevention and intervention strategies that aim to enhance modifiable protective factors in veterans. Just as risk factors may have additive and interactive effects, such that having multiple genetic, developmental, neurobiological, and/or psychosocial risk factors may increase allostatic load or stress vulnerability, having and enhancing multiple protective factors may help promote stress resilience ( 147 ). Prior research prevention and intervention strategies designed to enhance these protective factors have been limited to community samples and have received little to no empirical support ( 4 , 148 , 149 ). Results of NHRVS studies published to date suggest that interventions that aim to assist veterans in building social connections and becoming better integrated in their communities, such as interventions that promote volunteerism ( 150 ) and reduce loneliness ( 151 , 152 ) may help enhance resilience among veterans and warrant further investigation ( 153 ).

Extant research from the NHRVS has covered a broad range of health issues of relevance to U.S. military veterans. In future research in the NHRVS, including a new cohort of more than 4,000 veterans who completed a baseline NHRVS survey in 2019–2020, we plan to examine other conditions that may co-occur with PTSD, such as attention-deficit/hyperactivity disorder, traumatic brain injury, chronic pain, and dementia. Despite the inclusion of numerous potential correlates in the initial two NHRVS cohorts, there are other relevant factors, such as a broader range of potentially traumatic experiences that were not assessed in these cohorts, that may be differentially associated with PTSD and related disorders. Additionally, the assessment of substance use (e.g., cannabis and AUD), as well as suicidality and non-suicidal self-harm behaviors has been expanded in this new cohort.

Information on genetic, epigenetic, and modifiable protective factors, such as social connectedness, attachment style, physical exercise, have the potential to be combined to develop clinically useful risk-prediction models for PTSD and related disorders. Each of these factors alone may be weakly or moderately informative when considered individually, but a combination of these factors may provide more integrative approaches for assessment, monitoring, and treatment to mitigate risk for mental disorders that are prevalent in veterans, and promote better functioning and QOL in veterans. Accordingly, a goal for future NHRVS studies is to employ advanced data analytic approaches such as machine learning to identify key combinations of psychological, social, and biological (i.e., genetic) factors linked to key health outcomes in veterans.

Longitudinal epigenome-wide association studies (EWAS) are also being planned to examine the stability and predictive utility of epigenetic (e.g., DNA methylation) changes associated with PTSD and related disorders in the NHRVS genetics subcohorts. Although longitudinal EWAS are expensive and difficult to conduct, cross-sectional studies cannot detect the dynamic nature of epigenetic mechanisms impacting complex and evolving psychiatric disorders such as PTSD, making it difficult to ascertain whether the underlying causal effect is environmental or genetic ( 154 ). These studies may also provide insight into time- or condition-varying effects in veterans ( 155 ).

In summary, NHRVS studies published to date have yielded several important new findings regarding the psychosocial and genetic epidemiology of mental disorders, suicidality, aging, resilience, and post-traumatic growth. Specifically, veterans report exposure to a wide range of potentially traumatic events and a considerable proportion of veterans report experiencing PTSD, MDD, AUD, and related symptoms in their lifetime. However, a majority of veterans were found to be psychologically resilient in later life. Results suggest that initiatives designed to promote protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life) and social connectedness (i.e., secure attachment, community integration, social engagement) may help promote resilience and growth in veterans, and may help mitigate risk for prevalent mental disorders in this population.

Given the nationally representative nature of the NHRVS, these findings can directly inform population-based prevention and treatment efforts in the broader U.S. veteran population. Many of the findings may also be applicable to the general U.S. adult population, as the majority of the NHRVS cohorts were comprised of non-combat-exposed veterans. Further research is needed to examine how demographic changes in the veteran population, including race and ethnic factors, older age, and a larger proportion of female veterans, may influence mental, physical, and cognitive health outcomes over time; and to translate findings from the NHRVS and other large-scale epidemiologic studies of veterans into novel and targeted prevention and treatment strategies to mitigating risk for major health conditions, and preserving functioning and overall quality of life in this population.

Author Contributions

BF was responsible for the formal analysis and writing, and original draft preparation. JT, NM, IH-R, JK, and SS contributed to writing, review, and editing of the manuscript. RP supervised and contributed to the conceptualization, investigation, analysis, data curation, writing, review and editing, and funding acquisition. All authors discussed the results, contributed to the writing, and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. This National Health and Resilience in Veterans Study was supported by the U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder. The funding sources had no role in the design, analysis, interpretation, or publication of this study. This work was supported by VA National Center for Posttraumatic Stress Disorder (NIA Grant #U01AG032284).

Crisis Intervention in Veteran’s Mental Health Essay

Introduction, reference list.

The military has always been forced to respond to the mental healthcare needs of combat veterans because of the role that they play. In this case, it is in both scenarios, that is, during and after deployment. During deployment, crisis intervention strategies or skills are supposed to be used because this is a critical stage where their actions might lead to problems. During deployment, combat veterans are in service and this means that any mental health disorder should be effectively attended to. This is based on the problems or crises that might emanate as a result of their actions while in deployment (Richard, 2005, p. 35). On the other hand, their mental health after deployment is also supposed to be taken care of. This is mostly done through effective assessment strategies and treatment modalities that will take care of their mental healthcare needs.

As far as crisis intervention strategies during deployment are concerned, combat veterans are given mental healthcare in the war zone. This is the first intervention strategy because they have to assess their situation and contain the patient in the war zone so that he/she might not cause any problem. The deployment of family members to the war zone to be with the combat veterans has always been used to support them as they are being treated. This is very important because it enables them to reconnect with their loved ones. In this case, there are occasions where they might reach crisis stages that require immediate intervention (Jones, 2001, p. 12). It should be known that coping skills training has been used to stabilize the situation as time goes by. As a matter of fact, skills training is effective as far as recovering during deployment is concerned. There is a training strategy that is used by the military on combat veterans’ so that they can adapt to deployment.

After deployment, their mental healthcare needs have been sustained through preventive programs. In this case, there are a lot of mitigation strategies where personnel is called in to respond to those veterans who are in crisis. This means that there is a deployment cycle that is used by the military as an assessment strategy for veterans who are returning from deployment. Psychological debriefing has occasionally been used by the military as a preventive measure (Richard, 2005, p. 24). In most cases, this is employed to avert any further crisis. As far as treatment modalities are concerned, there is a lot of mental health personnel who have been trained to ensure that they offer good prescription and treatment. This means that combat veterans have to be followed in their homes to assess their health as time goes by so that they can recover well. Individual programming has also been used as a treatment modality for combat veterans after deployment for long-term sustainability.

A foreshortened sense of the future has emerged as a barrier that might prevent veterans from seeking treatment. This is because veterans have a low expectation of life after returning from combat as far as their mental health problem is concerned. It should be known that this is a barrier because they are affected by trauma-related experiences during and after deployment. Trauma-related experiences keep coming back no matter how much the veterans might try to forget them (Jones, 2001, p. 19). This has proved to be a big barrier especially for veterans who experience severe and chronic combat-related problems. Posttraumatic stress should be effectively taken care of to ensure that combat veterans’ mental healthcare needs are on the right track.

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• The Trauma Symptom Inventory: Description and Use
• Use of Language and Stigma towards Persons With Substance Use Disorders
• Airway (Tracheal) Trauma Management
• Trauma Effects on Women in Combat
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Developing ash-free high-strength spherical carbon catalyst supports

• Domestic Catalysts
• Published: 28 June 2013
• Volume 5 , pages 156–163, ( 2013 )

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• V. V. Gur’yanov 1 ,
• V. M. Mukhin 1 &
• A. A. Kurilkin 1  

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The possibility of using furfurol for the production of ash-free high-strength active carbons with spheroidal particles as adsorbents and catalyst supports is substantiated. A single-stage process that incorporates the resinification of furfurol, the molding of a spherical product, and its hardening while allowing the process cycle time and the cost of equipment to be reduced is developed. Derivatographic, X-ray diffraction, mercury porometric, and adsorption studies of the carbonization of the molded spherical product are performed to characterize the development of the primary and porous structures of carbon residues. Ash-free active carbons with spheroidal particles, a full volume of sorbing micro- and mesopores (up to 1.50 cm 3 /g), and a uniquely high mechanical strength (its abrasion rate is three orders of magnitude lower than that of industrial active carbons) are obtained via the vapor-gas activation of a carbonized product. The obtained active carbons are superior to all known foreign and domestic analogues and are promising for the production of catalysts that operate under severe regimes, i.e., in moving and fluidized beds.

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Original Russian Text © V.V. Gur’yanov, V.M. Mukhin, A.A. Kurilkin, 2013, published in Kataliz v Promyshlennosti.

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Gur’yanov, V.V., Mukhin, V.M. & Kurilkin, A.A. Developing ash-free high-strength spherical carbon catalyst supports. Catal. Ind. 5 , 156–163 (2013). https://doi.org/10.1134/S2070050413020062

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Received : 08 December 2011

Published : 28 June 2013

Issue Date : April 2013

DOI : https://doi.org/10.1134/S2070050413020062

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