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. Author manuscript; available in PMC: 2024 May 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Jan 24;160:209295. doi: 10.1016/j.josat.2024.209295

Mental Health Treatment Utilization Among Gulf War Era Veterans with Probable Alcohol Use Disorder

Pallavi Aurora a,b, Catherine E Paquette a,c, Jean C Beckham a,b,d, Mary Jo Pugh e,f, Nathan A Kimbrel a,b,d,g, Patrick S Calhoun a,b,d,g
PMCID: PMC11060892  NIHMSID: NIHMS1963188  PMID: 38272121

Abstract

Introduction:

Alcohol use disorder (AUD) is prevalent among veterans, and excessive alcohol use is associated with significant mental and physical health consequences. Currently, the largest cohort of veterans seeking services at the VA are those from the 1990s Gulf War Era. This cohort of veterans is unique due to the nature of their deployment resulting in a myriad of unexplained symptoms collectively known as “Gulf War Illness” and higher rates of mental health problems. The present study sought to examine the association between probable AUD and mental health treatment utilization in a sample of 1126 (882 male) Gulf War-era veterans.

Methods:

Veterans completed a self-report survey including the AUDIT-C, questions about mental health treatment engagement, and demographic questions.

Results:

Results demonstrated that approximately 20% of the sample screened positive for probable AUD, determined by standard AUDIT-C cutoff scores. Among those screening positive for AUD, 25% reported engaging in mental health treatment in the past year. Veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Use of mental health services was associated with mental health comorbidity and identifying as Black/African American.

Conclusions:

The results of the present study highlight a significant unmet need for mental health treatment among Gulf War-era veterans with AUD.

Keywords: Alcohol, Veterans, Treatment Utilization, Mental Health

Alcohol use disorder (AUD) is a significant and costly problem among United States military veterans. The prevalence of AUD among U.S. Veterans is approximately 15%, a proportion greater than any other substance use disorder (SUD) except for tobacco use disorder (Boden & Hoggatt, 2018; Fuehrlein et al., 2016). Additionally, more than 40% of veterans have a lifetime history of AUD (Fuehrlein et al., 2016) with women and younger male veterans showing significantly greater rates of heavy drinking compared to civilians, with similar rates of heavy drinking among older veteran and civilians (Hoggatt et al., 2017). Problematic alcohol use is associated with several psychological and medical sequelae including increased rates of depression, liver cirrhosis, and premature death (Rehm et al., 2017; Sohi et al., 2021). Among veterans, AUD is also associated with significant psychiatric and medical comorbidity and increased risk of suicide attempts (Fuehrlein et al., 2016). Treatment for AUD is associated with numerous positive outcomes, including reduced mortality risk among veterans (Rogal et al., 2020), yet less than one-third of veterans diagnosed with AUD receive specialty treatment (Bensley et al., 2017; Halvorson et al., 2014; Vanneman et al., 2017).

Given the high rates of comorbidity between AUD and other mental health conditions, veterans with AUD represent a group for whom increasing access to mental health treatment is especially important. However, there is presently little research examining mental health treatment utilization among veterans with AUD. Research in the general population has found that AUD and other substance use disorders (SUD)s are associated with higher rates of mental health treatment utilization (Burnett-Zeigler et al., 2012; Fleury et al., 2014), whereas among veterans the evidence concerning the relationship between alcohol use, alcohol related problems, and mental health treatment utilization is mixed (Hankin et al., 1999; Wryobeck et al., 2006). Thus, the extent to which veterans with alcohol use problems seek mental health treatment in the Veterans Healthcare Administration (VHA) is currently unclear, and there has been little previous research examining disparities in mental health treatment access in this population.

Previous studies have identified disparities in VHA enrollment (Phillips et al., 2015), healthcare use (Ward et al., 2021), and mental health treatment engagement (Harris & Bowe, 2008; Saha et al., 2008; Satre et al., 2004). as a function of demographic factors including gender, age, race/ethnicity, education, income, and marital status. Indeed, due to the growing rates of mental health diagnoses among veterans (Hunt et al., 2019), there has been a significant push to further understand demographic factors that predict mental health treatment utilization, including among veterans with problematic or hazardous drinking. Broadly, research suggests that veterans with alcohol misuse as well as, those who are younger, have higher income, and are in a relationship are less likely to utilize Veterans Affairs (VA) care (Halvorson et al., 2014). However, among veterans reporting hazardous alcohol use, those with less education and lower income were more likely to receive advice about their drinking from providers (Calhoun et al., 2008; Dobscha et al., 2009). Research has also found racial and ethnic disparities, such that veterans who identify as Black with AUD are more likely to engage in mental health treatment compared to White veterans (Bensley et al., 2017; Keyes et al., 2008). Given the significant variability in demographic factors associated with mental health treatment utilization, it is important to continue to examine who is and is not receiving treatment to better engage veterans with AUD in mental health care and improve their quality of life. Additionally, limited research has examined veteran engagement in mental health treatment through the (VA) compared to community treatment. Indeed, VA health care provides an advantage given the already established prevention and screening methods (Calhoun et al., 2016) which might assist in early detection and facilitate smoother transition into treatment, yet limited is known about the benefits of engaging in VA care vs community care on engagement in treatment for AUD. Thus, to further improve our understanding about treatment engagement understanding treatment location might be an important factor.

Gulf War era veterans currently represent the largest cohort of U.S. veterans (Schaeffer, 2021), and make up over one-quarter of current VHA enrollees (Wang et al., 2021). Gulf War era veterans are an important population given the high prevalence of these veterans seeking treatment for physical and mental health problems in the VA system today, as well as the unique nature of their deployment resulting in a myriad of unexplained symptoms collectively known as “Gulf War Illness” (Institute of Medicine, 2014) and high rates of mental health disorders including PTSD and depression (Proctor et al., 1998; Toomey et al., 2007). Compared to non-deployed veterans, Gulf War veterans are at increased risk of developing AUD (Kelsall et al., 2015; The Iowa Persian Gulf Study Group, 1997), and problematic drinking in this cohort is associated with higher rates of psychiatric diagnoses including posttraumatic stress disorder (PTSD) and major depressive disorder (MDD; Coughlin et al., 2011). Despite the high rates of comorbidity, there is a gap in research examining mental health treatment engagement among Gulf War veterans. Thus, the present study sought to examine the association between probable AUD and mental health treatment utilization in a national sample of Gulf War era veterans. The study had the following aims: 1) investigate the prevalence of probable AUD in this sample, 2) examine the demographic and clinical correlates of veterans with probable AUD and 3) examine the correlates of any mental health use in the past year among those veterans with probable AUD.

Method

Procedure/Participants

Data for this study came from a large national survey investigating the healthcare needs, treatment utilization patterns, and related symptoms of Gulf War Era veterans (Grant #1I01HX0). An initial cohort of 1,098,992 veterans who served in an active-duty capacity between May 1, 1990, and February 28, 1991, were identified using VHA administrative databases. Stratified random sampling was used to select a subsample of 6,000 veterans. Sampling was stratified to ensure geographic representation and to oversample women with the goal of at least 25% women veterans. A modified Dillman approach was used to promote high response rates (Dillman et al., 2014). A total of 3272 surveys were mailed to veterans, with 548 returned surveys due to incorrect mailing addresses, resulting in a total of 2724 surveys assumed to have been correctly received. A total of 1153 veterans completed and returned the survey, resulting in a response rate of 42.33% (1153/2724) and an overall return rate of 35.2% (1153/3272). Study procedures were approved by the Durham Veterans Affairs Health Care System Institutional Review Board and the Salt Lake City VA Health Care System (for a detailed description of all study information and recruitment procedures see Blakey et al., 2021). The final sample used in the present analyses included 1126 veterans (see Table 1 for demographics) with non-missing data on sex and measurement of alcohol misuse. Twenty-seven veterans were excluded from the analysis due to missing data.

Table 1.

Demographic Characteristics.

Full sample (n=1126) Probable AUD (n=232)
N (%) N (%)
Sex
 Male 882 (78.33) 190 (81.90)
 Female 244 (21.67) 42 (18.10)
Race
 White 727 (64.56) 159 (70.04)
 Black or African American 237 (20.16) 40 (17.62)
 Other 133 (11.81) 28 (12.33)
Age
 45–55 397 (35.35) 104 (44.83)
 56–65 413 (36.68) 69 (29.74)
 66–75 198 (17.58) 28 (12.07)
 76+ 9 (1.0) 1 (.004)
Deployed to Gulf War Theater 440 (39.89) 96 (42.11)
Use any VA Healthcare 793 (71.12) 159 (68.83)
Any Combat Warzone Experiences 516 (45.82) 120 (51.72)
Mental Health Diagnosis
 Probable Depression (PHQ-2) 242 (21.49) 71 (30.60)
 Probable PTSD (PCPTSD) 222 (19.72) 67 (28.88)
Current Smoker 156 14.03) 51 (22.27)
Past Year Cannabis Use 113 (10.11) 44 (19.13)
Any Mental Health Treatment Engagement 235 (20.87) 59 (25.43)
M (SD) M (SD)
AUDIT-C score 2.50 (2.57) 6.56 (2.11)
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Measures

Alcohol misuse.

The Alcohol Use Disorders Identification Test-Consumption Items (AUDIT-C; Bush et al., 1998) was used to assess self-reported probable AUD. The AUDIT-C is comprised of three items from the 10-item AUDIT with definitions consistent with ICD-10 definitions of alcohol dependence and alcohol use (Babor et al., 2001). The AUDIT-C has been demonstrated to be a reliable and valid measure of assessing hazardous drinking and alcohol use disorder in both veteran and general U.S. population samples (Bush et al., 1998; Reinert & Allen, 2002; Reinert & Allen, 2007). AUDIT-C scores range from 0–12, with probable AUD defined by gender-specific cutoff scores of ≥ 4 for women (Crawford et al., 2013; Dawson et al. 2005) and ≥ 5 for men (Crawford et al., 2013; Dawson et al., 2005). Internal consistency was good (α=.81).

Treatment utilization.

Treatment engagement was assessed from the larger self-report survey mailed to veterans. Three questions assessing mental health treatment utilization were used. Veterans were asked “Have you used VA health care in the last 12 months?” with response options of “no”; “yes, for physical health care needs”; and “yes, for mental health care needs”. Veterans were also asked “Have you used the Veterans Choice Program in the last 12 months?” and “In the past 12 months have you used non-VA community-based providers (not providers in the Veterans Choice Program)?” with responses of “no”; “yes, for physical health care needs”; “yes, for mental health care needs”; “yes, for prescription drugs”; and “yes, for pain medications”. Veterans were asked to “mark all that apply.” A dichotomous score was calculated for the outcome variable using all three treatment utilization questions where “yes, for mental health care needs” responses were coded as 1 and all other responses coded as 0. Additionally, veterans were asked “How many times have you seen a mental health provider during the past 12 months” with responses of none, 1–2 times, 3–4 times, 5–6 times, and more than 6 times.

Post Traumatic Stress Disorder.

To assess for probable PTSD, the Primary Care PTSD Screen for DSM-5 (PC-PTSD) was administered. The PC-PTSD is a 5-item measure used to assess any exposure to a traumatic event and how the trauma has affected them over the past month with a range of scores from 0–5 (Prins et al., 2016). A sample cut off score of 4 was utilized, such that veterans who scored greater or equal to 4 were coded as positive for probable PTSD and veterans who scored less than 4 were coded as negative for probable PTSD. Internal consistency of the PC-PTSD was good (α = 0.85).

Depression.

To assess probable depression, the Patient Health Questionnaire-2 (PHQ-2_ was administered (Kroenke et al., 2003). The PHQ-2 assesses the frequency of depressed mood and anhedonia for the past two weeks and is often used as a screener for depressive symptoms with a range of scores from 0–6. A cut off score of 3 was utilized such that veterans who score a 3 or higher suggest major depressive disorder is likely. Internal consistency of the measure was excellent (α = 0.90).

Alcohol or Substance Use Disorder.

To assess a diagnosis of alcohol or substance use disorder, a self-report question was asked “have you been diagnosed with the following” with responses of “yes” and “no.”

Current smoker.

To assess if the veteran was a current smoker a single item question was asked “Have you ever smoked cigarettes” with the following responses “no, never smoked”; “yes, still smoke every day”; “yes, still smoke some days”; “yes, but no longer smoke at all”. A dichotomized variable was created where current smoking was coded as positive if a veteran responded to “yes, still smoke every day” or “yes, still smoke some days.”

Cannabis Use.

A two-item measure was used to assess past year cannabis use, “in the past 12 months, have you used marijuana/cannabis as prescribed” and “in the past 12 months, have you used marijuana/cannabis recreationally” with responses of yes or no. A response of yes for either of the two items was coded as positive for past year cannabis use, if both responses were no then cannabis use was coded as negative.

Gulf War Deployment.

To assess gulf war deployment veterans were asked to respond to the following question: “did you deploy to the Persian Gulf region anytime between August 1990 and July 1991?”

Combat Exposure.

Severity of combat exposure was assessed with the Critical Warzone Experiences (CWE) questionnaire (Kimbrel et al., 2014). The CWE is a 7-item measure which asks veterans “thinking across your entire military career, how often did you experience the following during combat” with experiences ranging from seeing injured people to life threatening situations. Veterans are asked to respond on a scale of 0 (never), 1 time, 2–4 times, 5-times, or 10 + times for each item. A total sum score is calculated to determine combat warzones experiences. Internal consistency of the measure was good (α = 0.85).

Demographic variables.

Age (continuous variable), sex (male vs. female), and race (coded as White, Black, and Other) were assessed via self-report.

Analytic Plan

For the first aim, we examined the proportion of veterans who screened positive for probable AUD. Next, we examined the demographic and clinical correlates of veterans with probable AUD using bivariate and multiple logistic regression models. The same analytic strategy was used to examine the correlates of any mental health use in the past year among those veterans with probable AUD. We additionally examined the association of total AUDIT-C score with mental health use to examine whether increased severity of drinking was related to receipt of mental health services among those screening positive for AUD. Because PTSD and depression scores were highly correlated (r = .63, p<.0001) raising a concern about collinearity, we computed a mental health need variable defined as screening positive for either probable PTSD or depression for use in adjusted models. Multiple imputation was used to impute missing data (Johnson & Young, 2011; White et al, 2010). All analyses were conducted in SAS version 9.4.

Results

Table 1 shows demographic characteristics of the full sample and those who screened positive for probable AUD on the AUDIT-C. Out of the 1126 veterans, 232 (20.6%) screened positive for probable AUD on the AUDIT-C. Out of the 232 veterans who screened positive for probable AUD on the AUDIT-C, only 20% (n=47) reported having ever received a lifetime diagnosis of alcohol or other SUD.

To examine the unique associations between demographic variables and probable AUD, logistic regression analyses were conducted including all the demographic variables in Table 1. Bivariate and adjusted associations are displayed in Table 2. Results from the multiple regression model indicated that older age was significantly associated with reduced odds of screening positive for AUD, however other demographic variables including sex and race were unrelated. Severity of combat exposure was significantly related to screening positive for probable AUD, as was mental health need (screening positive for either depression or PTSD). Similarly, current tobacco smokers and those who reported using any cannabis in the past year were also more likely to screen positive for AUD (see Table 2).

Table 2.

Demographic and Clinical Correlates of Probable AUD (N=1126)

Probable AUD
Variable Unadjusted Adjusted
OR (95% CI) OR (95% CI)
Age 0.95*** (0.93–0.97) Age 0.97* (0.95–0.99)
Male Sex 1.32 (0.91–1.91) Male Sex 1.18 (0.79–1.76)
Race Race
 White  White
 Black 0.74 (0.50–1.08)  Black 0.70 (0.47–1.04)
 Other 0.94 (0.60–1.48)  Other 0.89 (0.55–1.42)
Deployed to Gulf Region 1.12 (0.83–1.50) Deployed to Gulf Region 0.76 (0.54–1.06)
Use VA Healthcare 0.87 (0.63–1.12) Use VA Healthcare 0.72 (0.51–1.00)
Combat Exposure Score 1.06*** (1.03–1.09) Combat Exposure Score 1.04** (1.01–1.07)
Probable Depression (PHQ-2) 1.88*** (1.36–2.60) Mental Health Need: Probable Depression or PTSD 1.44* (1.00–2.06)
Probable PTSD (PCPTSD) 1.88** (1.33–2.65)
Current Smoker 2.12*** (1.46–3.07) Current Smoker 1.78** (1.20–2.63)
Past Year Cannabis Use 2.84*** (1.89–4.28) Past Year Cannabis Use 2.16*** (1.39–3.36)
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Note.

*

p < .05

**

p < .01

***

p < .001

Next, we examined the relationship between demographic and clinical variables with the receipt of mental health treatment for participants who screened positive for AUD. Approximately 25% (n=59) of veterans who screened positive for probable AUD reported engaging in mental health treatment either in the VA or community in the past year. Among veterans using VA healthcare, approximately 33% of veterans with probable AUD reported use of mental health services in the past year compared to only 10% of veterans with probable AUD who did not use VA healthcare. Approximately 17% of veterans with probable AUD reported seeing a mental health provider for 1–4 sessions during the past year, 3% reported seeing a mental health provider for 5–6 sessions and 6% reported seeing a mental health provider for 6 or more sessions during the past year.

As shown in Table 3, mental health need (screening positive for either depression or PTSD) was significantly related to receipt of mental health care in both bivariate and adjusted models (Depression: unadjusted OR = 4.85; PTSD: unadjusted OR = 3.96; Probable Depression and PTSD Adjusted OR = 5.15). Further, veterans using VA healthcare were significantly more likely to report use of mental health care in both bivariate (OR=4.55) and adjusted models (OR=3.80). Specifically, veterans with probable AUD who use VA care had 3.8 times the odds of receiving mental health services than veterans not using VA care. Black veterans screening positive for AUD were significantly more likely than White veterans to report use of mental health treatment in the past year (unadjusted OR =3.26; adjusted OR =2.94). Total AUDIT-C scores, however, were unrelated to receipt of mental health services.

Table 3.

Correlates of Any Mental Health Use in the Past Year Among Those with Probable AUD N=157)

Among Those with Probable AUD Any Past Year Mental Health Use
Variable Unadjusted Variable Adjusted
OR (95% CI) OR (95% CI)
Age 0.98 0.94–1.02 Age 1.01 0.95–1.07
Male Sex 0.82 0.39–1.73 Male Sex 0.554 0.20–1.44
Race Race
 White -- --  White -- --
 Black 3.26** 1.56–6.80  Black 2.94* 1.26–7.07
 Other 1.68 0.68–4.15  Other 1.02 0.36–2.91
Deployed to Gulf Region 0.86 0.46–1.61 Deployed to Gulf Region 0.42* 0.18–1.00
Use VA Healthcare 4.55*** 1.95–10.64 Use VA Healthcare 3.80** 1.49–9.66
Combat Exposure Score 1.07** 1.07–1.12 Combat Exposure Score 1.05 0.98–1.13
Probable Depression (PHQ-2) 4.85*** 2.58–9.13 Mental health need: Probable Depression or PTSD 5.15*** 2.19–12.11
Probable PTSD (PCPTSD) 3.96*** 2.10–7.47
Current Smoker 1.00 0.48–2.06 Current Smoker 0.97 0.41–2.26
Past Year Cannabis Use 1.82 0.90–3.71 Past Year Cannabis Use 1.36 0.58–3.16
AUDIT-C Score 0.99 0.86–1.14 AUDIT-C Score 0.97 0.81–1.16
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Note.

*

p < .05

**

p < .01

***

p < .001

Discussion

The present study examined the association between probable AUD and mental health treatment utilization in a sample of Gulf War Era veterans. The prevalence of probable AUD was 20% in this nationally representative sample of Gulf War era veterans, which is similar to previous national samples of Gulf War veterans (e.g., 17.0%–19.4% Iowa Persian Gulf Study Group, 1997; 16% Kang et al., 2009) which have used different AUD assessment methods (e.g., 14.8%, Fuehrlein et al., 2016). Consistent with previous literature, veterans who screened positive for probable AUD were also more likely to screen positive for psychiatric comorbidity including MDD and PTSD. Indeed, prior research demonstrates that veterans with AUD are at greater risk for comorbid psychiatric disorders often resulting in elevated psychosocial difficulties (Fuehrlein et al., 2016; Panza et al., 2022; Regier, 1990).

The present study is one of a small number of studies to examine engagement in both VA and community treatment. Overall, however, only 25% of veterans who screened positive for probable AUD reported engaging in mental health treatment either in the VA or community in the past year. The findings of the present study are consistent with previous literature demonstrating low rates of engagement in mental health and SUD treatment among veterans with substance use problems (e.g., Bensley et al., 2017; Vanneman et al., 2017; Wryobeck et al., 2006).

Lastly, we examined demographic factors associated with mental health treatment utilization in the subsample of Gulf War Era veterans who screened positive for probable AUD. Among those veterans with probable AUD, veterans using VA healthcare, race, and mental health need (screening positive for depression or PTSD) were related to receipt of any mental health services. Black veterans screening positive for AUD were more likely than at risk White veterans to report receipt of mental health care in the past year. Results suggesting at risk Black veterans were more likely to report use of mental health services is consistent with previous literature demonstrating racial and ethnic disparities among veterans utilizing mental health and SUD treatment (Bensley et al., 2017; Williams et al., 2017). One previous study among veterans with AUD noted that increased treatment utilization among Black veterans may be driven by greater mental health need including a higher prevalence of comorbid drug use disorders among Black vs. White veterans (Bensley et al., 2017). Black veterans with AUD are also diagnosed with comorbid mood and anxiety disorders at a higher rate than White veterans (Carr et al., 2021).

There are likely several other factors that contribute to treatment disparities, including structural racism (e.g., disproportionate criminalization resulting in court-mandated SUD treatment among Black people), patient-level differences (e.g., social support, resources, and norms around treatment-seeking; financial resources and insurance coverage), as well as clinician judgment and bias (Bensley et al., 2017; Saha et al., 2008). While it is important to continue examining causes of disparities in mental health treatment access and utilization, it is notable that across racial/ethnic groups in the current study, veterans with probable AUD demonstrated relatively low rates of engagement in treatment, suggesting significant unmet treatment needs regardless of race/ethnicity.

Among those veterans who screened positive for AUD, veterans using VA care were significantly more likely to report receipt of any mental health services. VHA has implemented universal screenings and interventions for alcohol misuse. Previous work has indicated that veterans misusing alcohol are more likely to be counseled to quit or cut back on their drinking if they are engaged in VA versus non-VA healthcare (Calhoun et al., 2016). Indeed, this is imperative for the era of Gulf war veterans, as they are characterized to be more likely to develop AUD compared to other veteran populations (Kelsall et al., 2015) which may further exacerbate other unique symptoms associated with Gulf War Illness. Thus, results of the current study suggest a possible benefit related to alcohol misuse for veterans engaged in VHA care through universal screenings and interventions. However, it is important to note that veterans engaged in VA healthcare services were more likely to report receipt of mental health treatment, data from the current study do not allow us to know whether this treatment specifically targeted alcohol misuse. Indeed, severity of AUDIT-C scores was unrelated to receipt of mental health services in the current study suggesting that other psychiatric need may be driving use of mental health services. In addition to screening for alcohol misuse, the VA has implemented universal screenings and referrals for PTSD and depression. Taken together, these findings highlight the importance of further unpacking the factors contributing to mental health treatment engagement. Specifically, with the aim to target AUD treatment in Gulf war veterans, because although they might be receiving mental health treatment more broadly, it may not be directly targeting alcohol misuse and therefore the continued use of alcohol use might be associated with exacerbation of other symptoms associated with Gulf War Illness.

Strengths and Limitations

A primary strength of this study is the use of a large national sample of Gulf-war veterans, which includes veterans of diverse backgrounds and medical and psychiatric comorbidities including both users and non-users of VHA services. Additionally, the present study examined engagement in mental health treatment in both VA and community settings. This is a significant strength of this study, as many veterans receive mental health treatment in the community instead of through VA services. Furthermore, as the Gulf-war era veteran population encompasses approximately one-quarter of current VHA enrollees (Wang et al., 2021), this study begins to shed some light on important factors associated with the experiences of Gulf-war veterans and how to potentially increase treatment engagement. Despite these strengths, there are several important limitations to consider. First, the cross-sectional design limits our understanding of causal factors which might place individuals at greater risk for AUD. To be able to fully capture and understand causal and temporal risk factors, future studies may benefit from a longitudinal study design. Furthermore, the evaluation of probable AUD was conducted using the AUDIT-C self-report measure. Although, the AUDIT-C is a well validated measure in veteran populations (Bradley et al., 2003; Bradley et al., 2006; Reinert & Allen, 2002) AUD was not assessed with gold-standard structured clinical interviews. Lastly, it is important to note that our sampled included only Gulf war veterans therefore findings might not be generalizable to other veteran populations.

Conclusion

The current study highlights a high prevalence of probable AUD among Gulf War Era veterans and suggests that many veterans with AUD do not access mental health treatment either within or outside of the VA. Low treatment engagement in this population may have significant public health implications including poorer physical health and psychological outcomes for these veterans. Treatment for SUD is associated with multiple positive outcomes, including reduced overdose risk (Stewart et al., 2002), criminal convictions (Gossop et al., 2005), and psychiatric symptoms (Gossop et al., 2006). Notably, individuals with comorbid mental health diagnoses report greater unmet needs for treatment as well as more barriers to treatment than those with SUD alone (Kaufmann et al., 2014). It is also important to continue examining reasons that some veterans do not engage in care, including factors that account for differences in engagement by race/ethnicity. This study also demonstrates that the veterans with probable AUD who do engage in treatment receive, on average, a small dose of four or fewer sessions. Together, these findings suggest a potential need for strategies to increase both initiation and retention in mental health treatment among Gulf War Era veterans.

Acknowledgments

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the United States Government or Department of Veterans Affairs. The authors have no conflicts of interest to disclose.

Funding

This research was supported by Grant #1I01HX001682 to Drs. Kimbrel and Pugh from the Health Services Research and Development Service of the Department of Veterans Affairs Office of Research and Development. Dr. Aurora was supported by a VA Office of Academic Affiliations Advanced Fellowship in Mental Illness Research and Treatment. Dr. Beckham was funded by a Senior Research Career Scientist award from VA Clinical Sciences Research and Development (IK6BX003777). Dr. Pugh was funded by a Research Career Scientist award from VA Health Sciences Research and Development (IK6HX002608).

Footnotes

Disclosures. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the United States Government or the Department of Veterans Affairs. The authors have no other conflicts of interest or other disclosures to disclose.

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