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. Author manuscript; available in PMC: 2025 Jun 1.
Published in final edited form as: J Psychiatr Res. 2024 Apr 23;174:283–288. doi: 10.1016/j.jpsychires.2024.04.043

Deployment-Related Toxic Exposures are Associated with Worsening Mental and Physical Health After Military Service: Results from a Self-Report Screening of Veterans Deployed After 9/11

Kyle J Bourassa 1,2,3, H Ryan Wagner 1,4, Tate F Halverson 1, Allison E Ashley-Koch 5, Jean Beckham 1,4, Melanie E Garrett 5; VA Mid Atlantic MIRECC Workgroup1, Nathan A Kimbrel 1,4,6, Jennifer C Naylor 1,4
PMCID: PMC11102311  NIHMSID: NIHMS1988460  PMID: 38678685

Abstract

Exposure to toxins—such as heavy metals and air pollution—can result in poor health and wellbeing. Recent scientific and media attention has highlighted negative health outcomes associated with toxic exposures for U.S. military personnel deployed overseas. Despite established health risks, less empirical work has examined whether deployment-related toxic exposures are associated with declines in mental and physical health after leaving military service, particularly among the most recent cohort of veterans deployed after September 11, 2001. Using data from 659 U.S. veterans in the VISN 6 MIRECC Post-Deployment Mental Health Study, we tested whether self-reported toxic exposures were associated with poorer mental and physical health. At baseline, veterans who reported more toxic exposures also reported more mental health, β = 0.14, 95% CI [0.04, 0.23], p = .004, and physical health symptoms, β = 0.21, 95% CI [0.11, 0.30], p < .001. Over the next ten years, veterans reporting more toxic exposures also had greater increases in mental health symptoms, β = 0.23, 95% CI [0.15, 0.31], p < .001, physical health symptoms, β = 0.22, 95% CI [0.14, 0.30], p < .001, and chronic disease diagnoses, β = 0.15, 95% CI [0.07, 0.23], p < .001. These associations accounted for demographic and military covariates, including combat exposure. Our findings suggest that toxic exposures are associated with worsening mental and physical health after military service, and this recent cohort of veterans will have increased need for mental health and medical care as they age into midlife and older age.

Keywords: Toxic exposure, health, mental health, veteran status, chronic diseases

Introduction

Exposure to toxic chemicals is linked to poorer mental and physical health (Chen, Chang, Tao, & Lu, 2015; Chowdhury et al., 2018; Nawrot et al., 2006; Needleman & Gatsonis, 1990; Rauh & Margolis, 2016; Sullivan & Krieger, 2001; Williams & Ross, 2007). Toxic exposures can be as ubiquitous as air pollution (Dominski et al., 2021) or specific to a time and place, such as radiation exposure during disasters (Cardis et al., 2011). The number of potential toxins is extensive and can vary from respiratory inhalation of particulates, to ingestion of heavy metals or the transfer of chemicals via physical contact with water, food, or soil (World Health Organization, 2022). Although it is challenging to encompass the full range of negative mental and physical health outcomes associated with toxins, some examples include increased risk for cardiovascular diseases (Chowdhury et al., 2018), cancer (Chen et al., 2015; Nawrot et al., 2006), and mental health diagnoses (Raugh & Margolis, 2016; Reuben et al., 2019) among individuals exposed to toxic metals. Air pollution alone was estimated to account for around 3 million premature deaths in 2015 (Lelieveld, Evans, Fnais, Giannadaki, & Pozzer, 2015). It is notable that the health burden of these exposures are not evenly distributed across society. Occupations, geographic locations, and socioeconomic groups can vary in their likelihood of exposure and could help explain mental and physical health disparities as people grow older. Better characterizing mental and physical health trajectories among groups at greater risk of toxic exposure could inform prevention efforts aimed at intervening and ameliorating the negative outcomes associated with those exposures.

Scientific and media attention has increasingly centered on the toxic exposures experienced by veterans deployed overseas during their military service (Garshick et al., 2019; National Academies of Science, Engineering, and Medicine, 2020). During the three decades spanning the first Gulf War and Operations Enduring Freedom, Iraqi Freedom, and New Dawn, millions of service members deployed to military combat zones in Southwest Asia (e.g., Afghanistan, Iraq, and Kuwait) were at increased risk for toxic exposures (Institute of Medicine, 2006, National Academies of Science, 2018). Possible toxicants in these areas included common exposures, such as particulates from burn pits used for waste disposal, as well as rarer events, such as exposure to chemical or biological weapons (Woskie et al., 2023). Evidence of the negative health outcomes associated with deployment-related exposures (Institute of Medicine, 2012; National Academies of Science, 2020; Pugh et al., 2016) contributed to the passage of the Promise to Address Comprehensive Toxics (PACT) Act in 2022 (U.S. Congress, 2022). This act represented the largest expansion of Veteran Affairs (VA) benefits in U.S. history (Department of Veterans Affairs, 2023) and came with the understanding that exposure to toxins during military service could lead to certain diseases, including cancers and chronic lung diseases (Institute of Medicine, 2006, Institute of Medicine, 2012; National Academies of Science, 2018; National Academies of Science, 2020). Of note, the PACT Act presumes toxic exposure to burn pits or other toxic substances for any military service member deployed to any of 17 countries (largely located in Southwest Asia) or the airspace above those countries. By this definition, at least 3.5 million veterans who served overseas since 1990 have presumptive exposure (Department of Veteran Affairs, 2015). There is an urgent need to characterize the negative health outcomes linked to deployment-related toxic exposure, especially as these veterans grow older and face increased risk for chronic disease, disability, and premature mortality.

Methods used to assess toxic exposure are numerous and vary in their feasibility to implement and usefulness for medical research and clinical decision-making. Direct approaches include the sampling of blood and tissue, which can be useful when investigating exposures such as heavy metals that remain in the human body and tissues over long periods. Examples of such chemicals include lead, mercury, arsenic, and cadmium (Witkowska, Slowik, & Chilicka, 2021). Similarly, Global Positioning System (GPS) coordinate data can be used to link individuals to exposures of gases or particulates associated with particular events, such as demolition of the Ammunition Storage Facility at Khamisiyah, Iraq in 1991 (Barth, Dursa, Bossarte, & Schneiderman, 2017). However, such methods are not useful in cases where toxins do not remain in the body for long periods or for which location-based evidence is unavailable, which includes numerous health-relevant toxins (e.g., air particulates). Complementary methods of assessment that address these limitations include self-report measures that capture potential deployment-related exposures, such as the Deployment Risk and Resilience Inventory-2 (DRRI-2; Vogt, Smith, King, & King, 2012). The 2022 PACT Act mandated administration of self-reported toxic exposure screening tools to all veterans and these assessments are underway. Although self-report measures might appear to lack in specificity compared to tissue samples or GPS data, such measures have the important advantages of being simple and cost-effective to administer.

As the PACT Act was implemented across the VA Health Care System in 2022–2023, it has remained unclear how mental and physical health changes after military deployment and reintegration into civilian life. For example, does toxic exposure translate to physical health symptoms and chronic disease states exclusively, or is toxic exposure also linked to mental health symptoms? Moreover, is toxic exposure associated with worsening health in the period following separation from the military? It is possible that the effects of toxic exposure are acute and do not translate to long-term negative outcomes. Conversely, it is possible that toxic exposures are associated with trajectories of poor health that will accumulate over time. Understanding trajectories of mental and physical health is particularly important in planning for the expansion of VA benefits associated with the PACT Act to address the health care needs of the most recent cohort of veterans as they age into midlife and beyond.

Present Study

The current study included 659 participants from the Post-Deployment Mental Health Study (PDMH; 1), a cohort of U.S. veterans deployed following September 11, 2001, and investigated associations between self-reported toxic exposure and mental and physical health. Participants completed a screening tool assessing 11 categories of deployment-related toxic exposure, as well as measures of mental and physical health at a baseline assessment and a follow-up approximately 10 years later. Mental and physical health outcomes included mental health symptoms, physical health symptoms, and a count of chronic disease diagnoses. We tested the association of toxic exposure with mental and physical health status at baseline, as well as change in mental and physical health over the subsequent decade. We hypothesized that veterans reporting more toxic exposure would have worse baseline mental and physical health and would show worsening mental and physical health over the subsequent decade.

Methods

Participants and Study Design

Participants were members of the PDMH (Brancu et al., 2017), a multi-site study of U.S. veterans deployed in the post-9/11 period. As described in more detail by Brancu and colleagues (2017), the VA Mid-Atlantic MIRECC began PDMH data collection in 2005 as a regional cohort data repository to understand the mental health and treatment needs of the millions of veterans returning from post-9/11 deployments. The cohort is in the process of completing a follow-up assessment approximately 10 years later (PDMH-L), and this data collection is ongoing. All participants provided written informed consent to participate in procedures approved by the Institutional Review Board at the Durham VA Healthcare System. The current study included participants who have completed the follow-up assessment to this point, resulting in an analytic sample of 659 veterans.

Measures

Deployment-related toxic exposures.

Deployment-related toxic exposures were assessed using the Deployment Risk and Resilience Inventory-2 (DRRI-2; Vogt et al., 2012). Survey “F” of the DRRI-2 assessed participants’ report of their “Exposure to Nuclear, Biological, or Chemical Agents” across 13 pre-deployment and deployment-related items. The current study used scores summed from 11 deployment-related exposures: exposure to nerve gas agents (e.g., sarin), mustard gas or blistering agents, government-issued DEET-containing insect repellants, other pesticides, smoke or air pollution, diesel or other petrochemical fuel on skin, fumes or exhaust from heater or generators, depleted uranium in munitions, burning trash or feces, chlorine gas, and nuclear/biological/chemical weapons. Toxic exposure was assessed only at the PDMH-L, and as such, reflect veterans’ retrospective reports of their toxic exposure approximately 10 years after the baseline PDMH assessment. Exposures were scored using the original DRRI-2 scoring method, in which “no” was coded as 0, “unsure” was coded as 1, and “yes” was coded as 2 (Vogt et al., 2012).

Mental health symptoms.

Mental health symptoms were assessed with the Symptom Checklist‐90‐Revised (Derogatis, & Unger, 2010). This measure includes 90 items spanning a broad range of psychological problems and symptoms of psychopathology. Items ask participants to what extent symptoms bothered them over the last week, with 5 responses ranging from “Not at all” to “Extremely.” We used the Global Severity Index, in which scores are averaged across all items such that higher scores represent more mental health symptoms, PDMH M = 0.87, SD = 0.81, PDMH-L, M = 0.76, SD = 0.69.

Physical health symptoms and chronic diseases.

Physical health symptoms and chronic disease counts were assessed using the National Vietnam Veterans Readjustment Study (NVVRS) Medical Questionnaire (Kulka et al., 1990). Two subscales of the NVVRS are designed to capture whether participants are experiencing any of 22 physical symptoms or any of 12 chronic disease categories. Values for each subscale were summed, such that higher scores represented more physical health symptoms, PDMH M = 4.05, SD = 3.9, PDMH-L, M = 4.51, SD = 3.7, and chronic disease counts, PDMH M = 1.05, SD = 1.1, PDMH-L, M = 1.80, SD = 1.5.

Demographic covariates.

Participants self-reported their age, gender, years of education, race, and ethnicity. Race and ethnicity were dichotomized into two approximately equal groups, veterans who identified as non-Hispanic White (43.9%) and those who reported other races/ethnicities (54.1%), primarily comprised of non-Hispanic Black veterans (81.6% of other races/ethnicities).

Military covariates.

Participants self-reported the number of months they were deployed, the year they ended active-duty military service, and their highest rank in the military. The date of participation in the PDMH was combined with the year participants reported leaving the military to calculate the time since ending military service, M = 8.2 years, SD = 9.5. Self-report highest rank was used to create a variable representing whether the participant’s highest rank was as an officer (10.7%) or enlisted service member (89.3%).

Combat exposure.

Combat exposure was assessed using the Combat Exposure Scale, a validated 7-item measure of wartime stressors experienced by combatants (Keane at al., 1989). Items included a 5-point scale and were scored in line with established methods (Keane at al., 1989), such that higher scores representing relatively more wartime stressors, M = 10.32, SD = 10.2. This average score corresponded to a light-moderate level of combat exposure according to standard scoring methods (Keane at al., 1989).

Data Analysis

We tested the association of toxic exposure with mental and physical health outcomes in a series of multiple regression models. Primary outcomes included mental health symptoms, physical health symptoms, and chronic disease counts; each outcome was modeled separately. First, we assessed the association of toxic exposure with mental and physical health at the baseline PDMH assessment. We next assessed change in mental and physical health over the following 10 years, from the PDMH baseline to PDMH-L assessment. Models assessing change included baseline measures of each outcome, which produced a test of residualized change. For each outcome, we specified a series of models with an increasing number of covariates. We first tested the bivariate association, then associations including demographic covariates (age, gender, race/ethnicity, and years of education), and next including military covariates (months deployed, combat exposure, time since separation, and rank). We also conducted sensitivity analyses to test whether different toxic exposure scoring methods resulted in different associations. All models were run in MPLUS version 8.3 (Muthen & Muthen, 2012) using full maximum likelihood estimation to account for missing data. Assumptions for multiple regression and visual inspection of residuals and observed values were conducted to ensure multicollinearity or outliers did not unduly influence our model estimates. Reported βs reflect standardized effect sizes.

Results

Of the 659 veterans included in the current study, 20.8% were women and 54.1% reported non-White race/ethnicity, primarily non-Hispanic Black (81.6%). On average, the sample was 38.8 years old (SD = 10.0 years) and had 13.7 years of education (SD = 3.3) at the PDMH baseline assessment.

Rates of Reported Toxic Exposure

Among veterans deployed in the post-9/11 period, 83.2% reported experiencing at least one toxic exposure, with an additional 3.8% endorsing at least one potential exposure (“unsure” response), leaving 13.1% of veterans who reported no deployment-related exposures. Out of a maximum score of 22, the average score of exposure was 10.1 (SD = 5.7), equivalent to approximately five categories of deployment-related toxic exposure (out of 11 total possible).

Toxic Exposure and Mental and Physical Health at the Baseline PDMH Assessment

At the baseline PDMH assessment, veterans who reported more categories of toxic exposure also reported more mental health symptoms, β = 0.26, 95% CI [0.18, 0.33], p < .001, and more physical health symptoms, β = 0.23, 95% CI [0.16, 0.31], p < .001. As shown in Table 1, these associations remained when controlling for demographic covariates, as well as military covariates. Toxic exposures were not associated with chronic disease count, β = 0.03, 95% CI [−0.06, 0.11], p = .518.

Table 1.

Associations between self-reported toxic exposure and health

Associations with toxic exposure Bivariate Adding demographics Adding military covariates
N = 659 β 95% CI β 95% CI β 95% CI
Baseline analyses
Mental health symptoms 0.26** [0.18, 0.33] 0.26** [0.19, 0.33] 0.14** [0.04, 0.23]
Physical health symptoms 0.23** [0.16, 0.31] 0.24** [0.16, 0.32] 0.21** [0.11, 0.30]
Chronic disease count 0.03 [−0.06, 0.11] 0.05 [−0.03, 0.13] 0.03 [−0.07, 0.13]
Analyses of change
Change in mental health symptoms 0.18** [0.12, 0.25] 0.18** [0.12, 0.24] 0.23** [0.15, 0.31]
Change in physical health symptoms 0.17* [0.10, 0.23] 0.18* [0.11, 0.24] 0.22** [0.14, 0.30]
Change in chronic disease count 0.12* [0.06, 0.19] 0.13* [0.01, 0.15] 0.15** [0.07, 0.23]
Open in a new tab

Note: Each model adds more covariates to the model. Demographic covariates include age, gender, race/ethnicity, and years of education. Military covariates include months deployed, combat exposure, time since separation, and rank.

*

p < .05.

**

p < .01.

Toxic Exposure and Change in Mental and Physical Health Over 10 Years

Over a 10-year period, veterans who reported more categories of toxic exposure had a greater increase in their mental health symptoms, β = 0.18, 95% CI [0.12, 0.25], p < .001, physical health symptoms, β = 0.17, 95% CI [0.10, 0.23], p < .001, and chronic disease count, β = 0.12, 95% CI [0.06, 0.19], p < .001 (see Fig. 1). As shown in Table 1, these associations remained when controlling for demographic and military covariates.

Figure 1.

Figure 1.

Open in a new tab

Visualization of the number of mental health symptoms, physical health symptoms, and chronic diseases reported among veterans with different levels of toxic exposure. Low exposure represented veterans with 0 to 3 exposures (n = 181, 27.5% of the sample), moderate exposure represented veterans with between 3 and 8 exposures (n = 306, 46.4% of the sample), and high exposures represented veterans with 8+ exposures (n = 171, 26.1% of the sample). The time between the PDMH baseline and the PDMH-L assessment was approximately 10 years. Groups were created for visualization purposes only; statistical models used the continuous measure of exposures.

Sensitivity Analysis: Alternative Methods of Scoring Toxic Exposure

The results reported in the main analyses used the original scoring method of the DRRI, in which scores of 0, 1, and 2 are assigned to responses of no, unsure, and yes, and summed across categories of exposure (Vogt et al., 2012). To determine whether the primary findings would replicate using alternative scoring methods for the “unsure” category, we calculated toxic exposure values in two different ways. First, we coded “unsure” responses as indicating toxic exposure (inclusive method, no exposure coded as 0, unsure or yes coded as 1). Second, we coded “unsure” responses as no toxic exposure (exclusive method, no exposure and unsure coded as 0, yes coded as 1). These values were then multiplied by 2 to facilitate comparisons to the original scoring method. As would be expected, when compared to the original scoring method mean score, M = 10.1, SD = 5.7, the inclusive method produced a higher exposure score, M = 12.4, SD = 7.4, whereas the exclusive method produced a lower exposure score, M = 7.8, SD = 5.0.

The association of toxic exposure with mental and physical health outcomes at the PDMH baseline assessment and change over the next 10 years for each method of scoring are presented in Table 2. Although effect size estimates varied slightly, both methods of scoring “unsure” responses (inclusive method; exclusive method) resulted in associations that were similar to the original scoring method, with one exception. Baseline mental health symptoms were no longer associated with toxic exposure when “unsure” responses were coded as no exposure when including all covariates (from β = 0.23 to β = 0.06). These results suggest that the different possible methods of scoring the DRRI-2 (specifically the treatment of “unsure” responses) produce relatively similar associations with health outcomes at baseline and over time, though associations with mental health symptoms may require additional investigation and validation.

Table 2.

Associations of toxic exposure with mental and physical health using different scoring methods

Associations with toxic exposure Bivariate Adding demographics Adding military covariates
N = 659 β 95% CI β 95% CI β 95% CI
“Unsure” coded as a reported toxic exposure
Mental health symptoms 0.26** [0.19, 0.33] 0.26** [0.19, 0.34] 0.15** [0.07, 0.23]
Physical health symptoms 0.25** [0.18, 0.32] 0.25** [0.18, 0.33] 0.22** [0.13, 0.30]
Chronic disease count 0.03 [−0.06, 0.11] 0.05 [−0.03, 0.13] 0.02 [−0.07, 0.12]
Change in mental health symptoms 0.18** [0.12, 0.25] 0.18** [0.12, 0.24] 0.21** [0.13, 0.28]
Change in physical health symptoms 0.13** [0.07, 0.20] 0.14** [0.08, 0.21] 0.16** [0.08, 0.24]
Change in chronic disease count 0.11** [0.04, 0.17] 0.11** [0.04, 0.17] 0.11** [0.03, 0.19]
“Unsure” coded as no toxic exposure
Mental health symptoms 0.20** [0.13, 0.28] 0.21** [0.13, 0.28] 0.06 [−0.03, 0.15]
Physical health symptoms 0.17** [0.09, 0.25] 0.17** [0.09, 0.25] 0.11* [0.01, 0.21]
Chronic disease count 0.03 [−0.06, 0.11] 0.05 [−0.03, 0.13] 0.04 [−0.06, 0.14]
Change in mental health symptoms 0.14** [0.08, 0.20] 0.14** [0.08, 0.21] 0.18** [0.10, 0.26]
Change in physical health symptoms 0.18** [0.12, 0.25] 0.19** [0.13, 0.26] 0.25** [0.17, 0.33]
Change in chronic disease count 0.13** [0.06, 0.19] 0.13** [0.07, 0.20] 0.17** [0.09, 0.25]
Open in a new tab

Note: Each model adds more covariates to the model. Demographic covariates include age, gender, race/ethnicity, and years of education. Military covariates include months deployed, combat exposure, time since separation, and rank.

*

p < .05.

**

p < .01.

Discussion

In this cohort of 659 veterans who served in the post-9/11 period, veterans who reported more deployment-related toxic exposures also reported more mental and physical health symptoms. Notably, veterans who reported more toxic exposures also showed worsening health over the subsequent decade in the form of more mental health symptoms, more physical health symptoms, and a greater number of chronic disease diagnoses. Our models assessing change in mental and physical health accounted for baseline differences, suggesting that toxic exposure is not only associated with differences in health outcomes when military service members reintegrate into civilian life—poor health continues to accumulate after leaving military service. These associations remained when accounting for a number of relevant demographic and military covariates, including combat exposure. Our findings highlight the importance of accounting for increased demand for physical and mental health treatment for veterans exposed to toxins in the post-9/11 period as they move into midlife and older age.

With the passage of the PACT Act in 2022 and the associated expansion of VA services, these findings highlight the importance of considering the need for both mental and physical health care for veterans exposed to toxins during their deployments. Although the majority of the presumptive illnesses detailed by the PACT Act and VA are physical health conditions (Department of Veteran Affairs, 2023; U.S. Congress, 2022), it is likely that veterans receiving care for their physical health conditions at the Veterans Health Administration (VHA) would also seek out mental health services. Notably, rates of mental health conditions among the most recent cohort of post-9/11 veterans are high (Waszak & Holmes, 2017), suggesting there will be an increased need for mental health services and additional providers to treat veterans. Our results suggest this need will grow over time as more veterans from the post-9/11 period enroll in the VHA following the PACT Act require care to address increases in their mental health symptoms over time.

A methodological finding from the current study is that different scoring methods of the DRRI-2 (Vogt et al., 2012) did not result in markedly different patterns of associations (Table 2). One concern with screening measures like the DRRI is how to treat responses of “unsure” to different exposures categories. Our findings suggest that the observed associations between ill health and toxic exposure are maintained whether unsure responses are coded as exposure, no exposure, or between the two (as it is conventionally scored), providing some evidence of consistency in results. Our findings are also notable in that the screening measure used in the current study was both retrospective and self-report, without a specific measure of dosage. Although alternative assessments could provide reliable measurement of exposures, our results suggest screening measures have the potential to predict poor health outcomes. This is notable given that retrospective self-reports will serve as a primary method of screening veterans for toxic exposure and potential VA benefits and treatment. Future studies would benefit from triangulating results from self-reported toxic exposure with complementary methods, such as military deployment records, GPS location-based data, or biomarkers assessing toxins that can remain in the body (e.g., heavy metals such as lead). However, such research will depend on the availability of data from alternative methods of assessing toxic exposure. Similarly, beyond the methods used to assess toxic exposure, there are additional toxins and exposures that might be important to include in future studies, such as exposure to heavy metals or repeated concussive blasts.

These findings should be interpreted within the context of the study’s limitations. First, toxic exposure was assessed by self-report. As noted previously, self-reported exposure is part of the PACT Act rollout at the VA (Department of Veteran Affairs, 2023; U.S. Congress, 2022), which highlights the importance of linking self-reported toxic exposure to relevant health outcomes. Although retrospective self-report screening measures have distinct advantages, there are also challenges to interpreting the observed associations. For example, more details about the timing or dosage of various toxins might provide additional useful information. Second, our health outcomes were derived from self-report. Although previously validated (Derogatis, & Unger, 2010; Kulka et al., 1990), it is possible that the use of these measures contributed to shared method variance, inflating observed associations. Future research would benefit from including biomarker or electronic medical record-derived outcomes. Similarly, our measure of mental health symptoms did not include psychiatric diagnoses. Future studies might benefit from including measures of psychiatric diagnoses, in addition to mental health symptoms. Finally, our study included a subset of the PDMH cohort assessed at a second wave (the PDMH-L) and it will be important to test the observed associations with a larger sample as more data is collected in this cohort.

Conclusions

Toxic exposure during deployment reported by 659 veterans was associated with poorer mental and physical health. Veterans reporting more toxic exposures showed worsening health over the next decade, including mental health and physical health symptoms, as well as the accumulation of chronic diseases. Findings underscore the importance of addressing the mental and physical health sequelae of toxic exposure to prevent increases in excess disability, morbidity, and premature mortality among post-9/11 veterans as they age. Veterans reporting toxic exposure during deployment in the post-9/11 period are at particular risk of declining mental and physical health and might benefit from efficacious treatments.

Acknowledgement:

This research was supported by Award #IK2CX002694 to Dr. Bourassa from the Clinical Science and Research and Development (CSR&D) Service of VA ORD, Award #IK2RX004803 from the Rehabilitation Research and Development (RR&D) Service of VA ORD to Dr. Halverson, and a Senior Research Career Scientist Award (#lK6BX003777) to Dr. Beckham from CSR&D. The authors also received support from the VA Mid-Atlantic Mental Illness Research, Education and Clinical Center (MIRECC), the Mental Health and Research Services of the Durham VA Healthcare System, the Durham VA Geriatrics Research, Education, and Clinical Center (GRECC), and the Department of Psychiatry and Behavioral Sciences at the Duke University School of Medicine. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA, the U.S. government, Duke University, or any other affiliated institution. The authors do not have any competing interests to report. The VA Mid-Atlantic MIRECC Workgroup contributors for this paper include: Pallavi Aurora, PhD, Patrick S. Calhoun, PhD, Eric Dedert, PhD, Eric B. Elbogen, PhD, Robin A. Hurley, MD, Jason D. Kilts, PhD, Angela Kirby, MS, Anna T. Magnante, PsyD, Sarah L. Martindale, Ph.D, Brandy S. Martinez, PhD, Christine E. Marx, MD, MS, Scott D. McDonald, PhD, Scott D. Moore, MD, PhD, Victoria O’Connor, PhD, Rajendra A. Morey, MD, MS, Jared Rowland, PhD, Robert D. Shura, PsyD, Cindy Swinkels, PhD, & Elizabeth E. Van Voorhees, PhD. Please direct correspondence to Dr. Kyle J. Bourassa, kyle.bourassa@duke.edu, 508 Fulton Street, Durham, NC 27705.

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