Abstract
Objective
To compare delay of treatment for posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder among post-9/11 veterans relative to pre-9/11 veterans and civilians.
Method
The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III), a nationally representative survey of US non-institutionalized adults was used. Participants included 13,528 civilians, 1,130 pre-9/11 veterans, and 258 post-9/11 veterans with lifetime diagnoses of PTSD, major depression, and/or alcohol-use disorder. Cox proportional hazard models, controlling for relevant demographics, were used to estimate differences in treatment delay (i.e., time between diagnosis and treatment).
Results
Post-9/11 veterans were less likely to delay treatment for PTSD and depression than pre-9/11 veterans (AHRs=0.69 95% CI=0.49-0.96, 0.74 95% CI=0.56-0.98, for PTSD and depression, respectively) and civilians (AHRs=0.60 95% CI=0.47-0.76, 0.67 95% CI=0.53-0.85, for PTSD and depression, respectively). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol-use disorder. Pre-9/11 veterans did not differ from civilians in delay of treatment for any of the three disorders. In an exploratory analysis, post-9/11 veterans with past year military health care coverage (e.g., Veterans Health Administration) showed the shortest delay for depression treatment, although past year coverage did not predict treatment delay for PTSD or alcohol-use disorder.
Conclusions
Post-9/11 veterans delay treatment for some common psychiatric conditions less than pre-9/11 veterans or civilians, which may reflect efforts to engage recent veterans in mental health care. All groups exhibited low initiation of treatment for alcohol-use disorder, highlighting the need for further engagement efforts.
Starting in October 2001, approximately 4 million veterans were involved in active conflicts in and around Afghanistan and Iraq.1 Post-9/11 veterans have high rates of psychiatric conditions (36.9 to 43%).2,3 Three of the most common psychiatric conditions among recent veterans are post-traumatic stress disorder (PTSD), major depressive disorder, and alcohol-use disorders.2–7
Considerable attention has been paid to the unmet treatment needs of post-9/11 veterans,1,3,8,9 aimed at decreasing delays into treatment. In response to high rates of psychiatric diagnoses among post-9/11 veterans and associated difficulties with reintegration,10 the Veterans Health Administration (VHA), Department of Defense (DoD), Veterans Service Organizations,11 and non-governmental agencies have made concerted efforts in the past decade to increase veterans’ engagement in mental health treatment.1,12 Recent initiatives include providing mental health treatment outside of specialty mental health settings (e.g., Primary Care Mental Health Integration [PCMHI]),13,14 public awareness campaigns (e.g., Veterans Crisis Line, Make the Connection),15 post-military discharge outreach,16,17 increased peer support programs,18 and enhanced eligibility for VHA benefits for post-9/11 veterans for five years following discharge.19
Nonetheless, recent evaluations indicate there remain substantial unmet mental health needs among post-9/11 veterans. For example, 31% of post-9/11 veterans with AUD received mental health treatment in the past year8 and 48% of soldiers screening positive for PTSD post-deployment received mental health treatment in the past six months.9 Failure to engage and delay in mental health treatment is common within the general US population. Data collected between 2001 and 2003 in the National Comorbidity Survey Replication indicate that, on average, individuals with PTSD, depression, and alcohol-use disorder delay treatment for 12, 8, and 9 years after symptom onset, respectively.20 Treatment delay is associated with persistent symptoms, adverse functional outcomes, and social costs.21,22 Given substantial changes in policy and initiatives to increase veteran engagement in mental health care, it is important to understand whether treatment delay among post-9/11 veterans is comparable to veterans of prior service eras and civilians using recent epidemiological data.
The current study compared treatment delay for PTSD, depression, and alcohol-use disorder in post-9/11 veterans relative to pre-9/11 veterans and civilians. Based on recent initiatives and policy changes aimed at engaging recent veterans in mental health care, we expected shorter treatment delays among post-9/11 veterans relative to pre-9/11 veterans and civilians. We employed data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a nationally representative survey of the general US population.23
Method
All procedures for NESARC-III data collection were approved by the Institutional Review Boards of the National Institutes of Health and Westat, Inc. The current study was approved by the Institutional Review Board at the U.S. Department of Veterans Affairs Puget Sound Health Care System–Seattle Division.
Sample
The NESARC-III used probability sampling to select a representative sample of non-institutionalized US residents age 18 years and older who were not on active duty military during 2012-2013.23 Individual counties or groups of contiguous counties served as primary sampling units; census-defined blocks served as secondary sampling units; and households within secondary sampling units served as tertiary sampling units, with eligible adults randomly selected within households.23 Hispanic, Black, and Asian respondents were oversampled. The full NESARC-III sample was 36,309 respondents, with a response rate of 60.1%, comparable to other US national surveys.24
Measures
Psychiatric diagnoses and symptom severity
The Alcohol Use Disorder and Associated Disabilities Interview Schedule 5 (AUDADIS-5) is a validated, in-person diagnostic interview used to measure DSM-5 criteria for PTSD, major depressive disorder, and alcohol use disorder.25,26 To receive a lifetime diagnosis of PTSD in NESARC-III, an individual had to report witnessing, learning about, or experiencing at least one of 19 potentially traumatic events (Criterion A) along with ≥1 intrusion symptoms (Criterion B), ≥1 avoidance symptoms (Criterion C), ≥3 negative mood or cognitive changes (Criterion D), and ≥3 increased arousal symptoms (Criterion E). Requiring ≥3 D and E symptoms is higher than the two symptoms required for DSM-5 criteria, however this definition has been used in other studies based on NESARC-III.27,28 Lifetime major depressive disorder and alcohol-use disorder diagnoses were assessed with the AUDADIS-5 consistent with DSM-5 criteria.23,29 In addition to lifetime diagnoses, counts of lifetime PTSD symptoms (out of 20 potential symptoms), depression symptoms (out of nine), and alcohol-use disorder symptoms (out of 11) were computed as metrics of severity.25,26
Treatment delay
Among those meeting lifetime diagnostic criteria for PTSD, major depressive disorder, or alcohol-use disorder, a single item assessed age of diagnosis onset and a separate item assessed age at time help was first received for that disorder, if ever. Additional items assessed various types of help received (e.g., inpatient treatment, self-help group). We categorized treatment types into formal (e.g., inpatient treatment) or informal (e.g., self-help group; Supplemental Table 1).
For survival analyses, the dependent variable was the length of time in years between the onset of diagnosis and first receipt of care (formal or informal). Those who did not report ever receiving treatment at the time of the survey were censored. A portion of respondents reported receiving treatment at an age younger than that of diagnosis onset, yielding negative values for estimates of time to treatment (n=95, 4.07% for PTSD; n=552, 7.45% for depression; n=455, 4.57% for alcohol-use disorder). Due to concerns of introducing bias through imputation of our dependent variable, negative values were coded as missing. Veteran status was not associated with likelihood of reporting a negative time to treatment (Supplemental Table 3).
Explanatory variables
The primary predictor of interest was veteran status assessed using the question: “Have you ever served on Active Duty in the U.S. Armed Forces, Military Reserves, or National Guard?” Respondents answering “Yes, on active duty in past, but not now” were classified as veterans. Those indicating training in National Guard/Reserve only (n=200) or with unknown veteran status (n=8) were excluded from analyses due to ambiguity regarding whether they should be categorized as veterans or civilians. Subsequent items assessed time periods of active duty. Individuals who endorsed any service post-9/11 were categorized as post-9/11 veterans and those who did not were categorized as pre-9/11 veterans.
Given efforts by the VHA and DoD may have contributed to increased probability of treatment for post-9/11 veterans, in exploratory analyses we included a survey item that asked respondents whether they were enrolled in VHA, CHAMPVA or CHAMPUS/TRICARE in the past 12 months. This variable, referred to as VHA/TRICARE, was set to zero for civilian respondents. All post-9/11 veterans are eligible for VHA for five years after discharge. CHAMPVA is only available to dependents of veterans and thus, was not a relevant response option for veterans. TRICARE is only available to retired military personnel. Because almost none of the post-9/11 veterans were over the age of 65 and relatively few were between the ages of 45-64, the VHA/TRICARE variable mostly represents enrollment in VHA. For the pre-9/11 veteran groups, this variable likely represents a combination of VHA enrollment and TRICARE coverage. The VHA/TRICARE variable does not indicate if veterans actually used VHA/TRICARE services. Thus, analyses including VHA/TRICARE coverage were considered exploratory. We created a five-level variable reflecting VHA/TRICARE coverage crossed with veteran status and era of service (civilian, pre-9/11 veterans with or without past year VHA/TRICARE coverage, post-9/11 veterans with or without past year VHA/TRICARE coverage).
Demographic covariates
Demographic characteristics that could not be influenced by military service (age, gender, race/ethnicity) previously linked with treatment seeking30,31 were included as covariates. Sensitivity analyses included other demographics that could be influenced by military services (marital status, income).
Analysis procedures
All analyses were adjusted for clustering, oversampling, and non-response and weighted to represent the US non-institutionalized population, accounting for the complex survey design of NESARC-III. Survival analysis was used to model delay to treatment, while accounting for individuals who had not received treatment at the time of the survey (i.e., right censoring).32 Cox proportional hazard models were constructed using the ‘svycoxph’ function in the ‘survey’ package in R.33,34 A lower cumulative hazard represents a longer delay to treatment. Models were run separately for each diagnostic category (PTSD, depression, alcohol-use disorder), using the subsample of individuals who met criteria for a lifetime diagnosis of the given disorder. An individual could be in more than one of the subsamples.
Subsequent sensitivity analyses assessed several potential sources of bias. These included: (1) Controlling for additional demographic covariates that could be influenced by military service (marital status, income); (2) Restricting to male respondents to account for the possibility that increasing representation of women in the military influenced patterns of treatment among recent veterans;31 (3) Restricting treatment to formal care only, to assess exposure to more effective treatments; (4) Controlling for the co-occurrence of the other psychiatric disorders of interest (PTSD, depression, alcohol-use disorder), as comorbidity has been associated with reduced treatment delay;31 and (5) Controlling for severity of PTSD, depression, and alcohol-use disorder to rule out the possibility that differences in treatment delay are driven by differences in severity.22
A final set of models examined the relationship between past year VHA/TRICARE coverage and treatment delay to explore the possibility that treatment delay was influenced by efforts within VHA or TRICARE affiliated clinics.
Results
The sample included 14,916 unique respondents, including those with a lifetime diagnosis of PTSD (n=2,335), major depressive disorder (n=7,406), and/or alcohol-use disorder (n=9,943). The majority were civilians (n=13,528), with 1,130 pre-9/11 veterans and 258 post-9/11 veterans (Table 1). Across all three groups, most respondents with lifetime PTSD received treatment for PTSD (weighted percentages=58.3% to 79.8%) and the majority with lifetime major depressive disorder received treatment for depression (69.3% to 76.3%). Consistent with prior reports,23 a considerably smaller percentage of respondents with alcohol-use disorder received treatment for alcohol-use disorder (17.5% to 26.3%). Using unadjusted Kaplan-Meier models, median survival time (i.e., time at which 50% had received treatment) was shortest for post-9/11 veterans for PTSD (median=2.5 years, vs. 16.0 years and 15.0 years, for pre-9/11 veterans and civilians, respectively) and depression (median=1.0 years, vs. 7.0 years and 5.0 years, for pre-9/11 veterans and civilians, respectively). Median survival times could not be computed for alcohol-use disorder, as no group reached 50% receiving treatment.
Table 1.
Demographics of veteran and civilian sample
| PTSD (n = 2,335) | MDD (n = 7,406) | AUD (n = 9,943) | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Study Variable | Pre-9/11 | Post-9/11 | Civilian | Pre-9/11 | Post-9/11 | Civilian | Pre-9/11 | Post-9/11 | Civilian | |||||||||
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Total n | 172 | 100.00 | 57 | 100.00 | 2,106 | 100.00 | 414 | 100.00 | 92 | 100.00 | 6,900 | 100.00 | 879 | 100.00 | 211 | 100 | 8,853 | 100 |
| Male, n(%) | 140 | 84.70 | 41 | 69.81 | 496 | 26.03 | 346 | 86.85 | 63 | 73.98 | 1,914 | 30.32 | 801 | 92.96 | 163 | 79.42 | 4,567 | 55.27 |
| Age, n(%) | ||||||||||||||||||
| 18-29 | 1 | 0.57 | 22 | 35.69 | 494 | 25.25 | 1 | 0.24 | 37 | 36.12 | 1,524 | 22.44 | 0 | 0.00 | 83 | 34.99 | 2,722 | 30.41 |
| 30-44 | 26 | 14.24 | 23 | 42.80 | 703 | 30.83 | 58 | 14.24 | 41 | 46.26 | 2,128 | 28.14 | 137 | 16.29 | 87 | 43.83 | 2,946 | 31.67 |
| 45-64 | 102 | 55.02 | 12 | 21.52 | 747 | 36.39 | 243 | 55.05 | 13 | 13.38 | 2,522 | 38.27 | 468 | 47.8 | 39 | 19.76 | 2,750 | 32.79 |
| 65+ | 43 | 30.16 | 0 | 0.00 | 162 | 7.53 | 112 | 30.47 | 1 | 4.23 | 726 | 11.14 | 274 | 35.92 | 2 | 1.43 | 435 | 5.12 |
| Race/ethnicity, n(%) | ||||||||||||||||||
| White, NH | 105 | 69.73 | 28 | 64.62 | 1,178 | 68.39 | 292 | 80.13 | 55 | 70.18 | 4,296 | 73.80 | 615 | 81.52 | 128 | 70.85 | 5,411 | 73.38 |
| Black, NH | 42 | 15.73 | 16 | 19.50 | 420 | 11.39 | 73 | 9.77 | 18 | 11.13 | 1,090 | 8.60 | 165 | 9.48 | 36 | 10.56 | 1,511 | 8.86 |
| Other, NH | 13 | 9.00 | 2 | 3.65 | 105 | 6.06 | 20 | 5.02 | 2 | 1.88 | 370 | 5.61 | 41 | 4.04 | 10 | 4.04 | 439 | 5.48 |
| Hispanic | 12 | 5.54 | 11 | 12.23 | 403 | 14.16 | 29 | 5.08 | 17 | 16.81 | 1,144 | 11.99 | 58 | 4.96 | 37 | 14.56 | 1,492 | 12.29 |
| Income <$20K, n(%) | 51 | 24.11 | 10 | 16.19 | 821 | 31.16 | 104 | 20.62 | 15 | 12.61 | 1,982 | 22.30 | 209 | 16.52 | 33 | 11.39 | 2,325 | 19.97 |
| Married, n(%) | 74 | 59.09 | 20 | 35.14 | 802 | 47.69 | 170 | 55.08 | 38 | 44.14 | 2,909 | 52.57 | 428 | 64.83 | 99 | 53.31 | 3,758 | 52.93 |
| Sx age, M(SD) | 26.04±15.24 | 23.02±11.35 | 23.43±17.52 | 37.17±17.21 | 24.99±11.39 | 28.58±17.02 | 29.83±18.42 | 24.50±11.55 | 25.79±13.08 | |||||||||
| Tx seek, n(%) | 116 | 64.69 | 43 | 79.80 | 1,197 | 58.28 | 278 | 69.38 | 67 | 76.31 | 4,646 | 69.30 | 272 | 26.34 | 45 | 17.46 | 1,738 | 19.18 |
| Type of tx received, n(%) | ||||||||||||||||||
| Formal | 115 | 64.21 | 43 | 79.80 | 1,170 | 56.68 | 274 | 68.58 | 65 | 74.82 | 4,561 | 68.17 | 233 | 22.25 | 33 | 11.87 | 1,445 | 15.95 |
| Informal | 42 | 24.86 | 16 | 35.86 | 332 | 15.75 | 78 | 19.41 | 19 | 19.89 | 1,070 | 14.56 | 235 | 22.69 | 31 | 12.92 | 1,404 | 15.18 |
| Tx age, M(SD) | 35.18±23.65 | 28.22±14.18 | 27.40±22.48 | 40.23±20.04 | 26.99±12.61 | 30.89±20.19 | 32.76±24.96 | 24.90±9.93 | 28.98±28.52 | |||||||||
| Tx delay, M(SD) | 9.35±19.31 | 4.77±11.00 | 5.31±16.10 | 4.98±14.13 | 1.89±5.23 | 3.92±11.35 | 8.72±19.09 | 3.53±11.00 | 6.17±21.77 | |||||||||
| Sx count, M(SD) | 16.04±3.14 | 16.19±3.18 | 15.61±3.52 | 7.47±1.48 | 7.41±1.85 | 7.47±1.55 | 6.05±3.38 | 5.42±3.28 | 5.68±3.49 | |||||||||
| VHA/TRICARE, n(%) | 80 | 46.28 | 35 | 61.21 | 0 | 0.00 | 144 | 31.41 | 50 | 57.21 | 0 | 0.00 | 284 | 29.42 | 116 | 57.56 | 0 | 0.00 |
Note: Treatment delay computed only for those who reported seeking help. PTSD = post-traumatic stress disorder; MDD = major depressive disorder; AUD = alcohol-use disorder; NH = non-Hispanic; Sx age = age at symptom onset; Tx seek = number seeking treatment for a given disorder; Tx age = age when treatment first received; Tx delay = years between symptom onset and treatment initiation; Sx count = number of symptoms of a given disorder; VHA/TRICARE = Veteran Health Administration (VHA) or TRICARE coverage in the past 12 months. See Supplemental Table 2 for comparisons between pre-9/11 veterans, post-9/11 veterans, and civilians on probability of ever receiving treatment.
Cox proportional hazard models included 14,088 respondents with complete data (n=828 were excluded, largely due to missing treatment data). Several demographic variables were associated with treatment delay (Table 2). In particular, men showed longer delays for depression treatment and shorter delays for alcohol-use disorder treatment than women. Older individuals showed longer delays for PTSD and depression treatment than younger individuals. Black and Hispanic individuals showed longer delays for PTSD and depression treatment than non-Hispanic White individuals.
Table 2.
Cox proportional hazard models predicting treatment delay by veteran era of service
| Predictor | PTSD (n = 2,162) | MDD (n = 6,663) | AUD (n = 9,300) | |||
|---|---|---|---|---|---|---|
| AHR | 95% CI | AHR | 95% CI | AHR | 95% CI | |
| Veteran status | ||||||
| Specification 1 | ||||||
| Post-9/11 veteran | Ref | Ref | Ref | |||
| Civilian | .60 | .47-.76 | .67 | .53-.85 | 1.19 | 1.78-1.81 |
| Pre-9/11 veteran | .69 | .49-.96 | .74 | .56-.98 | 1.16 | .73-1.83 |
| Specification 2 | ||||||
| Civilian | Ref | Ref | Ref | |||
| Post-9/11 veteran | 1.67 | 1.31-2.13 | 1.49 | 1.18-1.90 | .84 | .55-1.27 |
| Pre-9/11 veteran | 1.15 | .87-1.51 | 1.10 | .95-1.29 | .97 | .79-1.20 |
| Male gender | .92 | .79-1.08 | .71 | .65-.76 | 1.36 | 1.19-1.55 |
| Age | ||||||
| 18-29 | Ref | Ref | Ref | |||
| 30-44 | .89 | .76-1.05 | 1.07 | .99-1.16 | .86 | .71-1.06 |
| 45-64 | .72 | .60-.86 | .89 | .82-.97 | .97 | .80-1.17 |
| 65+ | .38 | .28-.52 | .69 | .61-.79 | .77 | .58-1.02 |
| Race/ethnicity | ||||||
| White, NH | Ref | Ref | Ref | |||
| Black, NH | .72 | .61-.86 | .65 | .59-.71 | 1.15 | .96-1.37 |
| Other, NH | .81 | .62-1.06 | .68 | .59-.79 | 1.42 | 1.11-1.82 |
| Hispanic | .72 | .61-.86 | .68 | .62-.74 | 1.04 | .88-1.24 |
Note: PTSD = post-traumatic stress disorder; MDD = major depressive disorder; AUD = alcohol-use disorder; AHR = adjusted hazard ratio (controlling for age, gender, race/ethnicity); Ref = reference group; NH = non-Hispanic. Table displays results from models using either post-9/11 veterans or civilians as reference group. Sample sizes for Cox models are reduced from full sample due to missingness for one or more modeled variables. n = 14,088 unique respondents.
When post-9/11 veterans were specified as the reference group (Specification 1), post-9/11 veterans with PTSD delayed PTSD treatment less than both pre-9/11 veterans (AHR=0.69 95% CI=0.49-0.96]) and civilians (AHR=0.60 95% CI=0.47-0.76, Table 2, Figure 1), adjusting for age, gender, and race/ethnicity. Similarly, post-9/11 veterans with depression delayed depression treatment less than both pre-9/11 veterans (AHR=0.74 95% CI=0.56-0.98) and civilians (AHR=0.67 95% CI=0.53-0.85). No differences in treatment delay were observed between post-9/11 veterans and pre-9/11 veterans or civilians for alcohol-use disorder. In models with civilians as the reference group (Specification 2), pre-9/11 veterans did not differ from civilians in treatment delay for any of the three disorders (AHRs=0.97 to 1.15).
Figure 1.
Survival curves with Kaplan-Meier estimates predicting mental health treatment seeking from veteran status and era of service. Forest plot displays hazard ratios and 95% confidence intervals from Cox proportional hazard models adjusted for age, gender, and race/ethnicity with post-9/11 veterans as reference group, separated by diagnosis. Hazard ratios represent the ratio of hazard rates and indicate instantaneous risk of a given event (in this case, receipt of treatment). Hazard ratios below 1 indicate the specified group delayed treatment longer than the reference group (i.e., post-9/11 veterans). PTSD = post-traumatic stress disorder; MDD = major depressive disorder; AUD = alcohol-use disorder
In a series of five sensitivity analyses (Table 3), post-9/11 veterans delayed PTSD and depression treatment less than both pre-9/11 veterans and civilians, with one exception. There was no difference in delay for formal (as opposed to any) depression treatment between post-9/11 veterans and pre-9/11 veterans (AHR=0.76 95% CI=0.58-1.01).
Table 3.
Sensitivity analyses
| Model | Predictor | PTSD | MDD | AUD | |||
|---|---|---|---|---|---|---|---|
| AHR | 95% CI | AHR | 95% CI | AHR | 95% CI | ||
| Additional covariates | Civilian | .61 | .48-.78 | .67 | .53-.85 | 1.15 | .75-1.75 |
| Additional covariates | Pre-9/11 veteran | .69 | .49-.98 | .74 | .56-.98 | 1.13 | .72-1.79 |
| Males only | Civilian | .58 | .42-.81 | .64 | .48-.86 | 1.40 | .85-2.29 |
| Males only | Pre-9/11 veteran | .57 | .38-.88 | .70 | .49-.99 | 1.43 | .84-2.44 |
| Formal tx | Civilian | .58 | .46-.74 | .67 | .53-.86 | 1.28 | .80-2.06 |
| Formal tx | Pre-9/11 veteran | .68 | .48-.95 | .76 | .58-1.01 | 1.29 | .77-2.15 |
| Comorbidity | Civilian | .59 | .47-.76 | .68 | .54-.87 | 1.24 | .81-1.88 |
| Comorbidity | Pre-9/11 veteran | .68 | .48-.96 | .73 | .55-.96 | 1.17 | .74-1.85 |
| Sx severity | Civilian | .60 | .47-.76 | .68 | .53-.87 | 1.05 | .66-1.68 |
| Sx severity | Pre-9/11 veteran | .66 | .47-.93 | .73 | .55-.97 | 1.06 | .64-1.75 |
Note: Post-9/11 veterans are reference group in all models. Previously modeled demographic variables (age, gender, race/ethnicity) included in all sensitivity analyses but not displayed. PTSD = post-traumatic stress disorder; MDD = major depressive disorder; AUD = alcohol-use disorder; AHR = adjusted hazard ratio (controlling for age, gender, race/ethnicity); Additional covariates = income, marital status; Formal tx = required engagement with formal treatment (i.e., not self-help group) to qualify as treatment seeking; Comorbidity = modeled lifetime diagnosis of other psychiatric conditions (PTSD, MDD, AUD); Sx severity = modeled symptom count.
In exploratory analyses, past year VHA/TRICARE coverage was not associated with PTSD treatment delay (Supplemental Table 4). In particular, no differences were found in PTSD treatment delay between post-9/11 veterans with and without past year VHA/TRICARE coverage (AHR=0.95 95% CI=0.61-1.49, Specification 1). Both post-9/11 veterans with and without past year VHA/TRICARE delayed PTSD treatment less than civilians (AHRs=1.70 95% CI=1.24-2.34 and 1.62 95% CI=1.16-2.27, respectively, Specification 2). Past year VHA/TRICARE coverage was associated with depression treatment delay, however. Specifically, post-9/11 veterans without past year VHA/TRICARE showed longer delays to treatment for depression relative to post-9/11 veterans with past year VHA/TRICARE (AHR=0.56 95% CI=0.35-0.90, Specification 1). And, only post-9/11 veterans with past year VHA/TRICARE and not post-9/11 veterans without past year VHA/TRICARE delayed depression treatment less than civilians (AHRs=1.89 95% CI=1.43-2.49 and 1.06 95% CI=0.72-1.56, respectively, Specification 2). No differences were observed for alcohol-use disorder treatment delay between those veterans with and without past year VA/TRICARE.
Discussion
To better understand patterns of post-9/11 veterans’ mental health treatment, the current study examined NESARC-III, a nationally representative sample of the US population. We compared the degree to which post-9/11 veterans delay treatment for common psychiatric conditions relative to pre-9/11 veterans and civilians. Results indicated that post-9/11 veterans are less likely than both pre-9/11 veterans and civilians to delay mental health treatment for PTSD and depression. Differences were clinically meaningful. Median time to PTSD treatment was 2.5 years for post-9/11 veterans compared to 16.0 years and 15.0 years, for pre-9/11 veterans and civilians, respectively. Median time to depression treatment was 1.0 year for post-9/11 veterans compared to 7.0 years and 5.0 years, for pre-9/11 veterans and civilians, respectively. This pattern was not present for alcohol-use disorder, for which all three groups reported low rates of treatment engagement. Results for PTSD and depression were largely consistent across sensitivity analyses, suggesting that shorter treatment delay for post-9/11 veterans is not attributable to differences in demographic factors, symptom severity, or psychiatric comorbidity. Shorter delay to depression treatment for post-9/11 veterans relative to pre-9/11 veterans was not significant when restricting to formal treatment. It may be that efforts to engage recent veterans in mental health treatment have emphasized the need for formal treatment for PTSD more than for depression.
Increased engagement in PTSD and depression treatment for post- vis-à-vis pre-9/11 veterans could be attributable to a host of recent historic, cultural, and policy changes. Universal post-deployment mental health screening is one policy change that may have contributed to reduced treatment delay for post-9/11 veterans. Screening efforts9,17 may have improved detection of post-deployment mental health concerns and increased engagement in treatment.
Other potential contributors are efforts by the VHA and other organizations to engage post-9/11 veterans in treatment.1,12,36 These include educational public health initiatives, dissemination of educational resources for community providers, creation of programs targeting reintegration and returning veteran mental health, suicide hotlines, and development of veteran-specific mobile health resources.16,36–39 Although not designed specifically for post-9/11 veterans, efforts to improve detection of mental health concerns in VHA primary care settings40 and integration of mental health services in these settings (i.e., PCMHI) may also have increased engagement.41
Findings from exploratory analyses partially supported the possibility that past year VHA/TRICARE coverage may be associated with decreased treatment delay for post-9/11 veterans. Post-9/11 veterans reporting no past year VHA/TRICARE coverage delayed depression treatment longer than post-9/11 veterans reporting past year VHA/TRICARE coverage. Past year VHA/TRICARE coverage was not, however, associated with treatment delay for PTSD or alcohol-use disorder. These analyses should be interpreted cautiously given the small number of post-9/11 veterans with VHA/TRICARE coverage.
Despite shorter treatment delay for PTSD and depression among post-9/11 veterans along with high rates of treatment receipt (74.82%−79.80%), engagement with alcohol-use disorder treatment for post-9/11 veterans was low (17.46%). This finding is consistent with previous reports17,23 and concerning given morbidity and mortality associated with alcohol-use disorder.42,43 Several factors may help explain low rates of engagement among those with alcohol-use disorder that likely apply to both veterans and non-veterans alike. A study of over 22 million Americans with current substance use disorders who had not sought care in the past year found the most commonly stated reasons were not feeling ready to stop drinking and lacking health insurance or means to pay for treatment.44 Lack of problem recognition and stigma are also common reasons for not seeking substance abuse treatment.8,45,46 A review of 17 population studies indicated alcohol misuse is less likely to be perceived as a mental illness and is more stigmatized than other psychiatric disorders,47 which may account for the lower alcohol-use disorder treatment engagement across our sample relative to PTSD and depression. Limited alcohol-use disorder treatment across multiple studies suggests that future research and clinical efforts to engage individuals in treatment are critically important. Future research could also explore why faster treatment engagement for PTSD and depression among recent veterans is not seen for alcohol-use disorder.
While not the focus of the current study, longer delays for PTSD and depression treatment were found for racial/ethnic minority individuals relative to non-Hispanic White individuals. This finding is consistent with broader mental health disparities literature indicating racial/ethnic minority individuals are less likely to engage in and more likely to delay mental health treatment.20 Future studies could examine risk and protective factors associated with treatment delay for racial/ethnic minority individuals and interventions to increase engagement.
Limitations of the current study include a modest number of veterans, particularly post-9/11 veterans, impacting our ability to detect small effects and the accuracy of observed effects. We also lacked information regarding where treatment was received, limiting our ability to draw conclusions regarding which engagement efforts are responsible for reduced treatment delay among post-9/11 veterans. Likewise, the VHA/TRICARE variable likely reflected different levels of access for pre-9/11 and post-9/11 veterans and another aspect of access (service connection) was not assessed. The cross-sectional nature of the study increases risk for recall biases (e.g., inaccuracies in recalling age at symptom onset and treatment initiation for more temporally distant events), which may be larger for pre-9/11 veterans. Despite these limitations, the study has several strengths, including a large and nationally representative sample of the US population, assessment of DSM-5 diagnoses of psychiatric conditions prevalent among veterans and for which evidence-based treatments are available, and inclusion of a number of sensitivity analyses to increase confidence in the pattern of findings.
Taken together, results indicate that recently returning post-9/11 veterans are less likely than pre-9/11 veterans and civilians to delay mental health treatment for PTSD and depression. It is possible that efforts in the past decade by the VHA, DoD and non-governmental organizations have been influential in promoting mental health treatment engagement for this recent generation of military service members.
Supplementary Material
Highlights.
Delay to mental health treatment for military veterans and civilians was examined using a population-based survey study of 14,916 adults with lifetime diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder, and/or alcohol-use disorder.
Post-9/11 veterans had significantly shorter delays to treatment for PTSD and major depression, but not alcohol-use disorder, compared to pre-9/11 veterans and civilians.
Post-9/11 veterans with past year military health care coverage showed the shortest delay to treatment for major depression.
Post-9/11 veterans receive treatment for some psychiatric disorders sooner, potentially due to efforts by the military and veterans’ organizations.
Acknowledgements
Drs. A and B were supported by a VA Office of Academic Affiliations’ Advanced Fellowship in Health Services Research and Development (TPH 61-000-24 and TPH 61-000-14, respectively). Drs. C and D were supported by VA Clinical Science Research & Development (CSR&D, CX000867) and Health Services Research & Development (HSR&D CDA 13-266) Career Development Awards (CDAs), respectively. Dr. E was supported by the National Institutes of Health Extramural Loan Repayment Program for Health Disparities Research (L60 MD009373) and a Mentored Research Scientist Development Award (K01 AA023859). Dr. F was supported by a grant (PCS-1406-19295) from the Patient Centered Outcomes Research Institute and by a VA HSR&D Research Career Scientist Award. Dr. G was supported by the Center on Substance Addiction Treatment and Education (CESATE). The views expressed in this article are solely those of the authors and do not reflect an endorsement or the official policy or position of the Department of Veterans Affairs. The authors declare that they have no conflict of interest.
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