Introduction
As of 2020, there were roughly 18 million military veterans in the US, representing approximately 7 percent of the US population (Vespa, 2020). US military veterans are a known high-risk group for adverse psychiatric outcomes, such as posttraumatic stress disorder (PTSD), substance use disorders, and suicide (U.S. Department of Veterans Affairs, 2021; Wiechers et al., 2015; Williamson et al., 2018).
There have been several studies of the psychiatric characteristics of US veterans of different war eras, including World War II/Korean War (Schnurr et al., 2002), Vietnam War (Marmar et al., 2015), Gulf War (Dursa et al., 2021), and the Iraq/Afghanistan wars (Goldberg et al., 2019). What is lacking, however, is population-based data on the psychiatric status of veteran cohorts from different eras.
To address this gap, we analyzed data from a contemporary, nationally representative sample of US combat veterans to examine sociodemographic, military, trauma, and psychiatric characteristics by war era. Characterization of these differences is important, as provides population-based insight into the unique psychiatric needs of US veterans of specific war eras, which can help inform clinical and policy efforts.
Materials and Methods
Participants
Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative sample of US military veterans. The sample completed a 60-minute online self-report survey. Among the 4,069 veterans who completed the survey (median completion date: 11/21/2019), 1,257 veterans reported serving in a combat role as part of five major war eras (i.e., World War II, Korean War, Vietnam War, Persian Gulf War, Iraq/Afghanistan War) and were the focus of the current study. Details of the study, including the recruitment protocol, has been described previously (Nichter et al., 2021). Briefly, the NHRVS sample was drawn from KnowledgePanel®, a survey research panel of more than 50,000 U.S. households maintained by Ipsos, a survey research firm. To ensure generalizability of the results to the U.S. veteran population, poststratification weights were computed based on the demographic distribution of veterans in the Veterans Supplement of the U.S. Census Current Population Survey (U.S. Census Bureau, 2020). The study protocol was approved by the Human Subjects Committee of the VA Connecticut Healthcare System, and all participants provided informed consent.
Measures
Adverse childhood experiences.
Total score on Adverse Childhood Experiences Questionnaire (Felitti et al., 1998), a 10-item questionnaire in seven categories of childhood exposure to adverse experiences (e.g., psychological, physical, or sexual abuse; violence against mother; or living with household members who had a substance use problem, mental illness, or suicidal behavior, or were ever imprisoned).
Lifetime trauma exposure.
Total score on Life-Events Checklist-5 (LEC-5, Weathers et al., 2013a) was used to measure exposure to 16 events that may potentially result in PTSD or distress, with an additional item assessing any other stressful event not captured in the 16 items.
Combat exposure.
Combat exposure was defined with the following questions “Have you ever served in a combat or war zone?” If affirmatively endorsed, a follow-up question asked: “In which war era did you serve?” with the response options including all major war eras. Combat exposure severity was assessed using the Combat Exposure Scale (Keane et al., 1989).
Military sexual trauma.
Endorsement of either of two items from the VHA military sexual trauma screen assessing for exposure to military sexual harassment and military sexual assault was considered a positive screen for military sexual trauma. Military sexual harassment was assessed using an item which asked, “When you were in the military, did you ever receive unwanted, threatening, or repeated sexual attention?” Military sexual assault was assessed using an item which asked, “When you were in the military, did you have sexual contact against your will or when you were unable to say no?
Lifetime and current PTSD.
Score of ≥33 on PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013b), modified to assess both lifetime and past-month ratings of PTSD symptoms in relation to “worst” Criterion A trauma on the LEC-5 (Weathers et al., 2013a).
Current major depressive disorder.
Score≥3 on the depressive items of the Patient Health Questionnaire (PHQ)-4 (Kroenke et al., 2009).
Current generalized anxiety disorder.
Score ≥3 on the anxiety items of the PHQ-4 (Kroenke et al., 2009).
Current alcohol use disorder.
Score ≥8 on the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 1992).
Current drug use disorder.
Score ≥7 on the Screen of Drug Use (Tiet et al., 2015), which asked “How many days in the past 12 months have you used drugs other than alcohol?” or score of ≥2 to the question: “How many days in the past 12 months have you used drugs more than you meant to?”
Current cannabis use disorder.
Veterans reported on their recent (i.e., past 6 months) cannabis use by first responding “yes” or “no” to the question: “Have you used any cannabis (i.e., marijuana, hashish, tetrahydrocannabinol [THC], pot, grass, weed, reefer) over the past 6 months?” Veterans who endorsed any cannabis use in the past 6 months were administered the Cannabis Use Disorder Identification Test–Short Form (CUDIT-SF; Bonn-Miller et al., 2016). A positive screen for past-6-month cannabis use disorder was defined as a score ≥2.
Lifetime major depressive disorder.
Modified self-report version of major depressive disorder module from the DSM-5 version of the Mini Neuropsychiatric Interview (Sheehan, 2016).
Lifetime alcohol use disorder.
Modified self-report version of alcohol use disorder module from the DSM-5 version of the Mini Neuropsychiatric Interview (Sheehan, 2016).
Lifetime drug use disorder.
Modified self-report version of drug use disorder module from the DSM-5 version of the Mini Neuropsychiatric Interview (Sheehan, 2016).
Lifetime nicotine use disorder.
Score ≥ 5 on the Fagerström Test for Nicotine Dependence scale (Heatherton et al., 1991) was considered a positive screen.
Past-year suicidal ideation.
Past-year suicidal ideation was assessed via positive endorsement of any frequency of suicidal ideation (1 to 5+ times) on Question 2 of the Suicide Behaviors Questionnaire-Revised (SBQ-R; Osman et al., 2001): “How often have you thought about killing yourself in the past year” Response options: Never; Rarely (1 time); Sometimes (2 times); Often (3–4 times); and Very Often (5+ times).
Future suicidal intent.
Item which asked, “How likely is it you will attempt suicide in the future?”. Responses options were Never;” “No chance at all;” “Rather unlikely;” “Likely;” “Rather likely; and” “Very likely”. Endorsement of Likely, Rather likely, or Very likely were indicative of positive endorsement of a likely suicide attempt in the future.
Mental health treatment history.
Lifetime utilization of mental health care was assessed with the item: “Have you ever received mental health treatment (e.g., prescription medication or psychotherapy) for a psychiatric or emotional problem?
Current mental health treatment.
Current utilization of mental health care was assessed with the item: “Are you currently taking prescription medication for a psychiatric or emotional problem? If this item was endorsed affirmatively, the following two questions were asked: “Are you currently taking prescription medication for a psychiatric or emotional problem?” and “Are you currently receiving psychotherapy or counseling for a psychiatric or emotional problem?”
2.3. Data analysis
Analyses of variance and χ2 analyses were conducted to compare sociodemographic, military, trauma, and psychiatric characteristics between veterans of different war eras. In these descriptive analyses, we did not adjust for sociodemographic, military, and psychiatric variables. Bonferroni-corrected pairwise contrasts were computed to compare veterans by war era.
3. RESULTS
Among the total sample of 1,257 veterans, 61 (weighted 4.9%) were World War II or Korean War veterans, 767 (weighted 44.5%) were Vietnam War veterans, 168 (weighted 14.5%) were Gulf War veterans, and 261 (weighted 36.2%) were Iraq/Afghanistan War veterans.
Background characteristics by war era
Table 1 shows sample characteristics by war era. Significant group differences were observed for all of the variables assessed except education. Age reflected the time from different war eras, with World War II and Korean War veterans being the oldest, and the Iraq/Afghanistan War veterans being the youngest. Further, post-Vietnam War era veterans (i.e., Iraq/Afghanistan and Gulf War veterans) had larger proportion of female veterans relative to Vietnam and WWII/Korean war veterans.
Table 1.
Sociodemographic, Military, Trauma, and Psychiatric Characteristics by War Era
| Total N=1,257 | World War II or Korean War (1) | Vietnam War (2) | Gulf War (3) | Iraq/Afghanistan War (4) | ||||
|---|---|---|---|---|---|---|---|---|
| n=61 (weighted 4.9%) | n=767 (weighted 44.5%) | n=168 (weighted 14.5%) | n=261 (weighted 36.2%) | |||||
| Mean (SD) or No. (%) |
Mean (SD) or No. (%) |
Mean (SD) or No. (%) |
Mean (SD) or No. (%) |
Mean (SD) or No. (%) |
χ2 or F | P value | Pairwise Contrasts | |
| Demographic characteristics | ||||||||
| Age | 59.6 (16.8) | 88.1 (5.2) | 72.6 (5.7) | 53.8 (8.0) | 42.7 (9.3) | 1679.90 | <.001 | 1>2>3>4 |
| Male sex | 1,186 (93.8%) | 61 (100%) | 762 (99.7%) | 146 (90.4%) | 218 (87.2%) | 77.10 | <.001 | 1,2>3,4 |
| White, non-Hispanic race/ethnicitya | 1,011 (76.3%) | 53 (84.1%) | 666 (86.6%) | 121 (69.5%) | 171 (65.2%) | 72.64 | <.001 | 1,2>3,4 |
| Married or partnered | 927 (71.8%) | 39 (66.7%) | 582 (75.7%) | 118 (70.6%) | 188 (68.2%) | 8.22 | 0.042 | 2>4 |
| College graduate or higher education | 603 (37.0%) | 29 (34.9%) | 363 (35.5%) | 78 (33.2%) | 133 (40.6%) | 4.47 | 0.21 | -- |
| Retired | 731 (44.2%) | 53 (87.3%) | 607 (77.9%) | 36 (15.5%) | 35 (8.3%) | 619.06 | <.001 | 1,2>3>4 |
| Annual household income ≥$60K | 788 (63.2%) | 30 (52.4%) | 459 (59.5%) | 122 (74.3%) | 177 (64.7%) | 17.03 | <.001 | 3>1,2,4 |
| Military and trauma characteristics | ||||||||
| Enlisted into military | 919 (76.6%) | 38 (57.1%) | 518 (66.4%) | 143 (88.8%) | 220 (86.8%) | 181.11 | <.001 | 3,4>1,2 |
| Branch of military | 99.92 | <.001 | ||||||
| Army | 505 (47.3%) | 31 (53.2%) | 327 (51.0%) | 58 (41.4%) | 89 (44.3%) | 2>3,4 | ||
| Navy | 297 (22.3%) | 12 (22.6%) | 195 (23.1%) | 49 (34.4%) | 41 (16.5%) | 3>2>4 | ||
| Air Force | 234 (14.3%) | 11 (16.1%) | 151 (17.0%) | 25 (9.7%) | 47 (12.6%) | 2>3,4 | ||
| Marine Corps | 101 (6.5%) | 3 (3.2%) | 55 (5.2%) | 18 (8.1%) | 25 (7.9%) | -- | ||
| Other | 120 (9.5%) | 4 (4.8%) | 39 (3.7%) | 18 (6.5%) | 59 (18.6%) | 4>1,2,3 | ||
| 10+ years in military | 632 (53.5%) | 7 (9.5%) | 282 (35.8%) | 132 (73.8%) | 211 (72.9%) | 223.23 | <.001 | 3,4>2>1 |
| Combat exposure severity | 10.7 (9.7) | 7.2 (8.4) | 11.3 (10.1) | 5.2 (6.2) | 12.9 (9.6) | 36.28 | <.001 | 4>2>1,3 |
| VA is primary source of healthcare | 317 (28.8%) | 7 (11.1%) | 175 (24.7%) | 38 (24.7%) | 97 (37.8%) | 34.41 | <.001 | 4>2,3>1 |
| Adverse childhood experiences | 1.4 (1.9) | 0.3 (0.5) | 1.1 (1.5) | 2.0 (2.4) | 1.8 (2.1) | 29.23 | <.001 | 4,3>2,1 |
| Lifetime traumatic events | 11.1 (9.3) | 6.1 (5.0) | 9.6 (8.1) | 11.9 (9.2) | 13.1 (10.5) | 20.16 | <.001 | 4>3>2>1 |
| Military sexual trauma | 76 (7.4%) | 5 (12.7%) | 21 (2.5%) | 20 (12.9%) | 30 (10.5%) | 37.66 | <.001 | 1,3,4>2 |
| Lifetime psychiatric disorders | ||||||||
| Major depressive disorder | 196 (18.2%) | 3 (4.8%) | 81 (10.2%) | 42 (23.0%) | 70 (27.9%) | 64.13 | <.001 | 3,4>1,2 |
| Posttraumatic stress disorder | 177 (18.1%) | 3 (3.2%) | 71 (9.7%) | 34 (20.9%) | 69 (29.3%) | 76.96 | <.001 | 4>3>1,2 |
| Alcohol use disorder | 523 (42.9%) | 15 (21.0%) | 323 (40.8%) | 76 (48.1%) | 109 (46.3%) | 17.38 | <.001 | 2,3,4>1 |
| Drug use disorder | 138 (11.9%) | 1 (1.6%) | 75 (8.9%) | 23 (13.4%) | 39 (16.4%) | 20.94 | <.001 | 4>2>1 |
| Nicotine use disorder | 216 (16.0%) | 4 (8.1%) | 154 (19.8%) | 29 (16.6%) | 29 (12.3%) | 13.78 | 0.003 | 2>1,4 |
| Suicide attempt | 43 (4.2%) | 0 (0%) | 13 (1.2%) | 9 (5.4%) | 21 (7.8%) | 31.13 | <.001 | 3,4>2; 4>1 |
| Non-suicidal self-injury | 33 (4.7%) | 0 (0%) | 5 (0.9%) | 4 (1.6%) | 24 (11.3%) | 71.64 | <.001 | 4>1,2,3 |
| Current psychiatric disorders | ||||||||
| Major depressive disorder | 111 (11.7%) | 5 (6.3%) | 33 (4.4%) | 24 (15.5%) | 49 (19.9%) | 63.06 | <.001 | 3,4>2; 4>1 |
| Posttraumatic stress disorder | 95 (9.7%) | 1 (1.6%) | 38 (5.0%) | 20 (14.4%) | 36 (14.7%) | 37.20 | <.001 | 3,4>1,2 |
| Generalized anxiety disorder | 71 (8.7%) | 3 (3.2%) | 17 (1.9%) | 17 (11.8%) | 34 (16.4%) | 71.77 | <.001 | 3,4>1,2 |
| Alcohol use disorder | 131 (12.3%) | 1 (1.6%) | 72 (9.0%) | 22 (13.9%) | 36 (17.2%) | 23.42 | <.001 | 4>2>1 |
| Drug use disorder | 95 (9.4%) | 1 (1.7%) | 53 (7.8%) | 17 (10.1%) | 24 (12.4%) | 10.50 | 0.015 | 4>1; 3>1,2 |
| Suicidal ideation | 137 (14.6%) | 4 (4.8%) | 47 (4.9%) | 29 (18.4%) | 57 (26.3%) | 100.28 | <.001 | 4>3>1,2 |
| Future suicidal intent | 17 (1.4%) | 1 (1.6%) | 4 (0.3%) | 6 (3.7%) | 6 (1.7%) | 12.46 | 0.006 | 3,4>2 |
| Mental health treatment history | ||||||||
| Ever received treatment | 319 (28.6%) | 3 (3.3%) | 164 (20.5%) | 59 (39.0%) | 93 (37.7%) | 65.49 | <.001 | 3,4>2>1 |
| Currently receiving treatment | 167 (17.0%) | 0 (0%) | 74 (10.2%) | 32 (19.9%) | 61 (26.4%) | 61.07 | <.001 | 3,4>2>1 |
| Psychotropic medication | 143 (14.6%) | 0 (0%) | 65 (9.3%) | 26 (16.6%) | 52 (22.3%) | 45.58 | <.001 | 3,4>2>1 |
| Psychotherapy or counseling | 105 (11.7%) | 0 (0%) | 40 (5.4%) | 19 (10.8%) | 46 (21.4%) | 71.71 | <.001 | 4>3>2>1 |
Post-Vietnam War veterans were more likely to have enlisted into the military compared to Vietnam and earlier war veterans. They also endorsed a greater number of adverse childhood experiences and lifetime traumatic events, and were more likely to report utilizing the VA as their primary source of health care. Iraq/Afghanistan War veterans reported the highest severity of combat exposure.
Mental health characteristics by war era
As shown in Table 1, post-Vietnam War veterans were more likely to screen positive for a lifetime history of major depressive disorder, PTSD, and suicide attempts relative to Vietnam and World War II/Korean War veterans. They were also more likely to screen positive for current major depressive disorder, PTSD, and generalized anxiety disorder, and to endorse current SI and future suicidal intent. Among all era groups, Iraq/Afghanistan war veterans were most likely to report lifetime PTSD, drug use disorder, cannabis use disorder, and non-suicidal self-injurious behaviors. They were also most likely to screen positive for current alcohol use disorder, drug use disorder and current suicidal ideation.
Post-Vietnam War veterans were more likely to have received mental health treatment relative to Vietnam and World War II/Korean War veterans, and were more likely to report taking current psychotropic medications. Iraq/Afghanistan War veterans were the most likely to be currently engaged in psychotherapy or counseling.
4. DISCUSSION
To our knowledge, this is the first study to examine sociodemographic, military, trauma, and psychiatric characteristics of US combat veterans by major war era. Gulf and Iraq/Afghanistan War veterans endorsed greater trauma burden, and were more likely to screen positive for lifetime and current major depressive disorder and PTSD, as well as current suicidal thoughts. Among all war era groups, Iraq/Afghanistan war veterans reported the greatest lifetime trauma and combat exposure severity, and were most likely to screen positive for lifetime PTSD, and current alcohol use disorder, drug use disorder, cannabis use disorder, and suicidal ideation. Specifically, more than 1-in-4 Iraq/Afghanistan War veterans reported current suicidal ideation, which is nearly 3-times higher than the 9% prevalence observed in the general US veteran population from our previous study of the entire NHRVS cohort, which included combat and non-combat veterans (Nichter et al., 2021).
Sociodemographic characteristics of Gulf and Iraq/Afghanistan War era veterans reflected the shifting demographic composition of younger veterans, which include increasingly more women and racial/ethnic minorities (Vespa, 2020). The finding that post-Vietnam era veterans endorsed a greater number of adverse childhood experiences relative to Vietnam/pre-Vietnam era veterans may be in part explained by the incremental increase in the proportion of enlisted veterans in recent war eras, who are more likely to come from disadvantaged socioeconomic backgrounds and have greater trauma burden (Merians et al., 2022).
One of the main findings of this study is that post-Vietnam era veterans, particularly Iraq/Afghanistan War veterans, had higher rates of psychiatric difficulties. Further, Iraq/Afghanistan War veterans had the highest prevalence of current alcohol use disorder, drug use disorder, cannabis use disorder, and suicidal ideation. Several explanations may account for these findings. First, closer temporal proximity to combat among more recent era veterans may be linked to higher rates of psychiatric disorders. Second, more recent era veterans reported the highest severity of adverse childhood experiences, cumulative traumas, and combat severity, which may mediate the relation between war era and adverse mental health outcomes (Davis et al., 2022; Nichter et al., 2021). Third, given that PTSD is associated with increased mortality (Schnurr, 2022), mortality bias may partly account for these findings, with older veterans having greater cumulative mortality. Lastly, it is possible that younger veterans may have been more forthcoming in reporting their mental health problems relative to older veterans, which could be reflective of lower mental health stigma among younger individuals (Bradbury, 2020).
Taken together, our findings underscore the importance of mental health screening, monitoring, and treatment efforts for Iraq/Afghanistan War veterans. For example, given the high prevalence of substance use disorders and suicidal ideation in this population, implementation of routine screening procedures with validated measures such as the AUDIT (Babor et al., 1992), Screen of Drug Use (Tiet et al., 2015), and Suicide Behaviors Questionnaire-Revised (Osman et al., 2001) in primary care settings may be beneficial. Further, Iraq/Afghanistan War veterans presenting to mental health clinics in both VA and non-VA settings may benefit from a thorough assessment for substance use and suicidality, as well as close monitoring and, if indicated, treatment.
An encouraging finding of this study is that, in line with having higher rates of positive screens for psychiatric disorders, more recent war era veterans were more likely to be engaged in mental health treatment. Approximately 4-in-10 post-Vietnam era veterans reported ever receiving mental health treatment, and 1-in-4 Iraq/Afghanistan War veterans reported currently receiving treatment. It is possible that recent efforts to help alleviate mental health stigma (Botero et al., 2020) may have had a more direct effect on younger veterans. Further, Iraq/Afghanistan War veterans were most likely to report utilizing the VA as their primary source of health care.
Limitations of this study must be noted. First, screening instruments were used to assess psychiatric measures instead of structured clinical interviews. Second, given the cross-sectional nature of analyses, we were not able to examine whether recovery from substance use disorders may have influenced the prevalence of psychopathology and suicidality of veterans of different war eras. Third, while nationally representative, our sample only comprised of a small sample of World War II and Korean War veterans, which may limit statistical power of comparisons with this group. Fourth, as mentioned above, mortality bias may, at least in part, account for the lower prevalence of psychiatric disorders and suicidality observed in older veterans. However, we would like to emphasize that our study reports on the lifetime and current prevalence of these outcomes among survivors. Further studies are needed to examine the effect of mortality bias on these estimates.
Notwithstanding these limitations, results of this study provide the first known population-based characterization of characteristics of US military veterans by different war eras. Collectively, our findings indicate that the more recent era veterans have a higher prevalence of psychiatric conditions relative to older era veterans. Iraq/Afghanistan veterans were the most likely to endorse adverse mental health outcomes, and may deserve close clinical attention and monitoring, as well as early interventions and supportive resources. Further research is needed to identify proximate and evolving risk and protective factors for veterans of different war eras.
Supplementary Material
Acknowledgment:
We thank the veterans who participated in the National Health and Resilience in Veterans Study.
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