Most Iraq and Afghanistan veterans with PTSD did not get enough care, study shows

Between 2002 and 2008, fewer than 10 percent of U.S. veterans of the wars in Iraq and Afghanistan who were newly diagnosed with post-traumatic stress disorder received the recommended course of care for their condition at VA health facilities, according to a study by researchers at the San Francisco VA Medical Center (SFVAMC) and the University of California, San Francisco (UCSF).

The study, which appears in the online Early View section of the Journal of Traumatic Stress, looked at the health care records of 238,098 veterans who received VA health care services between April 1, 2002 and March 31, 2008. It did not look at veterans who received care at facilities outside the VA such as Vet Centers, private medical practices, or community-based clinics.

The authors found that 49,425 veterans – more than 20 percent of the study population – received a diagnosis of PTSD for the first time, a figure consistent with earlier studies, according to lead author Karen Seal, MD, MPH, a physician at SFVAMC.

Of that group, only 9.5 percent received the recommended course of treatment, which for purposes of the study was defined as about 10 weekly treatment sessions within a time span of 15 weeks. Twenty-seven percent received the recommended number of treatment sessions over the course of one year following diagnosis.

Seal notes that the successes of the VA’s most recent efforts to enhance PTSD care are not reflected in this study.

The authors found that a number of factors were associated with a decreased likelihood of receiving sustained treatment: being male, being under 25, living in a rural area, and having received a PTSD diagnosis from a primary care clinic rather than a mental health program.

Seal, who is also an associate professor of medicine and psychiatry at the University of California, San Francisco, says that while the study did not investigate underlying reasons for the low treatment numbers, “these pre-disposing factors immediately bring to mind some possible barriers to care. First, young veterans of Iraq and Afghanistan might have competing priorities, such as school, work, and family obligations – and if they live in a rural area, getting to treatment would be an additional challenge. If they received their diagnosis from a primary care clinic, they have to get a referral to a mental health specialty clinic, which is an additional step and thus an additional barrier. And, importantly, the stigma of a PTSD diagnosis is likely to play a strong role in discouraging care among young veterans.”

Additionally, says Seal, PTSD, itself, is associated with symptoms such as avoidance, denial, and mild cognitive impairment, and comorbid disorders such as depression, “all of which can serve as barriers to seeking care.”

Seal observes that over 45 percent of Iraq and Afghanistan veterans have enrolled in VA health care, making the VA the single largest provider of health care for separated Iraq and Afghanistan veterans in the United States. “Since early, evidence-based treatment may prevent chronic PTSD and associated problems such as substance abuse and suicide, it is essential that we continue to develop ways to overcome these barriers and get more young veterans into effective treatment,” she says.

Seal points to the OEF/OIF Integrated Care Clinic at SFVAMC, which she co-directs, as a model for one potentially effective strategy. “Our clinic provides integrated primary and mental health care to veterans of Operation Enduring Freedom [Afghanistan] and Operation Iraqi Freedom. It’s literally ‘one-stop’ care, where veterans get physical and mental health assessments on the same day in the same place.” She says that since care for PTSD, depression, and associated conditions takes place in a primary care setting, “there is no mental health stigma.”

Co-authors of the study are Shira Maguen, PhD and Beth Cohen, MD, MAS, of SFVAMC and UCSF; Kristian S. Gima, BA, Thomas J. Metzler, MA, Li Ren, MS, and Daniel Bertenthal, MPH, of SFVAMC; and Charles R. Marmar, MD, of SFVAMC and UCSF at the time of the study.

The study was supported by funds from the Department of Veterans Affairs and the National Institutes of Health.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.