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MILITARY MEDICINE, 177, 7:814, 2012

Access to VA Services for Returning Veterans With PTSD

Brian Shiner, MD, MPH*; Robert E. Drake, MD, PhD†; Bradley V. Watts, MD, MPH‡; Rani A. Desai, PhD, MPH§; Paula P. Schnurr, PhD∥

ABSTRACT Objective: In order to understand access to treatment services for post-traumatic stress disorder (PTSD) in the Veterans Health Administration (VHA), we reviewed existing literature to estimate the proportion of Iraq and Afghanistan veterans who have used VHA services. Methods: We reviewed studies regarding the prevalence of PTSD among Iraq and Afghanistan War veterans to estimate the need for treatment. We then compared need to Veterans Affairs utilization in order to estimate the proportion accessing care. Results: Access to VHA services is high, with 58% of the estimated population of Iraq and Afghanistan veterans accessing some PTSD-related service. However, there is insufficient information about the quality of these services. Conclusions: The Veterans Affairs has been successful in providing access to treatment services for Iraq and Afghanistan Veterans with PTSD. Additional studies are needed to further characterize the quality of services provided.

INTRODUCTION Public policy concerns regarding veterans returning from the

Wars in Iraq and Afghanistan with post-traumatic stress

disorder (PTSD) are high. 1 Identifying these veterans early

and helping them to access evidence-based treatments in a

timely fashion may prevent the long-term problems that

untreated veterans have experienced. 2,3

Addressing these

policy issues will require, as first steps, estimating the num-

ber of returning veterans with PTSD and the proportion who

are already accessing services. These estimates are necessary

for the Veterans Health Administration (VHA) to address

the problems of lack of treatment and inadequate treatment.

This article reviews and synthesizes the existing literature on

access to derive best estimates.

Access is a complex construct. Anderson et al 4 described

four aspects—potential access, realized access, equitable

access, and inequitable access—based on availability of

treatment, use of treatment, and sociodemographic predic-

tors of use. He later delineated the concepts of effective

access and efficient access to indicate whether use of health

services actually improved health and whether a gradient

existed between use and benefit. 5 Thornicroft and Tansella

offered two concepts relating need to resources: “true prev-

alence,” denoting the number of cases of a particular condi-

tion, and “treated prevalence,” denoting the fraction of that

number receiving care. These concepts, in turn, led to

notions of “coverage” as an indicator of the proportion of

people who could benefit from a treatment 7 and “focus” as

an indicator of whether those people who received a treat-

ment actually needed it. Furthermore, high-quality health

care should be easily attainable in terms of geography, pay-

ment, waiting time, and cultural relevance. 8

American veterans who have served in Afghanistan

(Operation Enduring Freedom [OEF]) and Iraq (Operation

Iraqi Freedom [OIF]) have been called OEF/OIF veterans.

Although American service members continue to serve in

other conflicts around the world, their numbers are small,

and we have the best data to make estimates of access in

the OEF/OIF population. The VHA Environmental Epide-

miology Service reported that as of the end of the 2010

fiscal year, over 2.1 million service members served in

OEF and OIF, and 1,250,663 had separated from the military

and became eligible for VHA services (Internal Report,

reviewed below).

METHOD Our goal was to estimate the percentage of returning vet-

erans with PTSD who are accessing VHA health care, based

on the concept of coverage (the proportion of patients that

could benefit and actually receives the service). We therefore

sought to summarize available information in order to esti-

mate access in the following equation: Access = Utilization/

Need (Fig. 1).

Because the diagnosis of PTSD requires “clinically sig-

nificant distress or impairment in social, occupational, or

other important areas of functioning, 9 ” we assumed that

every veteran with PTSD has some related health need (our

denominator). To estimate PTSD treatment-related needs, we

followed a 2-step process. First, we reviewed relevant litera-

ture on the prevalence of PTSD among veterans in order to

determine the best estimate. Authors from the RAND Corpo-

ration of a recent review searched the Published International

Literature on Traumatic Stress (PILOTS) database using the

terms “PTSD” and “Iraq War or Afghanistan, or Operation

Enduring Freedom or OEF” and “epidemiology or health care

*VA Medical Center, 215 Main Street, 11Q, White River Junction,

VT 05009.

†Dartmouth Psychiatric Research Center, 85 Mechanic Street, Suite B4-1,

Lebanon, NH 03766.

‡VA National Center for Patient Safety Field Office, 215 North Main

Street, 10A4B1, White River Junction, VT 05009.

§VA Northeast Program Evaluation Center, 950 Campbell Avenue, West

Haven, CT 06516.

kVA National Center for PTSD Executive Division, 215 North Main Street, White River Junction, VT 05009.

MILITARY MEDICINE, Vol. 177, July 2012814

utilization.” After additional reference and internet searches,

the authors identified 29 studies of the prevalence of PTSD

among OEF/OIF veterans as of mid-2009. 10

Estimates of

PTSD prevalence varied widely between 1.4% and 60%,

creating a puzzle for epidemiologic logic. We proceeded as

follows. Because treatment-seeking samples are likely to

overestimate population prevalence, we eliminated 10 studies

that examined treatment-seeking veterans. 11–20

We also elim-

inated 11 studies that used convenience samples 21–31

and one

study of British veterans. 32

The seven remaining studies

(Tables I and II) included three evaluations of administrative

data derived from population-level screening 33–35

and four

population-based surveys. 36–39

Repeating the original RAND

search and applying these additional limitations, we did not

find additional studies as of December 31, 2010.

Our second step in estimating need was multiplying our

expected prevalence of PTSD by the number of VHA-eligible

OEF/OIF veterans. For this step, we used data from the

FIGURE 1. Access to VHA PTSD services among returning veterans.

TABLE I. PTSD Prevalence Estimates Based Upon Population Level Screening

Study Sensitive Criteria Specific Criteria

Hoge et al, 2006

OEF/OIFPDHA

PC-PTSD-2 (Sensitivity 0.91, Specificity 0.72) PC-PTSD-3 (Sensitivity 0.84, Specificity 0.90)

22,584/238,938 10,964/238,938

9.5% 4.6%

OEF OIF OEF OIF

762/16,318 21,822/222,620 355/16,318 10,609/222,620

4.7% 9.8% 2.2% 4.8%

Martin, 2007

OIFPDHA/RA

PC-PTSD-2 (Sensitivity 0.91, Specificity 0.72) No Specific Criteria Used

PDHA PDHRA — —

23,368/222,183 15,755/91,408 — —

10.5% 17.3% — —

Milliken et al, 2007

OIFPDHA/RA

PC-PTSD-2 (Sensitivity 0.91, Specificity 0.72) PC-PTSD-3 (Sensitivity 0.84, Specificity 0.90)

PDHA PDHRA PDHA PDHRA

10,686/88,235 17,239/88,235 5,593/88,235 9,682/88,235

12.1% 19.5% 6.3% 11.0%

Active a

N.G./Res. b

Active a

N.G./Res. b

Active a

N.G./Res. b

Active a

N.G./Res. b

6,634/56,350 4,052/31,885 9,424/56,350 7,815/31,885 3,474/56,350 2,119/31,885 5,113/56,350 4,569/31,885

11.8% 12.7% 16.7% 24.5% 6.2% 6.6% 9.1% 14.3%

a Active—Active Duty Components.

b N.G./Res.—National Guard and Reserve Component.

MILITARY MEDICINE, Vol. 177, July 2012 815

Access to VA Services for Returning Veterans With PTSD

VHA Environmental Epidemiology Service. The Environ-

mental Epidemiology Service receives military separation

information regarding OEF/OIF veterans from the Depart-

ment of Defense’s Defense Manpower Data Center. Apply-

ing eligibility rules related to combat status and service

component (active duty vs. National Guard and Reserves),

they determine the first date of VHA eligibility for each

OEF/OIF veteran. As few OEF/OIF veterans became eligible

for VHA services in fiscal year 2001, those veterans were

included in the 2002 numbers. We obtained the cumulative

number of VHA-eligible OEF/OIF veterans from the 2002

through 2010 fiscal years.

Because a diagnosis of PTSD associated with a visit implies

that a PTSD-related service was delivered, we used diagnosis

at an episode of care as our measure of utilization (our numer-

ator). The VHA maintains historic administrative databases on

health services utilization among OEF/OIF veterans by com-

bining eligibility information described above with utilization

data from the National Patient Care Database. These databases

contain information on visits to the VHA as well as diagnoses

associated with these visits. We obtained the cumulative num-

ber of OEF/OIF VHA users who were diagnosed with PTSD

during fiscal years 2002 through 2010. Because some active

duty service members use VHA services through sharing

agreements, we excluded all users who had known future

military service. Two recent studies have established that the

positive predictive value of a clinician diagnosis of PTSD in

the VHA is 0.75. 40,41

Therefore, we multiplied our cumulative

number of OEF/OIF veterans with Veterans Affairs (VA)-

diagnosed PTSD by 0.75 in order to determine the minimum

number who received VHA PTSD services. Finally, we esti-

mated the minimum level of access by dividing this number by

the expected number of VHA-eligible OEF/OIF veterans with

PTSD through the same time period.

After estimating access for OEF/OIF veterans with PTSD,

we reviewed the literature for national studies characterizing

the care they received. To ensure that we were learning about

a consistently defined population, we searched for studies

that used the same data sources to identify VHA users. We

searched the PILOTS database using the terms “PTSD” and

“Veterans” and “Health Care Utilization,” and “Iraq War or

Afghan War” as of December 31, 2010. We identified

36 peer-reviewed journal articles. Of these, we selected the 7

that used the Defense Manpower Data Center information to

identify OEF/OIF veterans in the National Patient Care Data-

base. 20,42–46

A search using the same terms in PubMed and

PsycINFO revealed one additional reference, which was

published online first. 47

TABLE II. PTSD Rates Based Upon Population-Based Samples

Study Sensitive Criteria Specific Criteria

Abt Associates, 2006

OEF/OIF TRICARE

PCL-DSM (Sensitivity 1.00, Specificity 0.92) No Specific Criteria Used

162/2,724 —

5.9% —

Deployed Not Deployed —

108/1,382 54/1,342 —

7.3% 4.1% —

Smith et al, 2008

OEF/OIF Millennium

Cohort Study

PCL-DSM (Sensitivity 1.00, Specificity 0.92) PCL-DSM-50 (Sensitivity 0.60, Specificity 0.99)

708/11,714 562/11,912

6.0% 4.7%

No Baseline PTSD Baseline PTSD No Baseline PTSD Baseline PTSD

589/11,394 119/320 498/11,739 64/173

5.2% 37.2% 4.2% 37.0%

Combat N.C. a

461/5,299 128/6,095 89/186 30/134 409/5,382 89/6,357 47/108 17/65

8.7% 2.1% 47.9% 22.4% 7.6% 1.4% 43.5% 26.2%

Schneiderman et al, 2008

OEF/OIF Capital

Region Survey

PCL-50 (Sensitivity 0.82, Specificity 0.83)

250/2,235

11.2%

OEF Both OEF and OIF OIF

23/356 71/576 156/1,303

6.5% 12.3% 12.0%

Men Women Men Women Men Women

18/308 5/48 56/508 15/68 123/1,120 33/183

5.8% 10.4% 11.0% 22.1% 11.0% 18.0%

Schell and Marshall, 2008

OEF/OIFR AND

PCL-DSM (Sensitivity 1.00, Specificity 0.92) No Specific Criteria Used

181,000–270,000/1,640,000 —

13.8% (95% CI: 11.1–16.5%) —

Active b

N.G./Res. b

Separated b

—

44,930–66,788/628,120 34,282–50,960/241,080 102,828–152,853/770,800 —

8.9% (7.2–10.6%) 17.7% (14.2–21.1%) 16.6% (13.3–19.8%) —

a N.C.—Non-Combat.

b Components: Active—Active Duty, N.G./Res.—National Guard and Reserves, Separated—separated from military service.

MILITARY MEDICINE, Vol. 177, July 2012816

Access to VA Services for Returning Veterans With PTSD

RESULTS

Estimating Need Using Administrative Screening Data

In April 2003, 1 month after the war began in Iraq, the

Department of Defense mandated that all service members

complete the Postdeployment Health Assessment (PDHA)

immediately upon return from any deployment. The three-

page self-administered instrument was intended to assess

general health, physical symptoms, mental health concerns,

and exposures. It included a validated 4-question screen for

PTSD called the Primary Care PTSD Screen. 48,49

Compared

to the gold-standard Clinician-Administered Scale for

PTSD, 50

the screening instrument has a sensitivity of 0.91

and a specificity of 0.72 when 2 of 4 questions are positive

and a sensitivity of 0.84 and a specificity of 0.90 when 3 of

4 questions are positive. Soldiers complete the PDHA within

1 to 2 weeks of returning home after a deployment. A copy

of the completed survey is included in the Defense Medical

Surveillance System database.

Several concerns have been raised about the PDHA assess-

ment process. Because PTSD symptoms are not always stable

in the months following a traumatic event, 51–53

assessment

immediately following return from deployment might miss

some cases. The Department of Defense therefore initiated

the Postdeployment Health Reassessment (PDHRA), con-

taining the same 4-question PTSD screen but designed for

administration 3 to 6 months following return from deploy-

ment. A second issue is that some service members may

underreport their mental health symptoms for fear that treat-

ment may delay their separation from the military. 54

This

concern was confirmed in one small study. 55

Stigma might

also cause underreporting, as validated by another study. 56

Hoge et al 33

examined Defense Medical Surveillance Sys-

tem data between May 1, 2003 and April 30, 2004, when

82% of eligible soldiers returning from OIF, OEF, and other

military operations took the survey. Of the 222,620 soldiers

returning from OIF who took the PDHA, 9.8% screened

positive using a threshold of 2 positive responses and 4.8%

screened positive using a threshold of 3 positive responses. For

the 16,318 soldiers returning from OEF, 4.7% screened

positive using a threshold of 2 positive responses and 2.1%

screened positive using a threshold of 3 positive responses.

Martin 34

repeated the same analysis for 222,183 (76.8%

response) soldiers returning from OIF in 2005. Using a thresh-

old of 2 positive responses, 10.5% screened positive for PTSD.

Among those who had both assessments, 17.3% screened

positive for PTSD on the PDHRA, only 29.9% of whom had

screened positive on the PDHA. This validated concerns that

many cases not initially detected at immediate postdeployment

screening emerged in the months following a deployment.

Milliken et al 35

further clarified the relationship between

positive PTSD screens in the immediate postdeployment

period and in the period several months later. Examining

88,235 Army soldiers returning from OIF who completed

both assessments, June 2005 and December 2006, and

using a cutoff of two positive responses, they found that

12.1% screened positive for PTSD on the PDHA and

19.5% screened positive on the PDHRA. Using a threshold

of 3 positive responses, the analogous figures were 6.3%

and 11%.

Estimating Need Using Population-Based Surveys

Four population-based studies analyzed surveys using the

PTSD Checklist, 57

which has been validated in this popu-

lation. 58

The PCL is a 17-item self-report measure that

assesses whether patients meet symptomatic criteria for

PTSD. Each item has is scored from 1 to 5, where a score

of 3 or higher indicates that the patient has the given symp-

tom. The total score ranges from 17 through 85. These four

studies used three different methods of case finding with the

PCL. The first, examining whether patients meet DSM-IV

criteria for re-experiencing, avoidance and numbing, and

hyperarousal clusters, is called the “PCL-DSM” case defini-

tion and has a sensitivity of 1.00 and a specificity of 0.92. 59

The second, examining whether patients have a severity

score of 50 or higher, is called the “PCL-50” case definition

and has a sensitivity of 0.82 and a specificity of 0.83. 57

The

third, examining whether patients both meet DSM-IV symp-

tomatic criteria and whether they have a severity score of 50,

is called the “PCL-DSM-50” case definition and has a sen-

sitivity of 0.60 and a sensitivity of 0.99. 59

Abt Associates 36

identified OEF/OIF participants using

Defense Medical Surveillance System files to obtain demo-

graphic, deployment, and combat status information for active

duty component service members from all military branches

and attempted to survey an age-stratified random sample of

6,000 active duty soldiers. Among 2,761 soldiers (1,419 deployed)

who returned completed surveys (49% response), 5.9% of

participants screened positive for PTSD using the sensitive

PCL-DSM case definition. The rate was higher in those

deployed (7.3%) than in those not deployed (4.1%).

Smith et al reported the first stage of the Millennium

Cohort Study, a 21-year prospective study of randomly

selected service members from all military branches, both

active duty and National Guard members, and Reservists.

They oversampled several subgroups, including women,

those previously deployed, reservists, and guardsmen. 38

77,047 invited to participate, 36% consented and 71% of

those participated in the first 3-year follow-up questionnaire.

After exclusions, the authors analyzed data from 50,128

participants using a longitudinal approach and stratifying by

combat exposure during deployment. Using the PTSD

Checklist and DSM-IV symptomatic criteria, 6.0% of par-

ticipants screened positive for PTSD using the sensitive

PCL-DSM case definition and 4.7% screened positive using

the specific PCL-DSM-50 criteria.

Schneiderman et al 37

conducted a survey of service

members who had been deployed to OEF/OIF living in the

MILITARY MEDICINE, Vol. 177, July 2012 817

Access to VA Services for Returning Veterans With PTSD

Washington, DC, metro area. Although the researchers were

studying mild traumatic brain injury, they included the PTSD

Checklist. They identified 7,259 OEF/OIF service members

and achieved a 34% participation rate. Using the PCL-50

case definition, 11% of participants screened positive for

PTSD. As seen in Table II, those who served in OIF were

twice as likely to screen positive for PTSD as those who

served in OEF alone, and women serving in both war zones

were twice as likely as men to screen positive for PTSD.

Schell and Marshall designed a survey to overcome prob-

lems related to variation in the prevalence of PTSD by sam-

pling relevant subgroups. They conducted a telephone survey

in 24 geographic regions of the United States with large mili-

tary bases. 39

Using random digit dialing within each region,

they screened for past deployment and interviewed 1,938

respondents who screened positive. The telephone survey

included the PCL, and the authors used the sensitive PCL-

DSM case definition. Poststratification sampling weights

matched the deployed force on critical variables including

branch, current duty status, rank, race, marital status, sex,

theater, multiple deployments, time since deployment, length

of deployment, and age. Overall, 13.8% of participants

screened positive for PTSD (95% CI: 11.1%–16.5%). Among

these subgroups, active duty participants had the lowest risk of

PTSD, whereas those who had separated from the military or

were in the National Guard and Reserves had higher relative

risks when compared to active duty components (1.87 and

1.99, respectively). From these numbers, we can calculate the

risk for our population of interest (those separated and eligible

for VA services) as 16.6% (95% CI: 13.3%–19.8%). Subgroup

risks for active duty and guard and reserve are presented in

Table II. Limitations of this study were geography (areas

proximal to military installations), use of random digit dialing,

and low response rate.

The Schell and Marshall study was the most relevant for

our estimates because it was designed to answer questions

about prevalence of mental health disorders in OEF/OIF-

deployed service members and provided estimates for OEF/

OIF veterans who have separated from the military and are

most likely to be eligible for VHA care. Further, when service

component (active duty vs. National Guard and Reserves) and

military separation status are considered, the results of most

other studies fall within Schell and Marshall’s confidence inter-

vals, validating the findings. Thus, using our VHA-eligible

population (1,250,663 OEF/OIF veterans) and multiplying by

our calculated prevalence of PTSD for separated OEF/OIF

returnees (16.6%; 95% CI: 13.3%–19.8%), we estimate that as

of the end of the 2010 fiscal year there were 207,610 OEF/OIF

veterans with PTSD (95% CI: 158,340–235,373). This number

represents the denominator in our coverage equation.

Estimating Utilization

Veterans’ use of VHA services is observable because we can

use the electronic health record to count the number of unique

veterans who have presented to the VHA and had a diagnosis

of PTSD associated with a visit. We found that of 593,569

OEF/OIF veterans who had at least one visit at a VHA facility

from 2002 through 2010, 161,507 had a PTSD diagnosis.

Using a positive predictive value of 75%, 121,130 likely had

PTSD, yielding a number to represent the minimal numerator

in our coverage equation.

Access: Who Uses the VHA and What Services do They Receive?

Access equals approximately 121,130 (utilization) divided by

207,610 (need), or 58%. Table III shows that the rate since has

increased since the start of the OEF/OIF conflicts. As noted

above, researchers have used the same national administrative

data to document care received by OEF/OIF veterans with PTSD.

Four studies identify overall characteristics of those with

who use the VHA. Kang and Hyams 43

examined 48,733 OEF/

OIF veterans who had accessed VHA health services from

2003 through 2005. They found a steady rise in the rate of

mental disorders in this population, especially for those with

PTSD, which increased from 3% to 10%. Those who had

served in Army and Marine ground forces, compared to

the Navy and Air Force, had higher rates. Rates were simi-

lar among reserve and National Guard units compared to

active duty units. Seal et al 45

later examined VA data on

289,328 veterans, between 2001 and 2008, and found that the

rate of PTSD had increased from 0.2% to 21.8%. Extending

back 2 years revealed a rapid increase in the first quarter of

2003, following the invasion of Iraq. Veterans of active duty

components younger than age 25 had a significantly higher

risk of PTSD than veterans of active duty components older

than age 40, whereas the relationship was reversed in veterans

of National Guard and Reservist components.

Two of the studies describing overall characteristics of

OEF/OIF VHA users were especially relevant to women vet-

erans. Kimerling et al 60

examined characteristics of OEF/OIF

TABLE III. Access to VA Services for OEF/OIF Veterans With PTSD

Fiscal

Year

Eligible a

Expected

PTSD b

³ 1PTSD Diagnosis

Minimum

Number

With

PTSD d

Lowest

Estimate

for Access

(%) e

2002 68,646 11,395 18 14 0.1

2003 196,151 32,561 170 128 0.4

2004 367,506 61,006 3,747 2,810 4.6

2005 552,041 91,639 14,904 11,178 12.2

2006 714,978 118,686 30,925 23,194 19.5

2007 862,624 143,196 54,858 41,144 28.7

2008 1,010,598 167,759 86,486 64,865 38.7

2009 1,147,097 190,418 122,851 92,138 48.4

2010 1,250,663 207,610 161,507 121,130 58.3

a Source: VA Environmental Epidemiology Service.

b Assuming 16.6% have

PTSD. c Source: VHA Administrative Data.

d Using positive predictive value

of 0.75. e Using coverage equation (access = utilization/need).

MILITARY MEDICINE, Vol. 177, July 2012818

Access to VA Services for Returning Veterans With PTSD

veterans who screened positive for military sexual trauma

between 2001 and 2007 (80.5% of women and 75.8% of men

were screened). They found that 15.1% of 17,508 OEF/OIF

women and 0.7% of 108,149 men screened positive. Just over

50% of both men and woman who screened positive for mili-

tary sexual trauma received a diagnosis of PTSD. Mattocks

et al 46

examined the prevalence of mental health problems

among women OEF/OIF veterans receiving prenatal care

between 2003 and 2008. The prevalence of PTSD in these

women was over twice as high as in other women (21% vs.

9%), with over 66% of the women receiving a PTSD diagnosis

before they began receiving prenatal care. The authors noted

that one possibility for this finding may be that many of these

women presented to the VHA for mental health care and were

duly referred for prenatal care.

Two studies arrived at similar results regarding the use

of general medical services by OEF/OIF veterans. Frayne

et al 61

examined nonmental health care among 90,558 vet-

erans from 2005 through 2006 and found that those with a

diagnosis of PTSD had a greater number of general medical

diagnoses and greater primary care service utilization than

those without a mental health diagnosis. These differences

were more pronounced in women. Cohen et al 42

extended

the period of observation to 2001 through 2007 and stratified

veterans by whether they had PTSD, other mental disorders,

or no mental disorders. Among the 249,440 OEF/OIF vet-

erans, PTSD was the most common mental health diagnosis

(21.5%). Utilization of both outpatient and inpatient general

medical care was highest for those with PTSD; veterans with

PTSD consumed almost twice as much general health care

as those without a mental health diagnosis. Again, women

with PTSD had higher general medical service use. Several

mechanisms could explain the findings: The traumatic events

that caused PTSD might have also caused physical injury

requiring general health care; both somatic symptoms associ-

ated with PTSD and stigma could have led veterans to use

VA primary care clinics; PTSD could have caused biological

and behavioral changes that led to increased physical illness;

and increased contact with the medical system associated with

PTSD treatment could have led to increased detection of

physical illnesses.

Two studies evaluated mental health service use. Seal

et al 20

identified 103,788 OEF/OIF veterans using the VA

from October 2001 through September 2005. Overall, 13%

had been diagnosed with PTSD. Of demographic variables,

only younger age was associated with a PTSD diagnosis. In

a second study, Seal et al identified all OEF/OIF veterans

who were new to VA care from 2002 through 2008 and

examined mental health services utilization for those with

PTSD diagnoses over 1 year following their initial diagno-

sis. 44

Significantly greater proportions of those with PTSD

were single, male, under the age of 25, and had served in the

Marines. Of those with PTSD, 39,540 (80.0%) had at least

one follow-up visit in mental health during the first year

following their initial diagnosis. Having other mental health

diagnoses in addition to PTSD and age over 25 years was

associated with having a mental health follow-up visit. Not

having a mental health clinic follow-up was associated with

receiving a PTSD diagnosis at a nonmental health clinic,

living more than 50 miles from a VA facility, and primarily

having received care at an outreach clinic.

Our overall goal was to examine access to care for OEF/

OIF veterans with PTSD. Most studies we reviewed did not

comment on the quality of care those veterans received. The

one exception was the second Seal et al study, which also

examined the quality of PTSD services based on defining

minimum adequate treatment as at least nine mental health

treatment sessions over 15 weeks. Only 9.5% of 49,425 vet-

erans with PTSD received this level of care, but the propor-

tion increased to 27.0% when the standard was relaxed

to nine visits over the first year. Veterans were more likely

to receive adequate treatment if they initially received their

PTSD diagnosis in a mental health clinic. This single study

does caution that when defined with the coverage equation,

access does not necessarily mean access to the most effec-

tive care.

DISCUSSION We estimate that approximately 58% of OEF/OIF veterans

with PTSD have used VA services to receive some PTSD-

related treatment. We also estimate that OEF/OIF veterans

with PTSD have been increasingly likely to use VA services

over time. Prior studies have shown that these veterans have

high rates of physical health problems and use general med-

ical services at a much higher rate than those without PTSD.

Furthermore, these veterans are more likely to use mental

health services if they have additional mental health prob-

lems, if they are diagnosed in a mental health clinic, if they

are over age 25, and if they live near a VA facility and

receive care there.

The 58% figure appears to be significantly higher than

observed in the community. For example, in the National

Comorbidity Study Replication, only 7.1% of adults talked

to a health care provider about their PTSD symptoms in the

year following onset of the disorder and the lifetime figure

was just over 50%. 62

There are multiple explanations

for why 42% of OEF/OIF veterans with PTSD did not

receive VA PTSD care. Some received care from non-VHA

sources. 63,64

Others may seek care but not gain access. Some

may not yet recognize their need for treatment, whereas

others may recognize a need but experience internal or

external obstacles. 65,66

Outreach and motivational interven-

tions may help some of these veterans to access services and

prevent long-term disability. 67–69

One possible limitation to this analysis is an inaccurate

estimate of need. Most of our estimates are based upon PCL

screening for PTSD. The sensitivity and specificity of this

instrument in identifying PTSD is less than 1.00, meaning

that there were both false positives and false negatives in

MILITARY MEDICINE, Vol. 177, July 2012 819

Access to VA Services for Returning Veterans With PTSD

the Schell and Marshall 39

survey used to calculate our esti-

mate of need for PTSD treatment. Gravely et al 41

also used

follow-up with the PCL in calculating the positive predic-

tive value of a clinical diagnosis of PTSD made in the VHA,

which we used to adjust our estimate of utilization. As a

result, both the numerator and the denominator of our access

equation rely on the same instrument. However, the exact

effect of the use of the PCL in either under- or overestimating

access is unclear.

Access denotes more than coverage. Simply having con-

tact does not necessarily mean that veterans receive effec-

tive, appropriate, local, and culturally appropriate services.

Although it is possible that PTSD is frequently identified

and then ignored, primary care-based screening efforts

appear to be effective directing patients to mental health

treatment. Seal et al 19

found that patients who were identi-

fied with PTSD through VHA postdeployment screening at a

single facility and 5 associated community clinics were highly

likely (63%) to complete a mental health visit within 90 days.

Lindley et al 70

replicated this finding at another VHA facility,

finding that over half accepted a referral and three-quarters

of those referred presented to mental health for a first visit.

However, both reports look at only the first mental health

visit, whereas most PTSD treatments require multiple visits.

Using national data, Seal et al 44

found that at most 9.5% of

treatment-seeking OEF/OIF veterans had enough visits to

receive the most effective psychotherapies for PTSD. None-

theless, some facilities have developed clinics that consis-

tently provide exceptional PTSD care to this population. 71,72

A systematic method of identifying and learning from these

high-performing facilities could help maximize quality.

We have provided, based upon our review of literature and

use of administrative data, a best estimate of access to VA

PTSD care for OEF/OIF veterans. We have not described

how convenient, culturally relevant, and timely that access

was. Without access, there is no quality care. However, access

only begins the discussion of the quality. As we improve our

understanding of access, a broader effort to understand

quality as defined by the Institute of Medicine’s six aims

for quality improvement—including safety, effectiveness,

patient-centeredness, timeliness, efficiency, and equity 73–75

—

will ensure that the VHA can capitalize on the opportunity to

improve the health of OEF/OIF veterans with PTSD.

ACKNOWLEDGMENT

This work was supported by a VA-New England Early Career Development

Award to Dr. Shiner (V1CDA2010-03).

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