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With increasing age of Vietnam era veterans and the current conflicts in Afghanistan and
Iraq, the amount of veterans depending on medical care from the Department of Veterans Affairs
shows little sign of diminishing. With improving research, studies are beginning to show that
psychiatric injuries are just as common as physical injuries. Many veterans of the US Armed
Forces are returning home with little to no Post Traumatic Stress Disorder (PTSD) counseling
and this is causing many of them to have difficulty adjusting to life in the United States. Much
of this PTSD can be traced to mild to severe head injuries that occurred during service and may
or may not have been examined within a reasonable amount of time. The difficulty in adjusting
can set them up for further social problems, which may include homelessness or a brief transient
lifestyle.
Rosenheck and Frisman (1994) state that 38% of homeless men are veterans compared to
only 30% in the general population. Because of the numerous government benefits that veterans
receive when they return home, including housing and medical care, it would seem likely that the
rate of homeless veterans would be much lower than the baseline average in the United States.
The 1994 Rosenheck paper reviewed the 1987 Current Population Survey that is conducted by
the Bureau of the Census and used to estimate the proportion of male veterans in the general
population by age-race cohorts. The survey reported that of white males in the 20-34 age group,
veterans were 4.8 times more likely to be homeless than their non-veteran counterparts in the
general population (Rosenheck 1994). The study also showed that both Caucasian and African
Americans had a significantly higher propensity towards substance abuse and that Caucasians in
particular had a 2-3 times higher chance of developing psychiatric disorders (Rosenheck 1994).
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The combined effect of both substance abuse and psychiatric disorders are likely the driving
Research has indicated that veterans with psychiatric disorders, specifically PTSD, are
directly related to brain injuries. Doll and Bowley (2008) report that until recently there has
been little research done into blunt force injuries that commonly lead to brain injury and eventual
discharge. Recent improvements in care has made it more likely that the subject will be less
likely to die from an attack and more likely to survive an attack by a blunt force object or an
improvised explosive device. Doll and Bowley state that up to two thirds of veterans returning
from Afghanistan and Iraq and treated at Walter Reed Army Medical Center were diagnosed
with traumatic brain injury (Doll 2008). From this same veteran population, up to a third of all
Iraq and Afghanistan refugees report stress or mental disorder and seek some sort of treatment
from the Veteran's Administration (Doll 2008). While there are many veterans who do not need
care, the Veteran's Administration (VA) has repeatedly stated that it is often difficult to reach all
those on the periphery. Doll and Bowley conclude that the contribution of intense traumatic
events and exposure to blast injury and traumatic brain injury is difficult to fully understand. It
does seem clear that veterans with brain injuries have an increased likelihood to be vulnerable to
functioning of 800 Army soldiers before and after a one-year military deployment to Iraq. Both
surveys were done with an interviewer and the same interviewer was used to help control for
introduced bias. The results showed that post deployment PTSD was only marginally related to
day-to-day health related functioning controlling for other health symptoms (Vasterling 2008).
Instead, PTSD symptoms seem to adversely impact physical health functioning via their negative
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effect on health symptoms, which in turn negatively influence day-to-day functioning (Vasterling
2008). Finally, this study was uniquely able to predict future outcomes because of the nature of
the study. Based on the evidence, the authors recommended attempting to deal with PTSD
earlier in military service to increase productivity and to lower the overall costs which may be
The results found by Doll and Bowley were further supported by Hoge et al (2008) who
conducted a large cross-sectional study on 2714 soldiers from two different military units who
had similar times of service and saw similar levels of activity. Soldiers with mild traumatic brain
injury, primarily those who had loss of consciousness, were significantly more likely to report
poor general health, missed workdays, medical visits, and a high number of somatic and post
concussive symptoms than were soldiers with other injuries (Hoge 2008).
These soldiers were interviewed 3-4 months after returning from a yearlong service duty
in Iraq (Hoge 2008). The 3-4 month period was chosen to minimize recall bias and to allow
symptoms of post-discharge conditions to develop further. The data was collected via voluntary
survey and the survey was generally administered at a meeting or other military function where
many members were present. Of the 2525 soldiers whose data was analyzed, 124 (4.9%)
reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental
status, and 435 (17.2%) reported other injuries during deployment (Hoge 20008). Of those
reporting loss of consciousness, 43.9% met criteria for PTSD, as compared with 27.3% of those
reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury.
This sample chose a non-random study group consisting of two military brigades and
approximately 95% of the sample was male. Together both of these make the study not very
generalizable to the general population but will certainly make the study more generalizable to
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the veteran population. In this study as well as in others, the results are only as valid as the
administration of the test and the wording of the questions on the questionnaire that was given to
the military personnel. Because this study was reported based on self-reported data that was
collected 3-4 months after discharge and not the event itself, there is a significant possibility that
recall bias was introduced. However, the results still stand and make a strong case that head
injuries and more specifically PTSD need more attention at all levels of medical care.
Resnick et al took this issue further by using multivariate modeling to examine the
relationship between PTSD, other aspects of military service, and employment among 5,862
(VHA) program called Compensated Work Therapy (CWT) aims to provide diverse vocational
approaches and strong collaborative methods with the ultimate goal being vocational
rehabilitation for those enrolled in the program (Resnick 2008). In one component of this
program, employers work with the CWT program to find veterans to perform the various tasks
and jobs. Those enrolled in one of the 122 CWT programs nationwide were eligible to be
subjects in the research study. The study was able to analyze a unique subset of all discharged
veterans because it focused solely on those who had been discharged from the service and were
now trying to re-enter society with some assistance from the Department of Veteran’s Affairs.
The analysis observed that those who were competitively employed were more likely to
be younger, earned less public support income, and had fewer medical conditions (Resnick
2008). The rate of employment at discharge from the program was 30% for veterans with PTSD
and 36% for those without PTSD (Resnick 2008). It was observed that veterans with PTSD were
19% less likely to be employed at discharge (odds ratio = 0.81, p = 0.02) after controlling for
potentially confounding variables (Resnick 2008). While this may be significant, it can still be
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observed that both groups have very low rates of employment in general. Even with government
This issue was further examined by Rosenheck who compared the effects of race on
patient outcome for the CWT program. Rosenheck performed a similar study to the one done by
Resnick but instead made sure that out of 972 veterans surveyed, 470 of them were African
American (Rosenheck 1998). For both Caucasians and African Americans, both had very
similar rates for almost all categories including percent that successfully completed the program
(49 vs. 52.1%), average hours worked per week (33.5 vs. 31.8 hours), and average length of stay
in the program (188 vs. 199.7 days) (Rosenheck 1998). Although no statistically significant
trends were observed, it was noted that there were clear preferences for both to remain with
people of their own race and especially important to be seen by a doctor of their own race. These
are interesting observations, but they likely do not translate to any observation of interest in the
general population. Because the VA system is a government-operated system that is often the
only choice for many of its patients, it seems to be somewhat immune to the issue of bias
Because of the nature of the relationship between the military and the US Government,
there are few programs that can effectively bridge the gap outside of the military. One
governmental program that has experienced success is the CWT program, which was analyzed
by Resnick. The CWT program has many sub-programs such as Transitional Work Experience
which aims to use research and previous evidence-based services to make it easier for veterans to
return to employment in the civilian sector. The current programs are being expanded both to
make room for more veterans and because of past success with evidence-based Supported
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Employment (SE) programs (Resnick 2008). It is hoped that these programs will become
Even after finding a job it can still be difficult for veterans as well as the general
population to keep stable housing and keep that job. O’Connell et al studied this and determined
that an individual will be much more successful if they are actively followed and mentored.
O’Connell performed a secondary analysis of data from the Housing and Urban Development –
Veterans Affairs Supported Housing (HUD-VASH) and attempted to observe what predictors
were present to determine if a veteran would return to being homeless (O’Connell 2008). Of 392
formerly homeless veterans enrolled at the program at baseline, approximately 44% lived
homeless for at least one day after successfully being placed in housing (O’Connell 2008).
There were many reasons for this, but it was observed that PTSD resulted in an 85% higher risk
of reduced housing tenure (O’Connell 2008). Although the study was well designed to be
randomized and cover a wide geographic area, there are still some issues with generalizability.
Most the most significant issue is that the study only loosely defines homelessness as one day of
being homeless after being placed into housing. Also, the study falls into the area of bias that
seems to affect many other studies in this area that is the significantly disproportionate
client-level measures of service integration. Mares used data collected from different surveys of
service delivery and interagency trust and respect by 734 chronically homeless adults in 11 cities
across the country (Mares 2007). Analysis of the data showed that veterans were more likely to
visit outpatient clinics, have serious drug problems, have diagnoses of PTSD, but to have less
serious alcohol problems (Mares 2007). Although this agrees with previous studies, Mares
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argues that although there are positive associations between client-level measures of integration
and health status, the negative relationships that exist may represent greater frustrations among
analyzing recently implemented programs. The study followed clients from the greater Los
Angeles area and attempted to gauge their response to a new program which integrated patient
care by co-locating programs and services in one building (Blue-Howells 2007). With the
integrated services, veterans were easier to care for because they could have more medical needs
met at one place. It is hoped that the VA system integrates the model developed in LA into their
Although PTSD as a condition in veterans has been well studied, few have studied the
types of treatment used such as Mohamed and Rosenheck. Mohamed used data from 274,297
veterans whom were all diagnosed with PTSD in the year 2004. After multivariate analysis, it
was observed that 80% of veterans were prescribed psychotropic medication that likely seems to
be targeted at specific symptoms such as flashbacks and insomnia (Mohamed 2008). Mohamed
also suggests that further research may be needed to better diagnose and treat PTSD instead of
the current method, which aims to treat the peripheral conditions in the hope that it will treat the
main problem.
All studies were subject to some sort of bias, especially recall bias occurring because the
subjects may have had difficulty recalling all the events required by the survey. Many of these
surveys were administered a certain amount of time after their discharge date. Many injuries
were likely sustained during the time of service and using the discharge date is often the only
possible date that researchers can use. Another type of bias present in many of these studies is
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information bias, which is likely common in a diagnosis as wide-ranging as PTSD. The other
major deficiency with many of these studies is the lack of generalizability to the non-military
world. Because most of the study populations are more than 90% male, it makes the results of
these studies slightly more difficult to apply to the entire population. However, because this is
typical of the military population, the results only need to be specifically applied to the military.
All of the studies were fairly similar in design with the exception of a few such as the Rosenheck
study. The 1994 Rosenheck paper is more of an incidence survey than a prevalence survey and
no military records were examined to confirm the individual was present in the military. This
could potentially be biasing the actual results in terms of length of that individual being
All of these papers demonstrate that vocational deficits exist for those veterans who
return home with PTSD. Although almost all of the veterans seek some sort of care or treatment
from the Veterans Affairs, there is much room for improvement within these programs.
Hopefully the Department of Veterans Affairs will take steps to improve their re-establishment
programs to make them more reflective of current research. Because homelessness is a multi-
faceted problem related to PTSD and lack of vocational training, both problems must be
addressed to begin to observe progress on the issue. With earlier intervention and better
diagnoses of PTSD, it is hoped that re-establishment programs will be better able to deal with
these issues and the programs will be better positioned to improve the lives of veterans.
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References
Doll, D., Bowley, D. Veterans' health--surviving acute injuries is not enough, The Lancet. 2008.
Volume 371, Issue 9618. Page: 1053-1055.
Hoge, Charles W., McGurk, Dennis, Thomas, Jeffrey L., Cox, Anthony L., Engel, Charles C.,
Castro, Carl A. Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq. N Engl J
Med 2008 358: 453-463
Mares AS, Greenberg GA, Rosenheck RA. Client-level measures of services integration among
chronically homeless adults. Community Ment Health J. 2008 Oct;44(5):367-76. Epub 2008
May 1.
O'Connell MJ, Kasprow W, Rosenheck RA. Rates and risk factors for homelessness after
successful housing in a sample of formerly homeless veterans. Psychiatr Serv. 2008
Mar;59(3):268-75.
Resnick, Sandra G., Rosenheck, Robert A. Posttraumatic Stress Disorder and Employment in
Veterans participating in Veterans Health Administration Compensated Work Therapy. Journal
of Rehabilitation Research and Development. 2008. Volume: 45. Number: 3. Page: 427-436
Vasterling JJ, Schumm J, Proctor SP, Gentry E, King DW, King LA. Posttraumatic stress
disorder and health functioning in a non-treatment-seeking sample of Iraq war veterans: a
prospective analysis. J Rehabil Res Dev. 2008;45(3):347-58.