Financial well-being and postdeployment adjustment among Iraq and Afghanistan war veterans

Characteristics of recently incarcerated primary care patients with and without a positive posttraumatic stress disorder screening upon clinic intake

OBJECTIVE

Posttraumatic stress disorder (PTSD) is prevalent among people who have been incarcerated. Here, we examined whether screening positive for PTSD was associated with other indicators of poor health, acute healthcare utilization, and poverty among primary care patients upon release from incarceration.

METHOD

We conducted a cross-sectional survey in a national network of primary care clinics serving people recently released from incarceration. Participants were 416 patients who completed the Primary Care PTSD screen (PC-PTSD) and other questions about mental and physical health, acute healthcare utilization, and economic status within 6 months of release.

RESULTS

Screening positive for PTSD was associated with worse status across nearly all variables examined, including being more likely to report: poor/fair health (61.6% vs. 41.7%), current depressive symptoms (89.7% vs. 50.8%), lifetime depression diagnosis (63.3% vs. 35.3%), cannabis use since release (20.7% vs. 9.6%), homelessness (31.9% vs. 18.5%), having no cash on hand (56.3% vs. 39.0%) and severe food insecurity (29.3% vs. 18.2%; all ps < .01). Reporting recent suicidality (14.3% vs. 7.0%), alcohol use since release (30.2% vs. 20.0%), and emergency department utilization (20.4% vs. 12.2%) was also more likely (all ps ≤ .03). These trends were largely upheld when controlling for demographic characteristics and chronic physical health conditions using linear probability regression.

CONCLUSIONS

Primary care patients recently released from incarceration have a need for wrap-around services that address health challenges and poverty. Patients with significant PTSD symptoms face even greater challenges. Identification and treatment of PTSD both during and after incarceration is warranted. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Reintegration of cyber veterans: challenges and strategies for post-war transition

Battles in the cyber domain often lack visibility compared to the physical domain, which can lead to insufficient appreciation of its actors' achievements by the general public and society. Nonetheless, it has become a crucial area of modern warfare in which cyber professionals defend the nation's critical infrastructure, support other military operations and achieve military objectives that could not be attained in other domains. Although cyber combatants might not have as high a risk of injury or death as those on the front lines, they still can face traumatic events and suffer from the same types of issues after the war as any other veteran. Earlier studies on war veterans have shown they have elevated risks of mental health issues, substance use, social problems and financial difficulties which might push some individuals towards a path of crime. The cyber domain is also not limited by time or place, which has given rise to cyber volunteerism in which skilled individuals around the globe decide to assist their own country or friendly nations. This publication aims to identify the challenges cyber veterans might face when transitioning back to civilian life and develop appropriate strategies to facilitate their reintegration. It also raises the awareness of the hundreds of thousands of volunteers who can develop similar problems after the war. Without proper awareness, support and dialogue, some of these individuals can also drift towards harmful social implications such as cybercrime.

Food Insecurity and Suicidal Ideation: Results from a National Longitudinal Study of Military Veterans

OBJECTIVE

Research examining social determinants of suicide risk in veterans suggests a potential link between food insecurity and subsequent suicidal ideation in military veterans. The objective of this study is to investigate, if and how, food insecurity predicts subsequent suicidal ideation in a nationally representative longitudinal survey of veterans.

METHODS

A national longitudinal survey was analyzed of participants randomly drawn from over one million U.S. military service members who served after September 11, 2001. N = 1,090 veterans provided two waves of data one year apart (79% retention rate); the final sample was representative of post-9/11 veterans in all 50 states and all military branches.

RESULTS

Veterans with food insecurity had nearly four times higher suicidal ideation one year later compared to veterans not reporting food insecurity (39% vs 10%). In multivariable analyses controlling for demographic, military, and clinical covariates, food insecurity (OR = 2.37, p =.0165) predicted suicidal ideation one year later, as did mental health disorders (OR = 2.12, p = .0097). Veterans with both food insecurity and mental health disorders had a more than nine-fold increase in predicted probability of suicidal ideation in the subsequent year compared to veterans with neither food insecurity nor mental health disorders (48.5% vs. 5.5%).

CONCLUSION

These findings identify food insecurity as an independent risk marker for suicidal ideation in military veterans in addition to mental disorders. Food insecurity is both an indicator of and an intervention point for subsequent suicide risk. Regularly assessing for food insecurity, and intervening accordingly, can provide upstream opportunities to reduce odds of suicide among veterans.

Contextual factors of financial capability and financial well-being for adults living with brain injury: a qualitative photovoice study

OBJECTIVE

To identify the contextual factors related to financial capability and financial well-being for adults living with acquired brain injury (ABI).

DESIGN & METHOD

We conducted a qualitative descriptive study using photovoice and included 17 adults who live with ABI in Manitoba, Canada. Over 3-to-5 weeks, participants took photos of their financial capability (i.e. knowledge, skills, and behaviors related to managing finances) or their financial well-being (i.e. subjective and objective financial outcomes). Participants were interviewed about their photos. Five researchers iteratively and thematically analyzed interview transcripts.

MAIN OUTCOMES/RESULTS

Analysis identified the importance of the economic, social, technology, and physical or sensory context. Subthemes related to: (i) hard times finding financial resources; (ii) processes not making sense; (iii) getting help from the right person; and (iv) invisible disability bias and stigma.

CONCLUSIONS

There is decreased literature about financial capability or financial well-being after ABI. The results of this study highlight the salience of finance to living with ABI and the importance of the context to addressing financial-related life participation for people living with ABI. Information about contextual factors related to finance can improve rehabilitation assessment and intervention practice as well as emphasize needed accessibility changes to financial environments.

Digital tools to support technology-enabled budget management in people with acquired brain injury: a rapid review

People with acquired brain injuries (ABI) face financial challenges that affect their daily lives. Managing finances is a crucial activity that can help avoid social isolation. However, this task becomes difficult for people with ABI because of their cognitive impairments. Recent advances in digital technology can help people with ABI manage their finances more effectively. This study aims to identify and describe available digital tools that can help ABI in budget management, and identify their effectiveness, barriers and facilitators to implementation. To address this issue, we conducted a rapid review of academic databases followed by a modified Google/Google Scholar search to identify the digital tools to support budgeting tasks (DBT) used and tested by people with ABI. Our rapid review included only two articles on the use of DBT. The first study showed that common portable electronic devices were acceptable and desirable as memory and organisational aids for people with ABI. The second study documented the development of a DBT and the perception of users (research participants) who found it appealing and user-friendly. However, for both articles, the technologies used are outdated and lack information on barriers and facilitators to using DBT. In conclusion, this literature review revealed that digital technologies have the potential to support budget management in people with ABI, but technology needs to be made available on the market to benefit the users. Further research and development are needed to create new ways to help people with brain injuries manage their budgets.

Low household income, financial literacy, or financial health: Which is the strongest risk factor and outcome of depressive symptomatology?

BACKGROUND

Depression's relations to psychosocial processes are complex, bidirectional, and include financial functioning. The current study compared the extent to which household income, financial literacy (knowledge and skill), and financial health (saving, spending, borrowing, and planning behavior) were risk factors and outcomes of depression.

METHODS

A United States national sample of working-aged adults (N = 6565) completed self-report measures of financial functioning and depression in years 2020 and 2022. Depression scales assessed both negative (depressive symptoms) and positive (life satisfaction) affective dimensions.

RESULTS

Lower income, less financial literacy, and especially poorer financial health correlated significantly with more depressive symptoms and lower life satisfaction. Poorer financial health demonstrated the strongest prospective relations with increasing depressive symptoms and decreasing life satisfaction over the two-year retest interval. In parallel, higher depressive symptoms and lower life satisfaction each predicted subsequent decreases in financial health.

LIMITATIONS

Results from this longitudinal, observational study suggested but could not establish causal connections between depression and financial functioning. The study's novel results require replication before clinical application.

CONCLUSIONS

More so than low income or limited financial literacy, poor financial health is both a risk factor and potential outcome of depression, including more depressive symptoms and lower life satisfaction. If these findings are replicated, financial health may be an important research and clinical target for depression assessment, prevention, and treatment.

Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review

Introduction

As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans.

Methods

The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire.

Results

The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder.

Discussion

Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.

Rate and correlates of post-traumatic stress disorder (PTSD) following the Beirut blast and the economic crisis among Lebanese University students: a cross-sectional study

BACKGROUND

Post-traumatic stress disorder (PTSD) is a mental illness that develops in some people after they have experienced a stunning, scary, or dangerous incident. Due to major disasters like as the Economic Crisis and the Beirut Blast, Lebanese people are struggling with a variety of mental health issues. The study objectives were to find the rate of PTSD and its association with stress, anxiety, depression, financial well-being and coping strategies among university students in Lebanon.

METHODS

This is a cross-sectional study, conducted between May and August 2021, which enrolled 419 university students from all districts of Lebanon. The PTSD Checklist-Specific Version (PCL-S) was used to evaluate manifestation of PSTD.

RESULTS

The results showed that 132 (31.5%), 109 (26.0%) and 169 (40.3%) had PTSD from COVID, Beirut blast and economic crisis respectively. More avoidant coping (Beta = 0.52) and more anxiety (Beta = 0.62) were significantly associated with more PTSD from the Beirut Blast. More avoidant coping (Beta = 0.56), depression (Beta = 0.40) and anxiety (Beta = 0.49) were significantly associated with more PTSD from the economic crisis, whereas more financial wellbeing (Beta = - 0.31) was significantly associated with less PTSD from the economic crisis.

CONCLUSION

Significant rates of PTSD were found in our sample of Lebanese university students, whether from the Beirut blast, or from the current economic crisis. Significant correlations of these PTSD rates were found with factors such as avoidant coping, depression, anxiety and financial wellbeing. Such findings must raise the attention to serious mental and psychosocial alteration endured by Lebanese youth that are still under fatal cumulative traumatic events, that were and even may be, intergenerationally and unintentionally transmissible, therefore, affecting not only the present, but also the future of a whole nation.

Associations between mental health and job loss among middle‐ and low‐income veterans and civilians during the COVID‐19 pandemic: An exploratory study

This study examined the relationship between job loss and mental health during the pandemic among a nationally representative sample of middle- and low-income military veterans and civilians. Participants were recruited from Amazon Mechanical Turk in May-June 2020. Our sample was comparable to the U.S. population with respect to key demographics (i.e., sex, race, ethnicity, and geographic region). More veterans were male (36.9% civilians vs. 74.1% veterans), and on average they were older than civilians (M_civilians  = 47.86 vs. M_veterans  = 52.64). After controlling for sociodemographic factors, probable anxiety (adjusted odds ratio for veterans = 1.96, 95% [1.22-3.15]) was significantly associated with job loss among veterans, whereas among civilians, probable anxiety (adjusted odds ratio for civilians [AOR_c ] = 1.48, 95% [1.21-1.81]), probable COVID-19 era-related stress (AOR_c  = 1.73, 95% [1.45-2.07]), and loneliness (AOR_c  = 1.09, 95% [1.04-1.13]) were associated with job loss. Results demonstrated that veteran sample's effect sizes were larger than civilian sample's effect sizes; however, our moderation analyses results revealed that veteran status did not moderate the relationships between mental health and job loss. The findings in this study support a relationship between job loss and poorer mental health, suggesting that increased mental health services may be important to address ongoing effects of the COVID-19 pandemic.

Psychosocial well-being among veterans with posttraumatic stress disorder and substance use disorder

OBJECTIVE

Concurrent posttraumatic stress disorder and substance use disorder (PTSD/SUD) in U.S. military veterans represents an urgent public health issue associated with significant clinical challenges. Although previous research has shown that veterans with PTSD/SUD endorse more psychosocial risk factors and fewer protective factors than veterans with neither or only one of these disorders, no study has applied a comprehensive framework to characterize the vocational, financial, and social well-being of veterans with PTSD/SUD. Furthermore, it is not fully known how well-being among veterans with PTSD/SUD compares to that of veterans with posttraumatic stress disorder (PTSD) only, substance use disorder (SUD) only, or neither disorder.

METHOD

This cross-sectional observational study analyzed data from the National Post-Deployment Adjustment Survey, which recruited a random national sample of U.S. veterans who served on/after September 11, 2001. Participants (weighted N = 1,102) self-reported sociodemographic, clinical, and military background information in addition to aspects of their vocational, financial, and social well-being.

RESULTS

Veterans with PTSD/SUD were particularly likely to report lifetime experiences of homelessness, violent behavior, suicidal ideation, and suicide attempts. Veterans with PTSD/SUD reported worse social well-being than the PTSD-only, SUD-only, and neither-disorder groups. They also reported worse vocational and financial well-being than veterans with SUD only or with neither disorder but did not significantly differ from the PTSD-only group on vocational or financial well-being.

CONCLUSIONS

The findings underscore the importance of assessing multiple aspects of well-being in veterans with PTSD and/or SUD. The findings also point to promising treatment targets to improve psychosocial functioning and overall quality of life among veterans with PTSD and/or SUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Financial Status and Well-being in Recently Separated Military Veterans

INTRODUCTION

Veterans transitioning from military service to civilian life manage numerous changes simultaneously, in health, employment, social relationships, and finances. Financial problems may impact financial well-being as well as adjustment to civilian life in general; yet, research on Veterans' financial challenges remains limited. This study examined six indicators of perceived financial status among newly transitioned Veterans over a period of 3 years and then examined perceived financial well-being measured in two domains-satisfaction and functioning-and difficulty adjusting to civilian life as functions of financial status.

MATERIALS AND METHODS

A sample representing 48,965 Veterans who separated from active duty/activated status in fall 2016 provided informed consent and survey data over their first 33 post-military months; data were analyzed in weighted regression models that included demographics, military characteristics, social support, resilience, life stress, and indicators of financial status.

RESULTS

Financial status immediately post-separation included having stable housing (88%), being able to pay for necessities (83%), keeping up with creditors (88%), having insurance for catastrophic events such as disability (79%), saving for retirement (62%), and setting aside 3 months of salary (50%). Thirteen percent of Veterans disclosed troubled financial status, having achieved no more than two of these financial goals; 38% had moderate and 49% excellent financial status. Troubled or moderate financial status, Black race, enlisted, and higher levels of stress predicted lower financial functioning. Older age, college degree at baseline, employment, and social support predicted better financial satisfaction. Veterans with troubled financial status reported greater difficulty adjusting to civilian life (odds ratio 1.34); women were less likely to report difficulty adjusting to civilian life (odds ratio 0.85).

CONCLUSIONS

Findings indicate that financial satisfaction and functioning may be sensitive to psychosocial factors (social support and stress). Findings also underscore the value of assessing Veterans' financial status (poor debt management and lack of future planning), providing encouragement and assistance to pursue a college degree, and improving household financial management, thus increasing the likelihood that Veterans will have the necessary tools to manage their finances after separation and achieve whole health well-being.

The Map of Need: identifying and predicting the spatial distribution of financial hardship in Scotland's veteran community

INTRODUCTION

During military service, many household costs for both married and single service personnel are subsidised, and transition can leave veterans unprepared for the financial demands of civilian life. Armed Forces organisations such as Sailor, Soldier, Air Force Association (SSAFA) play a central role in understanding the financial challenges that UK veterans face and provide an insight into the financial hardship experienced by veterans. The aim of this study was to use SSAFA beneficiary data as a proxy to identify the nature of financial benefit, the spatial distribution of financial hardship in the Scottish SSAFA beneficiary community and explore factors that might predict where those recipients are located.

METHODS

Using an anonymised data set of Scottish SSAFA financial beneficiaries between 2014 and 2019, this study used a geographical methodology to identify the geospatial distribution of SSAFA benefit recipients and exploratory regression analysis to explore factors to explain where SSAFA beneficiaries are located.

RESULTS

Over half of benefit applicants (n=10 735) were concentrated in only 50 postcode districts, showing evidence of a clustered pattern, and modelling demonstrates association with area-level deprivation. The findings highlight strong association between older injured veterans and need for SSAFA beneficiary assistance.

CONCLUSION

The findings demonstrate that beneficiaries were statistically clustered into areas of high deprivation, experiencing similar challenges to that of the wider population in these areas. Military service injury or disability was strongly associated with areas of high SSAFA benefit use and in those areas high unemployment was also a significant factor to consider.

Food insecurity among active duty soldiers and their families during the coronavirus disease 2019 pandemic

OBJECTIVE

We examined the determinants of food insecurity among active duty Army households that transitioned into food insecurity during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

We compared Army households that recently transitioned into marginal food insecurity with those households that remained highly food secure (n 2832) to better understand how these households differ in their resilience to food insecurity during economic downturns using data from a military installation in the USA in 2020.

SETTING

A US military installation in the USA.

PARTICIPANTS

Active duty US Army soldiers.

RESULTS

Prior to the pandemic, the prevalence of marginal food insecurity among Army households was similar to that reported for households in the general population. Marginal food insecurity among Army households increased over 1·5-fold - from 19 % to 33 % - with the onset of the pandemic. Relative to Army households with consistently high food security, the Army households that transitioned into marginal food insecurity after the onset of the pandemic were more likely to report concerns about financial insecurity and the job security of their family members.

CONCLUSIONS

Army households, like their civilian counterparts, are vulnerable to food insecurity because of instability in their income during periods of economic uncertainty. Periods of economic uncertainty are more common for Army households because of the frequent relocations associated with military service which could lead to predictable periodic spikes in their food insecurity.

Childhood Trauma Differentially Impacts Depression and Stress Associations with Reintegration Challenges Among Post-9/11 U.S. Veterans

BACKGROUND

Post-9/11 veterans exhibit high prevalence of deployment stress, psychological conditions, and traumatic brain injury (TBI) which impact reintegration, especially among those with a history of interpersonal early life trauma (I-ELT). The relative importance of each risk factor is unclear.

PURPOSE

We examined major deployment and clinical exposures of reintegration challenges among veterans with and without I-ELT.

METHOD

We analyzed cross-sectional data of 155 post-9/11 veterans from the Translational Research Center for TBI and Stress Disorders study.

FINDINGS

Depression severity had the strongest association with reintegration challenges, followed by posttraumatic stress disorder (PTSD) severity, post-deployment stress, and deployment safety concerns. Deployment safety concerns had a stronger, significant association among veterans with I-ELT. In nearly every model, PTSD and depression severities were weaker for veterans with I-ELT, compared to those without.

DISCUSSION

Clinicians should consider the relative risk of concurrent clinical conditions and trauma histories when considering veterans' reintegration needs.

Post-9/11 military veterans' adjustment to civilian life over time following separation from service

OBJECTIVES

US military veterans face many challenges in transitioning to civilian life; little information is available regarding veterans' reintegration experiences over time. The current study characterized veterans' postdeployment stressful life events and concurrent psychosocial wellbeing over one year and determined how stressors and wellbeing differ by demographic factors.

METHODS

Recent Post-911 veterans (n = 402) were assessed approximately every three months for 1 year. Participants were 60% men, primarily White (78%), and 12% Latinx; the average age was 36 years.

RESULTS

The frequency of stressful events decreased over time but was higher for men and minority-race veterans (independent of time since separation). Veterans reported high mean levels of posttraumatic stress disorder, anxiety, and insomnia symptoms, which improved slightly over time. Minority-race and Latinx veterans had higher symptom levels and slower rates of symptom reduction.

CONCLUSION

Veterans remain distressed in their overall transition to civilian life. Interventions to promote resilience and help veterans manage readjustment to civilian life appear urgently needed.

Psychosocial functioning in veterans with combat-related PTSD: An evolutionary concept analysis

BACKGROUND

Veterans returning from combat have a greater risk for developing posttraumatic stress disorder (PTSD) and greater severity of psychosocial functioning impairment. Previous research has demonstrated the strong association between PTSD and psychosocial functioning impairment. Psychosocial functioning is an ambiguous term often used in literature to discuss PTSD-associated consequences, intervention response, and symptom progression. An evolutionary concept analysis was conducted to clarify understanding of psychological functioning in veterans with combat-related PTSD. Rodgers' method for an evolutionary concept analysis was used to examine the concept of psychosocial functioning. A literature search using the Cumulative Index to Nursing and Allied Health Literature and SCOPUS databases and subsequent screening yielded twenty articles meeting established criteria for analysis. The analysis highlights significant attributes, antecedents, consequences, and implications for future concept development. Psychosocial functioning environment/domain, social support, and engagement in treatment were distinguishing attributes identified. Combat exposure and various PTSD symptoms are related antecedents. Consequences such as decreased intimacy, decreased work function, low parenting satisfaction, and inadequate productivity in educational settings are all components of this concept. The concept of psychosocial functioning is meaningful in the everyday lives of US combat veterans with PTSD and requires special consideration in treatment planning by healthcare providers.

Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs

OBJECTIVES

To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex.

DESIGN

Retrospective cross-sectional design.

SETTING

National VA Polytrauma System of Care outpatient settings.

PARTICIPANTS

Veterans with a confirmed TBI event (N=6065).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis.

RESULTS

The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item.

CONCLUSIONS

There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

Delayed Homelessness After Military Discharge: Examination of a Sleeper Effect

INTRODUCTION

Addressing veteran homelessness is a major federal priority, but there has been little research on the period between military discharge and homelessness. There are public concerns about new waves of homelessness among recent veterans and questions about a possible sleeper effect, that is, a delayed risk that becomes stronger with time.

METHODS

Data from 2 national samples were analyzed: Department of Veterans Affairs administrative records of a population-based sample of 275,775 homeless Department of Veterans Affairs service users in 2000-2019 and a nationally representative community survey of 115 veterans with a history of homelessness conducted in 2018.

RESULTS

In the Department of Veterans Affairs sample, the average time between discharge and homelessness was 5.5 (SD=4.2) years. In the community veteran sample, the average time between discharge and homelessness was 9.9 (SD=10.5) years. Service in Iraq and Afghanistan was significantly associated with shorter duration between discharge and homelessness. Service in Vietnam, younger age at military discharge, more chronic medical conditions, depression, and alcohol use problems were associated with longer interval between discharge and homelessness. Among homeless service users who were discharged from 2000 to 2003, the rate of homelessness doubled between 10 and 15 years after discharge. Similarly, among those discharged from 2009 to 2013, the rate of homelessness more than doubled between 2 and 5 years after discharge.

CONCLUSIONS

There appears to be a sleeper effect in veteran homelessness after military discharge. The primary and secondary preventions focused on chronic health conditions, and social adjustment may be needed to address homelessness among recent veterans.

Reducing barriers to post-9/11 veterans' use of programs and services as they transition to civilian life

BACKGROUND

Numerous programs exist to support veterans in their transitions to civilian life. Programs are offered by a host of governmental and non-governmental stakeholders. Veterans report encountering many barriers to program participation. This study identified barrier reduction strategies offered by programs that new post-9/11 veterans reported using, determined which strategies veterans use and value, and examined veteran characteristics that impact their odds of using programs that offer barrier reduction strategies.

METHOD

This study reflects findings from the first wave of data collection of The Veterans Metrics Initiative (TVMI), a longitudinal study examining the military-to-civilian reintegration of new post-9/11 veterans. The websites of programs used by respondents were coded for barrier reduction components. Veterans also indicated which barrier reduction components they found most helpful in meeting their reintegration goals.

RESULTS

Of 9566 veterans who participated in Wave 1 data collection, 84% reported using a program that offered at least one barrier reduction component. Barrier reduction components included tangible supports (e.g., scholarships, cash), increased access to programs, decreased stigma, and encouraged motivation to change. Although only 4% of programs that were used by veterans focused on helping them obtain Veterans Administration benefits, nearly 60% of veterans reported that this component was helpful in reaching their goals. Access assistance to other resources and supports was also reported as a helpful barrier reduction component. For instance, approximately 20% of veterans nominated programs that offered transportation. The study also found evidence of a misalignment between the kinds of barrier reduction components veterans valued and those which programs offered. Veterans from the most junior enlisted ranks, who are at most risk, were less likely than those from other ranks to use barrier reduction components. Study limitations and ideas for future research are discussed.

CONCLUSIONS

Despite the evidence that barrier reduction components enhance access to programs and contribute to program sustainability, many programs used by post-9/11 veterans do not offer them. There was also a misalignment between the barrier reduction strategies that veterans value and the strategies offered by programs. Veteran serving organizations should increasingly implement barrier reduction strategies valued by veterans.

Cognitive Impairment and Predicting Response to Treatment in an Intensive Clinical Program for Post-9/11 Veterans With Posttraumatic Stress Disorder

OBJECTIVE

This study examined whether objectively measured pretreatment cognitive impairment predicted worse response to treatment for posttraumatic stress disorder. Participants were 113 veterans and active duty service members who participated in a new multidisciplinary 2-week intensive clinical program that included individual trauma-focused cognitive-behavioral therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments (mean age: 39.7 years [SD=8.5]; 20% women).

METHODS

Prior to treatment, participants completed a brief computerized cognitive battery (CNS Vital Signs) and were operationalized as having cognitive impairment if they scored in the ≤5th percentile on two or more of five core cognitive domains. Participants completed measures of traumatic stress, depression, cognitive self-efficacy, and satisfaction with their ability to participate in social roles before and after treatment.

RESULTS

There were no significant correlations between pretreatment individual cognitive test scores and change in the clinical outcome measures. One-half of the study sample (49.6%) met criteria for cognitive impairment. In a mixed multivariate analysis of variance, the interaction between cognitive impairment and time was not significant (F=0.83, df=4, 108, p=0.51), indicating that the pre- to posttreatment changes in outcome scores were not significantly different for the cognitively impaired group compared with the cognitively intact group. The multivariate main effect for time was significant (F=36.75, df=4, 108, p<0.001). Follow-up univariate tests revealed significant improvement in traumatic stress, depression, cognitive self-efficacy, and satisfaction with social roles after treatment.

CONCLUSIONS

Cognitive impairment was not associated with worse response to treatment in veterans with severe and complex mental health problems. Veterans with and without cognitive impairment reported large improvements in symptoms and functioning after treatment.

Tele-Psychiatry Assessment of Post-traumatic Stress Symptoms in 100 Patients With Bipolar Disorder During the COVID-19 Pandemic Social-Distancing Measures in Italy

The acute phase of the COrona VIrus Disease-19 (COVID-19) emergency determined relevant stressful burdens in psychiatric patients, particularly those with chronic mental disorders such as bipolar disorder (BD), not only for the threat of being infected but also for the strict lock-down and social-distancing measures adopted, the economic uncertainty, and the limited possibilities to access psychiatric services. In this regard, telepsychiatry services represented a new important instrument that clinicians could adopt to monitor and support their patients. The aim of the present study was to investigate acute post-traumatic stress symptoms (PTSS) reported by patients with BD followed in the framework of a telepsychiatry service, set up in the acute phase of the COVID-19 outbreak at the psychiatric clinic of the University of Pisa (Italy). A sample of 100 patients were consecutively enrolled and assessed by the IES-r, GAD-7, HAM-D, and YMRS. Patients reported a mean (±SD) IES-r total score of 18.15 ± 13.67. Further, 17% of the sample reported PTSS (IES-r > 32), 17% depressive symptoms (HAM-D > 17), and 26% anxiety symptoms (GAD-7 > 10). Work and financial difficulties related to the COVID-19 pandemic and anxiety symptoms appeared to be positively associated with the development of acute PTSS. Acute manic symptoms appeared to be protective. The data of the present study suggest the relevance of monitoring patients with BD exposed to the burden related to the COVID-19 outbreak for prompt assessment and treatment of PTSS.

Psychosocial Risk Factors and Other Than Honorable Military Discharge: Providing Healthcare to Previously Ineligible Veterans

INTRODUCTION

In response to a strong focus on suicide prevention for all veterans, the Department of Veterans Affairs (VA) recently revised policy to provide emergency mental healthcare for veterans who received Other Than Honorable (OTH) discharges from the military. This current study takes a preliminary step toward identifying demographic, historic, military, clinical, and social characteristics of veterans with OTH discharges.

MATERIALS AND METHODS

N = 1,172 Iraq/Afghanistan-era veterans were evaluated between 2005 and 2016 in the multi-site VA Mid-Atlantic Mental Illness, Research, Education and Clinical Center (MIRECC) Study of Post-Deployment Mental Health (PDMH Study).

RESULTS

Veterans with OTH discharges constituted 2.7% of our sample, approximating the estimated rate in the overall U.S. veteran population. Compared to veterans discharged under honorable conditions, veterans with OTH discharges were more likely to be younger and have greater odds of reporting family history of drug abuse and depression. Further, veterans with OTH discharges reported a lower level of social support and were more likely to be single, endorse more sleep problems, score higher on measures of drug misuse, have a history of incarceration, and meet diagnostic criteria for major depressive disorder. A subsequent matching analysis provided further evidence of the association between OTH discharge and two risk factors: drug misuse and incarceration.

CONCLUSION

These findings elucidate potential factors associated with veterans with OTH discharges, particularly substance abuse and criminal justice involvement. Results also indicate higher incidence of risk factors that often accompany suicidal ideation and should be a highlighted component of healthcare delivery to this vulnerable cohort of veterans.

Financial stress, financial stability, and military spousal well-being

Introduction: Not only do military families face similar financial stressors as civilian families, but they also face a number of unique financial stressors as a result of the military lifestyle. In this article, we explore factors that contribute to military spouses’ perceived financial stress and the effect of financial stability on military spouses’ psychological well-being and life satisfaction. Methods: The data sets used in the analyses include female civilian spouses of Canadian Armed Forces (CAF) Regular Force members who completed the Quality of Life (QOL) survey administered in 2009 ( N = 1,518) and 2013 ( N = 1,189). In Study 1, we conducted a series of analyses to assess whether CAF spouses’ socio-demographic and military lifestyle characteristics contribute to their perceived level of financial stress (2009 QOL data). In Study 2, we conducted a series of analyses to assess whether financial stress and stability contribute to CAF spouses’ well-being and life satisfaction (2009 and 2013 QOL data). Results: Results showed that socio-demographic and military lifestyle characteristics predicted military spouses’ financial stress and that more financial stress and less financial stability reduced their psychological well-being and life satisfaction. Discussion: These findings suggest that reducing military spouses’ financial stress and improving their financial stability may enhance their well-being.

The Veterans Metrics Initiative study of US veterans' experiences during their transition from military service

PURPOSE

Efforts to promote the health and well-being of military veterans have been criticised for being inadequately informed of veterans' most pressing needs as they separate from military service, as well as the programmes that are most likely to meet these needs. The current article summarises limitations of the current literature and introduces The Veterans Metrics Initiative (TVMI) study, a longitudinal assessment of US veterans' well-being and programme use in the first three years after they separate from military service. Veterans were assessed within 3 months of military separation and will complete five additional assessments at 6-month intervals during the subsequent period.

PARTICIPANTS

The TVMI study cohort consists of a national sample of 9566 newly separated US veterans that were recruited in the fall of 2016.

FINDINGS TO DATE

The TVMI sample includes representation from all branches of service, men and women, and officers and enlisted personnel. Although representative of the larger population on many characteristics, differential response rates were observed for some subgroups, necessitating the development of non-response bias weights. Comparisons between unweighed and weighted results suggest that the weighting procedure adequately adjusts for observed differences.

FUTURE PLANS

Analyses are under way to examine veterans' well-being and programme use in the period following separation after military service, as well as factors associated with poor outcomes. We have also begun to decompose programmes into their core components to facilitate examination of how these components relate to well-being. Once our third data collection is complete, we will examine factors related to different patterns of readjustment over time.

A Pilot Test of Group Based Cognitive Behavioral Therapy to Augment Vocational Services for Persons With Serious Mental Illness: Feasibility and Competitive Work Outcomes

Persons with serious mental illness (SMI) struggle with work functioning even with the assistance of vocational services. The current study sought to address this problem by examining a cognitive-behavioral therapy to augment vocational services. Fifty-two adults with SMI receiving vocational services participated in a pre-post feasibility trial of the Cognitive Behavior Therapy for Work Success (CBTw) intervention. CBTw is a 12-week manualized intervention that addresses cognitive and behavioral factors that impact work functioning. Competitive work outcomes were assessed in the 12 weeks preceding baseline and after the intervention. The results demonstrate strong session attendance and a low attrition rate. There were also significant improvements in work outcomes. Specifically, among participants unemployed at baseline, 50.0% attained work during follow-up. These findings provide preliminary evidence that CBTw may be a feasible intervention to augment vocational services; further controlled research should examine its benefit to work outcomes in people with SMI.

Depression in Female Veterans Returning from Deployment: The Role of Social Factors

Objective

Women are serving in the armed forces and deployed to areas of conflict in increasing numbers. Problems such as depressive symptoms and risks related to combat exposure can have negative effects on adjustment following service; understanding the relationship between these problems may contribute to strategies providers can use to facilitate healthy adjustment after deployment. The purpose of this study is to examine social factors as they relate to mental health adjustment, namely depressive symptoms among female veterans who served in Iraq and Afghanistan as part of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OND). We hypothesized that combat exposure would predict higher levels of depressive symptoms and that social support would moderate the relationship between combat exposure and depression.

Methods

In a cross-sectional design, 128 female Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans completed an online survey about combat experience, social support, depression, demographic characteristics, and behavioral health symptom history. We conducted multiple regression analyses to examine linear and moderating relationships.

Results

There was no significant relationship between combat exposure and depression; social support did not significantly moderate the relationship between combat exposure and depression. However, higher levels of social support and financial comfort were significantly related to lower levels of depression.

Conclusion

This study highlights the role of social factors, specifically social support and perceived financial status, as potential barriers to healthy emotional readjustment following deployment. These findings suggest that it may be beneficial for mental health providers to screen female veterans and refer them to appropriate services to reduce financial stressors and strengthen their use of social support. More research should continue to examine more fully the impact of combat exposure on female service members' mental health and work to isolate the factors most strongly related to depression.

Subjective Experiences of the Benefits and Key Elements of a Cognitive Behavioral Intervention Focused on Community Work Outcomes in Persons With Mental Illness

New research suggests that group-based cognitive behavioral therapy (CBT) may help improve employment outcomes in persons with mental illness, yet the effects and potential key elements facilitating change in such interventions are unclear. Using a mixed methods approach, this study examined the perspectives of persons with mental illness after participating in a pilot study of the "CBT for Work Success" intervention. Findings demonstrate that participants valued the intervention and perceived that it assisted them in achieving work goals. Therapeutic effects included improved self-efficacy, work motivation, enhanced sense of self as workers, and increased beliefs that work success is attainable. CBT for Work Success elements perceived to be important in facilitating work goals included cognitive restructuring, behavioral coping strategies, problem solving work barriers, meaningful reflection on oneself as a worker, and important factors associated with the group process. The authors discuss the implications of these findings and future research directions.

The association between unemployment status and physical health among veterans and civilians in the United States

This study analyzed data from the 2012 Behavioral Risk Factor Surveillance System to examine the association between unemployment status and physical health among a sample of 170,924 civilians and 12,129 veterans (aged 18-50 years). Multivariate regression analysis was used to test the interaction effect between employment status and veteran/civilian status on physical health. Veterans who were unemployed long term (longer than 27 weeks) reported a significantly greater number of days with poor physical health than civilians who experienced long-term unemployment. Timely prevention and intervention efforts to integrate veterans into the workforce could lead to substantially improved physical health outcomes. Public health policies and programs that are funded to assist veterans in securing and maintaining gainful employment can have lasting implications for their overall improved health and physical well-being.

Military Veterans' Experiences with Suicidal Ideation: Implications for Intervention and Prevention

We sought to understand Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans' experiences with suicidal ideation. Semi-structured interviews with 34 OEF/OIF veterans addressed circumstances leading up to disclosure of suicidal ideation during brief clinical assessments. We used an iterative, inductive and deductive thematic analysis approach. Results revealed three pervasive, persistent domains that reinforce the uniqueness of veteran suicidal thoughts: military culture, difficult deployment experiences, and postdeployment adjustment challenges. Within postdeployment, we identified four themes that serve as intervention targets: adjusting to civilian culture, changes to sense of self, feeling overwhelmed by stressors, and lacking life purpose or meaning.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.

Community integration after deployment to Afghanistan: a longitudinal investigation of Danish soldiers

OBJECTIVE

In the years following military deployment, soldiers may experience problems integrating into the community. However, little is known about the nature and prevalence of these problems and if they relate to posttraumatic symptomatology.

METHODS

In a prospective, longitudinal study of Danish soldiers deployed to Afghanistan in 2009 (N = 743), we assessed community reintegration difficulties 2.5 years after home coming (study sample: N = 454). Furthermore, symptoms of posttraumatic stress disorder (PTSD) were assessed before, during, and after deployment. Trajectories of PTSD symptoms from a previously published latent growth mixture modeling analysis were used to address whether community reintegration difficulties differ as a result of course and level of PTSD symptoms.

RESULTS

Between 3.6 and 18.0% reported to have some, a lot, or extreme difficulties in reintegration domains such as interpersonal functioning, productivity, community involvement, and self-care. Mean level of reintegration difficulties differed significantly across six PTSD symptom trajectories (range 6.35-36.00); with more symptomatic trajectories experiencing greater community reintegration difficulties.

CONCLUSIONS

Reintegration difficulties after deployment are present in less than 20% of Danish soldiers who return from Afghanistan. Difficulties are greater in individuals who follow symptomatic PTSD trajectories in the first years following deployment than in those who follow a low-stable trajectory with no or few symptoms.

Psychosocial concerns of veterans of operation enduring freedom/operation iraqi freedom

U.S. veterans present with complex medical and psychosocial concerns postdeployment. Identification of psychosocial concerns is necessary for appropriate and targeted social work interventions to improve delivery and receipt of health care through the U.S. Department of Veterans Affairs. The purpose of this article is to identify specific psychosocial concerns of veterans of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF) presenting at the War Related Illness and Injury Study Center. A retrospective chart review of psychosocial concerns from all OIF/OEF veterans seen fromJune 2008 toJune 2010 provided data for this mixed methods study. Veterans in the sample (N= 356) reported an average of 5.2 psychosocial concerns (SD = 2.32, range = 0 to 11). The most commonly reported concerns were pain (72 percent), sleep (62 percent), cognition (61 percent), vocational issues (53 percent), education (49 percent), finances (42 percent), relationships (37 percent), anger (30 percent), substance abuse (23 percent), and social support (20 percent), though these categories were not exclusive and many veterans endorsed more than one category. Multiple psychosocial concerns reported by veterans suggest the need for targeted social work intervention.

Comparing life experiences in active addiction and recovery between veterans and non-veterans: a national study

The costs of addiction are well documented, but the potential benefits of recovery are less well known. Similarly, substance use issues among both active duty military personnel and veterans are well known but their recovery experiences remain underinvestigated. Furthermore, little is known about whether and how addiction and recovery experiences differ between veterans and non-veterans. This knowledge can help refine treatment and recovery support services. Capitalizing on a national study of individuals in recovery (N = 3,208), we compare addiction and recovery experiences among veterans (n = 481) and non-veterans. Veterans' addiction phase was 4 years longer than non-veterans and they experienced significantly more financial and legal problems. Dramatic improvements in functioning were observed across the board in recovery with subgroup differences leveling off. We discuss possible strategies to address the specific areas where veterans are most impaired in addiction and note study limitations including the cross-sectional design.

Homelessness and money mismanagement in Iraq and Afghanistan veterans

OBJECTIVES

We examined the empirical link between money mismanagement and subsequent homelessness among veterans.

METHODS

We used a random sample of Iraq and Afghanistan War era veterans from the National Post-Deployment Adjustment Survey in 2009-2011.

RESULTS

Veterans were randomly selected from a roster of all US military service members in Operation Iraqi Freedom or Operation Enduring Freedom who were separated from active duty or in the Reserves/National Guard. Veterans (n = 1090) from 50 states and all military branches completed 2 waves of data collection 1 year apart (79% retention rate). Thirty percent reported money mismanagement (e.g., bouncing or forging a check, going over one's credit limit, falling victim to a money scam in the past year). Multivariate analysis revealed money mismanagement (odds ratio [OR] = 4.09, 95% CI = 1.87, 8.94) was associated with homelessness in the next year, as were arrest history (OR = 2.65, 95% CI = 1.33, 5.29), mental health diagnosis (OR = 2.59, 95% CI = 1.26, 5.33), and income (OR = 0.30, 95% CI = 0.13, 0.71).

CONCLUSIONS

Money mismanagement, reported by a substantial number of veterans, was related to a higher rate of subsequent homelessness. The findings have implications for policymakers and clinicians, suggesting that financial education programs offered by the US Departments of Defense and Veterans Affairs may be targeted to effectively address veteran homelessness.

Community-based Rehabilitation Needs: Perceptions of Individuals with Brain Injury and Their Families in the Midwestern United States

This study investigated the rehabilitation and services needs, rehabilitation goals and barriers of individuals with brain injury (n = 81, males = 59%, females = 41%, age range 18 to 87), and their family members (n = 19; females = 75%, age range 18 to 65), (ethnicity = white = 89%). Data were collected using a survey instrument and focus group interviews. A descriptive analysis of the quantitative data was conducted, while content analysis was used to analyse the qualitative data. Results suggest that individuals with brain injury and their families experience many unmet needs across the domains of employment, independent living, financial resources and housing. Family involvement was found to be important to community participation after brain injury.