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Am J Public Health. 2009 September; 99(9): 1651–1658.
PMCID: PMC2724454

Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans Using Department of Veterans Affairs Health Care, 2002–2008

Abstract

Objectives. We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans.

Methods. We determined the prevalence and predictors of mental health diagnoses among 289 328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from 2002 to 2008 using national VA data.

Results. Of 289 328 Iraq and Afghanistan veterans, 106 726 (36.9%) received mental health diagnoses; 62 929 (21.8%) were diagnosed with posttraumatic stress disorder (PTSD) and 50 432 (17.4%) with depression. Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk = 2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD.

Conclusions. Mental health diagnoses increased substantially after the start of the Iraq War among specific subgroups of returned veterans entering VA health care. Early targeted interventions may prevent chronic mental illness.

The United States invaded Afghanistan on October 7, 2001, and Iraq on March 20, 2003. To date, over 1.6 million veterans have served in those 2 theaters of war. High rates of military service-related mental disorders among military service personnel and veterans of Operation Enduring Freedom (OEF; principally taking place in Afghanistan) and Operation Iraqi Freedom (OIF; principally in Iraq) have been described and publicized.17 Among 100 000 OEF and OIF veterans first seen at Department of Veterans Affairs (VA) health care facilities between 2001 and 2005, 25% received mental health diagnoses.4 Since that study, however, there has not been a published description of the accruing prevalence of mental health disorders and specific risk factors for these disorders among OEF and OIF veterans entering VA health care.

Until recently, in January 2008, when Congress extended the combat veteran health care benefit to 5 years postdischarge,8 the VA provided OEF and OIF veterans 2 years of free military service–related health care dating from service separation. After this period of free care, OIF and OEF veterans are eligible to continue to use VA health care services without charge or must pay a nominal co-payment scaled to income.9 OIF and OEF veterans who have health insurance through employment or school, for example, may also seek non-VA health care services in their communities.1012 Nevertheless, 41% of all 837 458 separated OIF and OEF veterans eligible for VA health care have enrolled in the VA since 2002.5

This is historically high for VA. Only 10% of Vietnam veterans enrolled in the VA,13 and enrollment has been increasing ever since, making VA the single largest health care provider for OIF and OEF veterans. Thus, longitudinal trends in the prevalence of mental disorders among OIF and OEF veterans using VA health care may reflect the overall public health obligation to treatment-seeking OIF and OEF veterans within the United States. Further, identification of high-risk subgroups of OIF and OEF veterans will facilitate development of targeted mental health services within the VA and other health care systems in an effort to stem an epidemic of chronic mental illness, as occurred with Vietnam-era veterans.13

METHODS

The VA OIF/OEF Roster is a database of veterans separated from OIF and OEF military service who have enrolled in VA health care. The roster derives from the VA Health Eligibility Center enrollment file and the US Department of Defense (DoD) Defense Manpower Data Center (DMDC) database. From October 1, 2001, through January 31, 2008, 424 143 OIF and OEF veterans enrolled in VA and have been included in the VA OIF/OEF Roster database.14

Veterans who served in or in support of either OEF or OIF or both may have also served in prior conflicts and may have accessed VA services prior to 2001 after separation from these tours of duty. Because we were focused on mental diagnoses specifically associated with OEF and OIF military service, we excluded some individuals listed in the OIF/OEF Roster to ensure that our study population consisted only of OIF and OEF veterans who were first-time users of VA services after the start of OEF or OIF. First, we excluded 36 108 veterans listed in the roster who had had their first clinical visit to VA prior to October 7, 2001 (date of the United States invasion of Afghanistan). We also excluded 5282 veterans seen within the first 180 days after the invasion of Afghanistan to allow time to access VA services. In addition, we excluded 34 488 veterans listed in the roster who were seen at a VA facility during the study period but prior to their OIF and OEF service separation date. We excluded 57 726 OIF and OEF veterans who had enrolled in the VA but had not yet had a VA clinical visit prior to March 31, 2008, the study end date. Finally, we excluded 1211 OIF and OEF veterans who had accessed VA services but were subsequently killed in action. Thus, our final study population consisted of 289 328 OIF and OEF veterans who were first-time users of VA health care after their OIF and OEF military service.

Source of Data

The OIF/OEF Roster included information on veterans' gender, date of birth, race/ethnicity, armed forces component type (national guard or reserve versus active duty), branch of service, rank, and whether they had been deployed once or more than once (but not the specific number of deployments). Scrambled Social Security numbers of OIF and OEF veterans listed in the Roster database through January 31, 2008, were linked to VA clinical data contained in the VA National Patient Care Database through March 31, 2008, which allowed 60 days of clinical follow-up time for veterans of both wars. Clinical data contained in the VA National Patient Care Database were derived from clinical visits to any of the 153 VA medical centers and 900 VA outpatient clinics nationwide. The VA electronic record includes the date of the visit, clinic type, and associated diagnoses designated using International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM), codes.15,16

ICD-9-CM codes associated with specific VA inpatient and outpatient encounters were used to categorize mental health diagnoses (if any) from the date of the first VA visit through March 31, 2008.4,16 We examined all mental health diagnoses, defined as any ICD-9-CM16 diagnoses from 290.0 to 319.0, corresponding to the Diagnostic and Statistical Manual, 4th Edition (DSM-IV).17 We also designated a broader definition of “mental health problems,” which included psychosocial and behavioral problems, such as marital and family problems, denoted by selected ICD-9-CM V-codes. In addition, we focused on 4 ICD-9-CM mental health diagnostic categories that have been associated with military service3,16,18,19: posttraumatic stress disorder (PTSD), depressive disorders, alcohol use disorders (alcohol abuse and dependence), and drug use disorders (nonalcohol-related drug abuse and dependence, excluding nicotine dependence).

Statistical Analyses

To present a more comprehensive description of temporal trends in new mental diagnoses among OIF and OEF veterans using VA health care, we analyzed our data in 4 distinct ways. First, we determined the cumulative prevalence of mental health diagnoses in the VA system during the entire study period. The study period consisted of 24 calendar quarters from April 1, 2002, through March 31, 2008. A veteran was counted as part of the actual number of veterans entering the VA system (the denominator) in the calendar quarter of his or her first VA clinical visit. OIF and OEF veterans have the opportunity to receive VA health care even after the 2 years of free care; thus, veterans remained in the denominator for all subsequent quarters after their initial visit. Veterans receiving 1 or more new mental health diagnoses were counted as part of the subgroup of veterans receiving mental health diagnoses at a given time (the numerator) during the quarter when they received their first mental health diagnosis and we assumed that they remained in the numerator until study end, because we lacked data to indicate whether their symptoms remitted.

Second, we investigated the accrual of new mental health diagnoses among distinct cohorts of OIF and OEF veterans entering VA care in successive calendar quarters and followed for increasing lengths of time from 1 to 4 years. Third, we determined the 2-year period prevalence of distinct cohorts of OIF and OEF veterans entering VA health care in successive calendar quarters and followed for the 2-year health care benefit period. Veterans entered the denominator in the calendar quarter of their first VA clinical visit and entered the numerator if they received 1 or more mental health diagnoses during the 2-year follow-up period. Fourth, unadjusted 2-year prevalence rates for mental health diagnoses were compared between the pre–Iraq War period (April 1, 2002, through March 31, 2003) and after the start of the Iraq War (January 1, 2005, through March 31, 2006). To determine the independent association of the Iraq War with the prevalence of mental health diagnoses, we used negative log-binomial models adjusted for gender, age group, race/ethnicity, marital status, rank, military service branch, multiple deployments, and time period to calculate adjusted relative risks (ARRs). Because we found significant interactions between component type and age group, risk analyses were stratified by component type to simplify interpretation.

Finally, we estimated risk for each of the 4 target mental health diagnoses for OIF and OEF veterans stratified by component type and adjusted for calendar quarter of first VA visit and other sociodemographic and military service covariates. All statistical analyses were conducted using Stata software version 10.20

RESULTS

Among 289 328 OIF and OEF veterans entering and using VA health care from April 1, 2002, through March 31, 2008, 58.6% were active duty veterans, and 41.4% were national guard or reserve veterans. Demographic and military service characteristics of the 2 armed forces component types were similar but differed in that two-thirds of active duty veterans were younger than 30 years compared with the national guard and reserve veterans, of whom over half were 30 years or older (Table 1). During the study period, the median time in VA health care was 19.5 months (intraquartile range [IQR] = 8.2–33 months); the median number of clinical visits was 10 (IQR = 4–22 visits).

TABLE 1
Demographic Characteristics of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans (N = 289 328) Using Veterans Affairs Health Care Facilities, by Armed Forces Component Type: April 1, 2002–March 31, 2008

Cumulative Prevalence of Mental Health Diagnoses

New mental health diagnoses among OIF and OEF veterans during the study period increased 6-fold, from 28 of 439 veterans (6.4%) in April 2002 to 106 726 of 289 328 veterans (36.9%) by March 31, 2008. Among the 106 726 veterans with mental health diagnoses by study end, the majority had comorbid diagnoses: 29% had 2 and one-third had 3 or more different mental health diagnoses. When we examined mental health problems that included psychosocial and behavioral problems, the prevalence increased from 9.1% to 42.7% by study end. The prevalence of new PTSD diagnoses increased most during the study period, from 1 of 439 veterans (0.2%) to 62 929 of 289 328 veterans (21.8%), followed by depression diagnoses, which increased from 10 (2.3%) to 50 432 (17.4%) veterans. Both alcohol and drug use disorder diagnoses were less prevalent and accrued at a slower rate during the study period; diagnoses of alcohol use disorders increased from 1.1% to 7.1%, and drug use disorder diagnoses increased from 0.2% to 3.0%. (See figures available as an online supplement to this article at http://www.ajph.org.)

New Mental Health Diagnoses With Extended Time in the Veterans Affairs Health Care System

The prevalence of new mental health diagnoses increased steadily in cohorts of OIF and OEF veterans entering VA health care and followed for increasing lengths of time from 1 to 4 years (Figure 1). For instance, in the cohort of OIF and OEF veterans who entered VA care in quarter 1 of 2004 (the last quarter for which there was 4-year follow-up data), the proportion receiving first mental health diagnoses increased from 14.6% at 1 year to 20.3% after 2 years. After 4 years of follow-up, the cumulative prevalence of new mental health diagnoses in this cohort of OIF and OEF veterans had nearly doubled from 14.6% to 27.5% (Figure 1).

FIGURE 1
Cumulative prevalence of new mental health diagnoses in successive cohorts of Operation Iraqi Freedom and Operation Enduring Freedom veterans entering the Department of Veterans Affairs health care system and followed for increasing lengths of time, from ...

Two-Year Period Prevalence of Mental Health Diagnoses

The 2-year period prevalence of new mental health diagnoses was 6.6% among the cohort of OEF veterans entering VA care April 1, 2002, and followed for 2 years (Figure 2a). The 2-year period prevalence of new mental health diagnoses accelerated after the start of the Iraq War. Among the cohort of OIF and OEF veterans entering VA care in the first quarter of 2006 and followed for the 2-year health-benefit period until study end, 26.2% received new mental health diagnoses. Similarly, the 2-year period prevalence of each of the 4 target mental health diagnoses increased after the start of OIF; diagnoses of PTSD increased most sharply, closely followed by depression diagnoses (Figure 2b).

FIGURE 2
Cohorts of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom veterans entering the Department of Veterans Affairs health care system during successive calendar quarters and followed for 2 years and 2-year period prevalence of (a) mental health ...

Substantial increases in the 2-year period prevalence of all new mental health diagnoses were observed for both active duty and national guard and reserve veterans after the start of the Iraq War (Table 2). After adjustments for sociodemographic and military service characteristics, national guard and reserve veterans had higher ARRs for all mental health diagnoses, and for PTSD and depression in particular, than did active duty veterans in association with the start of the Iraq War. Active duty veterans were at higher independent risk for new alcohol and drug use disorders than were national guard and reserve veterans in association with the start of the conflict in Iraq (Table 2).

TABLE 2
Two-Year Period Prevalence Rates and Adjusted Relative Risks (ARRs) of Mental Health Diagnoses Among Operation Iraqi Freedom and Operation Enduring Freedom Veterans Using Department of Veterans Affairs Facilities Before and After the Start of the Iraq ...

Independent Risk for Mental Health Diagnoses Among Subgroups of Veterans

In multivariate analyses adjusted for sociodemographic and military service characteristics stratified by component type, the youngest active duty veterans (aged 16–24 years) were at higher risk for all new mental health diagnoses and problems (except depression) than were active duty veterans older than 40 years. Specifically, the youngest active duty OIF and OEF veterans younger than 25 years were at nearly twice the risk for PTSD diagnoses (ARR = 1.95; 95% confidence interval [CI] = 1.80, 2.12), over twice the risk for alcohol use disorder diagnoses (ARR = 2.21; 95% CI = 1.89, 2.59), and at a nearly 5-fold risk for drug use disorder diagnoses (ARR = 4.92; 95% CI = 3.63, 6.66) than were active duty veterans older than 40 years.

By contrast, with the exception of drug use disorder diagnoses, adjusted risks for PTSD (ARR = 1.18; 95% CI = 1.11, 1.27) and depression (ARR = 1.49; 95% CI = 1.39, 1.61) were significantly higher among national guard and reserve veterans older than 40 years compared with their counterparts younger than 25 years. Of note, female veterans of both armed forces components were at a higher risk for depression (ARR = 1.41) than were male veterans (ARR = 1.43), whereas men were at significantly greater risk for drug use disorders (ARR = 2.05) than were female veterans (ARR = 2.32). Also, among active duty veterans, proxies for higher combat exposure, such as being of enlisted rank as opposed to officer rank, being a member of the army versus other branches, and being deployed more than once were independently associated with heightened risk for PTSD. This pattern was not consistent for the other target mental disorders nor for national guard and reserve veterans. (See the table available as an online supplement to this article at http://ajph.org.)

DISCUSSION

Of 289 328 veterans who were first-time users of VA health care following OEF or OIF military service, over one-third of veterans received mental health diagnoses, and over 40% received mental health diagnoses or were found to have psychosocial and behavioral problems or both. Of note, the cumulative prevalence of mental health diagnoses detected among successive cohorts of OIF and OEF veterans increased linearly with increasing length of time in the VA health care system from 1 to 4 years. Further, 2-year prevalence rates of all new mental health diagnoses, particularly PTSD, followed by depression, increased substantially in association with the start of the Iraq War.

The prevalence rates of ICD-9-CM mental health diagnoses reported herein derive from the population of OIF and OEF veterans who were first-time users of VA health care after the start of the conflicts in Afghanistan and Iraq. Our results are similar to a recent RAND study based on interviews of a representative sample of 1965 returning troops from Iraq and Afghanistan from August 2007 to January 2008.7 The RAND study estimated that 14% met criteria for PTSD and 14% met criteria for depression, which was very similar to our findings for 2-year period prevalence of new PTSD diagnoses (18.2%) and depression diagnoses (14.4%) among our final cohort of OIF and OEF veterans entering the VA health care system January 1, 2006, and followed for 2 years.7

Hoge et al. reported that of 303 905 army and marine veterans, 35% accessed military mental health services within 1 year of returning home.2 Although not directly comparable, this finding suggests that the prevalence of mental health concerns among military personnel may be similar to the cumulative prevalence of mental health diagnoses in the VA system (36.9%). However, in Hoge et al.'s study, a far smaller proportion (12%) of veterans received formal mental health diagnoses from military health services than the proportion receiving diagnoses in VA health care facilities.2 The higher prevalence rates of mental health diagnoses in the VA health care system may reflect the fact that veterans seeking VA care may have less stigma- and career-related concerns than do active duty military personnel about disclosing mental health problems, and VA clinicians may be more apt to record mental health diagnoses in the clinical record than are military health providers.

During most of our study period, the VA offered OIF and OEF veterans 2 years of free military service–related health care dating from service separation. We found a continued linear increase in the cumulative prevalence of new mental health diagnoses, however, when veterans were followed beyond the 2-year period of free medical care out to 4 years after their initial VA visit. Similarly, Milliken et al. recently demonstrated increases in mental health symptoms among OIF and OEF veterans who were screened several months after returning home compared to rates among those screened immediately after returning from the war zone.6 Solomon et al. have observed PTSD emerging in Israeli soldiers 20 years after combat stress.21

Factors contributing to delayed mental health diagnoses may include the stigma of mental illness leading to a reluctance to disclose mental health problems until problems interfere with functioning,3 delayed onset of military service–related mental health symptoms developing months to years following deployment,21,22 and somatization or comorbidity confounding mental health diagnosis.10,23,24 The recent VA policy change that has extended free VA military service–related health care to 5 years will likely result in greater detection and more opportunities to engage OEF and OIF veterans in treatment.

The 2-year prevalence and risk for mental health diagnoses among OIF and OEF veterans entering the VA health care system accelerated after the start of the Iraq War in March 2003 compared with that among OEF veterans entering VA care after the invasion of Afghanistan, even after adjustment for potential military service and sociodemographic confounders. The Iraq War may have triggered an increase in mental health problems for several reasons. First, waning public support and lower morale among troops may predispose returning veterans to mental health problems, as occurred during the Vietnam era.1 Second, the insurgency in Iraq has had no definable “front-line,” characterized by unexpected threats to life such as roadside bombs and improvised explosive devices.18 Finally, multiple and more-lengthy deployments and heightened media attention may contribute to a steady increase in new mental health disorders.1

Our analyses, which were stratified by component type, revealed that active duty and national guard and reserve veterans entering the VA health care system had differential risk for mental health diagnoses based on age. The youngest active duty veterans, aged 16 to 24 years, were at the highest risk for diagnoses of PTSD and drug and alcohol use disorders compared with active duty veterans older than 40 years.4,25 Younger active duty veterans likely had greater combat exposure as a function of lower rank, which may explain higher rates of mental health diagnoses.1,3,25 Indeed, as other studies have shown, more-direct proxies for combat exposure—rank, branch, and multiple deployments—were independently associated with higher rates of PTSD among active duty veterans.6,13 By contrast, older national guard and reserve veterans older than 30 years were at higher risk for PTSD and depression than were younger national guard and reserve veterans.

Further investigation of the causes of mental health diagnoses among older national guard and reserve veterans is warranted because proxies of greater combat exposure are not consistently associated with increased prevalence of mental health diagnoses. One explanation for greater distress among older national guard and reserve members is that, when called to arms, they are more likely established in civilian occupations; have family, social, and community ties; and may have had less preparation for combat, making their transition to the war zone and then home again more stressful.1,26

In both active duty and national guard and reserve components, we found that women were at higher risk for depression diagnoses than were men.27 Women may respond to combat and readjustment stress differently than their male counterparts, who are more likely to develop alcohol and drug use disorders.27,28 Being divorced, widowed, or separated, our only proxy for possible lack of social support or possible inability to maintain a close relationship, may pose a risk for new postdeployment mental health problems, underscoring the need for ancillary support services for returning OIF and OEF veterans who are unmarried or without social support.

Limitations

Several limitations apply to our findings. First, our results do not generalize to all OIF and OEF veterans. Indeed, as shown for other era veterans, rates of pre-existing or new mental health diagnoses may be higher among OIF and OEF veterans who use the VA health care system compared with nonusers.29 However, VA enrollment has increased, and over 40% of OIF and OEF veterans are enrolled in VA health care, which may mitigate this historical bias.

Second, in determining cumulative prevalence of mental health diagnoses, we retained all veterans with mental health diagnoses in the numerator, because we lacked data on clinical outcomes. Indeed, spontaneous remission and full recovery with improved treatments now widely available in the VA likely occurred in an undetermined number of cases. Further, because OIF and OEF veterans may remain in the VA health care system beyond the 2-year period of free care, we retained all OIF and OEF veterans entering the VA in the denominator until study end, notwithstanding possible subsequent deployments and the receipt of care outside of the VA. We addressed this limitation, however, by conducting more-specific analyses of 2-year period prevalence (corresponding to the 2-year VA health care benefit) of mental health diagnoses in distinct cohorts of OIF and OEF veterans entering VA care.

Third, diagnostic prevalences reported herein are based on ICD-9-CM codes listed in administrative databases, which have been shown to be a valid proxy for estimating disease,16,30,31 but are subject to physician or patient reporting biases, including increased awareness of mental health problems in returning combat veterans and, as a result, increased reporting and case-finding, as well as misclassification clerical errors. For instance, our estimates of alcohol and drug use disorders are notably low in comparison with other studies of OIF and OEF soldiers and veterans.3,5,6,32 Underreporting on the part of patients and clinicians because of shame and possible illegal activity may explain this discrepancy.3 Also, ICD-9 CM codes may represent “rule out” diagnoses. In a prior study, however, we found that the majority of veterans (72%) received mental health diagnoses on 2 or more occasions, and of those veterans who first received a mental health diagnosis in a non–mental health setting, during a follow-up mental health visit, 92% received the same diagnosis.4

Conclusions

The prevalence of new mental health diagnoses among OIF and OEF veterans using VA facilities increased rapidly following the invasion of Iraq. Targeted screening and early intervention with evidence-based treatments tailored to the problems of particular subgroups of OIF and OEF veterans may be the best defense against chronic mental health and social and occupational problems.

Acknowledgements

This study was funded by a VA Health Services Research and Development Career Development Transition Award and the VA Seattle Epidemiological Research and Information Center.

We acknowledge and thank veterans of Iraq and Afghanistan for their service.

Human Participant Protection

The study was approved by the Committee on Human Research, University of California, San Francisco, and the San Francisco VA Medical Center.

References

1. Friedman MJ. Veterans' mental health in the wake of war. N Engl J Med 2005;352(13):1287–1290 [PubMed]
2. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023–1032 [PubMed]
3. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351(1):13–22 [PubMed]
4. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med 2007;167(5):476–482 [PubMed]
5. Kang H. Analysis of VA Health Care Utilization Among US Global War on Terrorism (GWOT) Veterans. Washington, DC: Department of Veterans Affairs; 2008
6. Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA 2007;298(18):2141–2148 [PubMed]
7. Tanielian T, Jaycox L., eds Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008
8. National Defense Authorization Act of 2008, HR 4986, 110th Cong, 2nd Sess (2008)
9. Hearing Before the Committee on Veterans Affairs, US House of Representatives, 109th Cong, 1st Sess (2005) (statement of Michael J. Kussman, Under Secretary of Health, Dept of Veterans Affairs)
10. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry 2007;164(1):150–153 [PubMed]
11. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome–like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol 2003;157(2):141–148 [PubMed]
12. Hoge CW, Lesikar SE, Guevara R, et al. Mental disorders among US military personnel in the 1990s: association with high levels of health care utilization and early military attrition. Am J Psychiatry 2002;159(9):1576–1583 [PubMed]
13. Kulka RA, Schlenger WE, Fiarbank JA, et al. Trauma and the Vietnam War Generation: Findings from the National Vietnam Veterans Readjustment Study. New York, NY: Brunner/Mazel; 1990
14. OEF/OIF Roster (RMTPRD.MED.SAS.OEFOIF.ROSTER) [database online] Washington, DC: Dept of Veterans Affairs, National Data Systems; 2008
15. Boyko EJ, Koepsell TD, Gaziano JM, Horner RD, Feussner JR. US Department of Veterans Affairs medical care system as a resource to epidemiologists. Am J Epidemiol 2000;151(3):307–314 [PubMed]
16. The International Classification of Diseases, Ninth Revision, Clinical Modification. Vol. 1 and 2 3rd ed.Hyattsville, MD: Dept of Health and Human Services; 1989
17. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.Washington, DC: American Psychiatric Association; 2000
18. National Center for PTSD and War-Related Illness Iraq War Clinician Guide Washington, DC: Dept of Veterans Affairs; 2004
19. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. JAMA 2002;288(5):581–588 [PubMed]
20. STATA [computer program]. Version 10. College Station, TX: StataCorp; 2005.
21. Solomon Z, Mikulincer M. Trajectories of PTSD: a 20-year longitudinal study. Am J Psychiatry 2006;163(4):659–666 [PubMed]
22. Prigerson HG, Maciejewski PK, Rosenheck RA. Combat trauma: trauma with highest risk of delayed onset and unresolved posttraumatic stress disorder symptoms, unemployment, and abuse among men. J Nerv Ment Dis 2001;189(2):99–108 [PubMed]
23. Schnurr PP, Spiro A, 3rd, Paris AH. Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans. Health Psychol 2000;19(1):91–97 [PubMed]
24. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52(12):1048–1060 [PubMed]
25. West AN, Weeks WB. Mental distress among younger veterans before, during, and after the invasion of Iraq. Psychiatr Serv 2006;57(2):244–248 [PubMed]
26. Jacobson IG, Ryan MA, Hooper TI, et al. Alcohol use and alcohol-related problems before and after military combat deployment. JAMA 2008;300(6):663–675 [PMC free article] [PubMed]
27. Wright KM, Huffman AH, Adler AB, Castro CA. Psychological screening program overview. Mil Med 2002;167(10):853–861 [PubMed]
28. Gahm GA, Lucenko BA, Retzlaff P, Fukuda S. Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care. J Clin Psychol 2007;63(3):199–211 [PubMed]
29. Kazis LE, Miller DR, Clark J, et al. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med 1998;158(6):626–632 [PubMed]
30. Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol 2003;56(6):530–535 [PubMed]
31. Borzecki AM, Wong AT, Hickey EC, Ash AS, Berlowitz DR. Identifying hypertension-related comorbidities from administrative data: What's the optimal approach? Am J Med Qual 2004;19(5):201–206 [PubMed]
32. Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR. Getting beyond “Don't ask; don't tell”: an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. Am J Public Health 2008;98(4):714–720 [PMC free article] [PubMed]

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