Over 50 % of all returned combat Veterans have enrolled in VA health care. This is historically high for VA; only 10 % of Vietnam veterans enrolled in VA health care (Kulka et al., 1990). Since 2001, the VA had provided OEF/OIF Veterans 2 years of free military service-related health care from the time of service separation, a benefit which was extended to 5 years in 2008 (“National Defense Authorization Act of 2008”). Most of the over 150 VA medical centers in the United States offer a complete spectrum of mental health services, including over 140 PTSD specialty clinics. For rural veterans living far from a VA medical center, over 900 VA community-based outpatient clinics offer basic health care and some offer basic mental health services. After the 5-year period of combat-related health coverage, OEF/OIF/OND veterans are eligible to continue to use VA healthcare services without charge (if they have a service-connected disability) or they are assessed a nominal co-pay scaled to income. Of note, Iraq and Afghanistan veterans who have health insurance through employment, school, or otherwise, may seek non-VA reimbursed healthcare services in their communities, and VA data systems do not capture this non-VA healthcare utilization.

Early, adequate evidence-based mental health treatment has been shown to prevent mental health disorders, such as PTSD, from becoming chronic (Bryant, Moulds, Guthrie, & Nixon, 2003). Multiple studies of veterans and civilians reveal however that a substantial proportion of those suffering from mental health problems either do not access, delay, or fail to complete an adequate course of specialty mental health treatment (Hoge et al., 2004; Tanielian & Jaycox, 2008; Wang et al., 2005). Studies have shown that mental health disorders other than PTSD, such as depression and substance use disorders, may be managed in primary care as opposed to specialty mental health clinics (Batten & Pollack, 2008). Some specific symptoms of PTSD, such as insomnia, may be managed by primary care clinicians in primary care. However, consistent with the Institute of Medicine’s finding that only two trauma-focused therapies have demonstrated efficacy for PTSD, Cognitive Processing Therapy and Prolonged Exposure Therapy, the VA mandates that veterans with a PTSD diagnosis have access to treatment by mental health providers trained in these evidence-based therapies, which typically occurs in specialty mental health clinics (Department of Veterans Affairs Uniformed Mental Health Services Handbook, 2008).

Evidence-based PTSD treatments require a minimum of nine or more sessions, ideally spaced at weekly intervals (Foa, Hembree, & Rothbaum, 2007; Monson et al., 2006). We found that of nearly 50,000 Iraq and Afghanistan veterans with newly diagnosed PTSD, 80 % compared to 49 % of those receiving mental health diagnoses other than PTSD had at least one VA mental health visit in the first year of diagnosis (Seal et al., 2010). Nevertheless, only 9.5 % with new PTSD diagnoses attended nine or more follow-up sessions in 15 weeks or less after receiving their diagnosis. When the follow-up period was extended to 1 year, a larger proportion, 27 % attended nine or more mental health sessions. Among OEF/OIF/OND veterans receiving mental health diagnoses other than PTSD (e.g., depression), only 4 % attended nine or more follow-up sessions in 15 weeks or less and slightly more, and 9 % attended nine or more sessions when the follow-up period was extended to 1 year (Fig. 17.4a, b). Our study was limited in that we lacked information about non-VA mental health treatment utilization and the specific type of mental health treatment received. Thus, we can draw no firm conclusions about the adequacy and intensity of mental health care for OEF/OIF/OND veterans since we lack data on care received outside the VA system. Nevertheless, VA is currently the single largest provider of health care for OEF/OIF veterans and, of those with new PTSD diagnoses, in the first year of diagnosis, at the time the study that was conducted under 10 % appear to have received what would approximate evidence-based mental health treatment for PTSD at a VA facility, and those with other mental health diagnoses received an even lower intensity of VA care.

Our study revealed that factors such as being young (under age 25) and male, factors linked to a greater likelihood of receiving a PTSD diagnosis, were also associated with a failure to receive minimally adequate PTSD treatment (Seal et al., 2010). These findings may reflect the symptoms of PTSD itself, including avoidance, denial, and comorbid disorders such as depression and substance abuse. In young male veterans, stigma surrounding health care likely also plays a major role (Hoge et al., 2004). In addition, we found that having received a mental health diagnosis from a nonmental health clinic (i.e., primary care) and living far from a VA facility (>25 miles) were associated with failing to receive adequate PTSD treatment. Veterans who receive PTSD diagnoses from VA primary care may be less symptomatic than those receiving diagnoses from mental health clinics and less in need of specialty mental health treatment or prefer primary care-based treatments. Indeed, many mental health problems of combat veterans other than PTSD, such as depression, may be effectively managed in primary care. In fact, we found that among veterans receiving mental health diagnoses other than PTSD, more than 85 % had attended at least one primary care visit in the year following diagnosis, the majority of which were coded to indicate that a mental health concern had been discussed. It is also possible that veterans who receive PTSD diagnoses from nonmental health clinics or who live far from VA services fall through the cracks in the referral for specialty mental health care. Indeed, rural veterans experience significantly greater mental health morbidity than their urban counterparts. (Wallace, Weeks, Wang, Lee, & Kazis, 2006 ) In sum, our research findings support ongoing implementation efforts by VA leadership to promote expanded access and adherence to specialty mental health care, especially for rural veterans (Zeiss & Karlin, 2008).

Our results suggest that OEF/OIF/OND veterans may, in fact, be more likely than Vietnam-era veterans to have had at least one initial VA mental health follow-up visit after receiving a new mental health diagnosis. In the National Vietnam Veterans Readjustment Study (NVVRS), a nationally representative sample of Vietnam-era veterans, a much lower proportion of Vietnam Veterans (30 %) reported having sought any mental health treatment and only 7.5 % used VA mental health services (Kulka et al., 1990). A more recent study demonstrated that after adjustments for potential confounding, variables such as age and the complexity of mental health disorders were more important predictors of whether veterans received mental health treatment as opposed to the era during which they served (Harpaz-Rotem & Rosenheck, 2011).

It stands to reason that Iraq and Afghanistan veterans would be more likely than prior-era veterans to have had at least an initial mental health visit. In comparison to Vietnam-era veterans, a higher proportion of OEF/OIF/OND veterans have experienced “front-line” combat exposure and have survived their injuries (Gawande, 2004). These factors have been associated with the development of mental health disorders and increased need for mental health services (Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Unlike in prior eras, Congress extended health coverage for OEF/OIF/OND veterans to 5 years after service separation. Thus, many newly returned veterans facing economic hardship have taken advantage of blanket VA healthcare coverage and have used VA services. Also, different from prior eras, the Department of Defense, in an effort to reduce stigma, now openly discusses combat-related stress with active duty service members. Similarly, widespread media attention focused on mental health disorders in Iraq and Afghanistan veterans has likely lowered the threshold for recently returned veterans to seek care. Finally, both the VA and the military have implemented population-based post-deployment mental health screening programs and routinely refer veterans who screen positive for further mental health assessment and/or treatment (Hoge, Auchterlonie, & Milliken, 2006; Seal et al., 2008), all factors which support initial VA mental health services utilization.

Nevertheless, despite initial use of VA mental health services among returned combat veterans, retention in VA mental health services appears less robust. The strongest predictor of retention in VA mental health treatment services in our study, as in others, was “need” for mental health treatment (Spoont, Murdoch, Hodges, & Nugent, 2010). Veterans receiving PTSD diagnoses (as opposed to other mental health diagnoses) and those receiving additional comorbid mental health diagnoses in conjunction with PTSD were more likely to remain in care and receive minimally adequate PTSD treatment. Unfortunately, compared to studies of civilians however, retention in VA mental health treatment appears inferior. For instance, the National Comorbidity Survey Replication Study, a population-based survey of 9,282 US civilian adults, found that 48 % of patients with any mental disorder (including PTSD) reported having received at least “minimally adequate therapy,” defined by evidence-based national mental health treatment guidelines, within the first year of diagnosis (Wang et al., 2005). In contrast, similar to our findings, a RAND Corporation study reported that a much lower proportion, 25 % of a nationally representative sample of Iraq and Afghanistan veterans with PTSD and depression, received “minimally adequate therapy” within the first year of diagnosis (Tanielian & Jaycox, 2008).

In summary, we found that the majority of Iraq and Afghanistan veterans that were enrolled in VA care and received new mental health diagnoses, including PTSD, attended at least one mental health follow-up visit in the year after mental health diagnosis. However, the vast majority of OEF/OIF/OND veterans with new PTSD diagnoses failed to attend a minimum number of mental health sessions within a recommended time frame required for evidence-based PTSD treatment. Because early, evidence-based PTSD treatment may prevent chronic PTSD, it will be important that the VA, in its mission to provide the best care for returning combat veterans, continue to develop and implement interventions to improve retention in mental health treatment, with particular attention to the needs of more vulnerable combat veterans.