Posttraumatic stress disorder and hypertension in older adult Vietnam Era male and female veterans

J Trauma Stress. 2025 May 12. doi: 10.1002/jts.23162. Online ahead of print.

Authors

Kelsey N Serier  ^{1   2} , Hannah M Burns  ¹ , Kathryn M Magruder  ³ , Avron Spiro  ^{2   4   5} , Anica Pless Kaiser  ^{2   6   7} , Rachel Kimerling  ^{8   9} , Susan M Frayne  ^{9   10} , Amy M Kilbourne  ^{11   12} , Eileen M Stock  ¹³ , Christopher W Forsberg  ¹⁴ , Nicholas L Smith  ^{14   15} , Brian N Smith  ^{1   2}

Affiliations

• ¹ National Center for PTSD Women's Health Sciences Division, VA Boston Healthcare System, Boston, Massachusetts, USA.
• ² Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA.
• ³ Departments of Psychiatry and Behavioral Sciences and Public Health, Medical University of South Carolina, Charleston, South Carolina, USA.
• ⁴ Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts, USA.
• ⁵ Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA.
• ⁶ National Center for PTSD Behavioral Science Division, VA Boston Healthcare System, Boston, Massachusetts, USA.
• ⁷ VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, Massachusetts, USA.
• ⁸ Department of Veterans Affairs, National Center for PTSD, VA Palo Alto Health Care System, Menlo Park, California, USA.
• ⁹ VA HSR Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, USA.
• ¹⁰ Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.
• ¹¹ Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA.
• ¹² Office of Research and Development, U.S. Department of Veterans Affairs, Washington, DC, USA.
• ¹³ Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, Maryland, USA.
• ¹⁴ Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs, Seattle, Washington, USA.
• ¹⁵ Department of Epidemiology, University of Washington, Seattle, Washington, USA.

• PMID: 40353294
• DOI: 10.1002/jts.23162

Abstract

Hypertension is a known risk factor for cardiovascular disease, a leading cause of death for older adults. Posttraumatic stress disorder (PTSD) may increase the likelihood of developing hypertension; however, little is known about this association in older adult male and female veterans. To better understand the ways in which aging and biological sex impact the link between PTSD and hypertension, the present study used data from two cohorts of older adult Vietnam Era veterans (women: N = 4,104, M_age = 67.4 years; men: N = 5,767, M_age = 61.9 years). Veterans completed a telephone structured clinical interview assessing lifetime PTSD and self-reported hypertension diagnosis, age of onset, and past-year treatment. Weighted logistic regression analyses adjusted for relevant covariates revealed an association between PTSD and a higher likelihood of hypertension in male veterans, OR = 1.57, 95% CI [1.30, 1.91]. There was no association between lifetime PTSD and hypertension in female veterans, OR = 0.93; 95% CI [0.77, 1.11]. Exploratory secondary analyses suggested an association between PTSD and hypertension onset in early and middle adulthood in men. PTSD was not associated with past-year hypertension treatment. Overall, these findings suggest that PTSD may contribute to hypertension risk in older adult male veterans, which has important implications for their long-term cardiovascular health. The association between PTSD and hypertension may differ across the lifespan and for male and female veterans. Additional prospective research is needed to confirm these findings and further clarify the association between PTSD and hypertension to inform veteran clinical care.

© 2025 International Society for Traumatic Stress Studies.

The Impact of Military Service on Social Determinants as Predictive Factors for Suicide among Female Veterans

J Community Health. 2025 Jun;50(3):483-490. doi: 10.1007/s10900-024-01427-5. Epub 2024 Dec 25.

Authors

Amanda Straus  ¹ , Rachel Larson  ² , Wanda Wright  ³

Affiliations

• ¹ College of Health Solutions, Arizona State University, Phoenix, AZ, USA. arstrau1@asu.edu.
• ² College of Health Solutions, Arizona State University, Phoenix, AZ, USA.
• ³ College of Integrative Sciences and Arts, Arizona State University, Tempe, AZ, USA.

• PMID: 39720973
• DOI: 10.1007/s10900-024-01427-5

Abstract

Female Veterans experience disproportionately poorer outcomes in mental health and physical health, as well as other conditions, compared to their male counterparts and non-Veteran females. The Arizona Veteran Survey aims to understand the unique experiences of female Veterans in the state of Arizona and assess how these experiences impact their health. The goal is to identify key risk factors contributing to health challenges among this population, enabling the development of targeted interventions. The statewide Arizona Veteran Survey was conducted to analyze the current impact of common social determinants of health for several demographics of Veterans. There were a total of 841 female Veteran respondents. The data on female Veterans' social determinants of health and the association with suicidality was analyzed using chi-square and logistic regression. A variety of social determinants were analyzed to evaluate their association with suicidality. Female Veteran respondents were 1.4 times more likely to experience suicidality if they were seeking care for mental health concerns, 1.8 times more likely if they felt isolated or lonely, 1.7 times more likely if they felt depressed or hopeless, and 2.5 times more likely to experience suicidality if they struggled to pay for or access medication in the past 12 months leading up to the survey. Female Veterans are a growing population disproportionately affected by experiences that elevate their risk of suicidality. The findings in this paper highlight the need for expanding services and resources while addressing inequities to improve overall well-being.

Keywords: Female veterans; Health; MST; Suicide.

© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Conflict of interest statement

Declarations. IRB Approval: Study STUDY00013822 was approved by the Arizona State University Institutional Review Board. Competing Interests: The authors have no competing interests to declare that are relevant to the content of this article.

'One Is Too Many' preventing self-harm and suicide in military veterans: a quantitative evaluation

BMJ Mil Health. 2025 May 21;171(3):213-220. doi: 10.1136/military-2023-002623.

Authors

Alan Finnegan  ¹ , K Salem  ² , L Ainsworth-Moore  ²

Affiliations

• ¹ Westminster Centre for Research in Veterans, University of Chester, Chester, UK a.finnegan@chester.ac.uk.
• ² Westminster Centre for Research in Veterans, University of Chester, Chester, UK.

• PMID: 38443145
• DOI: 10.1136/military-2023-002623

Abstract

Introduction: In 2021, the Armed Forces Covenant Fund Trust allocated over £2 million to programmes designed to have a clear and demonstrable impact on suicide prevention. Four grant holders delivered a combination of psychotherapeutic interventions, group activities, social prescribing, peer support mentoring, life skills coaching, educational courses and practical help with housing and employment. The evaluation was completed between August 2021 and July 2023.

Methods: A survey was completed by 503 participants at entry and 423 at exit. It captured data regarding demographic and military-specific details, health status, situational stressors, predisposing symptoms, help-seeking behaviour, social engagement, housing, living arrangements and employment status. The questionnaire included a number of validated psychometric questionnaires.

Results: This evaluation revealed reductions in situational stressors, symptoms and mental health illnesses. Seventy-six per cent of participants had completed an Operational Tour, and 77% were exposed to a traumatic event during service. It was the negative impact of unresolved traumatic effects that influenced service-users to require support. Forty-nine per cent delayed seeking help, and 36% self-referred to the One Is Too Many programme which demonstrates the importance of this option. There were improvements in the participants' social networking, social activities, club membership and having people to rely on. Only 4% of participants were women which reinforces the requirement to explore initiatives to engage with female veterans.

Conclusions: Timely therapeutic and social prescribing interventions in a safe environment lowered depression, anxiety and the associated situational stressors leading to self-harming and may have reduced suicide. It presented another option to veterans and their families regarding where they can obtain support, care and therapeutic interventions. The programme provided a strong foundation for delivery organisations to forge lasting collaborative partnerships that can be extended to working with other authorities and institutes. The results highlight pathways for prevention and intervention strategies to inform policymakers, healthcare professionals and third-sector organisations.

Keywords: depression & mood disorders; mental health; psychiatry; statistics & research methods; suicide & self-harm.

© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.

Antidepressant Medication Prescription and Incident Cardiovascular Disease in Women Veterans

J Clin Psychiatry. 2025 May 7;86(2):24m15647. doi: 10.4088/JCP.24m15647.

Authors

Jennifer A Sumner  ^{1   2} , Paul A Dennis  ^{3   4} , Carlos A Alvarez  ^{5   6} , Aaron Perkins  ^{5   6} , Jean C Beckham  ^{3   7} , Ramin Ebrahimi  ^{8   9}

Affiliations

• ¹ Department of Psychology, University of California, Los Angeles, Los Angeles, California.
• ² Corresponding Author: Jennifer A. Sumner, PhD, University of California, Los Angeles, Department of Psychology, Psychology Building 1285, Box 951563, Los Angeles, CA 90095-1563 (jsumner@psych.ucla.edu).
• ³ Veterans Affairs Durham Health Care System, Durham, North Carolina.
• ⁴ Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
• ⁵ Texas Tech University Health Sciences Center, School of Pharmacy, Dallas, Texas.
• ⁶ Veterans Affairs North Texas Health Care System, Dallas, Texas.
• ⁷ Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.
• ⁸ Department of Medicine, University of California, Los Angeles, Los Angeles, California.
• ⁹ Veterans Affairs Greater Los Angeles Health Care System, Los Angeles, California.

• PMID: 40338288
• DOI: 10.4088/JCP.24m15647

Abstract

Objective: Antidepressants are commonly prescribed, yet understanding of consequences for cardiovascular disease (CVD) risk is less well-developed. We examined associations of antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], other antidepressants) with incident CVD in women Veterans, a population with a high psychiatric and CVD risk burden.

Methods: Using Veterans Health Administration (VHA) electronic health records, we identified women Veterans who were VHA patients from January 1, 2000, to December 31, 2019. Exclusion criteria included <12 months of baseline data before index visit, prior CVD or antidepressant prescription, and no encounters after index visit. Antidepressant prescriptions were documented in pharmacy data. Our primary outcome was an incident CVD composite, comprising first-onset ischemic heart disease, stroke, atrial fibrillation/flutter, heart failure/ cardiomyopathy, and pulmonary hypertension based on diagnostic codes.

Results: Women Veterans (N = 609,546) had a mean age of 41.3 years. During mean follow-up of 8.8 years, 40.1% of women were prescribed SSRIs, 18.2% SNRIs, and 38.6% other antidepressants; 9.2% developed CVD. Marginal structural modeling was used to de-confound associations of antidepressants with incident CVD, accounting for demographics, VHA engagement, traditional CVD risk factors, and psychiatric disorders. SSRIs, SNRIs, and other antidepressants (vs no antidepressants) were associated with lower incidence of the CVD composite, as well as ischemic heart disease and stroke (relative risk: 0.27-0.76). Additionally, the inverse association between antidepressants and CVD was larger for women with major depressive disorder, posttraumatic stress disorder, and anxiety disorders.

Conclusion: As antidepressants are widely prescribed in the VHA and beyond, these results are encouraging for patients receiving this care.

© Copyright 2025 Physicians Postgraduate Press, Inc.

Collaborative tailoring of the Reach Out, Stay Strong Essentials (ROSE) program for pregnant veterans in the U.S. Veterans Health Administration: a qualitative case study of contextual conditions and adaptations

BMC Health Serv Res. 2025 May 23;25(1):746. doi: 10.1186/s12913-025-12871-x.

Authors

Erin P Finley  ^{1   2} , Alison B Hamilton  ^{3   4} , Ismelda Canelo  ³ , La Shawnta S Jackson  ³ , Rachel Lesser  ³ , Rebecca S Oberman  ³ , Julia Yosef  ³ , Joya G Chrystal  ³ , Erica H Fletcher  ³ , Bevanne Bean-Mayberry  ^{3   4} , Tannaz Moin  ^{3   4} , Melissa M Farmer  ³ , Ariel J Lang  ^{5   6}

Affiliations

• ¹ Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. erin.finley@va.gov.
• ² Long School of Medicine, UT Health Science Center San Antonio, San Antonio, TX, USA. erin.finley@va.gov.
• ³ Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
• ⁴ David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
• ⁵ VA San Diego Healthcare System Center of Excellence for Stress and Mental Health, San Diego, CA, USA.
• ⁶ University of California San Diego, San Diego, CA, USA.

• PMID: 40410822
• PMCID: PMC12100789
• DOI: 10.1186/s12913-025-12871-x

Abstract

Background: Reach Out, Stay Strong Essentials (ROSE) is an evidence-based intervention for preventing post-partum depression being implemented across U.S. Veterans Health Administration (VA) sites as part of the EMPOWER 2.0 implementation trial comparing Replicating Effective Programs (REP) and Evidence-Based Quality Improvement (EBQI) strategies for improving women's health care. As both REP and EBQI support adaptation to meet local needs, the EMPOWER 2.0 implementation team and participating sites have collaboratively developed adaptations of ROSE to better serve pregnant veterans. We describe contextual conditions arising during the first three years of implementation, associated adaptations to the intervention and implementation approach, and implications for pragmatic tailoring and diffusion of evidence-based interventions.

Methods: We conducted a qualitative case study that included rapid qualitative analysis of 50 periodic reflections (brief guided discussions with templated notes) completed with EMPOWER 2.0 implementation team members February 2021-February 2024. Contextual conditions were characterized according to domains of the updated Consolidated Framework for Implementation Research (CFIR); adaptations were characterized using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) and Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS).

Results: Sites reported high demand for ROSE in response to perceived gaps in care for pregnant veterans' mental health needs. Site-level challenges included the need to locate ROSE within existing services, although the salience of contextual conditions evolved across implementation phases. Notable adaptations included updates to the ROSE intervention (e.g., improving alignment with VA clinical practice guidelines) and adaptations to the implementation approach (e.g., offering training to VA providers beyond the original EMPOWER sites). Although the trial is ongoing, expansion of ROSE training has resulted in a total of 256 VA providers trained across 48 VA facilities nationwide.

Conclusions: In implementing ROSE across a national sample of VA sites, co-produced adaptations emerged to improve feasibility of delivery and increase acceptability of ROSE for pregnant veterans. Implementation of ROSE in EMPOWER 2.0 provides a pragmatic model for supporting rapid iteration and diffusion of adaptations to address perinatal mental health needs within large healthcare systems.

Trial registration: ClinicalTrials.gov: Enhancing Mental and Physical Health of Women Veterans (NCT05050266). Registration Date: 09/09/2021. https://clinicaltrials.gov/study/NCT05050266?term=EMPOWER%202.0&rank=1 .

Keywords: Adaptation; Collaborative tailoring; Contextual conditions; Perinatal mental health; Qualitative case study; Veterans.

© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

Conflict of interest statement

Declarations. Ethics approval and consent to participate: This proposal was funded through VA’s Quality Enhancement Research Initiative (QUERI), which uses operational funds to support program improvement. QUERI projects are conducted as quality improvement for the purposes of program implementation and evaluation and are approved as such by the main VA operations partner, which was the VA Office of Patient Care Services for EMPOWER 2.0 (approval received 11/26/2019). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Clinical Management of Sleep Disturbances in Post-9/11 Men and Women Veterans: A 20-year Prospective Cohort Study

J Gen Intern Med. 2025 May 6. doi: 10.1007/s11606-025-09534-2. Online ahead of print.

Authors

Allison E Gaffey  ^{1   2   3} , Sally G Haskell  ^{4   5} , Matthew M Burg  ^{4   6   7} , Henry K Yaggi  ^{4   8} , Kristin M Mattocks  ^{9   10} , Lori A Bastian  ^{4   5} , Melissa Skanderson  ⁴ , Eric C DeRycke  ⁴ , Eric D A Hermes  ^{4   11} , Cynthia A Brandt  ^{4   12}

Affiliations

• ¹ VA Connecticut Healthcare System, Yale School of Medicine, West Haven, CT, USA. allison.gaffey@yale.edu.
• ² Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT, USA. allison.gaffey@yale.edu.
• ³ Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. allison.gaffey@yale.edu.
• ⁴ VA Connecticut Healthcare System, Yale School of Medicine, West Haven, CT, USA.
• ⁵ Department of Internal Medicine (General Medicine), Yale School of Medicine, New Haven, CT, USA.
• ⁶ Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, CT, USA.
• ⁷ Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA.
• ⁸ Department of Internal Medicine (Pulmonary, Critical Care & Sleep Medicine), Yale School of Medicine, New Haven, CT, USA.
• ⁹ VA Central Western Massachusetts Healthcare System, Leeds, MA, USA.
• ¹⁰ Department of Population Health and Quantitative Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
• ¹¹ Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
• ¹² Department of Biomedical Informatics, Yale School of Medicine, New Haven, CT, USA.

• PMID: 40329029
• DOI: 10.1007/s11606-025-09534-2

Abstract

Introduction: Sleep disorders and chronic conditions that are comorbid with disordered sleep represent a high burden to the U.S. population, and Veterans have a particularly high risk for disordered sleep. Sleep disorders also present differently by sex and there is a rapidly growing proportion of women Veterans. Among the most recent Veteran cohort (i.e., discharged post-9/11), the extent of sleep disorders and how those conditions are managed is unknown. The objectives were to characterize the frequency of sleep assessment, diagnosis, and treatment among post-9/11 Veterans served by the Veterans Health Administration (VA), the timing of sleep management, and to determine if there were sex-based disparities in all sleep care.

Methods: This prospective cohort study included all post-9/11 Veterans who enrolled in VA care, and completed ≥ 1 outpatient encounter, 10/1/2001-9/30/2021. Diagnostic and procedural codes, health factors, and dates were used to extract variables for assessment (e.g., behavioral, polysomnography), diagnoses (i.e., insomnia, sleep-related breathing [SRBD], comorbid insomnia and SRBD [COMISA], sleep-related movement [SRMD], or Other disorders), treatment of insomnia or SRBD, and time to sleep assessment, diagnosis, and treatment. Logistic regressions assessed likelihood of sleep care by sex.

Results: The final sample included 1,113,633 patients (12% women, 61% White). Overall, 39% had sleep disorders - 27% with SRBD, 18% with insomnia, 8% with COMISA, 2% with SRMD, and 6% with Other. Men were more likely to have any diagnosis, especially SRBD. Women were assessed up to one year later than men and had greater odds of insomnia or SRMD. Women also had greater odds of insomnia treatment and those with SRBD were 31% less likely to receive treatment than men.

Conclusions: As managing sleep health is central to patient-centered care, concerted efforts are required to implement existing VA guidelines concerning sleep, bridging men and women Veteran's sleep needs with available resources.

Keywords: Clinical management; Insomnia; Sex differences; Sleep; Sleep apnea; Veterans.

© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

Conflict of interest statement

Declarations. Conflicts of Interest: The authors have no conflicts of interest to declare. Disclaimer: The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; the U.S. Department of Health and Human Services; or the U.S. Department of Veterans Affairs. Prior Presentations: None.

Veteran participation in the All of Us Research Program: applying an intersectionality lens to evaluate participant diversity

BMC Med Res Methodol. 2025 May 24;25(1):136. doi: 10.1186/s12874-025-02588-0.

Authors

Lauren O Thomann  ¹ , Katherine A Hanson  ² , Jane Plomp  ² , Jason L Vassy  ³ , Sherilyn J Sawyer  ⁴

Affiliations

• ¹ VA Palo Alto Healthcare System, Palo Alto, CA, U.S.. lauren.thomann@va.gov.
• ² Boston VA Research Institute, VA Boston Healthcare System, Boston, MA, U.S.
• ³ VA Boston Healthcare System, Harvard Medical School, Mass General Brigham, Boston, MA, U.S.
• ⁴ Boston VA Research Institute, VA Boston Healthcare System, Boston, MA, U.S.. sherilyn.sawyer@va.gov.

• PMID: 40413420
• DOI: 10.1186/s12874-025-02588-0

Free article

Abstract

Background: Many segments of the population are underrepresented in biomedical research (UBR). Lack of diversity in health research limits understanding of individual and population level differences and risks the generalizability of study results. Examining intersectionality among VA-enrolled Veteran participants in the All of Us Research Program offers a first look at in-depth understanding of Veteran identity.

Methods: Multi-modal approaches to engagement and recruitment were utilized to enroll a diverse cohort of Veterans nationally from 2018 to 2024. All of Us data were analyzed across eight UBR categories and their intersections to highlight the complexity of Veteran identity.

Results: Veteran All of Us participants reflect the diversity of Veterans nationwide. All of Us participant metrics shed new light on the diversity of the Veteran population, with over 75 unique UBR combinations identified among participants, and over 90% of participants meeting the criteria for at least one UBR category.

Conclusions: The use of a broad spectrum of engagement approaches was shown to be successful for reaching a more diverse Veteran base, and complex intersectional identities among Veterans are described. Greater understanding of intersectionality and its significance to representation can bolster the adaptation of Veteran engagement methodology in research and broader healthcare settings.

Keywords: All of Us Research Program; Biomedical research; Diversity; Engagement approaches; Identity; Intersectionality; Representation; VA; Veteran.

© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

Conflict of interest statement

Declarations. Ethics approval and consent to participate: The All of Us Research Program is governed and approved by the All of Us IRB. Consent for publication: Not applicable. Disclaimer: This content does not necessarily represent the official views of the Department of Veterans Affairs or All of Us Research Program. Competing interests: The authors declare no competing interests.

Experiences With VA-Purchased Community Care for US Veterans With Mental Health Conditions

JAMA Netw Open. 2025 May 1;8(5):e2511548. doi: 10.1001/jamanetworkopen.2025.11548.

Authors

Megan E Vanneman  ^{1   2   3} , Eric T Roberts  ^{4   5} , Yaming Li  ⁶ , Florentina E Sileanu  ⁶ , Utibe R Essien  ^{7   8} , Maria K Mor  ^{6   9} , Michael J Fine  ^{6   10} , Carolyn T Thorpe  ^{6   11} , Thomas R Radomski  ^{6   10} , Katie J Suda  ^{6   10} , Walid F Gellad  ^{6   10}

Affiliations

• ¹ Veterans Affairs (VA) Informatics, Decision Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah.
• ² Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.
• ³ Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City.
• ⁴ Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
• ⁵ VA Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
• ⁶ VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
• ⁷ David Geffen School of Medicine, University of California, Los Angeles.
• ⁸ VA Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, California.
• ⁹ Department of Biostatistics and Data Science, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.
• ¹⁰ School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
• ¹¹ Eshelman School of Pharmacy, University of North Carolina at Chapel Hill.

• PMID: 40397443
• PMCID: PMC12096262
• DOI: 10.1001/jamanetworkopen.2025.11548

Abstract

Importance: Veterans with mental health conditions (MHC) face unique challenges obtaining high-quality, coordinated health care. With a growing number of veterans receiving VA-purchased community care (CC) provided outside the Veterans Health Administration (VA), evidence is needed on how veterans in this high-prevalence, marginalized subgroup experience CC.

Objective: To compare experiences with CC over time for US veterans with and without MHC.

Design, setting, and participants: This retrospective, cross-sectional survey study analyzed responses to the Survey of Healthcare Experiences of Patients-Community Care Survey (SHEP-CCS) from 2016 to 2021. Ratings of CC were examined across 9 domains and compared for veterans with and without MHC, adjusting for differences in baseline characteristics using regression models. Data were analyzed from March 2023 to September 2024.

Exposure: Diagnosis of MHC, defined as bipolar disorder, major depression, posttraumatic stress disorder, schizophrenia, or psychosis.

Main outcomes and measures: Veterans' ratings of CC across 9 domains, overall satisfaction, overall clinician rating, clinician communication, eligibility determination, first appointment access, recent appointment access, nonappointment access, care coordination, and billing, were assessed on a scale of 1 to 100. Unadjusted annual ratings of care experiences were analyzed by survey domain. A series of 4 respondent-level linear regression models were examined for each domain and survey responses were pooled to test for differences in experiences between veterans with vs without MHC.

Results: This study included 231 869 veterans, including 62 911 veterans with MHC (27.1%) and 168 958 without MHC (72.9%). Veterans with MHC had a mean (SD) age of 55.8 (14.7) years, 8327 were female (18.5%), and 24 792 had 3 or more comorbidities (29.9%). Veterans without MHC had a mean (SD) age of 62.5 (15.2) years, 11 277 were female (11.0%), and 49 689 had 3 or more comorbidities (24.0%). In fully adjusted models, veterans with vs without MHC had lower adjusted overall satisfaction with CC by -1.8 (95% CI, -2.3 to -1.3) points (P < .001). Ratings in all domains were lower for veterans with vs without MHC (-0.09 to -0.05 SDs of domain scores) (P < .001 for all comparisons). Although ratings improved from 2016 to 2021, significant differences persisted over time for veterans with vs without MHC for all domains.

Conclusions and relevance: In this survey study of veterans receiving CC from 2016 to 2021, those diagnosed with MHC reported lower ratings of CC across all measured domains, and these differences persisted over time. These findings highlight where focused care coordination and quality improvement efforts could improve CC experiences for this vulnerable subpopulation of veterans.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Vanneman reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Roberts reported receiving grants from Department of Veterans Affairs during the conduct of the study and receiving grants from Agency for Healthcare Research and Quality, National Institute on Aging, and Arnold Ventures and personal fees from University of Southern California outside the submitted work. Dr Sileanu reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Mor reported receiving grants from Department of Veterans Affairs during the conduct of the study. Dr Thorpe reported receiving grants from the Department of Veterans Affairs and the National Institute on Aging. Dr Gellad reported receiving grants from the Department of Veterans Affairs during the conduct of the study. Dr Suda reported receiving grants from the Department of Veterans Affairs, Agency for Healthcare Research and Quality, and the National Institute of Dental and Craniofacial Research. No other disclosures were reported.