Original Research

Demographic Profile and Service-Connection Trends of Posttraumatic Stress Disorder and Traumatic Brain Injury in US Veterans Pre- and Post-9/11

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Introduction: This study seeks to understand the demographic changes in the active-duty service member profile, both prior to and following September 11, 2001 (9/11). The study analyzed diagnosis of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) and measures of severity of those diagnoses as recorded in service-connection ratings (percent disability).

Methods: A retrospective cohort-study of military veterans who received care at Veterans Health Administration medical centers between December 1998 and May 2014 was conducted based on clinical data recorded and stored within the Corporate Data Warehouse.

Results: A cohort of 1,339,937 veterans received an inpatient or outpatient diagnosis of PTSD and/or TBI. The cohort was divided into 4 service period groups and 3 diagnosis categories. The service periods included pre-9/11 (n = 1,030,806; 77%), post-9/11 (n = 204,083; 15%), overlap-9/11 (n = 89,953; 7%), and reentered post-9/11 (n = 15,095; 1%). The diagnosis categories included PTSD alone (n = 1,132,356; 85%), TBI alone (n = 100,789; 7%) and PTSD+TBI (n = 106,792; 8%). Results of the post-9/11 group revealed significant changes, including (1) increase of veterans with PTSD + TBI; (2) increase of female veterans with PTSD + TBI; and (3) increase of severity level of diagnosed PTSD/TBI as evidenced by higher service-connected disability pensions at younger age in the post-9/11 group. Additionally, data revealed unequal distribution of veterans with PTSD + TBI across geographic areas.

Conclusions: The veteran of the post-9/11 service period does not mirror the veteran of the pre-9/11 service period. Findings are valuable for policy making, allocation of resources, and for reconsidering the prevailing paradigm for treating veterans with PTSD and/or TBI.



The nature of combat and associated injuries in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), Operation New Dawn (OND), and Afghanistan War is different from previous conflicts. Multiple protracted deployments with infrequent breaks after September 11, 2001 (9/11) have further compounded the problem.

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) are the signature wounds of recent wars, with a higher incidence among the veterans of OEF and OIF compared with those from previous conflicts.1,2 More than 2.7 million who served in Iraq and Afghanistan suffer from PTSD.3,4 Symptoms of PTSD may appear within the first 3 months after exposure to a traumatic event or after many months and, in some cases, after a delay of many years and continue for life.5 Although delayed onset of PTSD in the absence of prior symptoms is rare,6,7 its incidence rises with increasing frequency of exposure to traumatic events8,9 and over time.10

According to the Brain Injury Association of America, TBI is “an alteration in brain function, or other evidence of brain pathology, caused by an external force.”8 TBI is often associated with increased risk of PTSD, depression, and posttraumatic headache,11-13 which may lead to broader cognitive, somatic, neurobiological, and psychosocial dysfunctions.14-17 According to Veterans Health Administration (VHA) data, 201,435 veterans from all eras enrolled with the US Department of Veterans Affairs (VA) have a diagnosis associated with TBI and 56,695 OEF/OIF veterans have been evaluated for a TBI-related condition.2 According to the Defense and Veterans Brain Injury Center (DVBIC), > 361,000 veterans have been diagnosed with TBI, with a peak of 32,000 cases in 2011.1,18 Moreover, the reported incidence and prevalence of PTSD and TBI among US veterans are not consistent. The incidence of PTSD has been estimated at 15% to 20% in recent wars3,19 compared with 10% to 30% in previous wars.3,19,20

When PTSD or TBI is deemed “related” to military service, the veteran may receive a service-connected disability rating ranging from 0% (no life-interfering symptoms due to injury) to 100% (totally disabling injury). The percentage of service connection associated with an injury is a quantifiable measure of the debilitating effect of injury on the individual. A significant majority (94%) of those who seek mental health services and treatment at VHA clinics apply for PTSD-related disability benefits.21 The estimated cost related to PTSD/TBI service-connected pensions is $20.28 billion per year and approximately $514 billion over 50 years.22 The cost of VA and Social Security disability payments combined with health care costs and treatment of PTSD is estimated to exceed $1 trillion over the next 30 years.22

The National Vietnam Veterans Readjustment Study (NVVRS) provided valuable information on prevalence rates of PTSD and other postwar psychological problems.23 Meanwhile, there have been no recent large-scale studies to compare the demographics of veterans diagnosed with PTSD and TBI who served prior to and after 9/11. A better understanding of demographic changes is considered essential for designing and tailoring therapeutic interventions to manage the rising cost.22

The present study focused on identifying changing trends in the demographics of veterans who served prior to and after 9/11 and who received a VA inpatient or outpatient diagnosis of PTSD and/or TBI. Specifically, this study addressed the changes in demographics of veterans with PTSD, TBI, or PTSD+TBI seen at the VHA clinics between December 1,1998 and May 31, 2014 (before and after September 11, 2001) for diagnosis, treatment and health care policy issues.


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