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

This study’s finding of an increase in nonmale soldiers with PTSD and/or TBI was not surprising. There is a paucity of data on the effect of war zone exposure on women veterans. Recently, women have been more actively involved in combat roles with 41,000 women deployed to a combat zone. Results of this study indicate a 2- to 3-fold increase in veterans identifying themselves as nonmale in post-9/11 groups with a higher proportion diagnosed with either PTSD alone or PTSD and TBI. Women are at a higher risk for PTSD than are men due in part to exposure to abuse/trauma prior to deployment, experience of higher rates of discrimination, and/or sexual assault.^31-33 One study involving First Gulf War female veterans reported higher precombat psychiatric histories as well as higher rates of physical and sexual abuse when compared with that of men.³¹

In this study, the average age of veterans adjudicated and compensated for PTSD and/or TBI pre-9/11, was 66 years compared with 36 years for post-9/11 veterans. Sixty-six percent of veterans from the post-9/11 group had ≥ 50% service-connected disability at age 36 years; 75% of veterans from the overlap group had ≥ 50% service-connected disability at age 41 years; and 76% veterans from the reentered group had ≥ 50% service-connected disability at age 46 years. Younger age at diagnosis and higher rates of disability not only pose unique challenges for veterans and family members, but also suggest implications for career prospects, family earnings, loss of productivity, and disease-adjusted life years. Also noted in the results, this younger cohort has a higher percentage of single/unmarried veterans, suggesting familial support systems may be more parental than spousal. Treatment for this younger cohort will likely need to focus on early and sustained rehabilitation that can be integrated with career plans.

For treatment to be effective, there must be evidence for veterans enrolling, remaining, and reporting benefits from the treatment. Limited research has shown currently advocated evidence-based therapies to have low enrollment rates, high drop-out rates, and mixed outcomes.⁴²

Results showing a gradual increase in the proportion of nonwhite, non-African American veterans diagnosed with PTSD alone, TBI alone, or both, likely reflect the changing demographic profile of the US as well as the Army. However, the reason that more African Americans were diagnosed with PTSD and/or TBI in the overlap and reentered groups when compared with the pre-9/11 group could not be ascertained. It is possible that more veterans identified themselves as African Americans as evident from a decrease in the number of veterans in the unknown category post-9/11 when compared with the pre-9/11 group. In 2016, the American Community Survey showed that Hispanic and African American veterans were more likely to use VA health care and other benefits than were any other racial group.⁴⁰ Improved screening for PTSD and TBI diagnoses, increased awareness, and education about the availability of VA services and benefits may have contributed to the increased use of VA benefits in these groups.

Data from this study are concordant with data from the National Center for Veterans Analysis and Statistics reporting on the younger age of diagnosis and higher rates of initial service-connected disability in veterans with PTSD and PTSD+TBI.⁴³ One study analyzing records from 1999 to 2004 showed that the number of PTSD cases grew by 79.5%, resulting in 148.7% increase in benefits payment from $1.7 billion to $4.3 billion per year.⁴⁴ In contrast, the compensation cost for all other disability categories increased by only 41.7% over this period. This study also revealed that while veterans with PTSD represented only 8.7% of compensation recipients, they received 20.5% of all compensation payments, driven in large part by an increase in > 50% service-connected disability ratings.⁴⁴

Thus, from financial as well as treatment points of view, the change in the demographic profile of the veteran must be considered when developing PTSD treatment strategies. While treatment in the past focused solely on addressing trauma-associated psychiatric issues, TBI and PTSD association will likely shift the focus to concurrent psychiatric and physical symptomology. Similarly, PTSD/TBI treatment modalities must consider that the profile of post-9/11 service members includes more women, younger age, and a greater racial diversity. For instance, younger age for a disabled veteran brings additional challenges, including reliance on parental or buddy support systems vs a spousal support system, integrating career with treatment, selecting geographic locations that can support both career and treatment, sustaining rehabilitation over time. The treatment needs of a 35-year-old soldier with PTSD and/or TBI, whether male or female, Asian or African American are likely to be very different from the treatment needs of a 65-year-old white male. Newer treatment approaches will have to address the needs of all soldiers.