[1.1] Individual’s Story Impact Discussion.Choose one individual from the Bill Moyers On Addiction: Close to Home film by self-enrolling into one of the groups here. Next explain how this individual’s story was meaningful regarding furthering your understanding of addiction to alcohol and/or drugs.The topic I chose is opioid. 250 words of opioid addiction amongst people especially veterans Hanson, G. R., Venturelli, P. J., & Fleckenstein, A. E. (2018). Drugs & Society (13th ed.). Burlington, MA: Jones & Bartlett Publishing.
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MILITARY M EDICINE, 178, 1:107,2013
Unmet Need for Treatment of Substance Use Disorders
and Serious Psychological Distress Among Veterans:
A Nationwide Analysis Using the NSDUH
Andrew Golub, PhD; Peter Vazan, PhD; Alexander S. Bennett, PhD; Hilary J. Liberty, PhD
ABSTRACT Many veterans returning from Afghanistan and Iraq experience serious mental health (MH) concerns
including substance use disorders (SUD), post-traumatic stress disorder, traumatic brain injury, depression, or serious
psychological distress (SPD). This article uses data from the 2004 to 2010 National Survey on Drug Use and Health to
examine the prevalence of unmet MH needs among veterans aged 21 to 34 in the general population. The prevalence of
untreated SUD among veterans (16%) was twice as high as untreated SPD (8%), a nonspecific diagnosis o f serious MH
concerns. Surprisingly, similar rates of untreated SUD and SPD were found among a nonveteran comparison sample
matched on gender and age. These findings suggest that reducing unmet need for MH treatment for veterans in the
general population may require improving outreach to all Americans and creating greater acceptance for MH treatment.
The need for further analyses of reasons for not obtaining treatment is discussed.
INTRODUCTION
Veterans reintegrating into civilian life after serving in Oper
ation Enduring Freedom (OEF) and Operation Iraqi Free
dom (OIF) have been facing mental health (MH) concerns,
especially post-traumatic stress disorder (PTSD), traumatic
brain injury (TBI), depression, and substance use disorders
(SUD).1-4 Prior research has evaluated the prevalence of MH
concerns and opportunities for treatment at various points in
the military/veteran career including postdeployment, among
those being treated at Veterans Affairs (VA) facilities, and in
the general population.1,5-7 This article analyzes the preva
lence and covariates of unmet need for MH treatment among
young veterans in the general population using data collected
by the National Survey on Drug Use and Health (NSDUH).
There are various reasons veterans may not be in treatment
at the VA. They may be receiving treatment elsewhere. Alter
natively, some research indicates that onset or attenuation of
symptoms can be delayed, especially for PTSD .1,8 On a
related matter, people often delay for years after onset before
obtaining MH treatment.9 Thus, some veterans with unmet
need at any time will eventually receive treatment. There are
also various reasons veterans avoid MH treatment. Some may
not be screened for MH problems or not encouraged to seek
treatment for problems such as hazardous drinking behav
iors.10’11 Many wish to treat their problems on their ow n.12
Many veterans and military personnel attach a stigma to MH
treatment, especially SUDs, which they or their peers per
ceive as inconsistent with the mental toughness prized in the
military.5,7,12,13 Other research identifies negative attitude
toward MH care as a major factor.13 The prevalence of unmet
MH treatment need in the general population is reduced to
N ational D e v elo p m en t an d R esearch In stitu tes, 71 W est 2 3rd Street,
8
th F loor, N ew Y o rk , N Y 10010.
P o in ts o f v iew ex p re sse d in th is article d o n o t n ecessarily re p re sen t the
official po sitio n o f th e U .S. G o v ern m en t, N IA A A , o r N D R I.
doi: 10 .7 2 0 5 /M IL M E D -D -12-00131
M ILITARY M EDICINE, Vol. 178, January 2013
the extent that people receive successful treatment and their
concerns are addressed.
More than half of the OEF/OIF veterans coming in contact
with the VA for any reason had MH concerns.14 Among those
seeking treatment, the covariates differ substantially across
disorders. Studies indicate PTSD was higher among veterans
who were male, African American, younger, and married or
divorced.15 In contrast, depression was higher among those who
were female, White non-Hispanic, older, divorced/separated/
widowed, enlisted, in the Army, and Reserve/National Guard.16
SUDs were more common among veterans who were male,
younger, not married, enlisted, and in the Army17; Hispanic
veterans were less likely to have a drug use disorder (DUD)
but not an alcohol use disorder (AUD).17
In 2007-2008, the RAND Corporation conducted a survey
of 1,965 OEF/OIF veterans to estimate the prevalence of MH
concerns among veterans in the general population, who were
not necessarily in contact with the VA.18 PTSD was higher
among veterans who were female, Hispanic, enlisted, and in
the Army, which differs substantially from the covariates in
the VA study described above. The covariates of major
depressive episode (MDE) were similar to those for PTSD:
female, Hispanic, and enlisted. TBI did not vary significantly
with any veteran characteristics.
The Substance Abuse and Mental Health Services Admin
istration (SAMHSA) has used the NSDUH to produce a
series of articles examining MH concerns and unmet treat
ment need among veterans in the general population. They
found Serious Psychological Distress (SPD)— a nonspecific
diagnosis of serious MH concerns19— was higher among vet
erans who were female, younger, and whose families earned
less than $20,000 per year 20 MDE was higher among those
w ho were female and younger.21 60% of veterans with an
M DE received past-year treatment.21 SUDs were more com
m on among veterans who were younger and whose families
ea rned less than $20,000 per year.20 In 2003, 85% of veterans
107
Veterans Treatment Need
dependent on alcohol or drugs had not received treatment,
which was slightly better than the 91% in a comparable
nonveteran population.22
The SAMHSA reports are short and limited. Wagner
et al23 provided a more extensive analysis of SUDs among
veterans interviewed by the NSDUH 2000-2003. They found
the prevalence of SUDs among veterans was 7.0%, which
was not statistically different from the 6.8% among compara
ble nonveterans. Few veterans received SUD treatment in the
past year (0.8%), but this percentage was higher than among
comparable nonveterans (0.5%). This article replicates prior
NSDUH analyses of veterans using recent data and presents
findings regarding SUD, SPD, and unmet need for treatment
as well as their covariates. The conclusion examines the
implications of the findings with regard to the provision of
outreach, screening, and treatment programs.
METHODS
Participants
The NSDUH is the primary source of statistical information
on the use of illicit drugs and alcohol in the civilian, noninsti
tutionalized population of the United States.24 The survey
employs a multilevel stratified hierarchical sampling proce
dure. Participants are interviewed face-to-face in their place
of residence. Audio computer-assisted self-interviewing is
used to assure confidentiality for sensitive questions. Partic
ipants receive $30 for completing the survey. This analy
sis used the NSDUH public-release data for 2004 through
2010 obtained from the Interuniversity Consortium for Polit
ical and Social Research. From 2004 to 2010, the response
rate varied between 74% and 77% 25-31 The complete sample
includes 118,625 participants aged 21 to 34 of whom 3,826
(3%) are veterans. All analyses presented used sample weights,
stratification information, and complex samples procedures
to obtain unbiased estimates and accurate statistical tests that
control for design effects.
Unfortunately, the NSDUH does not distinguish OEF/OIF
veterans from those who served elsewhere. The NSDUH asks
a single question about veteran status, “Have you ever been
in the United States armed forces?” It was assumed that many
of the youngest veterans would have served more recently
and served in Iraq and/or Afghanistan. Accordingly, the anal
ysis was restricted to younger veterans aged 21 to 34 at the
time of the interview. A comparable nonveterans group was
constructed by standardizing the weights of the nonveteran
subsample to match the age and gender distribution of the
veteran subsample, a conventional demographic procedure
used by SAMHSA in their analyses of veterans.22
Measures
The primary dependent variables were SUD and SPD in the
past year. The NSDUH defines SUD as abuse or depen
dence on alcohol or illicit drugs based on Diagnostic and
Statistical Manual of Mental Disorders criteria.19,32 To mea
108
sure SPD, the NSDUH uses the K6 screener, which was
designed to identify serious impairment from any MH con
cern other than SUD with six short questions (e.g., “How
often did you feel nervous?”) rated on a scale from none to
all of the tim e.19,33
Analyses
The article presents population estimates of SUD and SPD.
Unmet need for SUD or SPD treatment was estimated as
those participants with the condition who did not receive
treatment in the past year. The analysis also examined self
reported need for treatment provided in response to the ques
tion, “During the past 12 months, was there any time when
you needed MH treatment or counseling for yourself but
didn’t get it?”25 Separate estimates of unmet need for treat
ment were calculated for the veterans and the standardized
nonveterans population as well as the unstandardized popula
tion of all NSDUH participants aged 21 to 34.
Logistic regression was used to estimate how the preva
lence of past-year SPD and SUD varied across participant
characteristics including veteran status, gender, race/ethnicity,
age, education, employment, family income, marital status,
urbanicity, and interview year. Unfortunately, the NSDUH
public use datasets do not include a measure of region, which
precluded its analysis. The NSDUH urbanicity measure is
also quite limited indicating only whether a participant lives
in a core-based statistical area (CBSA) or a more rural loca
tion. The NSDUH measure of race/ethnicity distinguishes
White non-Hispanic, African American non-Hispanic, and
Hispanic participants.25 The remaining less common catego
ries were combined. Logistic regression was also used to
estimate the likelihood that a person with SPD received MH
treatment and similarly that a person with SUD received
alcohol or drug treatment. Each regression model included
an interaction term for each variable with veteran status
(e.g., veteran x gender) to identify whether the covariates
for veterans differed from those of the general population.
Because of the large sample size, many parameter estimates
were statistically significant. Accordingly, the analysis placed
greater emphasis on parameter estimates that were not only
statistically significant but also substantial such as an odds
ratio greater than 1.5.
RESULTS
Sample Characteristics
Table I presents the characteristics of the subsample of
NSDUH participants aged 21 to 34 interviewed in 2004
2010. The non veteran demographic entries for gender, age,
and race/ethnicity were not standardized. The subsequent
measures of social integration were standardized to control
for differences in gender and age between veterans and non
veterans. The total column is not standardized by gender and
race. It thus gives much greater weight to females than the
prior columns. Consequently, characteristics that are more
MILITARY M EDICINE, Vol. 178, January 2013
Veterans Treatment Need
TABLE I.
Characteristics of NSDUH Participants Aged 21 to 34,
2004-2010
V eteran s
N o n v eteran s
T o tal
3,826
114,793
118,625
82.1**
17 9 **
48.3
49.7
51.7
50.3
W hite (N o n -H isp an ic)
67.3**
60.1
60.3
A frican A m erican
15.5**
12.9
13.0
1 2 .0
19.3
S a m p le S ize (U n w eig h ted )
G e n d e r (U n sta n d ard ize d ) (% )
M ale
F em ale
R ac e /E th n icity
(U n sta n d ard ize d ) (% )
(N o n -H isp an ic)
H ispan ic
**
19.6
O ther
5.2**
7.5
7.4
M ean A ge
28.7**
27.4
27.4
(U n sta n d ard ize d ) (% )
E d u c a tio n (% )
N o H igh S ch o o l D eg ree
4.2**
15.9
14.1
28.2
27.6
S o m e C o lleg e
35.0**
42 .4 * *
25.7
29.5
C o lle g e D egree
18.4**
30.1
28.9
Full T im e
70.6
71.5
60.9
P art T im e
1 1 .8
13.2
17.8
5.8
5.3
5.5
1 0 .0
15.8
H igh S ch o o l D eg ree
E m p lo y m en t (% )
U n em p lo y ed
O th e r
1 1 .8
*
F am ily In co m e (% )
B elow P o v erty
7 . 1 **
13.5
16.8
N e ar P o v erty (1 0 0 -2 0 0 % )
22.5
21.7
2 2 .6
H ig h e r In c o m e (> 200% )
70.4**
64.8
60.6
M arried
48.6**
42.9
39.9
S e p a ra te d /D iv o rc ed /W id o w e d
S ingle
16.2**
7.1
7.4
35.2**
50.0
52.8
90.7**
92.7
92.7
9.3**
7.3
7.3
M arital S tatus
Prevalence of SUD and SPD
Table II compares the rates of substance use, SUD, and SPD
between veterans and comparable nonveterans. Veterans
were not more likely than nonveterans to use illegal drugs or
be dependent on them. Most veterans (75%) reported having
consumed alcohol in the past month, slightly more than non
veterans (68%). However, veterans were not more likely than
nonveterans to binge drink (defined as 5 or more drinks in a
single session), drink heavily (defined as binge drinking on 5
or more of the past 30 days), or have an AUD. Veterans in the
general population were slightly more likely to have SPD
than their nonveteran counterparts (14% vs. 12%) and even
more likely than nonveterans to have had an MDE (10% vs.
7%). There was substantial overlap between SUD and SPD;
5% of veterans had both conditions representing 29% of
those with SUD and 38% of those with SPD.
Table III examines the covariates of SUD and SPD. The
variation with veteran status was not statistically significant
in either model, although several of the interaction terms
were, especially for SPD. Unlike in the previous tables, the
first column for each model presents the factors for all
NSDUH participants (nonveteran and veteran) and the sec
ond column presents the interaction terms identifying how
veterans differ from nonveterans. The factor most associated
with variation in both SPD and SUD based on the Wald
statistic was gender, although with the opposite effects
between the models. Men were twice as likely as women to
TABLE II.
U rban icity
W ith in a C B S A
O u tsid e o f A n y C B S A
Variation in SUD and MH Disorders by
Veteran Status
% by S ubpo p u latio n
V eterans
*D ifferen c e b e tw ee n v eteran s and n o n v eteran s w as statistic a lly sig n ificant at
the α = 0.05 level; * * D ifferen ce b etw een v eteran s an d n o n v eteran s w as
statistic a lly sig n ifican t at th e a = 0 . 0 1 level.
common among females such as poverty were higher among
the total population than among either the veteran or the
standardized nonveteran subpopulations. Veterans were
much more likely to be male, were slightly older (perhaps
because younger persons are more likely to be still in the
service), and were more likely to be W hite or African Amer
ican as opposed to Hispanic or other.
Veterans were more likely to have completed high school
(generally a requirement to enter the military) and more
likely to have gone to college, though less likely to have
graduated. Veterans and nonveterans had relatively similar
employment profiles. Veterans were less likely to be living
in poverty. Veterans were more likely to be married, an
important protective factor; however, they were also more
likely to be separated, divorced, or widowed, which is often
associated with MH concerns as either a cause or a conse
quence. More than 90% of the sample lived in a CBSA,
although veterans were slightly more likely to live in a more
rural area outside of any CBSA.
MILITARY M EDICINE, Vol. 178, January 2013
N o n v eteran sα
T otal
P a st-M o n th U se
A ny A lcohol
74.6**
6 8 .0
64.8
B inge D rin k in g (5 + D rinks)
43.8
44.0
38.7
H eavy D rinking (5 + B inges)
14.2
1 2 .1
M ariju an a
1 1 .0
14.7
12.4
C o ca in e (A ny Form )
1 .6
1.9
1 .6
H allu cin o g en s
0.9
0.9
P ain K illers
3.5
0.9
3.4
11.4
3.3
SU D (P ast-Y e a r A buse o r D ependence)
A lcohol o r D rugs
17.7
18.2
16.2
A lcohol
15.3
15.4
13.6
A ny Illicit D rug
4.9
5.4
5.0
M ariju an a
2 .8
3.2
2.9
A ny Illicit D rug
2.4
2 .8
2 .6
E x c e p t M ariju an a
P ain K illers
1 .1
1 .2
1 .2
A ny P sych o th erap eu tic
1 .6
1.4
1.5
1 2 .0
14.8
M H D iso rd e r (P ast Y ear)
S erio u s P sy ch iatric D istress
M DE
C o -O ccu rrin g S U D and SPD
13.8*
9 . 5**
5.2
6.7
8.5
4.4
4.6
*D ifferen c e betw een v eterans and n o n v eteran s w as statistic a lly sig nificant at
the
α 0.05 level; * * D ifferen ce betw een v eterans and n o n v eteran s w as
statistic a lly significant a t the α = 0.01 level. αStan d ard ized to veteran sam ple
by g e n d e r and age.
109
Veterans Treatment Need
TABLE III.
Variation in MH Disorders (Logistic Regression)
O d d s R atio (W ald S tatistic)
o f a M H D iso rd er
SUD
O verall
SPD
V ets
O verall
V ets
0.14
In te rc e p t o r B ase O dds
0.33
V eteran S tatus
n/a
N on v eteran ”
n/a
V eteran
n/a
—
n/a
—
(84 2 .3 )* *
( 2 .0 )
(3 98.3)**
M ale”
1 .0
—
1 .0
(0 . 1 )
—
F em ale
0.5
—
1.7
—
(85.0)**
(2.3)
(8 2.9)**
(0.9)
G e n d er
R ace/E th n icity
( 0 .0 ).
—
n/a
(0.7)
n/a
—
—
W hite (N o n -H isp a n ic )α
1 .0
—
1 .0
A frican A m erican
0 .6
—
0 .6
—
H isp an ic
0.7
0 .6
—
—
0 .6
O ther
—
—
(N o n -H isp an ic)
A ge
(3 1.6)**
(1.9)
0.7
(4.4)
( 2 .6 )*
21
1.5
—
—
2 2 -2 3
1.5
—
—
1 .1
2 4 -2 5
1.4
—
—
1 .0
2 6 -2 9
1 .2
—
—
1 .1
3 0 -3 4 α
1 .0
—
—
E ducatio n
( 1 1 .6 )**
(0 . 1 )
(2 5.1)**
2 .2
1 .0
(1.9)
N o H igh School D egree
1 .2
—
1 .1
—
H igh School D egree”
1 .0
—
1 .0
—
S om e C o lleg e
1 .1
—
1 .1
—
C o lleg e D egree
1 .0
—
( 1 .2 )
0 .8
E m p lo y m en t
(18.6)**
(5 6.9)**
—
Full T im e”
1 .0
—
1 .0
(0.3)
—
P art T im e
1 .0
—
1 .1
—
U nem p lo y ed
1.4
—
1 .8
—
O ther
0.9
—
1.3
—
( 1 .8 )
( 0 .2 )
(1 6.4)**
(4.5)*
F am ily In co m e
B elo w P overty
—
—
1 .2
1.4
N e ar P o v erty (1 0 0 -2 0 0 % )
—
—
1 .1
1.7
H ig h er In co m e (> 200% )α
—
—
1 .0
1 .0
M arital S tatus
(29 2 .7 )* *
( 1.1)
(1 86.2)**
M arried
0.4
—
0 .6
(0.8)
—
S e p a ra te d /D iv o rc ed /
1 .0
—
1.5
—
W id o w ed
S ing leα
U rbanicity
1 .0
(19.0)**
W ith in a C B S A α
1 .0
O u tsid e o f A n y C B S A
0 .8
—
1 .0
(3.1)
—
( 0 .0 )
—
—
—
—
2004
( 1 .2 )
—
0.7
( 1 .8 )
—
2005
—
0 .6
—
—
2006
—
0 .6
—
—
2007
—
0.7
—
—
2008
—
—
—
—
0.7
1.4
—
—
—
1 .0
—
—
Y ear
2009
2010
”
(2.5)*
—
(0.3)
—
(2 . 1)
—
n/a, not applicable. *W ald statistic w as sig n ifican t at th e α = 0.05 level;
* *W ald statistic w as sig n ifican t at th e α = 0.01 level. “R eferen c e category.
have SUD. In contrast, women were 70% more likely to have
SPD. The second most significant factor was marital status.
Being married was strongly associated with lower SUD and
SPD. This is consistent with the idea that marriage serves as a
protective factor against MH concerns. However, there is a
110
possibility of reverse causation— that MH concerns can con
tribute to the dissolution of a relationship. Consistent with
this alternative explanation, being separated, widowed, or
divorced was associated with higher rates of SPD (but not
SUD). SUD and SPD were higher among Whites, higher
among the unemployed, and declined modestly with educa
tional level. SUD (but not SPD) declined with age and was
slightly higher within a CBSA than more rural location.
SPD (but not SUD) was higher among the poor and near
poor (those earning above the poverty level but below twice
this level). The interaction terms indicate that poor and near
poor veterans were even more likely to have experienced SPD
than comparable nonveterans. Having more than 1 covariate
that …
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