EDITORIAL
Mental Health Needs of Older Veterans Ira R. Katz, M.D., Ph.D.
I
n recent years, America has focused a good deal of attention on those younger veterans returning from the wars in Afghanistan and Iraq. Now that the American presence in Iraq has ended and its presence in Afghanistan is winding down, it is time to recognize the fact that most American veterans are old. In 2012, 46% of veteran men were over age 65 and 59% over age 60; conversely, 51% of American men over age 65 were veterans.1,2 Based on these statistics, a focus on the mental health needs of older veterans is an important part of population-based care. Moreover, understanding the trajectory of mental health needs over the lifespan is necessary to plan for the ongoing care of younger veterans as they age. Six articles in this month’s The American Journal of Geriatric Psychiatry focus on older veterans.3e8 They report on research addressing two themes. One is about the mental healthcare services provided to older adults by the Veterans Health Administration (VHA), the healthcare system of the U.S. Department of Veterans Affairs (VA). The other is concerned with post-traumatic stress disorder (PTSD) and related conditions and their impact across the lifespan, addressing the persistence of the effects of combat exposure into late life.
MENTAL HEALTH SERVICES PROVIDED BY VHA Three articles in this issue address matters directly related to mental healthcare services provide by VHA.3e5 VA research frequently focuses on the delivery of healthcare within VHA, in part because of the wealth of clinical and administrative data that are
available to VA investigators. In doing so, the research can, in general, serve two functions: raising issues that may be generalizable to other healthcare systems and identifying targets for quality improvement. Weichers et al.3 demonstrate that 30% of all VHA patients with prescriptions for a psychotropic medication in 2010 had no current mental health diagnosis in their medical records and, frequently, no apparent medical indication for the prescription. One of the primary findings was that this occurred most frequently among patients over age 65 and in those who did not receive mental health specialty services. The concern is that this may represent indiscriminate prescribing. It is possible that, in some cases, it could represent a well-meaning attempt to provide treatment without making diagnoses that could be perceived as stigmatizing; however, even allowing for this, there must be concerns about the specificity of prescribing without a diagnosis and about whether this sort of practice represents a barrier to appropriate monitoring and follow-up care. Weichers et al. note that the rates in VHA are similar to those reported elsewhere, and this article implicitly calls for further studies of the age dependence of prescribing without diagnoses and indications beyond VHA. More directly, the findings raise questions about the quality of psychopharmacologic treatment in VHA, especially for patients who do not receive mental health specialty care. This problem was discussed with VHA mental health leadership well before publication, and it has been included as a key issue in VHA’s ongoing quality improvement programming. Garrido et al.4 studied the care provided to seriously ill veterans who received inpatient consults for
Received January 29, 2014; accepted January 29, 2014. Send correspondence and reprint requests to Ira R. Katz, M.D., Ph.D., Philadelphia VA Medical Center, University and Woodland Aves., Philadelphia, PA 19104. e-mail: [email protected] Ó 2014 American Association for Geriatric Psychiatry http://dx.doi.org/10.1016/j.jagp.2014.01.014
Am J Geriatr Psychiatry 22:6, June 2014
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Editorial palliative care in one of VHA’s regional networks. They note that palliative care consults in this network included evaluations of psychological symptoms such as worry, nervousness, and sadness. Their major finding was that although 44% of the patients reported psychological distress in the past week, there was no evidence from the electronic medical record that the reports led to mental healthcare, either from the palliative care team or other providers. It is possible that the hospitals’ medical, nursing, and social work staff responded to the emotional needs of the palliative care patients in a way that was integrated in a moment to moment way with other components of their medical, nursing, and social work care; it is also possible that this was done but not documented in the medical record. Although this article focused on this issue as a problem within VHA, it is important to recognize that the roles of psychiatry and mental health services within hospices and palliative care are evolving on a national level. This was the focus of a special issue of this journal in 2012,9 and it remains an emerging dimension of psychiatric and mental health practice.10 The findings from Garrido et al.4 should be viewed as a call to action within VHA and should also serve as a cue to self-scrutiny for other hospice and palliative care programs. Finally, Yeager and Magruder5 report on agerelated changes in the psychometric properties of the PTSD Checklist, an instrument used by the VHA (and elsewhere) to screen for PTSD. They conducted a study in which both the screening test and “gold standard” clinical evaluations were conducted in a large sample of VHA patients, mostly selected at random. They report that the overall performance of the PTSD Checklist remained high across the entire sample but that there were significant differences in the optimal cut-points for identifying those who screened positive. Cut-points were 43 for veterans aged 21e49, 34 for veterans aged 50e64, and 24 for veterans aged 65e81. The findings update previous knowledge about how to identify patients with PTSD, especially in late life; this is of specific importance within the VHA. Of course, based on the current data, it is not possible to distinguish between age effects and those related to generational cohorts. Regardless, the differences are substantial, and the lower threshold should be considered in screening veterans for late-onset PTSD as well as for
528
monitoring those with histories of PTSD for relapses or recurrences. In addition, as suggested by the authors, the findings pose important questions about the nature of the differences between age groups (or cohorts) and whether they reflect differences in reporting styles, in the intensity with which symptoms are experienced, or in the nature and distribution of symptoms.
A LIFE-COURSE PERSPECTIVE ON COMBAT EXPOSURE Three articles in this issue are reports of findings from the National Health and Resilience in Veterans Study,6e8 a research study funded by the VA through the National Center for PTSD to characterize the longitudinal trajectories of PTSD and related mental health outcomes in a nationally representative sample of U.S. veterans; these articles are best viewed together with two other recent articles from this study.11,12 In general, this research is noteworthy because of the highly innovative approach it used to obtain web-based data from a representative sample of veterans and because of the area of investigation. Exposure to combat leads to increased rates of mental health conditions, including but not limited to PTSD. This effect accounts for a significant component of the nation’s burden of mental illness in young and middle aged adults.13 However, questions remain about the extent to which the effects of combat persist into late life, specifically about how combat exposure during military service affects the mental and physical health of veterans as they age and about the extent to which the effects are mediated through the association of combat with PTSD, other mental health conditions, and the observable physical and neurologic wounds of war. In an early report from this study, Pietrzak and Cook11 used cluster analyses of the number of reported traumatic events and symptoms of PTSD, depression, and generalized anxiety disorder to identify three clusters of veterans: a “control” group with low levels of exposure to traumatic events that accounted for 60% of the sample and two clusters with comparable exposure to higher numbers of traumatic events. These included a distressed group with high levels of current mental health symptoms that accounted for 12% of the sample and a resilient
Am J Geriatr Psychiatry 22:6, June 2014
Katz group that was experiencing low levels of symptoms in spite of their history of trauma that accounted for 28%. Combat exposure was reported by 54% of the distressed group and a comparable number, 53%, of the resilient group, both higher than the 28% reported in the control group. Clearly, combat exposure does not in and of itself lead to poor outcomes. Information about other characteristics of the person, the traumatic event(s), and life after the trauma (including information about treatment) are needed to explain differences between distressed and resilient outcomes in late life. Pietrzak et al.6 provide a view of successful aging in America’s veterans using confirmatory factor analysis to define a latent variable that includes selfperceptions of successful aging and measures of general health; physical, emotional, social, and cognitive functioning; enjoyment; and satisfaction. In univariate analyses, less successful aging was related to current mental health problems, primarily PTSD and major depression, as well as to histories of mental health and substance use disorders and combat exposure. Fanning and Pietrzak12 report that 6.0% of the sample had experienced thoughts of suicide within the previous 2 weeks. The rate in those with a history of combat exposure was 9%, higher than the 4% rate for other veterans. Across the entire sample, it was also associated with current symptoms and previous histories of PTSD and other mental health conditions. Current suicidal ideation was strongly associated with a history of a previous suicide attempt, providing further evidence that suicidality can be a chronic condition. In the study by Kuwert et al.,7 44% of older veterans reported feeling lonely at least some of the time and 10% reported feeling lonely often. The authors report that loneliness is associated with current symptoms of depression and PTSD; histories of mental health and substance use disorders were not evaluated. In contrast to the negative impact of combat on successful aging and suicidal ideation, univariate analyses demonstrated that combat exposure was weakly, but significantly, associated with lower levels of loneliness. For the negative outcomes reported in late life, such as less successful aging and suicidal ideation, the associations with PTSD and other mental health variables remained significant in multivariate analyses but the associations with combat exposure did
Am J Geriatr Psychiatry 22:6, June 2014
not. This suggests the persistent effects of combat may be mediated through the clinical, psychological, and social variables considered in these analyses. However, the multivariate models were complex, and the analyses presented could not identify the specific paths that may account for the effects. The National Health and Resilience in Veterans Study did, however, identify one direct effect of combat exposure that persists into late life. Monin et al.8 found that 20% of older veterans were providing care to someone in need, usually a family member. They presented multivariate analyses for physical and emotional burdens of caregiving as well as rewards, each of which considered caregiving-related variables, the veterans’ physical and mental health, cognitive status, and an array of other psychosocial variables, as well as combat exposure. Findings included observations that current mental health symptoms, primarily depression, predicted increases in emotional strain and that after controlling for other variables, combat exposure predicted decreases. To the extent that the ability to cope with the burdens of caregiving without increases in emotional strains represents a kind of stress test, this finding suggests that combat exposure may be associated with some improvements in functioning. In summary, the National Health and Resilience in Veterans study has already told us a good deal about older veterans. Most of them are aging successfully. In spite of their military service, most have had low levels of exposure to traumatic events, and among those who experienced high levels of trauma in combat or other contexts, most experienced a life course characterized by resilience. Twenty percent are actively involved in “careers” as caregivers for family members and others. However, as many as 44% are lonely and 6% experience suicidal ideation. Of course, these findings may be subject to biases related to the survival of those who are healthiest, fittest, least traumatized, and most resilient. Nevertheless, they are informative about the current generation of older veterans. Given that VA’s mission is to fulfill President Lincoln’s promise “To care for him who shall have borne the battle .,” the finding that negative effects of combat persist into late life represents a challenge. In an ideal world in which services to veterans were perfect, albeit one where there were still wars, the negative outcomes associated with combat would be
529
Editorial mitigated through treatment or, at least, reduced to those negative effects attributable to the irreversible physical and neurologic wounds of war. Unfortunately, veterans’ services are not perfect. However, together with other research, the National Health and Resilience in Veterans Study offers an opportunity for improvement. If additional analyses provide more information about the paths linking combat exposure with negative outcomes such as less successful aging and suicidal ideation in late life, the findings could inform the care of the current cohort of older veterans. Most simply, any potentially treatable condition that mediated the association between combat and the negative outcomes would be targets for added or
intensified interventions. In addition, understanding the outcomes associated with combat in the current cohort of older veterans could serve to inform longterm planning about how the VA should address the needs of younger veterans. Therefore, this information could be useful in guiding strategic planning for care for all veterans. Dr. Katz is an employee of the U.S. Department of Veterans Affairs where he serves as Senior Consultant for Mental Health Program Analysis. This Editorial does not reflect policies or positions of the U.S. Department of Veterans Affairs or the Veterans Health Administration.
References 1. U.S. Department of veterans Affairs: Veteran population. Population tables. 2013. Available at: www.va.gov/vetdata/Veteran_ Population.asp. Accessed January 26, 2014 2. U.S. Commerce Bureau: 2012 Gender table 1. 2013. Available at: www.census.gov/population/age/data/2012comp.html. Accessed January 24, 2014 3. Wiechars IR, Kirwin PD, Rosenheck R: Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses. Am J Geriatr Psychiatry 2014; 22:531e539 4. Garrido M, Penrod JD, Prigerson HG: Unmet need for mental health care among veterans receiving palliative care: assessment is not enough. Am J Geriatr Psychiatry 2014; 22:540e544 5. Yeager DE, Magruder KM: PCL scoring rules for elderly Veterans Affairs outpatients. Am J Geriatr Psychiatry 2014; 22:545e550 6. Pietrazk RH, Tsai J, Kirwin PD, et al: Successful aging among older veterans in the United States. Am J Geriatr Psychiatry 2014; 22:551e563 7. Kuwert P, Knaevelsrud C, Pietrzak RH: Loneliness among older veterans in the United States: results from the National Health and
530
8.
9. 10.
11.
12.
13.
Resilience in Veterans Study. Am J Geriatr Psychiatry 2014; 22: 564e569 Monin JK, Levy B, Pietrzak R: From serving in the military to serving loved ones: unique experiences of older veteran caregivers. Am J Geriatr Psychiatry 2014; 22:570e579 Irwin SA: Palliative care, geriatric psychiatry, and you. Am J Geriatr Psychiatry 2012; 20:281e283 Fairman N, Irwin SA: Palliative care psychiatry: update on an emerging dimension of psychiatry practice. Curr Psychiatry Rep 2013; 15:349 Pietrzak RH, Cook JM: Psychological resilience in older US veterans: results from the National Health and Resilience in Veterans Study. Depress Anxiety 2013; 30:432e443 Fanning JR, Pietrzak RH: Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study. J Psych Res 2013; 47:1766e1775 Prigerson HG, Maciejewski PK, Rosenheck RA: Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among US men. Am J Public Health 2002; 92:59e63
Am J Geriatr Psychiatry 22:6, June 2014
Mental Health Needs of Older Veterans Ira R. Katz, M.D., Ph.D.
I
n recent years, America has focused a good deal of attention on those younger veterans returning from the wars in Afghanistan and Iraq. Now that the American presence in Iraq has ended and its presence in Afghanistan is winding down, it is time to recognize the fact that most American veterans are old. In 2012, 46% of veteran men were over age 65 and 59% over age 60; conversely, 51% of American men over age 65 were veterans.1,2 Based on these statistics, a focus on the mental health needs of older veterans is an important part of population-based care. Moreover, understanding the trajectory of mental health needs over the lifespan is necessary to plan for the ongoing care of younger veterans as they age. Six articles in this month’s The American Journal of Geriatric Psychiatry focus on older veterans.3e8 They report on research addressing two themes. One is about the mental healthcare services provided to older adults by the Veterans Health Administration (VHA), the healthcare system of the U.S. Department of Veterans Affairs (VA). The other is concerned with post-traumatic stress disorder (PTSD) and related conditions and their impact across the lifespan, addressing the persistence of the effects of combat exposure into late life.
MENTAL HEALTH SERVICES PROVIDED BY VHA Three articles in this issue address matters directly related to mental healthcare services provide by VHA.3e5 VA research frequently focuses on the delivery of healthcare within VHA, in part because of the wealth of clinical and administrative data that are
available to VA investigators. In doing so, the research can, in general, serve two functions: raising issues that may be generalizable to other healthcare systems and identifying targets for quality improvement. Weichers et al.3 demonstrate that 30% of all VHA patients with prescriptions for a psychotropic medication in 2010 had no current mental health diagnosis in their medical records and, frequently, no apparent medical indication for the prescription. One of the primary findings was that this occurred most frequently among patients over age 65 and in those who did not receive mental health specialty services. The concern is that this may represent indiscriminate prescribing. It is possible that, in some cases, it could represent a well-meaning attempt to provide treatment without making diagnoses that could be perceived as stigmatizing; however, even allowing for this, there must be concerns about the specificity of prescribing without a diagnosis and about whether this sort of practice represents a barrier to appropriate monitoring and follow-up care. Weichers et al. note that the rates in VHA are similar to those reported elsewhere, and this article implicitly calls for further studies of the age dependence of prescribing without diagnoses and indications beyond VHA. More directly, the findings raise questions about the quality of psychopharmacologic treatment in VHA, especially for patients who do not receive mental health specialty care. This problem was discussed with VHA mental health leadership well before publication, and it has been included as a key issue in VHA’s ongoing quality improvement programming. Garrido et al.4 studied the care provided to seriously ill veterans who received inpatient consults for
Received January 29, 2014; accepted January 29, 2014. Send correspondence and reprint requests to Ira R. Katz, M.D., Ph.D., Philadelphia VA Medical Center, University and Woodland Aves., Philadelphia, PA 19104. e-mail: [email protected] Ó 2014 American Association for Geriatric Psychiatry http://dx.doi.org/10.1016/j.jagp.2014.01.014
Am J Geriatr Psychiatry 22:6, June 2014
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Editorial palliative care in one of VHA’s regional networks. They note that palliative care consults in this network included evaluations of psychological symptoms such as worry, nervousness, and sadness. Their major finding was that although 44% of the patients reported psychological distress in the past week, there was no evidence from the electronic medical record that the reports led to mental healthcare, either from the palliative care team or other providers. It is possible that the hospitals’ medical, nursing, and social work staff responded to the emotional needs of the palliative care patients in a way that was integrated in a moment to moment way with other components of their medical, nursing, and social work care; it is also possible that this was done but not documented in the medical record. Although this article focused on this issue as a problem within VHA, it is important to recognize that the roles of psychiatry and mental health services within hospices and palliative care are evolving on a national level. This was the focus of a special issue of this journal in 2012,9 and it remains an emerging dimension of psychiatric and mental health practice.10 The findings from Garrido et al.4 should be viewed as a call to action within VHA and should also serve as a cue to self-scrutiny for other hospice and palliative care programs. Finally, Yeager and Magruder5 report on agerelated changes in the psychometric properties of the PTSD Checklist, an instrument used by the VHA (and elsewhere) to screen for PTSD. They conducted a study in which both the screening test and “gold standard” clinical evaluations were conducted in a large sample of VHA patients, mostly selected at random. They report that the overall performance of the PTSD Checklist remained high across the entire sample but that there were significant differences in the optimal cut-points for identifying those who screened positive. Cut-points were 43 for veterans aged 21e49, 34 for veterans aged 50e64, and 24 for veterans aged 65e81. The findings update previous knowledge about how to identify patients with PTSD, especially in late life; this is of specific importance within the VHA. Of course, based on the current data, it is not possible to distinguish between age effects and those related to generational cohorts. Regardless, the differences are substantial, and the lower threshold should be considered in screening veterans for late-onset PTSD as well as for
528
monitoring those with histories of PTSD for relapses or recurrences. In addition, as suggested by the authors, the findings pose important questions about the nature of the differences between age groups (or cohorts) and whether they reflect differences in reporting styles, in the intensity with which symptoms are experienced, or in the nature and distribution of symptoms.
A LIFE-COURSE PERSPECTIVE ON COMBAT EXPOSURE Three articles in this issue are reports of findings from the National Health and Resilience in Veterans Study,6e8 a research study funded by the VA through the National Center for PTSD to characterize the longitudinal trajectories of PTSD and related mental health outcomes in a nationally representative sample of U.S. veterans; these articles are best viewed together with two other recent articles from this study.11,12 In general, this research is noteworthy because of the highly innovative approach it used to obtain web-based data from a representative sample of veterans and because of the area of investigation. Exposure to combat leads to increased rates of mental health conditions, including but not limited to PTSD. This effect accounts for a significant component of the nation’s burden of mental illness in young and middle aged adults.13 However, questions remain about the extent to which the effects of combat persist into late life, specifically about how combat exposure during military service affects the mental and physical health of veterans as they age and about the extent to which the effects are mediated through the association of combat with PTSD, other mental health conditions, and the observable physical and neurologic wounds of war. In an early report from this study, Pietrzak and Cook11 used cluster analyses of the number of reported traumatic events and symptoms of PTSD, depression, and generalized anxiety disorder to identify three clusters of veterans: a “control” group with low levels of exposure to traumatic events that accounted for 60% of the sample and two clusters with comparable exposure to higher numbers of traumatic events. These included a distressed group with high levels of current mental health symptoms that accounted for 12% of the sample and a resilient
Am J Geriatr Psychiatry 22:6, June 2014
Katz group that was experiencing low levels of symptoms in spite of their history of trauma that accounted for 28%. Combat exposure was reported by 54% of the distressed group and a comparable number, 53%, of the resilient group, both higher than the 28% reported in the control group. Clearly, combat exposure does not in and of itself lead to poor outcomes. Information about other characteristics of the person, the traumatic event(s), and life after the trauma (including information about treatment) are needed to explain differences between distressed and resilient outcomes in late life. Pietrzak et al.6 provide a view of successful aging in America’s veterans using confirmatory factor analysis to define a latent variable that includes selfperceptions of successful aging and measures of general health; physical, emotional, social, and cognitive functioning; enjoyment; and satisfaction. In univariate analyses, less successful aging was related to current mental health problems, primarily PTSD and major depression, as well as to histories of mental health and substance use disorders and combat exposure. Fanning and Pietrzak12 report that 6.0% of the sample had experienced thoughts of suicide within the previous 2 weeks. The rate in those with a history of combat exposure was 9%, higher than the 4% rate for other veterans. Across the entire sample, it was also associated with current symptoms and previous histories of PTSD and other mental health conditions. Current suicidal ideation was strongly associated with a history of a previous suicide attempt, providing further evidence that suicidality can be a chronic condition. In the study by Kuwert et al.,7 44% of older veterans reported feeling lonely at least some of the time and 10% reported feeling lonely often. The authors report that loneliness is associated with current symptoms of depression and PTSD; histories of mental health and substance use disorders were not evaluated. In contrast to the negative impact of combat on successful aging and suicidal ideation, univariate analyses demonstrated that combat exposure was weakly, but significantly, associated with lower levels of loneliness. For the negative outcomes reported in late life, such as less successful aging and suicidal ideation, the associations with PTSD and other mental health variables remained significant in multivariate analyses but the associations with combat exposure did
Am J Geriatr Psychiatry 22:6, June 2014
not. This suggests the persistent effects of combat may be mediated through the clinical, psychological, and social variables considered in these analyses. However, the multivariate models were complex, and the analyses presented could not identify the specific paths that may account for the effects. The National Health and Resilience in Veterans Study did, however, identify one direct effect of combat exposure that persists into late life. Monin et al.8 found that 20% of older veterans were providing care to someone in need, usually a family member. They presented multivariate analyses for physical and emotional burdens of caregiving as well as rewards, each of which considered caregiving-related variables, the veterans’ physical and mental health, cognitive status, and an array of other psychosocial variables, as well as combat exposure. Findings included observations that current mental health symptoms, primarily depression, predicted increases in emotional strain and that after controlling for other variables, combat exposure predicted decreases. To the extent that the ability to cope with the burdens of caregiving without increases in emotional strains represents a kind of stress test, this finding suggests that combat exposure may be associated with some improvements in functioning. In summary, the National Health and Resilience in Veterans study has already told us a good deal about older veterans. Most of them are aging successfully. In spite of their military service, most have had low levels of exposure to traumatic events, and among those who experienced high levels of trauma in combat or other contexts, most experienced a life course characterized by resilience. Twenty percent are actively involved in “careers” as caregivers for family members and others. However, as many as 44% are lonely and 6% experience suicidal ideation. Of course, these findings may be subject to biases related to the survival of those who are healthiest, fittest, least traumatized, and most resilient. Nevertheless, they are informative about the current generation of older veterans. Given that VA’s mission is to fulfill President Lincoln’s promise “To care for him who shall have borne the battle .,” the finding that negative effects of combat persist into late life represents a challenge. In an ideal world in which services to veterans were perfect, albeit one where there were still wars, the negative outcomes associated with combat would be
529
Editorial mitigated through treatment or, at least, reduced to those negative effects attributable to the irreversible physical and neurologic wounds of war. Unfortunately, veterans’ services are not perfect. However, together with other research, the National Health and Resilience in Veterans Study offers an opportunity for improvement. If additional analyses provide more information about the paths linking combat exposure with negative outcomes such as less successful aging and suicidal ideation in late life, the findings could inform the care of the current cohort of older veterans. Most simply, any potentially treatable condition that mediated the association between combat and the negative outcomes would be targets for added or
intensified interventions. In addition, understanding the outcomes associated with combat in the current cohort of older veterans could serve to inform longterm planning about how the VA should address the needs of younger veterans. Therefore, this information could be useful in guiding strategic planning for care for all veterans. Dr. Katz is an employee of the U.S. Department of Veterans Affairs where he serves as Senior Consultant for Mental Health Program Analysis. This Editorial does not reflect policies or positions of the U.S. Department of Veterans Affairs or the Veterans Health Administration.
References 1. U.S. Department of veterans Affairs: Veteran population. Population tables. 2013. Available at: www.va.gov/vetdata/Veteran_ Population.asp. Accessed January 26, 2014 2. U.S. Commerce Bureau: 2012 Gender table 1. 2013. Available at: www.census.gov/population/age/data/2012comp.html. Accessed January 24, 2014 3. Wiechars IR, Kirwin PD, Rosenheck R: Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses. Am J Geriatr Psychiatry 2014; 22:531e539 4. Garrido M, Penrod JD, Prigerson HG: Unmet need for mental health care among veterans receiving palliative care: assessment is not enough. Am J Geriatr Psychiatry 2014; 22:540e544 5. Yeager DE, Magruder KM: PCL scoring rules for elderly Veterans Affairs outpatients. Am J Geriatr Psychiatry 2014; 22:545e550 6. Pietrazk RH, Tsai J, Kirwin PD, et al: Successful aging among older veterans in the United States. Am J Geriatr Psychiatry 2014; 22:551e563 7. Kuwert P, Knaevelsrud C, Pietrzak RH: Loneliness among older veterans in the United States: results from the National Health and
530
8.
9. 10.
11.
12.
13.
Resilience in Veterans Study. Am J Geriatr Psychiatry 2014; 22: 564e569 Monin JK, Levy B, Pietrzak R: From serving in the military to serving loved ones: unique experiences of older veteran caregivers. Am J Geriatr Psychiatry 2014; 22:570e579 Irwin SA: Palliative care, geriatric psychiatry, and you. Am J Geriatr Psychiatry 2012; 20:281e283 Fairman N, Irwin SA: Palliative care psychiatry: update on an emerging dimension of psychiatry practice. Curr Psychiatry Rep 2013; 15:349 Pietrzak RH, Cook JM: Psychological resilience in older US veterans: results from the National Health and Resilience in Veterans Study. Depress Anxiety 2013; 30:432e443 Fanning JR, Pietrzak RH: Suicidality among older male veterans in the United States: results from the National Health and Resilience in Veterans Study. J Psych Res 2013; 47:1766e1775 Prigerson HG, Maciejewski PK, Rosenheck RA: Population attributable fractions of psychiatric disorders and behavioral outcomes associated with combat exposure among US men. Am J Public Health 2002; 92:59e63
Am J Geriatr Psychiatry 22:6, June 2014
