Epidemiologic Reviews Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Vol. 37, 2015 DOI: 10.1093/epirev/mxu003 Advance Access publication: January 19, 2015
Prevalence of Mental Health Disorders Among Justice-Involved Veterans
Janet C. Blodgett*, Tigran Avoundjian, Andrea K. Finlay, Joel Rosenthal, Steven M. Asch, Natalya C. Maisel, and Amanda M. Midboe * Correspondence to Janet C. Blodgett, Center for Innovation to Implementation, VA Palo Alto Health Care System (152MPD), 795 Willow Road, Menlo Park, CA 94025 (e-mail: [email protected]).
Justice-involved veterans are a special population with unique mental health needs compared with other veterans or justice-involved adults. Prevalence estimates of mental health concerns of justice-involved veterans across 18 samples of these veterans (1987–2013), including both incarcerated and community samples, were identified through a systematic literature search of published studies supplemented by Department of Veterans Affairs Veterans Justice Programs data. Despite heterogeneity across samples and measures used, the review highlights several prominent mental health concerns among veterans. Many justice-involved veterans have likely experienced at least one traumatic event, and many have post-traumatic stress disorder (prevalence from 4% to 39% across samples). At least half of justice-involved veterans have an alcohol and/or drug use disorder (estimates as high as 71% and 65%, respectively), and other psychiatric disorders, such as depression (14%–51%) and psychotic disorders (4%– 14%), are common. Justice-involved veterans with comorbid substance use and psychiatric disorders are at increased risk of negative outcomes, including homelessness and violent behavior. Overall, comparisons of justice-involved veterans with other justice-involved adults found a slightly higher rate of mental health concerns among justice-involved veterans, with some indication that intravenous drug use is more prevalent. Compared with other veterans, justiceinvolved veterans have consistently higher rates of mental health concerns, particularly substance use disorders. criminology; mental disorders; veterans
Abbreviations: OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn; PTSD, posttraumatic stress disorder; VA, Department of Veterans Affairs.
including negative outcomes such as homelessness and recidivism (5). A greater understanding of these, and other, mental health needs of justice-involved veterans by health-care providers (inside and outside VA), as well as others in the criminal justice system, may contribute to improved and increasingly responsive care for justice-involved veterans.
INTRODUCTION
The majority of men and women who serve in the US armed forces successfully return to a productive civilian life, while a minority contend with struggles such as mental health problems, substance use disorders, homelessness, and involvement in the criminal justice system. The subgroup of justiceinvolved veterans has been identified by the Department of Veterans Affairs (VA), the Substance Abuse and Mental Health Services Administration, and the Bureau of Justice Statistics as an important subgroup of justice-involved adults who may have unique mental health concerns (1–3). In general, justiceinvolved adults have high rates of traumatic experiences and increased risk for mental health concerns, with justice-involved veterans potentially at additional risk given the nature of military service (2, 4). Another prominent concern among justiceinvolved adults is the prevalence of substance use disorders, which can have a great impact on long-term adjustment,
Prevalence of justice-involved veterans
Approximately 10% of incarcerated adults (i.e., those in jail or prison) have served in the military (3, 6, 7), comprising approximately 210,000 veterans. Considering that approximately 75% of the total correctional population is on probation or parole in the community (8), the total number of justice-involved veterans may be several times larger than the number who are currently incarcerated. The VA has identified the population of justice-involved veterans as a special group that is likely to have additional and/or unique needs 163
Epidemiol Rev 2015;37:163–176
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Accepted for publication August 20, 2014.
164 Blodgett et al.
and has dedicated outreach resources to linking them with appropriate services. Unique characteristics of justice-involved veterans
Prevalence coding Current study
We provide a systematic review of the research literature to describe the prevalence of mental health problems among justice-involved veterans. We present rates as they relate to mental health concerns generally followed by rates for more specific concerns and diagnoses. These concerns include trauma and post-traumatic stress disorder (PTSD), substance use disorders, mood disorders, psychotic disorders, personality disorders, and suicidality. Finally, we examine direct comparisons of justice-involved veterans with other justice-involved adults and with other veterans. METHODS Selection criteria
Using very broad criteria, we included all published sources of information related to the rate of mental health problems among justice-involved veterans. The population of interest included all adults who previously served in any branch of the US military and were involved in any stage of the criminal justice system (i.e., courts, community supervision, jails, and prisons). A systematic search was focused on identifying reports of the prevalence of mental health problems in samples of justice-involved veterans. This included administrative data as well as more formal studies of selected samples. We excluded from the systematic review studies that focused on a sample of justice-involved veterans who all had a mental health problem (e.g., a study that examined rates of justice involvement among veterans who had a serious mental illness). Relevant studies that were excluded from the formal synthesis contributed to some discussion points. Search strategy
We searched bibliographic databases including PubMed, PsycInfo, Scopus, and Google Scholar. Search terms included veteran* (* is a wildcard symbol, in this case including in the search both “veteran” and “veterans”), justice-involvement
Two coders extracted information from each of the studies included in the synthesis of prevalence rates of mental health problems in justice-involved veterans. Extracted information included the setting (i.e., where the data were collected), the sample size (i.e., the number of justice-involved veterans included in the prevalence rate estimate(s)), a brief description of how and when the sample of justice-involved veterans was selected, the mean age of the sample of justice-involved veterans, the percentage of the justice-involved veteran sample that was women veterans, and the percentage of justiceinvolved veterans from different eras of service and/or with combat experience. The coders also recorded the prevalence rate of each type of mental health problem, as reported in each source. For substance use disorders, we recorded the prevalence where it was specified as abuse or dependence on drugs and/or alcohol rather than, for example, the proportion of justiceinvolved veterans who reported having ever used a specific substance during a specified period of time. For each mental health problem or condition, the coders recorded a brief description of how it was measured or identified (e.g., using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria, self-reported by the justice-involved veteran). RESULTS Description of the sample
Table 1 provides details of the identified sources of information on the rate of mental health problems among justiceinvolved veterans. A total of 14 publications met our criteria for inclusion in the synthesis estimating the prevalence of mental health problems among justice-involved veterans. We also obtained internal VA administrative data for the 2 Veterans Justice Programs, Veterans Justice Outreach and Health Care for Reentry Veterans. Several of these sources presented data for more than one distinct sample of justice-involved veterans (e.g., rates for justice-involved veterans in prisons and those in jails presented separately). In 2 instances, 2 publications were based on the same sample of data (Table 1). Epidemiol Rev 2015;37:163–176
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Justice-involved veterans are distinct from other justiceinvolved adults in a variety of ways and may also have different mental health needs. Demographically, justice-involved veterans tend to be older (i.e., with a median age of 10–12 years older), more educated, and more likely to be white nonHispanic than nonveterans (3, 7, 9). Justice-involved veterans have a somewhat different offense profile as compared with other justice-involved adults, with evidence of higher rates of certain types of violent offenses (e.g., sexual offenses and intimate partner violence) and of driving under the influence offenses (3, 7, 10; Department of Veterans Affairs Veterans Justice Programs, unpublished data, 2012). Finally, justice-involved veterans by definition have had the unique experience of serving in the military, sometimes in combat.
terms (e.g., justice-involved, offender*, criminal*, prison*, parole*, probation*, inmate*, incarcerat*), and psychiatric needs–related terms (e.g., psychiatric, mental illness, mental health problem*, drug, substance use, alcohol). Additional citations were identified by reviewing the reference sections of relevant publications. We also searched for relevant reports from specific organizations including the Bureau of Justice Statistics, the US National Institute of Justice, the Substance Abuse and Mental Health Services Administration’s National GAINS Center, and the US Bureau of Prisons. Further research, including internal data, was identified in partnership with the VA Veterans Justice Programs as part of a VA report synthesizing research relevant to justice-involved veterans (11). Expert reviewers provided feedback and additional important citations after reviewing that report. All samples identified from the aforementioned sources were examined by 2 coders, who reviewed full text publications to assess whether each report met all inclusion criteria and no exclusion criteria.
Mental Health of Justice-Involved Veterans 165
Table 1. Samples of Justice-Involved Veterans Included in the Systematic Review, 1987–2013 First Author, Year (Reference No.)
Setting(s)
Tsai, 2013 (15); Tsai, 2013 (54)a
Prisons
Tejani, 2014 (36)
Community
Sample Size
Description of the Sample and Selection Method
All veterans in state and federal prisons who had contact with HCRV from October 2007 to April 2011
9,534
Subgroup of veterans with a history of incarceration who entered VA’s HUD-VASH program during 2008 and 2009b
Department of Veterans Prisons Affairs, 2012 (unpublished data)
7,623
All veterans in state and federal prisons who had contact with HCRV from April 2011 to April 2012
Department of Veterans Jails and courts Affairs, 2012 (unpublished data)
7,055
All veterans in jails and courts who had contact with VJO from April 2011 to April 2012
132
Subgroup of veterans in a random sample of arrestees in Maricopa County in 2009c
42
Subgroup of sex offenders contacted by the Cincinnati VA through the Incarcerated Veteran Outreach Program from 2004 to 2008
White, 2012 (9)
Jail
Schaffer, 2011 (29)
Correctional settings and VA
Greenberg, 2009 (34)
Jails
636
Subgroup of male veterans included in the 2002 Survey of Inmates in Local Jailsb
Erickson, 2008 (33)
Community
228
Subgroup of veterans who were incarcerated within a year of their discharge from VA inpatient services (medical, surgical, psychiatric, or substance abuse) between 1993 and 1997b
Noonan, 2007 (3)d
State prisons
NRe
Subgroup of veterans included in the Survey of Inmates in State and Federal Correctional Facilities, 2004c
Federal prisons
NRf
Subgroup of veterans included in the Survey of Inmates in State and Federal Correctional Facilities, 2004c
Williams, 2010 (14)d
Prisons
142
Subgroup of veterans aged ≥55 years and within 2 years of release included in the 2004 Survey of Inmates in State and Federal Correctional Facilitiesc
Black, 2005 (32)
Community
497
Subgroup of ever-incarcerated Gulf War veterans included in a population-based telephone survey of Gulf War era veterans from Iowa conducted between September 1995 and May 1996b
McGuire, 2003 (35)
Jail
1,676
Veterans contacted in LA County Jail by HCRV outreach workers between May 1997 and October 1999b
Saxon, 2001 (13)
Jail
129
Convenience sample of veterans in the King County Jail system collected between April 1998 and June 1999
Mumola, 2000 (7)
State prisons
NRg
Subgroup of veterans included in the 1997 Survey of Inmates in State and Federal Correctional Facilitiesc
Federal prisons
NRh
Subgroup of veterans included in the 1997 Survey of Inmates in State and Federal Correctional Facilitiesc
Jails Shaw, 1987 (37)
Correctional institutions
718i 31
Subgroup of veterans included in the 1996 Survey of Inmates in Local Jailsc Random sample of Vietnam veterans in 6 Iowa correctional institutions within 100 milesj of Iowa City
Abbreviations: HCRV, Health Care for Reentry Veterans; HUD, Department of Housing and Urban Development; JIV, justice-involved veteran; LA, Los Angeles; NR, not reported; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn; VA, Department of Veterans Affairs; VASH, Veterans Affairs Supportive Housing; VJO, Veterans Justice Outreach. a Tsai et al. (15) and Tsai et al. (54) were both based on HCRV administrative data from 2007 to 2011. One of the publications (15) compared OEF/OIF/OND JIVs with other JIVs, and the other (54) made comparisons across racial groups. Only Tsai et al. (15) reported overall rates of mental health problems for the full sample, so that is what we report on here. b Also includes a comparison with other veterans. c Also includes a comparison with other justice-involved adults. d Williams et al. (14) focuses on a sample of older JIVs nearing release from prison that was a subgroup of the JIVs included in Noonan and Mumola (3). In this case, Williams et al. (14) report additional outcomes not reported in Noonan and Mumola (3) and report state and federal prisoners as a single sample, so we have included it as a separate sample in our analysis. e Full survey sample size (including veterans and nonveterans) = 14,499 (55). f Full survey sample size (including veterans and nonveterans) = 3,686 (55). g Full survey sample size (including veterans and nonveterans) = 14,285 (56). h Full survey sample size (including veterans and nonveterans) = 4,041 (56). i Sample size was reported by Harlow (57). j One mile = 1.6 km.
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30,968
166 Blodgett et al.
Prevalence of psychiatric disorders
Many justice-involved veterans have problems that may benefit from mental health treatment. Across 13 samples of justice-involved veterans that reported a general rate for mental health problems, 13%–62% of justice-involved veterans had some mental health problems (Table 3). Rates on the lower end were found by using more strict measures, such as a justice-involved veteran self-reporting that a mental health professional had diagnosed him or her with a specific condition, while the reported rates were higher when lessstrict measures were used (e.g., a justice-involved veteran self-reporting recently experiencing any symptoms of a psychiatric disorder). In the sections below, we will discuss reported rates of specific psychiatric conditions and groups of psychiatric conditions in the identified samples of justiceinvolved veterans. Likewise, we will discuss the important subgroup of justice-involved veterans who struggle with comorbid psychiatric and substance use disorders. This group requires particular attention because of its association with offending, as well as the importance of providing integrated psychiatric and substance use disorder treatment to those who have comorbid disorders (12). History of trauma and ongoing PTSD
Nearly all justice-involved veterans have experienced trauma, service related and/or non–service related. Servicerelated traumatic experience is not limited to combat trauma. For example, a justice-involved veteran may have been a victim
of military sexual trauma, been in noncombat traffic accidents that occurred during service, and/or experienced stress associated with long deployment periods followed by a difficult transition back to civilian life after discharge. In one sample of mostly male jail-incarcerated veterans, 87% reported a history of trauma, with the most common types of trauma including the following: being physically assaulted or threatened with a weapon (50%), being physically abused as a child (25%), and experiencing combat trauma (25%) (13). Such service-related and non–service-related traumatic experiences sometimes leave justice-involved veterans with ongoing trauma-related mental health issues, including PTSD. The overall rates of PTSD ranged from 4% to 39% for general PTSD (across 5 samples) and from 5% to 27% for specifically combat-related PTSD (across 4 samples). In subgroup comparisons, Williams et al. (14) found that, among older veterans in prison, PTSD was more common among combat veterans than non–combat veterans (24% vs. 7%), while Tsai et al. (15) found the rate of combat-related PTSD to be especially high among OEF/OIF/OND veterans in prison (38% compared with 5% of other veterans in prison). In the study of trauma in the justice-involved veterans mentioned above, those veterans who screened positive for current PTSD had a greater variety of traumas, more current legal problems, more alcohol and drug use, more psychiatric symptoms, worse general health, and more previous mental health, medical, and substance use disorder treatment compared with veterans who did not screen positive for PTSD (13). Within the context of a wide range of possible sources of trauma, particular attention in the literature has been paid to the specific impact of combat trauma on subsequent violence and offending by some veterans. With regard to combat trauma and criminal offending, although it is important to consider and acknowledge strong premilitary risk factors, such as a history of violence and/or family instability in childhood (16–18), of unique concern to justiceinvolved veterans is understanding the relation between combat trauma and criminal offending. A variety of research has found an association between combat trauma, especially that resulting in PTSD and/or high levels of anger/irritability, and subsequent, often violent, offending. For example, 2 reviews that explored perpetration of intimate partner violence by veterans concluded that it was particularly associated with the presence and severity of PTSD after combat exposure (10, 19). Additionally, a recent study by Elbogen et al. (20) found that, in a multivariate analysis, PTSD was associated with a higher risk of arrest only when accompanied by high levels of anger/irritability (odds ratio = 2.13) (P = 0.02). Substance use disorders
A significant concern among justice-involved veterans is substance abuse and dependence. Across the samples reporting the rate of alcohol and/or drug use disorders, the rate ranged from 21% to 71% for alcohol use disorders (across 15 samples) and from 26% to 65% for drug use disorders (across 11 samples). In the 2 samples that reported a rate for any substance use disorder, 57% and 61% of justice-involved veterans met criteria for a drug and/or alcohol use disorder. Epidemiol Rev 2015;37:163–176
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In total, the identified sources included 18 samples of justice-involved veterans. The sources included samples of justice-involved veterans from prisons (7 samples), jails and courts (6 samples), unspecified correctional institutions (2 samples), and other community settings (3 samples). Seven of the samples comprised justice-involved veterans identified through VA treatment services or by VA outreach workers, while a further 7 samples were based on surveys conducted by the Bureau of Justice Statistics. Table 2 includes summary demographic information for each of the included samples. The average age of justice-involved veterans in the samples was generally between 40 and 50 years of age. Women justice-involved veterans made up a very small part of the included samples (usually less than 2%). For the most part, the samples included few Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans, although the proportion was higher in some of the more recently selected samples. When reported, the proportion of justice-involved veterans who had combat experience (in any era) ranged from 15% to 30%. The measurement and definition of specific mental health problems varied across sources, from formal diagnoses of specific disorders to self-reports of troubling symptoms. Consequently, we are able to provide only a qualitative synthesis based around the range of findings across the identified samples. The large differences in sample characteristics, as well as significant variations in measures used, were not conducive to a quantitative synthesis of specific prevalence rates. Table 3 includes the prevalence rates for each mental health concern or condition.
Mental Health of Justice-Involved Veterans 167
Table 2. Summary of Justice-Involved Veterans Included in the Systematic Review, 1987–2013 Age, Years First Author, Year (Reference No.)
Women
Service Era
Setting(s) Mean
Tsai, 2013 (15); Tsai, 2013 (54) Prisons
Mean (SD)
Median
48.4 (10.6)
No.
524
Era of Service/Combat Experience
%
No.
%
2 OEF/OIF/OND Combat exposure
1,201 4,553
4 15
Combat exposure
Community
NR
NR
1,662
17
Department of Veterans Affairs, 2012 (unpublished data)
Prisons
50
187
2 OEF/OIF/OND Operation Desert Storm Vietnam War Korean War World War II Combat exposure
516 569 922 47 15 1,341
7 8 12 1
Vol. 37, 2015 DOI: 10.1093/epirev/mxu003 Advance Access publication: January 19, 2015
Prevalence of Mental Health Disorders Among Justice-Involved Veterans
Janet C. Blodgett*, Tigran Avoundjian, Andrea K. Finlay, Joel Rosenthal, Steven M. Asch, Natalya C. Maisel, and Amanda M. Midboe * Correspondence to Janet C. Blodgett, Center for Innovation to Implementation, VA Palo Alto Health Care System (152MPD), 795 Willow Road, Menlo Park, CA 94025 (e-mail: [email protected]).
Justice-involved veterans are a special population with unique mental health needs compared with other veterans or justice-involved adults. Prevalence estimates of mental health concerns of justice-involved veterans across 18 samples of these veterans (1987–2013), including both incarcerated and community samples, were identified through a systematic literature search of published studies supplemented by Department of Veterans Affairs Veterans Justice Programs data. Despite heterogeneity across samples and measures used, the review highlights several prominent mental health concerns among veterans. Many justice-involved veterans have likely experienced at least one traumatic event, and many have post-traumatic stress disorder (prevalence from 4% to 39% across samples). At least half of justice-involved veterans have an alcohol and/or drug use disorder (estimates as high as 71% and 65%, respectively), and other psychiatric disorders, such as depression (14%–51%) and psychotic disorders (4%– 14%), are common. Justice-involved veterans with comorbid substance use and psychiatric disorders are at increased risk of negative outcomes, including homelessness and violent behavior. Overall, comparisons of justice-involved veterans with other justice-involved adults found a slightly higher rate of mental health concerns among justice-involved veterans, with some indication that intravenous drug use is more prevalent. Compared with other veterans, justiceinvolved veterans have consistently higher rates of mental health concerns, particularly substance use disorders. criminology; mental disorders; veterans
Abbreviations: OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn; PTSD, posttraumatic stress disorder; VA, Department of Veterans Affairs.
including negative outcomes such as homelessness and recidivism (5). A greater understanding of these, and other, mental health needs of justice-involved veterans by health-care providers (inside and outside VA), as well as others in the criminal justice system, may contribute to improved and increasingly responsive care for justice-involved veterans.
INTRODUCTION
The majority of men and women who serve in the US armed forces successfully return to a productive civilian life, while a minority contend with struggles such as mental health problems, substance use disorders, homelessness, and involvement in the criminal justice system. The subgroup of justiceinvolved veterans has been identified by the Department of Veterans Affairs (VA), the Substance Abuse and Mental Health Services Administration, and the Bureau of Justice Statistics as an important subgroup of justice-involved adults who may have unique mental health concerns (1–3). In general, justiceinvolved adults have high rates of traumatic experiences and increased risk for mental health concerns, with justice-involved veterans potentially at additional risk given the nature of military service (2, 4). Another prominent concern among justiceinvolved adults is the prevalence of substance use disorders, which can have a great impact on long-term adjustment,
Prevalence of justice-involved veterans
Approximately 10% of incarcerated adults (i.e., those in jail or prison) have served in the military (3, 6, 7), comprising approximately 210,000 veterans. Considering that approximately 75% of the total correctional population is on probation or parole in the community (8), the total number of justice-involved veterans may be several times larger than the number who are currently incarcerated. The VA has identified the population of justice-involved veterans as a special group that is likely to have additional and/or unique needs 163
Epidemiol Rev 2015;37:163–176
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Accepted for publication August 20, 2014.
164 Blodgett et al.
and has dedicated outreach resources to linking them with appropriate services. Unique characteristics of justice-involved veterans
Prevalence coding Current study
We provide a systematic review of the research literature to describe the prevalence of mental health problems among justice-involved veterans. We present rates as they relate to mental health concerns generally followed by rates for more specific concerns and diagnoses. These concerns include trauma and post-traumatic stress disorder (PTSD), substance use disorders, mood disorders, psychotic disorders, personality disorders, and suicidality. Finally, we examine direct comparisons of justice-involved veterans with other justice-involved adults and with other veterans. METHODS Selection criteria
Using very broad criteria, we included all published sources of information related to the rate of mental health problems among justice-involved veterans. The population of interest included all adults who previously served in any branch of the US military and were involved in any stage of the criminal justice system (i.e., courts, community supervision, jails, and prisons). A systematic search was focused on identifying reports of the prevalence of mental health problems in samples of justice-involved veterans. This included administrative data as well as more formal studies of selected samples. We excluded from the systematic review studies that focused on a sample of justice-involved veterans who all had a mental health problem (e.g., a study that examined rates of justice involvement among veterans who had a serious mental illness). Relevant studies that were excluded from the formal synthesis contributed to some discussion points. Search strategy
We searched bibliographic databases including PubMed, PsycInfo, Scopus, and Google Scholar. Search terms included veteran* (* is a wildcard symbol, in this case including in the search both “veteran” and “veterans”), justice-involvement
Two coders extracted information from each of the studies included in the synthesis of prevalence rates of mental health problems in justice-involved veterans. Extracted information included the setting (i.e., where the data were collected), the sample size (i.e., the number of justice-involved veterans included in the prevalence rate estimate(s)), a brief description of how and when the sample of justice-involved veterans was selected, the mean age of the sample of justice-involved veterans, the percentage of the justice-involved veteran sample that was women veterans, and the percentage of justiceinvolved veterans from different eras of service and/or with combat experience. The coders also recorded the prevalence rate of each type of mental health problem, as reported in each source. For substance use disorders, we recorded the prevalence where it was specified as abuse or dependence on drugs and/or alcohol rather than, for example, the proportion of justiceinvolved veterans who reported having ever used a specific substance during a specified period of time. For each mental health problem or condition, the coders recorded a brief description of how it was measured or identified (e.g., using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria, self-reported by the justice-involved veteran). RESULTS Description of the sample
Table 1 provides details of the identified sources of information on the rate of mental health problems among justiceinvolved veterans. A total of 14 publications met our criteria for inclusion in the synthesis estimating the prevalence of mental health problems among justice-involved veterans. We also obtained internal VA administrative data for the 2 Veterans Justice Programs, Veterans Justice Outreach and Health Care for Reentry Veterans. Several of these sources presented data for more than one distinct sample of justice-involved veterans (e.g., rates for justice-involved veterans in prisons and those in jails presented separately). In 2 instances, 2 publications were based on the same sample of data (Table 1). Epidemiol Rev 2015;37:163–176
Downloaded from http://epirev.oxfordjournals.org/ at University of New Orleans on June 5, 2015
Justice-involved veterans are distinct from other justiceinvolved adults in a variety of ways and may also have different mental health needs. Demographically, justice-involved veterans tend to be older (i.e., with a median age of 10–12 years older), more educated, and more likely to be white nonHispanic than nonveterans (3, 7, 9). Justice-involved veterans have a somewhat different offense profile as compared with other justice-involved adults, with evidence of higher rates of certain types of violent offenses (e.g., sexual offenses and intimate partner violence) and of driving under the influence offenses (3, 7, 10; Department of Veterans Affairs Veterans Justice Programs, unpublished data, 2012). Finally, justice-involved veterans by definition have had the unique experience of serving in the military, sometimes in combat.
terms (e.g., justice-involved, offender*, criminal*, prison*, parole*, probation*, inmate*, incarcerat*), and psychiatric needs–related terms (e.g., psychiatric, mental illness, mental health problem*, drug, substance use, alcohol). Additional citations were identified by reviewing the reference sections of relevant publications. We also searched for relevant reports from specific organizations including the Bureau of Justice Statistics, the US National Institute of Justice, the Substance Abuse and Mental Health Services Administration’s National GAINS Center, and the US Bureau of Prisons. Further research, including internal data, was identified in partnership with the VA Veterans Justice Programs as part of a VA report synthesizing research relevant to justice-involved veterans (11). Expert reviewers provided feedback and additional important citations after reviewing that report. All samples identified from the aforementioned sources were examined by 2 coders, who reviewed full text publications to assess whether each report met all inclusion criteria and no exclusion criteria.
Mental Health of Justice-Involved Veterans 165
Table 1. Samples of Justice-Involved Veterans Included in the Systematic Review, 1987–2013 First Author, Year (Reference No.)
Setting(s)
Tsai, 2013 (15); Tsai, 2013 (54)a
Prisons
Tejani, 2014 (36)
Community
Sample Size
Description of the Sample and Selection Method
All veterans in state and federal prisons who had contact with HCRV from October 2007 to April 2011
9,534
Subgroup of veterans with a history of incarceration who entered VA’s HUD-VASH program during 2008 and 2009b
Department of Veterans Prisons Affairs, 2012 (unpublished data)
7,623
All veterans in state and federal prisons who had contact with HCRV from April 2011 to April 2012
Department of Veterans Jails and courts Affairs, 2012 (unpublished data)
7,055
All veterans in jails and courts who had contact with VJO from April 2011 to April 2012
132
Subgroup of veterans in a random sample of arrestees in Maricopa County in 2009c
42
Subgroup of sex offenders contacted by the Cincinnati VA through the Incarcerated Veteran Outreach Program from 2004 to 2008
White, 2012 (9)
Jail
Schaffer, 2011 (29)
Correctional settings and VA
Greenberg, 2009 (34)
Jails
636
Subgroup of male veterans included in the 2002 Survey of Inmates in Local Jailsb
Erickson, 2008 (33)
Community
228
Subgroup of veterans who were incarcerated within a year of their discharge from VA inpatient services (medical, surgical, psychiatric, or substance abuse) between 1993 and 1997b
Noonan, 2007 (3)d
State prisons
NRe
Subgroup of veterans included in the Survey of Inmates in State and Federal Correctional Facilities, 2004c
Federal prisons
NRf
Subgroup of veterans included in the Survey of Inmates in State and Federal Correctional Facilities, 2004c
Williams, 2010 (14)d
Prisons
142
Subgroup of veterans aged ≥55 years and within 2 years of release included in the 2004 Survey of Inmates in State and Federal Correctional Facilitiesc
Black, 2005 (32)
Community
497
Subgroup of ever-incarcerated Gulf War veterans included in a population-based telephone survey of Gulf War era veterans from Iowa conducted between September 1995 and May 1996b
McGuire, 2003 (35)
Jail
1,676
Veterans contacted in LA County Jail by HCRV outreach workers between May 1997 and October 1999b
Saxon, 2001 (13)
Jail
129
Convenience sample of veterans in the King County Jail system collected between April 1998 and June 1999
Mumola, 2000 (7)
State prisons
NRg
Subgroup of veterans included in the 1997 Survey of Inmates in State and Federal Correctional Facilitiesc
Federal prisons
NRh
Subgroup of veterans included in the 1997 Survey of Inmates in State and Federal Correctional Facilitiesc
Jails Shaw, 1987 (37)
Correctional institutions
718i 31
Subgroup of veterans included in the 1996 Survey of Inmates in Local Jailsc Random sample of Vietnam veterans in 6 Iowa correctional institutions within 100 milesj of Iowa City
Abbreviations: HCRV, Health Care for Reentry Veterans; HUD, Department of Housing and Urban Development; JIV, justice-involved veteran; LA, Los Angeles; NR, not reported; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn; VA, Department of Veterans Affairs; VASH, Veterans Affairs Supportive Housing; VJO, Veterans Justice Outreach. a Tsai et al. (15) and Tsai et al. (54) were both based on HCRV administrative data from 2007 to 2011. One of the publications (15) compared OEF/OIF/OND JIVs with other JIVs, and the other (54) made comparisons across racial groups. Only Tsai et al. (15) reported overall rates of mental health problems for the full sample, so that is what we report on here. b Also includes a comparison with other veterans. c Also includes a comparison with other justice-involved adults. d Williams et al. (14) focuses on a sample of older JIVs nearing release from prison that was a subgroup of the JIVs included in Noonan and Mumola (3). In this case, Williams et al. (14) report additional outcomes not reported in Noonan and Mumola (3) and report state and federal prisoners as a single sample, so we have included it as a separate sample in our analysis. e Full survey sample size (including veterans and nonveterans) = 14,499 (55). f Full survey sample size (including veterans and nonveterans) = 3,686 (55). g Full survey sample size (including veterans and nonveterans) = 14,285 (56). h Full survey sample size (including veterans and nonveterans) = 4,041 (56). i Sample size was reported by Harlow (57). j One mile = 1.6 km.
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30,968
166 Blodgett et al.
Prevalence of psychiatric disorders
Many justice-involved veterans have problems that may benefit from mental health treatment. Across 13 samples of justice-involved veterans that reported a general rate for mental health problems, 13%–62% of justice-involved veterans had some mental health problems (Table 3). Rates on the lower end were found by using more strict measures, such as a justice-involved veteran self-reporting that a mental health professional had diagnosed him or her with a specific condition, while the reported rates were higher when lessstrict measures were used (e.g., a justice-involved veteran self-reporting recently experiencing any symptoms of a psychiatric disorder). In the sections below, we will discuss reported rates of specific psychiatric conditions and groups of psychiatric conditions in the identified samples of justiceinvolved veterans. Likewise, we will discuss the important subgroup of justice-involved veterans who struggle with comorbid psychiatric and substance use disorders. This group requires particular attention because of its association with offending, as well as the importance of providing integrated psychiatric and substance use disorder treatment to those who have comorbid disorders (12). History of trauma and ongoing PTSD
Nearly all justice-involved veterans have experienced trauma, service related and/or non–service related. Servicerelated traumatic experience is not limited to combat trauma. For example, a justice-involved veteran may have been a victim
of military sexual trauma, been in noncombat traffic accidents that occurred during service, and/or experienced stress associated with long deployment periods followed by a difficult transition back to civilian life after discharge. In one sample of mostly male jail-incarcerated veterans, 87% reported a history of trauma, with the most common types of trauma including the following: being physically assaulted or threatened with a weapon (50%), being physically abused as a child (25%), and experiencing combat trauma (25%) (13). Such service-related and non–service-related traumatic experiences sometimes leave justice-involved veterans with ongoing trauma-related mental health issues, including PTSD. The overall rates of PTSD ranged from 4% to 39% for general PTSD (across 5 samples) and from 5% to 27% for specifically combat-related PTSD (across 4 samples). In subgroup comparisons, Williams et al. (14) found that, among older veterans in prison, PTSD was more common among combat veterans than non–combat veterans (24% vs. 7%), while Tsai et al. (15) found the rate of combat-related PTSD to be especially high among OEF/OIF/OND veterans in prison (38% compared with 5% of other veterans in prison). In the study of trauma in the justice-involved veterans mentioned above, those veterans who screened positive for current PTSD had a greater variety of traumas, more current legal problems, more alcohol and drug use, more psychiatric symptoms, worse general health, and more previous mental health, medical, and substance use disorder treatment compared with veterans who did not screen positive for PTSD (13). Within the context of a wide range of possible sources of trauma, particular attention in the literature has been paid to the specific impact of combat trauma on subsequent violence and offending by some veterans. With regard to combat trauma and criminal offending, although it is important to consider and acknowledge strong premilitary risk factors, such as a history of violence and/or family instability in childhood (16–18), of unique concern to justiceinvolved veterans is understanding the relation between combat trauma and criminal offending. A variety of research has found an association between combat trauma, especially that resulting in PTSD and/or high levels of anger/irritability, and subsequent, often violent, offending. For example, 2 reviews that explored perpetration of intimate partner violence by veterans concluded that it was particularly associated with the presence and severity of PTSD after combat exposure (10, 19). Additionally, a recent study by Elbogen et al. (20) found that, in a multivariate analysis, PTSD was associated with a higher risk of arrest only when accompanied by high levels of anger/irritability (odds ratio = 2.13) (P = 0.02). Substance use disorders
A significant concern among justice-involved veterans is substance abuse and dependence. Across the samples reporting the rate of alcohol and/or drug use disorders, the rate ranged from 21% to 71% for alcohol use disorders (across 15 samples) and from 26% to 65% for drug use disorders (across 11 samples). In the 2 samples that reported a rate for any substance use disorder, 57% and 61% of justice-involved veterans met criteria for a drug and/or alcohol use disorder. Epidemiol Rev 2015;37:163–176
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In total, the identified sources included 18 samples of justice-involved veterans. The sources included samples of justice-involved veterans from prisons (7 samples), jails and courts (6 samples), unspecified correctional institutions (2 samples), and other community settings (3 samples). Seven of the samples comprised justice-involved veterans identified through VA treatment services or by VA outreach workers, while a further 7 samples were based on surveys conducted by the Bureau of Justice Statistics. Table 2 includes summary demographic information for each of the included samples. The average age of justice-involved veterans in the samples was generally between 40 and 50 years of age. Women justice-involved veterans made up a very small part of the included samples (usually less than 2%). For the most part, the samples included few Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) veterans, although the proportion was higher in some of the more recently selected samples. When reported, the proportion of justice-involved veterans who had combat experience (in any era) ranged from 15% to 30%. The measurement and definition of specific mental health problems varied across sources, from formal diagnoses of specific disorders to self-reports of troubling symptoms. Consequently, we are able to provide only a qualitative synthesis based around the range of findings across the identified samples. The large differences in sample characteristics, as well as significant variations in measures used, were not conducive to a quantitative synthesis of specific prevalence rates. Table 3 includes the prevalence rates for each mental health concern or condition.
Mental Health of Justice-Involved Veterans 167
Table 2. Summary of Justice-Involved Veterans Included in the Systematic Review, 1987–2013 Age, Years First Author, Year (Reference No.)
Women
Service Era
Setting(s) Mean
Tsai, 2013 (15); Tsai, 2013 (54) Prisons
Mean (SD)
Median
48.4 (10.6)
No.
524
Era of Service/Combat Experience
%
No.
%
2 OEF/OIF/OND Combat exposure
1,201 4,553
4 15
Combat exposure
Community
NR
NR
1,662
17
Department of Veterans Affairs, 2012 (unpublished data)
Prisons
50
187
2 OEF/OIF/OND Operation Desert Storm Vietnam War Korean War World War II Combat exposure
516 569 922 47 15 1,341
7 8 12 1
