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Military service, and combat deployment in particular, has been found to be strongly associated with an increased risk of developing PTSD (Armenta et al., 2018; Hoge et al., 2006; Porter et al., 2018). The Veterans Health Administration (VHA) provides disability compensation for almost a million veterans and allocated almost $14 billion in mental health care for fiscal year 2023. However, many veterans with PTSD do not seek treatment (Bovin et al., 2019; FY 2023 Budget Submission - Budget in Brief, 2022; Smith et al., 2020). Characterizing who is or is not utilizing VHA services and seeking care for PTSD is critical to better understand how to identify and treat PTSD in veterans, but is difficult to accurately measure. This is because data on healthcare utilization outside of the VHA are not readily available. In our paper recently published in the Journal of Traumatic Stress, we utilized available longitudinal survey data linked with military administrative and VHA medical records to estimate PTSD care seeking among veterans between 2013 and 2016. 

Data Collection

Survey data were obtained from the Millennium Cohort Study (MCS), the largest and longest running prospective study of U.S. service members and veterans (Castaneda et al., 2023). The study was initiated in 2001 and has enrolled over 260,000 U.S. military service members representing all service branches and components. Questionnaires are sent to participants every 3 to 5 years to collect information on service-related experiences and mental, physical, and behavioral health, event after they leave military service. 

By using MCS data linked with the Department of Defense (DoD) and VHA medical encounter data, we were able to test whether recently separated active duty personnel (N=19,691) had probable PTSD, if they sought care, and where they sought care for PTSD in the year prior to completion of their 2014-2016 survey. By weighting the data, we were able to generalize the study data to be representative of all active duty service members who separated from service from 2001 to 2012. This procedure also allowed for the adjustment of estimates to account for participants who did not respond to survey requests. 


Less than half the study participants received care from the VHA in the year prior to survey completion. Compared with veterans not using VHA, those using VHA care were more likely to report mental health problems, including PTSD and depression. Among those veterans with PTSD, recent VHA use was the strongest predictor for seeking care for PTSD. This suggets that veterans with probable PTSD were more likely to use VHA services. Those with PTSD who used VHA services in other capacities were also more likely to seek care for PTSD than those who did not use VHA services in other capacities. We were also able to ascertain that not seeking care for PTSD may be due to underdiagnosis and not treatment avoidance, which is consistent with a previous study reporting that among veterans who screened positive for PTSD at the VHA, less than 20% declined treatment (Bovin et al., 2016). 


This study provides a comprehensive snapshot of VHA use and care seeking among veterans with probable PTSD from 2013 to 2016. As the VHA continues to increase outreach and improve PTSD screening and healthcare access for veterans, further research with more recently collected MCS data could increase understanding of changes in PTSD care seeking. Improving screening for PTSD can help patients with undiagnosed PTSD and allow for subsequent treatment within and outside of the VHA.

Discussion Questions

1. What steps can be taken to increase care seeking for veterans with PTSD?
2. How can VHA and practitioners in the community better identify PTSD among veterans?

About the Authors

Yunnuo Zhu, MPH is an epidemiologist in the Deployment Health Research Department at the Naval Health Research Center. She is a part of the Millenium Cohort Study and conducts research on psychological and physical military health.

Ben Porter, PhD is an assistant professor at Mississippi State University in the Department of Psychology. His research focuses on examining archival and publicly available datasets, particularly to investigate military and veteran health.

Edward J. Boyko, MD, MPH is a Staff Physician at VA Puget Sound Healthcare System and a Professor of Medicine at the University of Washington. He conducts epidemiological research and serves as primary care provider to a panel of veteran patients. He is the principal VA investigator of the Millennium Cohort Study, VA Cooperative Study #505, and has been involved in this research since its inception in 2000. 

Rudy Rull, PhD, MPH is a research epidemiologist and the Department Head for Deployment Health Research at the Naval Health Research Center (NHRC) in San Diego, CA. He is the Principal Investigator of the Millenium Cohort Study, the largest and longest-running longitudinal health study in military history with the objective of assessing the long-term impacts of military service on the psychological and physical health and health behaviors of service members and veterans. 


Bovin, M. J., Miller, C. J., Koenig, C. J., Lipschitz, J. M., Zamora, K. A., Wright, P. B., Pyne, J. M., & Burgess, J. F. (2019). Veterans' experiences initiating VA-based mental health care. Psychol Serv, 16(4), 612-620. https://doi.org/10.1037/ser0000233 
Castaneda, S. F., Belding, J. N., Kolaja, C. A., LeardMann, C. A., Jacobson, I. G., Rivera, A. C., Carey, F. R., Boparai, S., Walstrom, J. L., Sheppard, B. D., Boyko, E. J., Ryan, M. A. K., Rull, R. P., & Millennium Cohort Study, T. (2023). Cohort Profile Update: The US Millennium Cohort Study-evaluating the impact of military experiences on service members and veteran health. Int J Epidemiol, 52(4), e222-e231. https://doi.org/10.1093/ije/dyad088 
FY 2023 Budget Submission - Budget in Brief. (2022).  Retrieved from https://department.va.gov/administrations-and-offices/management/budget/
Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA, 295(9), 1023-1032. https://doi.org/10.1001/jama.295.9.1023 
Porter B, Dozier ME, Seelig A, Zhu Y, Patoilo M, Boyko EJ, Rull RP; Millennium Cohort Study Team. Posttraumatic Stress Disorder, Veteran Health Administration Use and Care Seeking Among Post-9/11 US Veterans. Journal of Traumatic Stress. http://doi.org/10.1002/jts.23019
Porter, B., Hoge, C. W., Tobin, L. E., Donoho, C. J., Castro, C. A., Luxton, D. D., & Faix, D. (2018). Measuring Aggregated and Specific Combat Exposures: Associations Between Combat Exposure Measures and Posttraumatic Stress Disorder, Depression, and Alcohol-Related Problems. J Trauma Stress, 31(2), 296-306. https://doi.org/10.1002/jts.22273 
Smith, J. R., Workneh, A., & Yaya, S. (2020). Barriers and Facilitators to Help-Seeking for Individuals With Posttraumatic Stress Disorder: A Systematic Review. J Trauma Stress, 33(2), 137-150. https://doi.org/10.1002/jts.22456 
​Study, t. (2018). Factors associated with persistent posttraumatic stress disorder among U.S. military service members and veterans. BMC Psychiatry, 18(1), 48. https://doi.org/10.1186/s12888-018-1590-5