The Veterans Health Administration (VHA) is the branch of the United States Department of Veterans Affairs (VA) that is responsible for providing healthcare services and medical assistance programs to veterans enrolled in VA’s healthcare services.
Barrera, T. L., McIngvale, E., Lindsay, J. A., Walder, A. M., Kauth, M. R., Smith, T. L., Van Kirk, N., Teng, E. J., & Stanley, M. A. (2018). Obsessive-compulsive disorder in the Veterans Health Administration. Psychological Services, 16(4), 605–611. https://doi.org/10.1037/ser0000249
Key Points
- The rate of OCD diagnosis in VHA medical records was 0.31% of VHA patients seen in 2010-2011, much lower than the estimated OCD prevalence.
- 80.7% of veterans newly diagnosed with OCD had comorbid mood disorders, 64.4% had comorbid anxiety disorders, 49.7% had PTSD, and 32.9% had substance use disorders.
- OCD was most frequently diagnosed by physicians (48.6%) and behavioral health providers (31.9%), predominantly in mental health settings (87.5%).
- In the year after an OCD diagnosis, veterans had an average of only 3.9 individual psychotherapy visits and 3.5 psychiatric medication management visits, suggesting inadequate treatment.
Rationale
This study examined rates of OCD diagnosis and treatment in veterans within the Veterans Health Administration (VHA) system.
OCD is a disabling disorder, yet little was known about OCD among veterans in VHA care (McIngvale, Van Kirk, & Stanley, 2015).
Previous research shows OCD is associated with substantial functional impairment, quality of life reductions, and occupational disability (Huppert et al., 2009; Macy et al., 2013; Markarian et al., 2010). OCD tends to be chronic without appropriate treatment (Eisen et al., 2013).
The prevalence of OCD may be elevated among veterans compared to the general population. Studies using structured interviews indicate higher 12-month OCD rates among veterans versus civilians (Gros, Magruder, & Frueh, 2013; Jordan et al., 1991; Orsillo et al., 1996; Roszell et al., 1991).
Associations found between OCD and trauma exposure (Cromer, Schmidt, & Murphy, 2007; Kimbrel et al., 2015) suggest OCD could be increased in veterans.
The study provides important data on the recognition and treatment of OCD in VHA to inform efforts to improve diagnostic and treatment services for veterans with OCD.
Enhancing OCD care is critical given the functional impacts of OCD and its likely underestimation and inadequate treatment within VHA.
Method
This retrospective study extracted data on 20,364 veterans with an OCD diagnosis in 2010-2011 from the VHA Corporate Data Warehouse.
A subset of 5,229 veterans newly diagnosed with OCD in 2010-2011 was further analyzed to examine diagnostic and treatment patterns.
Sociodemographic, diagnostic, clinic setting, provider type, and mental health utilization variables were extracted from medical records.
Sample
The majority of the over 20,000 veterans diagnosed with OCD were male (84.0%), with a mean age of 57.4 years. Of those newly diagnosed in 2010-2011, 56.9% were unmarried.
The majority had psychiatric comorbidities, including mood disorders (80.7%), anxiety disorders (64.4%), PTSD (49.7%), and substance use disorders (32.9%).
This complex clinical profile may contribute to the underrecognition of OCD in veterans.
Statistical Analysis
Descriptive analyses examined patient characteristics, settings, providers, and mental health visits associated with an OCD diagnosis.
Results
- The OCD diagnosis rate was 0.31% in the VHA during 2010-2011.
- 80.7% of newly diagnosed patients had mood disorders, 64.4% had anxiety disorders, 49.7% had PTSD, and 32.9% had substance use disorders.
- Initial OCD diagnosis occurred predominantly in mental health settings (87.5%) by physicians (48.6%) and behavioral health providers (31.9%).
- In the year after diagnosis, veterans had an average of 3.9 therapy sessions and 3.5 medication visits.
Insight
The low OCD diagnosis rate suggests underrecognition in VHA. Most patients had psychiatric comorbidities, compounding complex presentations.
Insufficient treatment after diagnosis indicates unmet needs. Better OCD assessment, diagnosis, guidelines, and services are required to address this disabling but overlooked disorder among veterans.
Strengths
- Use of national VHA databases provided a broad, representative sample of veterans diagnosed and treated for OCD across the entire VHA system.
- Examined multiple factors – patient characteristics, diagnostic settings/providers, and treatment patterns – to provide a comprehensive picture of OCD recognition and care.
- Focused on veterans, an understudied population regarding OCD.
Limitations
- Relied on diagnoses and coding entries in medical records, which have unknown validity and accuracy.
- Did not include OCD-related care received outside VHA.
- Data did not specify the types of psychotherapy or medications received.
Implications
The findings indicate gaps in awareness, assessment, and treatment of OCD among veterans in VHA care. Veterans likely do not receive guideline-recommended care like exposure and response prevention therapy.
Improved OCD clinical practice guidelines, screening, staff training, and services are greatly needed to reduce the burden and disability for veterans with OCD.
References
Primary reference
Barrera, T. L., McIngvale, E., Lindsay, J. A., Walder, A. M., Kauth, M. R., Smith, T. L., Van Kirk, N., Teng, E. J., & Stanley, M. A. (2018). Obsessive-compulsive disorder in the Veterans Health Administration. Psychological Services, 16(4), 605–611. https://doi.org/10.1037/ser0000249
Other references
Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007). An investigation of traumatic life events and obsessive–compulsive disorder. Behaviour Research and Therapy, 45(7), 1683-1691.
Eisen, J. L., Sibrava, N. J., Boisseau, C. L., Mancebo, M. C., Stout, R. L., Pinto, A., & Rasmussen, S. A. (2013). Five-year course of obsessive-compulsive disorder: Predictors of remission and relapse. Journal of Clinical Psychiatry, 74(3), 233-239.
Gros, D. F., Magruder, K. M., & Frueh, B. C. (2013). Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. General Hospital Psychiatry, 35(1), 71-73.
Huppert, J. D., Simpson, H. B., Nissenson, K. J., Liebowitz, M. R., & Foa, E. B. (2009). Quality of life and functional impairment in obsessive–compulsive disorder: A comparison of patients with and without comorbidity, patients in remission, and healthy controls. Depression and Anxiety, 26(1), 39-45.
Jordan, B. K., Schlenger, W. E., Hough, R., Kulka, R. A., Weiss, D., Fairbank, J. A., & Marmar, C. R. (1991). Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls. Archives of General Psychiatry, 48(3), 207-215.
Kimbrel, N. A., DeBeer, B. B., Meyer, E. C., Silvia, P. J., Beckham, J. C., Young, K. A., & Morissette, S. B. (2015). An examination of the broader effects of warzone experiences on returning Iraq/Afghanistan veterans’ psychiatric health. Psychiatry Research, 226(1), 78-83.
Macy, A. S., Theo, J. N., Kaufmann, S. C., Ghazzaoui, R. B., Pawlowski, P. A., Fakhry, H. I., Cassidy, K. L., & IsHak, W. W. (2013). Quality of life in obsessive compulsive disorder. CNS Spectrums, 18(1), 21-33.
Markarian, Y., Larson, M. J., Aldea, M. A., Baldwin, S. A., Good, D., Berkeljon, A., Murphy, T. K., Storch, E. A., & McKay, D. (2010). Multiple pathways to functional impairment in obsessive-compulsive disorder. Clinical Psychology Review, 30(1), 78-88.
McIngvale, E., Van Kirk, N., & Stanley, M. A. (2015, July). OCD and active duty members/veterans: A review. Poster presented at the 22nd Annual Conference of the International OCD Foundation, Boston, MA.
Orsillo, S. M., Weathers, F. W., Litz, B. T., Steinberg, H. R., Huska, J. A., & Keane, T. M. (1996). Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 184(5), 307-313.
Roszell, D. K., McFall, M. E., & Malas, K. L. (1991). Frequency of symptoms and concurrent psychiatric disorder in Vietnam veterans with chronic PTSD. Hospital & Community Psychiatry, 42(3), 293-296.
Keep Learning
- What barriers might prevent veterans from seeking an initial diagnosis or further treatment for OCD? How could those barriers be addressed?
- How might providers and health systems improve recognition, assessment, and diagnosis of OCD, given its heterogeneous symptoms and frequent comorbidities?
- What types of tailored interventions or treatment modifications might better meet the needs of veterans with OCD and common psychiatric comorbidities like PTSD or substance use disorders?
