Table 1 Systematic reviews of veterans’ mental, physical and social health

Arriola & Rozelle (2016)

Eligibility criteria: English language, peer reviewed publications from 1980 to 2015 reporting quantitative data;

Population: Adult US OEF/OIF Hispanic veterans;

Outcome: Traumatic Brain Injury;

34 articles included

• High rates of physical, cognitive, behavioral and emotional symptoms in Hispanic veterans who have suffered TBI

• PTSD is strongly associated with TBI

Physical health

Mental health

Interconnection

Factors affecting

Beste & Ioannou (2015)

Eligibility criteria: Published between 1992 and April 2014. Excluded: unrelated to the epidemiology of HCV prevalence and treatment, review articles, non–peer-reviewed work, practice guidelines and studies based on case reports/case series. Studies focussing on patients co-infected with HIV and HCV were excluded unless they included an HCV monoinfected arm;

Population: US veterans aged >18;

Outcome: Prevalence & treatment of Hepatitis C Virus;

28 articles included

• Approximately 175,000 patients with diagnosed HCV infection are currently in VA care, plus an estimated 45,000 additional patients with as yet undiagnosed infection

Physical health

Blore et al. (2015)

Eligibility criteria: Inclusion: (1) The population consisted of military personnel deployed to the Gulf War, Afghanistan or the Iraq War (Army, Navy, Air Force, Marines, Coast Guard, medics, and Reservists/National Guard), (2) published in English, (3) outcome of interest was depression, but studies containing any one of the psychological disorders of depression, anxiety disorders including PTSD, or substance or alcohol use disorders were included, (4) inclusion of an appropriate military comparison group that differed in its level of deployment exposure to the corresponding conflict, (5) enough information to generate an odds ratio (OR) by deployment. Exclusion: (1) The conflict deployed sample was of non-military personnel, (2) published in a language other than English, (3) sample based on clinical or injured or treatment/help-seeking population/s, (4) no appropriate military comparison group included;

Population: Gulf War, Afghanistan / Iraq War veterans;

Outcome: Depression;

14 articles included

• Gulf War veterans had over twice the odds of experiencing depression [OR 2.28, 95% CI 1.88–2.76] and dysthymia or chronic dysphoria (OR 2.39, 95% CI 2.0–2.86) compared to non-deployed military personnel

Mental health

Byrne, Montgomery & Dichter (2013)

Eligibility criteria: Inclusion: (1) focussed exclusively on female veterans, (2) included specific information about female veterans, and/or (3) involved a comparison of male and female veterans, (4) experimental, observational, descriptive and qualitative studies published in English; Excluded: (1) studies conducted outside of the United States or about veterans who served in the military of a foreign country;

Population: Female US veterans;

Outcome: Homelessness;

26 articles included

• Female veterans were at an increased risk of homelessness relative to their male veteran and female non-veteran counterparts

• Homeless female veterans were characteristically different from their male counterparts (younger, higher levels of unemployment, lower rates of drug or alcohol dependence or abuse but higher rates of mental health problems)

• Risk factors for homeless included unemployment, disability/TBI/poor health, PTSD and other mental health problems, sexual assault/harassment and substance use/abuse

Social health

Mental health

Physical health

Interconnection

Factors affecting

Goldzweig et al. (2006)

Eligibility criteria: Articles had to describe original research on veterans’ health that either pertained specifically to women veterans, or included explicit information about women veterans or compared men and women veterans;

Population: Women veterans;

Outcome: Health;

182 articles included

• Most research on women veterans’ health is descriptive in nature and has concerned PTSD, sexual harassment and assault, the utilisation and organisation of care, and various psychiatric conditions

Mental health

Physical health

Social health

Interconnection

Factors affecting

Hoggatt et al. (2015)

Eligibility criteria: Inclusion: English-language, peer-reviewed publications reporting on non-tobacco alcohol or drug misuse, abuse, or dependence in US women veterans; published since 1980. Exclusion: studies of women in substance use disorder treatment; clinical trials, studies with nonrepresentative samples (e.g., disease-specific populations), case studies, abstracts, reviews, and commentaries; studies that involved only deceased subjects or examined other addictive disorders; results for women in active duty military service (but included results for members of the reserve forces (National Guard and reserve members);

Population: US women veterans and National Guard/reserve members;

Outcome: Alcohol and Drug Misuse, Abuse, and Dependence;

56 articles included

• Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking

• Studies comparing women veterans and civilians reported no clear differences

• Substance misuse rates were generally lower among women veterans than men veterans

• Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates

Mental health

Physical health

Social health

Interconnection

Lan et al. (2016)

Eligibility criteria: Inclusion: (1) sampled US veterans or reported on US veterans as a separate analytic group, (2) assessed AUDs or DUDs using established DSM or WHO International Classification of Diseases (ICD) diagnostic criteria, (3) reported on the prevalence, distribution, or correlate(s) of SUD(s) in a US veteran sample, (4) published in English in the scientific, peer-reviewed literature. Exclusion: (1) studies that only used screening (rather than diagnostic) tools to identify problematic substance use behaviors, (2) studies that sampled veterans entirely from substance abuse treatment programs and studies that only reported on substance use patterns or frequency (rather than disorders), and did not assess SUDs using established measures, (3) studies published prior to 1987, (4) case reports, case series, editorials, commentaries and previously published narrative reviews. Only included RCTs if pretreatment baseline data on the distribution or correlates of SUDs were reported;

Population: US veterans;

Outcome: Substance Use Disorders;

72 articles included

• Relatively high rates of Alcohol Use Disorders (AUD: 32% using diagnostic criteria; 10% using administrative criteria) and Drug Use Disorders (DUD: 20% using diagnostic criteria; 5% using administrative criteria) among US veterans

• The observed prevalence of AUD and DUD diagnoses in the sample of veterans were higher than civilians

• High rates of PTSD comorbidity with Substance Use Disorders, particularly among veterans with other mental health problems

Mental health

Social health

Interconnection

MacManus et al. (2015)

Eligibility criteria: Inclusion: quantitative studies that 1) operationalised violence and/or aggression as actual physical harm caused by one person against another, a range of aggressive behaviors (property and physical aggression and threat of violence), offending behavior classified as violent, or incarceration for the latter and 2) explored such behaviors among serving or formerly serving military personnel who had been in Iraq or Afghanistan post-2001. Excluded: book chapters, dissertations, case studies, papers published before 2001, qualitative or nonempirical studies, intervention studies, studies reporting a sample size less than 100, articles not in English and studies concerning conflicts other than

Iraq and Afghanistan post-2001;

Population: Serving or formerly serving military personnel who had been in Iraq or Afghanistan post-2001;

Outcome: Aggressive & Violent Behaviour;

17 articles included

• Reported pooled estimates of 10% (95% CI: 1, 20) for physical assault and 29% (95% CI: 25, 36) for all types of physical aggression in the last month

• The majority of studies suggested a small-to-moderate association between combat exposure and postdeployment physical aggression and violence (pooled estimate of the weighted odds ratio = 3.24; 95% CI: 2.75, 3.82)

• Violence increased with intensity and frequency of exposure to combat traumas

• PTSD plays a mediating role between combat and postdeployment violence and alcohol is a factor, especially if comorbid with PTSD

Social health

Mental health

Interconnection

Factors affecting

Magruder & Yeager (2009)

Eligibility criteria: Deployed and non-deployed US Service Personnel, unique studies published in English, with enough information to estimate an odds ratio. Diagnosis of PTSD must be established using a valid and reproducible method, not based on clinical or treatment-seeking populations;

Population: Active duty military personnel and veterans;

Outcome: PTSD;

18 articles included

• Odds ratios indicate approximately a 1.5- to 3.5-fold increase in PTSD risk with deployment, regardless of war era

• The odds of PTSD for deployed versus non-deployed veterans were lowest among OIF/OEF veterans and highest for Vietnam veterans, with Persian Gulf veterans intermediate

Mental health

Factors affecting

McLaughlin, Nielsen & Waller (2008)

Eligibility criteria: Peer reviewed articles in English, excluded RCTs, included all other study designs provided that an appropriate control or comparison group (i.e., the general population) was included and reported all-cause, cancer, or external cause mortality;

Population: Military personal (currently serving & veterans);

Outcome: Mortality;

12 articles included in the meta-analysis

• The overall healthy soldier effect estimated ranges from 10% to 25%, depending on the cause of death studied and the period of follow-up

Physical health

O’Neil et al. (2014)

Eligibility criteria: Studies in English reporting outcomes in Veterans or military personnel with a history of mTBI (using a case definition consistent with VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury); report health or cost outcomes for members of the US armed forces or Veterans; Eligible study designs: systematic reviews; meta-analyses; randomized controlled trials; and cohort, case-control, cross-sectional, or case series studies, with a minimum of 30 mTBI cases.;

Population: Veterans or military personnel with a history of mTBI;

Outcome: Factors associated with mTBI;

31 articles included

• Cognitive, physical, and mental health symptoms were commonly reported by Veterans/military members with a history of mTBI

• Findings are consistent with civilian studies

Physical health

Mental health

Social health

Interconnection

Pompili et al. (2013)

Eligibility criteria: English language, peer reviewed articles, from 1980; excluded articles without abstracts, abstracts that did not explicitly mention suicidal behavior and war related PTSD;

Population: Veterans;

Outcome: PTSD and suicide risk;

18 articles included

• Having a history of PTSD is associated with higher rates of morbidity and mortality and increased the risk for suicidal behavior

• The association between PTSD and suicidal behavior was confirmed by the presence of other risk factors and high rates of comorbidity

Mental health

Physical health

Interconnection

Stevelink et al. (2015)

Eligibility criteria: Comprised data on (ex-)military personnel with a physical, visual or hearing impairment; administered at least one validated outcome measure of mental health or participants self-reported to have a mental health problem, or hospital records/military databases indicated the presence of a mental health problem; were reported in English;

Population: (Ex-)military personnel with a physical impairment;

Outcome: Mental health disorders;

25 articles included

• Mental health disorders including PTSD (range 2–59%), anxiety (range 16.1–35.5%), depression (range 9.7–46.4%) and psychological distress (range 13.4–36%) are frequently found in veterans with a physical impairment

• Alcohol misuse was least common (range 2.2–26.2%)

Mental health

Physical health

Social health

Interconnection

Stimpson et al. (2003)

Eligibility criteria: Contained data on veterans who had been deployed to the Gulf War on military, medical or peacekeeping grounds; any study design was eligible for inclusion provided that an appropriate control or comparison group was included to compare the prevalence of psychiatric disorder;

Population: Veterans of the Persian Gulf War of 1991;

Outcome: Psychiatric disorder;

20 articles included

• Prevalence of PTSD and common mental disorder were higher in the Gulf War veterans than active service personnel not deployed to the Gulf

Mental health

Social health

Factors affecting

Theodoroff et al. (2015)

Eligibility criteria: Studies involving US veterans and military service members who served in OEF/ OIF/ OND; original data, minimum sample size of 30, or systematic reviews. Excluded: Narratives, letters, editorials, commentaries; not address the key questions or differentiate between who did versus did not serve in OEF/ OIF/ OND or between veteran/military and civilian populations.

Population: US Service Members and Veterans Deployed to the Iraq and Afghanistan Wars;

Outcome: Hearing Impairment and Tinnitus;

14 articles included

• Auditory complaints are highly prevalent; in some injured populations, greater than 50%

• Among more than 90,000 veterans seen in the VHA system of care 16.4%– 26.6% of men and 7.3%– 13.4% of women were diagnosed with hearing problems

• Risk/protective factors appear to include age, gender, military branch and component, blast exposure, PTSD diagnoses, and characteristics of initial injuries

Physical health

Mental health

Interconnection

Factors affecting

Thomas et al. (2006a)

Eligibility criteria: Published between January 1990 and May 2004; included if they reported the prevalence of any symptom or condition that included the word “pain” in Gulf War veterans and in a comparison group of non-Gulf veterans. Excluded: measured simulated exposures/ non-health related outcomes; subjects were inhabitants of the Persian Gulf rather than deployed military personnel; examined pain within groups of Gulf veterans that had experienced differential exposures whilst in the Gulf;

Population: Gulf War veterans;

Outcome: Pain;

20 articles included

• A greater proportion of Gulf veterans reported symptoms at each of five main sites of pain (muscle, joint, chest/ heart, back and abdominal pain) when compared to a non-Gulf military group

• Gulf deployment was most strongly associated with abdominal pain (Gulf veterans more than three times more likely to report such pain than a comparison group (OR 3.23; 95%CI 2.31–4.51))

Physical health

Factors affecting

Thomas et al. (2006b)

Eligibility criteria: Published between January 1990 and May 2004; included if they compared the prevalence of chronic fatigue syndrome, multiple chemical sensitivity, CDC-defined chronic multi-symptom illness, fibromyalgia, or symptoms of either fatigue or numbness and tingling in Gulf War veterans and non-Gulf veterans;

Population: Gulf War veterans;

Outcome: Multi-symptom conditions;

23 articles included

• Gulf deployment most strongly associated with chronic fatigue syndrome (OR 3.8, 95% CI 2.2–6.7)

• Gulf War veterans were also approximately three and a half times more likely than non-Gulf veterans to report multiple chemical sensitivity or chronic multi-symptom illness as defined by CDC

Physical health

Factors affecting

Tsai & Rosenheck (2015)

Eligibility criteria: Published in English from 1900 to July 2014; sampled US veterans; assessed homelessness in the US; included homelessness as an outcome or dependent variable; examined variables in relation to homelessness as a main study aim with the intent to identify risk factors / characteristics associated with homelessness. Excluded: reported only the effects of a specific intervention / reported only qualitative data; case reports, published commentaries, and letters to the editor that did not report any quantitative data;

Population: US veterans;

Outcome: Homelessness;

31 articles included

• The strongest and most consistent risk factors for homelessness in US veterans were substance use disorders and mental illness, followed by low income and other income-related factors

• Veterans were at greater risk for homelessness than other adults

Mental health

Social health

Interconnection

Factors affecting

Wall (2012)

Eligibility criteria: Published in English between 2001 and 2011. Excluded: individual case studies; studies presented as meeting abstracts; studies involving veteran populations from conflicts other than OEF/OIF/OND; studies not measuring both PTSD and TBI; those involving civilian populations or non–U.S. military populations;

Population: US OEF/OIF military and veteran populations;

Outcome: PTSD and TBI;

20 articles included

• There is some evidence that comorbid PTSD and TBI result in greater reports of postconcussive symptomology than either condition alone

• Rates of PTSD vary between 11% and 79%, rates of TBI vary between 4.9% and 41%, and comorbid rates of PTSD and TBI vary between 0.02% and 26%

Mental health

Physical health

Interconnection

Wright et al. (2013)

Eligibility criteria: Published in English between January 1990 and October 2011; any study design; participants had been deployed to the Gulf War (1990–1991), the Afghanistan conflict (since 2001), or the Iraq War (since 2003); any deployed persons (army, navy, air force, marines, medics); reservists or regular military personnel; the outcome of focus was PTSD; diagnosis was defined through doctor diagnosis, self-report, health data linkage, or validated assessment tools. At least one of the following variables was included: unit cohesion or perceptions of unit cohesion, social support or perceptions of social support, family support or perceptions of family support, personality trait of neuroticism, or psychiatric history. Excluded: studies that looked at psychological outcomes which were not PTSD or PTSD as a psychological comorbidity; participant populations of contractors or nonmilitary personnel;

Population: Veterans of the Gulf War, Iraq War, and Afghanistan Deployments;

Outcome: Support mechanisms and vulnerabilities in relation to PTSD;

17 articles included

• Low unit cohesion was associated with PTSD, standardised mean difference of −1.62, 95% confidence interval (CI) [−2.80, −0.45]

• Low social support was associated with PTSD, standardised mean difference of −12.40, 95% CI [−3.42, −1.38]

• Significant relationship between low-family support and PTSD (insufficient data precluded a meta-analysis)

• Posttrauma factors of low support were associated with higher reporting of PTSD

Mental health

Social health

Interconnection

Factors affecting

Xue et al. (2015)

Eligibility criteria: Investigated risk factors for PTSD in military populations after deployment to combat areas; reported the odds ratios or relative risks and corresponding 95% confidence intervals for risk factors in the development of PTSD; included the selected postdeployment PTSD risk factors; included a sample of military personnel, veterans, or both. Excluded: measured only the acute trauma response rather than PTSD; used a categorical measure of PTSD; the study population consisted entirely of individuals already suffering from PTSD or from a specific comorbid psychiatric disorder or having committed a violent offense; did not specifically assess DSM-defined PTSD symptoms; contained insufficient data to calculate univariate effect sizes, and such data could not be obtained from the study author; review or qualitative studies not presenting new data or only presented qualitative analyses; primary aim to investigate the efficacy of treatment; the study used a single-case design;

Population: Military personnel and veterans;

Outcome: Risk factors for combat-related PTSD;

32 articles included

• The prevalence of combat-related PTSD ranged from 1.09%to 34.84%

• Risk factors stemming from before the trauma include female gender, ethnic minority status, low education, non-officer ranks, army service, combat specialisation, high numbers of deployments, longer cumulative length of deployments, more adverse life events, prior trauma exposure, and prior psychological problems

• Risk factors relating to aspects of the trauma period include increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma, and deployment-related stressors

• Lack of post-deployment support during the post-trauma period also increased risk of PTSD

Mental health

Physical health

Interconnection

Factors affecting