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Posttraumatic stress disorder (PTSD) remains largely untreated among adults with severe mental illnesses (SMI). The treatment of psychotic symptoms usually takes precedence in the care of adults with SMI. Such oversight is problematic in that PTSD in SMI populations is common (19%-43%), contributes a significant illness burden, and hinders mental health care. Yet few public-sector mental health agencies routinely provide specialized services for PTSD. The purpose of the article is to describe strategies and efforts to disseminate trauma-focused empirically based practices in a public-sector mental health system. Identified challenges include limited resources and commitment; knowledge deficits, attitudes, and biases; and limited practice accountability at provider, facility, and system levels. Proposed strategies for overcoming these challenges are to set clear goals, nurture broad-based organizational commitment and key stakeholder involvement, implement specialty training efforts to provide information and change attitudes, provide ongoing supervision, conduct fidelity monitoring, and ensure accountability to the extent possible.

Objective: We sought to compare female African-American (n = 84) and Caucasian (n = 99) veterans from primary care clinics at 4 Veterans Affairs Medical Centers (VAMCs) on rates of trauma, posttraumatic stress disorder, other psychiatric diagnoses, functional status, and use of VA services and disability benefits., Methods: Analyses were based on a cross-sectional, epidemiologic design incorporating self-report measures, structured interviews, and chart reviews., Results: With the exception of higher rates of child sexual abuse among Caucasian women and higher rates of physical assault among African-American women, there were no other statistically significant racial differences across analyses. However, some clinically meaningful trends emerged, and the implications of these findings are discussed within the context of our other results., Conclusions: Among female veterans seen in VA primary care clinics, African-Americans and Caucasians do not differ dramatically with regard to the manifestation or severity of psychopathology, or in their use of relevant VA health care services and disability benefits. These data are important because women represent the fastest growing segment of the VA population after aging veterans. Further research is needed to replicate and extend these findings to ensure that female veterans' needs are adequately identified and met by VAMC providers.

Using Andersen's (1995) [Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior 1995;36:1-10] behavioral model of healthcare use as our theoretical framework, we examined predisposing (i.e., sociodemographic), enabling (i.e., access resources), and need (i.e., illness) models of outpatient medical and mental healthcare utilization among a national sample of US veterans. Participants were 20,048 nationally representative participants completing the 2001 National Survey of Veterans. Outcomes were healthcare use variables for the past year, including the number of Veterans Affairs (VA) and non-VA outpatient healthcare visits, and whether VA and non-VA mental health treatment was used. Univariate results demonstrated that numerous predisposing, enabling and need variables predicted both VA and non-VA healthcare use intensity and mental healthcare use. In multivariate analyses, predisposing, enabling and need variables demonstrated significant associations with both types of healthcare use, but accounted for more variance in mental healthcare use. Need variables provided an additive effect over predisposing and enabling variables in accounting for medical and mental healthcare use, and accounted for some of the strongest effects. The results demonstrate that need remains an important factor that drives healthcare use among veterans and does not seem to be overshadowed by socioeconomic factors that may create unfair disparities in treatment access.

This study examined the nature and prevalence of sexual assault (SA), as well as its relationship to psychiatric sequelae and service use, among the veteran population. We performed a secondary data analysis of a cross-sectional dataset consisting of 643 male and 173 female veterans seen in four Veterans Affairs (VA) primary care clinics. Original data were obtained through semi-structured clinic assessments, structured telephone interviews, and medical chart reviews. Analyses included descriptive statistics, chi-square, analysis of variance (ANOVA), and logistic regression. The lifetime prevalence of SA was 38% among women and 6% among men. Of veterans reporting a history of SA, most experienced child sexual abuse and sexual revictimization. SA victims also had a more extensive trauma history and demonstrated greater psychological impairment in comparison to veterans reporting other types of trauma. However, only 25% of male SA survivors and 38% of female SA survivors used mental health services in the past year. These findings suggest that VA primary care clinics may benefit from expanding the current mandated screen for military sexual trauma to include lifetime experiences and trauma-related symptoms, thereby connecting more veterans with needed mental health services.

This article reviews the literature documenting the nature and prevalence of traumatic experiences, trauma-related mental and physical health problems, and service use among female veterans. Existing research indicates that female veterans experience higher rates of trauma exposure in comparison to the general population. Emerging data also suggest that female veterans may be as likely to be exposed to combat as male veterans, although not as directly or as frequently. Female veterans also report high rates of posttraumatic stress disorder, which has been associated with poor psychiatric and physical functioning. Although sexual assault history has been related to increased medical service use, further research is needed to understand relationships between trauma history and patterns of medical and mental health service use. Researchers also are encouraged to employ standardized definitions of trauma and to investigate new areas, such as treatment outcomes and mediators of trauma and health. Policy and practice implications are discussed.