CONGRESS OF THE UNITED STATES

CONGRESSIONAL BUDGET OFFICE

CBO

The Veterans Health 

Administration’s 

Treatment of 

PTSD and Traumatic

 Brain Injury Among 

Recent Combat Veterans

FEBRUARY 2012
Pub. No. 4097
The Congress of the United States O Congressional Budget Office

A

STUDY

CBO

The Veterans Health Administration’s 

Treatment of PTSD and Traumatic Brain 

Injury Among Recent Combat Veterans

February 2012
CBO

Notes

Unless otherwise indicated, all years referred to in this study are federal fiscal years (which run 

from October 1 to September 30).

Unless otherwise indicated, all dollar amounts in this study are expressed in 2011 dollars. 

Before providing cost data to the Congressional Budget Office (CBO), the Veterans Health 

Administration converted those data to fiscal year 2009 dollars on the basis of annual 

increases in the average cost of a primary care visit from 2004 to 2009. CBO indexed those 

data to 2011 dollars using the implicit price deflator for gross domestic product. CBO also 

converted other dollar amounts reported in this study to 2011 dollars using the implicit price 

deflator for gross domestic product.

Numbers in the text and tables may not add up to totals because of rounding.
Preface

CBO

Two combat-related conditions that affect some veterans who have served in Iraq and 

Afghanistan and that have generated widespread concern among policymakers are posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). In response to a request 

from the Ranking Member of the House Committee on Veterans’ Affairs, this Congressional 

Budget Office (CBO) study examines the following: 

• The clinical care that the Veterans Health Administration (VHA), the health care 

system within the Department of Veterans Affairs, provides for recent combat veterans;

• VHA’s coordination with the Department of Defense for the care of service members 

returning from Iraq and Afghanistan; 

• The prevalence of PTSD and TBI among veterans of those conflicts and the occurrence 

of those conditions among recent combat veterans using VHA’s services; and

• The costs to VHA of providing care to recent combat veterans for those conditions. 

In keeping with CBO’s mandate to provide objective, impartial analysis, this study makes no 

recommendations. 

Elizabeth Bass and Heidi Golding of CBO’s National Security Division prepared the study 

under the general supervision of David Mosher and Matthew Goldberg. Allison Percy 

served as the internal reviewer. Lindsay Coleman, Juan Contreras, Sunita D’Monte, and 

Ann Futrell provided thoughtful comments on a draft of the study, as did external reviewer 

Rajeev Ramchand of RAND Corporation. (The assistance of an external reviewer implies 

no responsibility for the final product, which rests solely with CBO.) Adebayo Adedeji factchecked the manuscript. The authors wish to thank the Department of Veterans Affairs and 

the Department of Defense for providing data used in the analysis. 

Juyne Linger edited the study, and John Skeen proofread it. Cindy Cleveland produced drafts 

of the manuscript. Maureen Costantino prepared the paper for publication and designed the 

cover. Monte Ruffin printed the initial copies, and Linda Schimmel handled the print distribution. The publication is available at CBO’s Web site (www.cbo.gov).

Douglas W. Elmendorf

Director

February 2012

Contents

CBO

Summary vii

Introduction 1

Clinical Care Within VHA 3

VHA’s Services for PTSD 3

VHA’s Services for TBI 5

Concurrent Diagnoses of PTSD and TBI 6

Polytrauma 6

Cooperation Between VHA and DoD 7

CBO’s Analytical Approach to VHA Data 8

Occurrence and Prevalence of PTSD and TBI 10

Use of VHA’s Services 12

Number of Patients Using VHA’s Services 14

Frequency of Use 15

Costs of VHA’s Services 16

Costs of All Health Care 17

Costs of PTSD- and TBI-Specific Care 18

Other Studies of the Costs of Treating PTSD and TBI 20

Polytrauma Patients 21

Appendix A: Background on PTSD and TBI 23

Appendix B: Data and Methods 27

Appendix C: Interpreting Published Estimates of the Prevalence of PTSD and TBI 31

Appendix D: VHA’s Average Annual Costs for OCO Veterans Who Continue to 

Seek Care 37
VI THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Tables

S-1. The First Year of Treatment for All Health Care Provided to 

OCO Patients by VHA viii

1. Total Costs for VHA’s Health Care Provided to OCO Patients 18

2. Average Costs for All of VHA’s Health Care and VHA’s PTSD- and 

TBI-Specific Care Provided to OCO Patients 19

3. Use and Costs of VHA’s Health Care Provided to OCO 

Polytrauma Patients 22

D-1. Sample Sizes 38

D-2. Alternative Calculation of Average Costs for All of VHA’s Health Care 

Provided to OCO Patients 39

Figures

1. Continuation of Use of VHA’s Services by OCO Veterans 14

2. Use of VHA’s Health Care Services by OCO Patients 15

3. Average Costs for All of VHA’s Health Care Provided to OCO Patients 20

B-1. Years of Potential Use of VHA’s Services, by OCO Patient’s Year of Entry 28

Boxes

1. Eligibility for VHA’s Services 2

2. Suicide and Mental Illness Among OCO Veterans 12
CBO

Summary

More than 2 million service members have 

deployed in support of overseas contingency operations 

(OCO) in Iraq and Afghanistan since October 2001. 

Some military service members receive medical care in 

the combat theater for injuries or other medical conditions sustained while deployed. Other service members 

have combat-related medical conditions that are identified and treated after they return from war—within the 

Department of Defense’s (DoD’s) health care system for 

active-duty personnel and within the Department of 

Veterans Affairs (VA) for veterans, including deactivated 

reservists. VA provides health care services through the 

Veterans Health Administration (VHA), which treats 

veterans for service-connected conditions and other 

conditions. 

VHA spent about $2 billion (in 2011 dollars) in fiscal 

year 2010 to treat veterans of recent overseas contingency 

operations, compared with total expenditures in 2010 on 

health care for veterans of all eras and conflicts of about 

$48 billion. From 2002 through 2010, VHA spent a total 

of $6 billion on health care expenditures for recent OCO 

veterans. 

Two conditions that affect some military service 

members during deployment to a combat theater and 

afterward are post-traumatic stress disorder (PTSD) and 

traumatic brain injury (TBI). PTSD is an anxiety disorder induced by exposure to a traumatic event, such as 

witnessing injury or death. It is characterized by symptoms that include reexperiencing the event, hyperarousal 

(irritability, anger, or hypervigilance, for example), and 

diminished responsiveness to or avoidance of stimuli 

associated with the trauma. 

TBI is caused by sudden trauma to the head and is commonly sustained by soldiers exposed to explosions. It may 

result in a decreased level of consciousness, amnesia, or 

neurological abnormalities, and it is classified as mild, 

moderate, or severe on the basis of its severity at the time 

of the injury. Mild TBI, which is also known as a concussion, may in some cases lead to ongoing symptoms that 

include headaches, memory difficulties, fatigue, irritability, and sleep problems. Diagnosing severe cases is 

straightforward, but mild TBIs—which account for 

about 90 percent of TBI cases among active-duty OCO 

service members—may be difficult to detect, both by 

those afflicted and by health care professionals, although 

most cases resolve quickly without medical intervention.1

Some observers contend that DoD and VHA may not 

adequately screen, diagnose, and treat OCO service 

members and veterans affected by PTSD and mild TBI. 

In this study, the Congressional Budget Office (CBO) 

analyzes VHA’s care of OCO patients diagnosed with 

PTSD or TBI and compares the reported rates of occurrence of those conditions within VHA with estimates of 

the prevalence of those conditions in the broader population of service members who have deployed to recent 

overseas contingency operations. (Prevalence estimates 

gauge the proportion of cases of a disease or condition in 

a population, whether or not people have received a diagnosis from a medical professional; by comparison, the 

reported occurrence of conditions among the people 

who have been treated within VHA reflects counts of 

diagnoses by medical professionals.) The study also examines the costs that VHA has incurred in treating patients 

diagnosed with PTSD and TBI. 

1. Diagnosis of mild TBI with persistent symptoms is complicated 

because the condition does not have a clinically validated definition—that is, a definition that is based on a substantive body of 

empirical research and is broadly accepted by the medical community. Moreover, many other conditions cause symptoms that are 

similar to those of mild TBI.
VIII THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Summary Table 1.

The First Year of Treatment for All Health Care Provided to 

OCO Patients by VHA

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for the first year of treatment. 

All of the TBI patients in the data that CBO examined had symptomatic TBI—that is, they exhibited symptoms that were attributed to 

TBI at the time of VHA’s medical screening or examination.

VHA converted costs provided to CBO to fiscal year 2009 dollars on the basis of annual increases in the average cost of a primary care 

visit from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the implicit price deflator for gross domestic product.

OCO = overseas contingency operations; VHA = Veterans Health Administration; PTSD = post-traumatic stress disorder; 

TBI = traumatic brain injury; * = less than 1 percent.

a. Patients in the PTSD group did not have TBI, but many had other conditions. 

b. Patients in the TBI group did not have PTSD, but many had other conditions.

In brief, CBO finds: 

 Among OCO patients treated by VHA from 2004 

through 2009, 21 percent were diagnosed with PTSD 

(but not TBI) and 2 percent with symptomatic TBI 

(but not PTSD) (see Summary Table 1).2

 An additional 5 percent had both PTSD and TBI; thus, about 

75 percent of those diagnosed with TBI had a concurrent diagnosis of PTSD. Seventy-two percent of 

patients had neither diagnosis. (CBO separately 

analyzed another 500 polytrauma patients—that is, 

ones with complex, severe injuries to multiple organ 

systems.)

 The average cost for OCO patients in the first year of 

their treatment was about four to six times greater for 

patients with a diagnosis of PTSD, TBI, or both than 

for patients without those conditions. 

 VHA’s average costs for OCO patients were highest 

during the first year of care and generally declined and 

then stabilized in subsequent years.

 For patients with TBI (including those with both 

PTSD and TBI), however, VHA’s average treatment 

costs appear to increase in the third and fourth years of 

care. That result is probably driven by a policy change 

that occurred in the middle of the period that CBO 

analyzed and the nature of the data that VHA provided to CBO.3

 In the absence of the policy change, 

Treatment Group

PTSD or TBI

PTSDa 103,500 8,300 21

TBIb 8,700 11,700 2

Both PTSD and TBI 13,800 26,600 5

No PTSD or TBI 2,400 358,000 72

Polytrauma 136,000 500 *

Average Cost

 (Dollars) OCO Patients

Number of

Share of All 

OCO Patients

(Percent)

per Patient

2. All of the TBI patients in the data that CBO examined had 

symptomatic TBI—that is, they exhibited symptoms that were 

attributed to TBI at the time of VHA’s medical screening or examination.

3. VHA’s clinical practices for TBI changed during the data period 

(2004 to 2009): In 2007, the agency initiated comprehensive 

screening for mild, symptomatic TBI. Therefore, patients whom 

VHA diagnosed with TBI in 2007 or later were more likely to 

have had mild TBI than those diagnosed before that year. As a 

result, the data that CBO analyzed included a smaller share of 

patients with mild TBI in their third and fourth years of treatment than in their first and second years. Because treating patients 

with moderate or severe TBI requires more extensive services and 

resources than does treating patients with mild TBI, that difference elevated the estimated average costs of treatment for TBI 

patients in the third and fourth years. 
SUMMARY THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS IX

CBO

costs for those patients probably also would have been 

highest during the first year of care and then declined 

and stabilized thereafter.

 A great deal of uncertainty surrounds the prevalence of 

PTSD and TBI within the OCO population and, 

hence, the number of veterans with those conditions 

that DoD, VHA, and other health care providers may 

encounter in the future. 

Projecting the future costs of treating veterans with 

PTSD and TBI requires estimating both the number 

of patients with those conditions who will seek VHA’s 

care and the costs per patient that VHA will incur. 

Because the research community has not reached a consensus about the prevalence of those conditions, such 

projections would be highly uncertain. CBO examined 

published studies that reported the prevalence of PTSD 

or TBI among different groups of service members or 

veterans who had deployed to overseas contingency 

operations. For PTSD, those prevalence estimates have 

generally ranged between 5 percent and 25 percent. For 

TBI, those estimates indicate that between 15 percent 

and 23 percent of service members may have experienced 

a TBI while deployed to an overseas contingency operation but that a smaller share, between 4 percent and 

9 percent, are still symptomatic when screened after 

returning to the United States. Estimates of the prevalence of PTSD and TBI vary widely among studies 

because of substantial differences in the assessment tools 

that researchers use to identify the conditions, the stringency of the criteria they employ, and the subgroups 

they sample. The percentage of OCO veterans whom 

VHA clinicians have diagnosed with PTSD (26 percent) 

is at the top of the range reported in published studies, 

whereas the percentage they have diagnosed with symptomatic TBI (7 percent) is in the middle of the 

reported range. 

The rates of diagnosis of PTSD and TBI among OCO 

veterans seeking treatment at VHA do not necessarily 

reflect the prevalence of those conditions in the entire 

OCO population. If veterans who suspected they had 

mental health or other medical problems were more likely 

than other veterans to seek medical care from VHA, the 

rates of PTSD and TBI diagnosed among VHA’s patients 

would tend to overestimate the prevalence in the entire 

OCO population. However, some veterans might not 

seek care from VHA for various reasons—the stigma 

associated with having a mental health problem, for 

example, or the inconvenience of undergoing additional 

evaluation and treatment. If a sufficient number of veterans with PTSD and TBI did not seek care from VHA, 

the rates of diagnoses for those conditions among VHA’s 

patients would tend to underestimate the prevalence in 

the OCO population. 

CBO

The Veterans Health Administration’s Treatment of 

PTSD and Traumatic Brain Injury Among 

Recent Combat Veterans

Introduction

The United States has been involved in overseas contingency operations (OCO) in Afghanistan and Iraq since 

October 2001 and March 2003, respectively, and has 

deployed more than 2 million service members in support of those operations. The Department of Defense 

(DoD) delivers medical care to service members while 

they are deployed. That care includes nearly 4 million 

medical encounters since January 2005 for a variety of 

conditions, including injuries; it also includes 71,000 

medical evacuations of service members from the combat 

theaters through November 2011. Both DoD and the 

Veterans Health Administration (VHA), the organization 

that provides medical care within the Department of 

Veteran Affairs (VA), screen for various conditions and 

provide health care after service members return from 

deployment. VHA treated 400,000 (31 percent) of 

1.3 million eligible OCO veterans in fiscal year 2010, 

up from 100,000 (20 percent) of 500,000 eligible OCO 

veterans in 2005. Many eligible veterans do not seek care 

at VHA in any given year or at any time, and most VHA 

patients seek additional health care outside of VHA. (See 

Box 1 for information about eligibility for VHA’s health 

care system.) Although OCO veterans made up 7 percent 

of the patients VHA treated in 2010, they accounted for 

only 4 percent ($2 billion) of the $48 billion (in 2011 

dollars) that VHA obligated for medical care that year. 

From 2002 through 2010, VHA spent a total of 

$6 billion on health care for OCO veterans.1

Two medical conditions that may affect OCO veterans 

have received particular attention: post-traumatic stress 

disorder (PTSD) and traumatic brain injury (TBI). 

PTSD is an anxiety disorder triggered by a traumatic 

event, such as may occur when engaging in combat; 

witnessing serious injury, brutality, or unnatural death, 

particularly of another soldier; or suffering a severe 

vehicle accident, including those caused by improvised 

explosive devices (IEDs). The symptoms of PTSD 

include reexperiencing the event, hyperarousal (irritability, anger, or hypervigilance, for example), and diminished responsiveness to or avoidance of stimuli associated 

with the trauma. TBI is a blow to the head that alters a 

person’s consciousness, if only momentarily. TBI may 

result in amnesia or neurological abnormalities at the 

time of injury. In the combat theater, explosions from 

IEDs or other bombs are a leading cause of TBI among 

military personnel, although TBIs also result from falls, 

motor vehicle accidents, and bullet wounds.2

 TBI is 

classified as mild, moderate, or severe on the basis of 

its severity at the time of injury. (That classification 

refers to the acuteness of initial symptoms only, not 

to that of persistent symptoms.) Mild TBI, also known 

as a concussion, typically resolves quickly without 

medical treatment, in many cases within weeks and 

in most cases within three months. Although some 

symptoms may linger for six months or more, there 

is considerable debate over whether those persistent 

symptoms can be attributed to mild TBI or to other 

1. For a recent overview of those costs, see the statement of Heidi 

L. W. Golding, Principal Analyst for Military and Veterans’ 

Compensation, Congressional Budget Office, before the Senate 

Committee on Veterans’ Affairs, Potential Costs of Health Care for 

Veterans of Recent and Ongoing U.S. Military Operations (July 27, 

2011).

2. Defense and Veterans Brain Injury Center, TBI Facts, 

accessed June 27, 2011, at www.dvbic.org/TBI---The-Military/

TBI-Facts.aspx.
2 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

conditions.3

 (See Appendix A for more detailed information about PTSD and TBI.) 

Few service members have been evacuated from combat 

theaters as a result of PTSD or TBI alone, although many 

have been evacuated for TBI in conjunction with other 

injuries. Many cases of PTSD and TBI may go unrecognized and consequently undiagnosed and untreated, both 

in the combat theater and once the service member 

returns home. PTSD can interfere with daily functioning 

when it results in emotional withdrawal from family and 

friends, inappropriate expressions of anger, irritability, 

overprotective behaviors, or substance abuse. Those with 

ongoing mild TBI may feel sad, nervous, or agitated; 

have difficulty concentrating and sleeping; and experience sensitivity to noise or light. Those with moderate 

or severe TBI may experience similar difficulties but 

also have more complex physical and neurological limitations, which in some cases affect their ability to live 

Box 1.

Eligibility for VHA’s Services

Eligibility for the health care system of the Veterans 

Health Administration (VHA) is based primarily on a 

veteran’s military service. Generally, veterans of the 

active components of the military must have served 

24 continuous months on active duty to be eligible; 

reservists and National Guard members may be 

eligible if they are called to active duty under a federal 

order and they complete that service. Those broad 

criteria, however, do not necessarily guarantee access 

to medical treatment. VHA operates an enrollment 

system that assigns a veteran to one of eight categories 

to establish his or her priority for using its health 

care services. Veterans with higher priority include 

those who have service-connected disabilities, low 

income, or both. In January 2003, VHA imposed a 

general freeze (with some subsequent modifications) 

on new enrollments in the lowest priority group 

(Priority Group 8).1

The Veterans Programs Enhancement Act of 1998 

(Public Law 105-368) guarantees access to VHA’s 

health care system, after separation from active military service, to members of the armed forces who 

have served on active duty in combat operations since 

the law was enacted in November 1998; reservists 

and members of the National Guard who have served 

in combat operations are also included under that 

guarantee. The law gave combat veterans two years 

(starting from their date of separation from the military) to enroll and use VHA’s health care system without requiring those veterans to document either that 

their income is below established thresholds or that 

they have a service-connected disability—requirements that noncombat veterans must fulfill. In 2008, 

lawmakers extended the enhanced eligibility period 

for care through VHA’s health care system to five 

years.2

 Under those legislative authorities, VHA provides free health care for medical conditions directly 

or potentially related to a veteran’s military service in 

combat operations for five years after separation. 

Veterans who had deployed to overseas contingency 

operations (OCO) may continue to use VHA’s services when the five-year period of enhanced eligibility 

ends, but their priority group for enrollment may 

change, depending on their disability status and 

income. In particular, OCO veterans may be moved 

to a lower priority group, including Priority Group 8, 

and incur the applicable copayments. 

1. Veterans in Priority Group 8 are those who have no serviceconnected disabilities (or, according to a determination by 

the Department of Veterans Affairs [VA], have serviceconnected disabilities that are ineligible for monetary compensation) and have annual income or net worth above VA’s 

means-test threshold and regional income threshold. See 

www.va.gov/healtheligibility/Library/AnnualThresholds.asp. 

2. See title XVII of the National Defense Authorization Act for 

Fiscal Year 2008, P.L. 110-181, 122 Stat. 493.

3. For further discussion, see Susanne Meares and others, “The 

Prospective Course of Postconcussion Syndrome: The Role of 

Mild Traumatic Brain Injury,” Neuropsychology, vol. 25, no. 4 

(July 2011), pp. 1–12; and Charles W. Hoge and others, “Care 

of War Veterans with Mild Traumatic Brain Injury—Flawed 

Perspectives,” New England Journal of Medicine, vol. 360, no. 16 

(April 16, 2009), pp. 1588–1591.
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 3

CBO

independently. Symptoms manifest themselves in different ways and with different intensity across people and 

situations; some people function well in some settings but 

not in others. 

Some policymakers have questioned whether DoD and 

VHA have the resources and capacity to serve the OCO 

population with PTSD and TBI. Some observers are also 

concerned about whether service members and veterans 

with those conditions are reluctant to seek the help they 

need. In this study, the Congressional Budget Office 

(CBO) examines the clinical care provided by VHA for 

OCO veterans with PTSD and TBI, VHA’s coordination 

with DoD for the care of service members and veterans, 

the rate of occurrence of PTSD and TBI among VHA 

patients and the estimated prevalence of those conditions 

in the broader population of recent OCO veterans, the 

use of VHA’s health care services by OCO veterans who 

have been diagnosed with PTSD or TBI, and the costs of 

providing that care. Because the prevalence of PTSD and 

TBI in the OCO population is highly uncertain, CBO 

has not projected VHA’s future costs for treating veterans 

with those conditions. 

Clinical Care Within VHA

To serve the growing population of veterans, VHA has 

hired more than 7,500 mental health professionals since 

2005 and has established specialized rehabilitation centers for veterans with multiple complex injuries, including TBI. Further, VHA offers a broad range of services 

and programs tailored specifically to OCO patients with 

PTSD and TBI. In this section, CBO presents a brief 

overview of typical strategies for diagnosing PTSD and 

TBI, along with treatment options that VHA provides for 

those conditions.

VHA’s Services for PTSD

As of September 2011, mental health diagnoses were the 

second largest diagnostic category among OCO veterans 

who had received health care services from VHA, affecting 52 percent of those patients.4

 VHA delivers PTSD 

care in primary care settings and in specialized programs 

of evaluation, treatment, and education. Through its 

electronic national clinical reminder system, VHA 

endeavors to administer a screening test for various medical conditions, known as the Iraq and Afghan PostDeploy Screen, to all OCO patients.5 That screen 

includes the Primary Care PTSD (PC-PTSD) screen, 

which consists of four questions. VHA’s policy is to 

screen for PTSD every year for the first five years a veteran uses VHA care and once every five years thereafter, 

except in cases in which a clinical need for more frequent 

screening has been identified. 

Veterans who screen positive for PTSD are referred for 

additional evaluation. For most patients, further assessment is provided by a mental health professional such as 

a psychiatrist, psychologist, or trained clinician. That 

assessment typically takes place at a follow-up appointment, although additional evaluation or a diagnosis may 

occur during the visit when the screening occurs. VHA 

clinicians make their diagnoses according to the American Psychiatric Association’s Diagnostic and Statistical 

Manual of Mental Disorders (DSM), which delineates 

the professionally certified criteria for mental disorders in 

the United States. Diagnoses are made using a variety of 

diagnostic tools, often in combination, such as structured 

interviews (the Clinician-Administered PTSD Scale), 

semistructured interviews (the Structured Clinical Interview for DSM Disorders), and self-reported evaluations 

(the PTSD Checklist). 

Although PTSD has a well-validated case definition and 

diagnostic criteria, it can nonetheless be difficult to diagnose and treat. First, some OCO veterans and service 

members do not seek treatment for mental health problems. Despite widespread outreach programs within the 

military and VHA, the stigma associated with mental 

health disorders may discourage veterans from scheduling 

an appointment for an assessment or from requesting 

treatment, and fear of harming one’s military career may 

inhibit service members from seeking treatment while 

they are on active duty. Second, as with many mental 

health disorders, there is no objective measure, such as 

a laboratory test result, for confirming a diagnosis of 

PTSD. Third, some PTSD symptoms—for example, 

irritability, emotional numbing, insomnia, and trouble 

concentrating—also occur with other conditions. Fourth, 

PTSD can impair judgment, especially if combined with 

4. The largest category of diagnoses—diseases of the musculoskeletal 

system or connective tissue system—applied to 56 percent of 

OCO patients. Veterans may receive diagnoses in more than one 

category, so the percentages of patients with different diagnoses 

sum to more than 100 percent. 

5. The screen for deployment-related health risks includes questions 

designed to detect depression, alcohol abuse, and TBI, in addition 

to those relating to PTSD. The screen may be given in one of 

several venues but commonly occurs during a primary care visit.
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associated conditions such as substance abuse, and 

thereby make it more difficult for veterans with PTSD to 

seek or maintain treatment.

VHA provides treatment for PTSD at VHA hospitals, 

outpatient clinics, community-based outpatient clinics 

(CBOCs), and Vet Centers.6

 In addition, VHA pays for 

some care delivered through outside providers. VHA 

reports that treatment for PTSD is commonly delivered 

in outpatient clinics and CBOCs, either through general 

mental health clinics or, less commonly, through specialized programs provided by PTSD Clinical Teams, Substance Use PTSD Teams, and Women’s Stress Disorder 

Treatment Teams. VHA guidelines instruct clinicians to 

tell patients to expect about six months of treatment, but 

for patients with severe cases of PTSD or multiple diagnoses of mental health disorders, treatment may extend 

for one to two years or longer. For many veterans, PTSD 

oscillates between remission and relapse. The National 

Center for PTSD reports that some veterans may never 

be free of symptoms; rather, patients may learn coping 

mechanisms that allow them to function in private and 

public spheres. One of VHA’s treatment goals is to help 

veterans develop those mechanisms.7

Treatment for PTSD is tailored to the patient and may 

include a combination of psychotherapy (treatment based 

on psychology techniques) and pharmacotherapy (treatment using prescription drugs). In addition, all treatment 

programs for PTSD in VHA provide education for families and veterans (including coping mechanisms). 

VHA offers two forms of evidence-based psychotherapy—that is, therapy based on a substantive body of 

empirical research broadly accepted by the medical community. Those therapies are cognitive processing therapy 

(CPT) and prolonged exposure (PE) therapy. CPT helps 

patients change the way the trauma is perceived—for 

example, by replacing blame and guilt with less distressing thoughts. In PE therapy, the traumatic events are 

narrated repeatedly and combined with exercises to 

reduce anxiety in specific situations. The Institute of 

Medicine has concluded that exposure therapies, such as 

PE therapy, or other therapies that include exposure as 

part of treatment, such as CPT, are the only types of psychotherapy that have been found effective for PTSD; 

however, the Institute also noted evidence that the effectiveness of exposure therapies for veterans is not as strong 

as for civilians.8

 Other therapies used by VHA include 

group and family therapy. 

Clinical research suggests that PTSD patients who 

undergo therapy require at least nine treatment sessions.9

VHA reported to CBO that 40 percent of OCO veterans 

initiating CPT or PE therapy complete a full course of 

therapy. Typically, VHA patients undergoing CPT meet 

one on one with a therapist for an hour each week; for 

patients undergoing PE therapy, VHA typically schedules 

one 90-minute session each week. VHA data from internal program evaluations indicate that OCO veterans who 

completed PE therapy attended an average of 11 sessions, 

whereas those who did not complete therapy attended an 

average of 5 sessions; results were similar for patients 

undergoing CPT. Additional data from a recently published study found that 80 percent of OCO veterans who 

used VHA’s services and received new PTSD diagnoses 

had at least one follow-up visit; nonetheless, fewer than 

half completed the recommended treatment sessions 

within one year.10 The reasons for not completing a full 

course of therapy may include the following: the distance 

between home and the location of care, a preference for 

receiving mental health care from providers outside 

VHA, difficulty scheduling appointments, negative perceptions of mental health care, and impaired judgment as 

a result of either the condition itself or associated problems such as substance abuse.

Pharmacotherapy in VHA consists mainly of the use 

of antidepressants, such as selective serotonin reuptake 

6. In addition to providing clinical care services, VHA operates 

about 300 Vet Centers for veterans and their families at no outof-pocket cost. Vet Centers offer readjustment services such as 

individual and family counseling, assistance in applying for VHA 

benefits, and information on other community and educational 

opportunities. Veterans using those services need not be enrolled 

for VHA’s health care services, and they retain anonymity for any 

counseling they receive.

7. For more information, see VHA’s National Center for PTSD Web 

site at www.ptsd.va.gov/public/index.asp.

8. Institute of Medicine, Treatment of Posttraumatic Stress Disorder: 

An Assessment of the Evidence (Washington, D.C.: National Academies Press, 2008).

9. Karen Seal and others, “VA Mental Health Services Utilization in 

Iraq and Afghanistan Veterans in the First Year of Receiving New 

Mental Health Diagnoses,” Journal of Traumatic Stress, vol. 23, 

no. 1 (February 2010), pp. 5–16.

10. Ibid.
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inhibitors (SSRIs) and serotonin norepinephrine 

reuptake inhibitors (SNRIs). If unsuccessful, treatment 

may expand to mood stabilizers, anticonvulsants, antipsychotics, or other agents to alleviate symptoms such as 

anxiety, intrusive thoughts, flashbacks, and insomnia. In 

one study, VHA researchers determined that pharmacotherapy was more likely to be prescribed for patients 

receiving a diagnosis in a mental health clinic than for 

those diagnosed in a general medical or PSTD clinic.11

A small share of OCO patients with PTSD diagnoses 

undergoes psychiatric hospitalization—5 percent through 

2010. Such hospitalizations include both traditional 

inpatient stays and specialized programs involving short 

residential stays; those stays involve counseling and treatment with social, vocational, and recreational therapies. 

VHA’s Services for TBI

TBI is classified as mild, moderate, or severe on the basis 

of its severity at the time of the injury. Because moderate 

and severe TBIs are easily identified and require immediate attention, acute care for combat-related TBIs is 

given by DoD, whereas VHA provides rehabilitation 

care. Moderate and severe TBIs are clinically different 

from mild TBIs, and their treatment typically involves 

substantially more health care resources. Veterans who 

experienced moderate or severe TBIs may receive inpatient rehabilitative care, outpatient rehabilitative care, 

or both, through programs that specialize in treating 

complex patients. Along with occupational, cognitive, 

physical, and other therapies, VHA also provides 

advanced technologies to veterans with ongoing needs 

related to sensory impairment, communication deficits, 

mobility, and self-care. The course of treatment prescribed and the services provided vary significantly by 

patient and are tailored to the severity of the TBI and 

ongoing problems.

Veterans with mild TBI are also eligible for VHA’s TBI 

rehabilitation programs, but they are usually treated on 

an outpatient basis for less intense clinical symptoms and 

for a much shorter duration than moderate and severe 

TBI patients. In April 2007, VHA directed that all OCO 

veterans who use VHA and have not received a prior 

diagnosis for TBI be screened for symptomatic TBI—

that is, TBI with currently occurring symptoms such as 

headaches, memory difficulties, or sleep problems. 

Because moderate and severe cases are readily detected, 

the purpose of this screen, in effect, is to identify mild 

TBI. Since April 2007, questions designed to detect TBI 

have been included in VHA’s Iraq and Afghan PostDeploy Screen. For those who screen positive, additional 

evaluation takes place with the patient’s agreement; in the 

absence of that consent, VHA requires that the patient’s 

refusal to undergo further evaluation be documented. 

Through 2009, approximately one in five OCO veterans 

screened positive for symptomatic TBI. Two-thirds of 

those screening positive (or 14 percent of all screened 

patients) completed a comprehensive evaluation (some of 

those may not have undergone further testing because 

symptoms had resolved before the full evaluation was 

conducted). Of the 14 percent receiving a comprehensive 

evaluation, VHA clinicians diagnosed symptomatic TBI 

in one-half of those who screened positive (or 7 percent 

of all those initially screened).12

Some VHA medical facilities use individual neurologists, 

rehabilitation physicians, or psychiatrists for the followup evaluation, whereas others refer patients to an 

interdisciplinary team. Evaluation includes a complete 

history of injury, a physical exam, and a neurobehavioral 

inventory of TBI symptoms. Other diagnostic tools for 

TBI are limited. In some cases, a veteran’s medical records 

from DoD are incomplete or unavailable, because DoD’s 

and VHA’s medical systems are not fully integrated. Correct diagnosis is problematic, as none of the symptoms 

of TBI are unique to that condition, and there is no 

clinically validated definition for TBI with persistent 

symptoms months after injury. Thus, many of the difficulties in diagnosing and treating PTSD also apply to 

symptomatic TBI: Some veterans may not seek care; 

11. Michele R. Spoont and others, “Treatment Receipt by Veterans 

After a PTSD Diagnosis in PTSD, Mental Health, or General 

Medical Clinics,” Psychiatric Services, vol. 61, no. 1 (January 

2010), pp. 58–63.

12. David Cifu, National Director of VA’s Physical Medicine and 

Rehabilitation Office, “The Veterans Health Administration Polytrauma System of Care” (PowerPoint slides transmitted via e-mail, 

May 2010).There is some controversy surrounding estimates of 

the prevalence of symptomatic TBI. Headaches, concentration 

and memory problems, fatigue, irritability, and sleep disturbance 

are common symptoms seen in veterans returning from war, as 

well as in individuals with other medical conditions. Whether 

symptoms that occur months or years after a TBI can be unequivocally attributed to mild TBI, as opposed to other conditions, has 

been the subject of considerable debate. See Charles Hoge and 

others, “Care of War Veterans with Mild Traumatic Brain 

Injury—Flawed Perspectives,” New England Journal of Medicine, 

vol. 360 (April 16, 2009), pp. 1588–1591.
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there is no objective diagnostic tool to confirm the 

diagnosis; symptoms may coincide with those of other 

conditions; and VHA’s diagnostic process often relies 

heavily on the veteran’s memory, which may be impaired 

as a result of TBI or another medical condition.13

After confirmation of the diagnosis, additional physical 

examinations, laboratory tests, and psychosocial evaluations may be performed.14 Because there is no standard 

treatment regimen, a team of clinicians typically evaluates 

the results and determines a treatment plan, which 

accounts for concurrent disorders. According to VHA’s 

guidelines, patients with symptoms persisting beyond 

four to six weeks of treatment should be reassessed, 

assigned to a case manager, and receive treatment for their 

remaining symptoms. 

VHA considers the management of physical, behavioral, 

and cognitive symptoms fundamental to treatment of 

mild TBI. The two mainstays of treatment are symptomspecific treatment (such as managing headache pain, the 

most common symptom of TBI) and educating patients 

on their expected recovery. VHA states that treatment 

through primary care clinics is appropriate for managing 

TBI when implemented by an interdisciplinary team of 

rehabilitation therapists, pharmacists, and mental health 

clinicians. Pharmacotherapy is sometimes used alone or 

in conjunction with other therapies to treat musculoskeletal pain, anxiety, or psychiatric symptoms. However, 

there is currently no clinically validated pharmacotherapy 

to improve neurocognitive function after a mild TBI. As 

with PTSD, providing education for veterans and families about TBI is an important part of treatment. VHA’s 

guidelines advise providers to reassure patients and their 

families that mild TBI is normally transient and full 

recovery without permanent damage is expected. Duration of treatment for mild TBI at VHA is normally one 

to three months, with follow-up four to six weeks later to 

confirm recovery, which is defined as the resolution of 

symptoms and normal functioning. For some patients, 

however, symptoms may persist beyond six months to a 

year or longer. Further evaluation for other conditions 

may be indicated for persistent symptoms.

Concurrent Diagnoses of PTSD and TBI

TBIs sustained in Iraq or Afghanistan are often the result 

of explosions and involve other injuries; moreover, PTSD 

has been shown to occur more commonly in veterans 

with combat-related concussions (mild TBIs) than in 

those with other injuries. The Institute of Medicine’s 

Committee on Gulf War and Health found evidence, 

albeit limited, suggesting that TBI and PTSD are 

associated.15 CBO’s analysis of VHA data found that 

three-quarters of OCO patients with a TBI diagnosis 

also had a diagnosis of PTSD and that one-fifth of 

OCO patients with a PTSD diagnosis also had a 

diagnosis of TBI.16

Because PTSD and TBI may generate many of the 

same symptoms, a person who has both conditions may 

be diagnosed for only one and not the other or, alternatively, diagnosed with both but have only one condition. 

Medical consensus is lacking on the accuracy of screening 

and diagnosis for both conditions if the person has concurrent PTSD and TBI. Diagnosing only one of the 

conditions when both are present can lead to difficulties 

with treatments. For example, treatments for either mild 

TBI or PTSD alone may not be effective for patients with 

both conditions, as cognitive impairment may hinder 

adherence to treatment. 

Polytrauma

VHA uses the designation “polytrauma” to describe complex, severe injuries to multiple organ systems that often 

13. For a more extensive discussion of the challenges that VHA clinicians face in diagnosing TBI, see Heather Belanger and others, 

“The Veterans Health Administration’s System of Care for Mild 

Traumatic Brain Injury: Costs, Benefits, and Controversies,” Journal of Head Trauma Rehabilitation, vol. 24, no. 1 (2009), pp.4–13.

14. Information presented in this and the following paragraph is from 

a document prepared jointly by the Department of Veterans 

Affairs and the Department of Defense, VA/DoD Clinical Practice 

Guideline for Management of Concussion/Mild Traumatic Brain 

Injury, April 2009.

15. Institute of Medicine, Gulf War and Health, vol. 7, Long-Term 

Consequences of Traumatic Brain Injury (Washington, D.C.:

National Academies Press, 2009).

16. Another study reported that among soldiers who had just returned 

from a deployment to Iraq, about one-third who reported 

suffering a mild TBI also screened positive for PTSD. See Lisa 

Brenner and others, “Traumatic Brain Injury, Posttraumatic Stress 

Disorder, and Postconcussive Symptoms: Symptom Reporting 

Among Troops Returning from Iraq,” Journal of Head Trauma 

Rehabilitation, vol. 25, no. 5 (September-October 2010), 

pp. 307–312. There is some evidence that PTSD explains most 

or all symptoms in OCO veterans with concussions. See Charles 

W. Hoge and others, “Mild Traumatic Brain Injury in U.S. 

Soldiers Returning from Iraq,” New England Journal of Medicine, 

vol. 358, no. 5 (January 31, 2008), pp. 453–463.
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 7

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result from the same event, such as an explosion. Those 

may include brain injury, amputation, hearing and vision 

impairments, spinal cord injuries, and psychological 

trauma. A small number of patients who have those complex injuries are treated in VHA’s Polytrauma System of 

Care, which provides comprehensive, interdisciplinary 

rehabilitation and other care for seriously disabled 

patients. The Polytrauma System of Care includes five 

Polytrauma Rehabilitation Centers for inpatient rehabilitation, as well as secondary sites and clinical teams for 

postdischarge care.17 

Cooperation Between VHA and DoD

Soon after the conflicts in Afghanistan and Iraq began, it 

became apparent that some wounded service members 

were encountering significant difficulties when making 

the transition from DoD’s health care system to VHA’s. 

To address those concerns, DoD and VHA have 

increased their cooperation and have devoted more 

resources to encouraging service members and veterans to 

seek care.18

In the summer of 2007, DoD and VHA instituted the 

Wounded, Ill, and Injured Senior Oversight Committee 

to address problems specific to those service members, 

which include the coordination of health care management, disability evaluation, and transition of OCO 

service members’ health care from DoD to VHA.19 The 

committee has several work groups charged with addressing particular issues, including one that focuses on the 

needs of service members and veterans with PTSD and 

TBI. 

The Wounded Warrior Act, part of the National Defense 

Authorization Act for Fiscal Year 2008 (Public Law 110-

181, sections 1601–1676) required DoD and VHA to 

implement many initiatives, including reducing waiting 

time for medical care, consolidating their disability evaluation systems, and establishing standards to determine 

whether and when wounded service members could 

return to active duty. The law also mandated that the 

Government Accountability Office (GAO) deliver progress reports on those initiatives to the Congress. In its July 

2009 report, GAO found that although DoD and VHA 

had not fully developed or implemented the requirements 

of the Wounded Warrior Act, they had made considerable progress.20

DoD and VHA have targeted the coordination of health 

care management to service members with TBI or with 

PTSD and other mental health conditions. In particular, 

the agencies are collaborating on myriad issues such as 

screening, diagnosing, and treating those conditions, as 

well as assisting service members in their transition from 

DoD’s health care system to that of VHA. One result of 

that collaboration is the TBI screen used by VHA, which 

was derived from the screen first used by DoD at certain 

military bases. DoD and VHA have formed joint committees, such as the VHA/DoD Mental Health Working 

Group; participate in joint research ventures, such as the 

Defense and Veterans Brain Injury Center; and share 

clinical practice guidelines, such as Management of 

Concussion/Mild Traumatic Brain Injury.

21 DoD and 

VHA clinicians may collaborate on service members’ 

transition to VHA’s care; however, the proliferation of 

programs and case managers can be confusing for service 

members and has led to some duplication of efforts.22

Because the sharing of medical records between DoD and 

VHA would greatly facilitate the transition of service 

members between the agencies, the Wounded Warrior 

Act included provisions designed to achieve such sharing; 

17. The five centers are located in Minneapolis, Minn.; Palo Alto, 

Calif.; Richmond, Va.; Tampa, Fla.; and San Antonio, Tex. For 

more information, see VHA’s Polytrauma/TBI System of Care 

Web site at www.polytrauma.va.gov.

18. VHA, for example, created a Mental Health Enhancement Initiative to provide funding to facilitate greater community outreach, 

place PTSD specialists or treatment teams in each VHA Medical 

Center, and expand evidence-based care for PTSD. 

19. The Wounded, Ill, and Injured Senior Oversight Committee is 

among numerous review groups, task forces, and commissions 

that have examined or are currently charged with improving the 

care and benefits that DoD and VA provide to service members 

and veterans.

20. Government Accountability Office, DOD and VA Have Jointly 

Developed the Majority of Required Policies but Challenges Remain,

GAO-09-728 (July 2009). 

21. The Defense and Veterans Brain Injury Center became one of 

the component centers of the Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury, an umbrella 

organization that was established in November 2007. For more 

information, see the Defense Centers of Excellence Web site at 

www.dcoe.health.mil.

22. Robin M. Weinick and others, Programs Addressing Psychological 

Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families (Santa Monica, Calif.: RAND 

Corporation, 2011).
8 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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however, that objective remains a work in progress. 

DoD and VHA do have complex sharing agreements and 

information-exchange projects to coordinate their independent record systems. For example, DoD can transfer 

the medical records of service members who have separated from DoD and are eligible for VHA care through 

the Federal Health Information Exchange. Moreover, 

health care clinicians for DoD and VHA can access 

records for patients treated by providers in either agency 

through the Bidirectional Health Information Exchange. 

Yet technical and organizational challenges have made it 

difficult to construct a unified electronic medical record. 

The Virtual Lifetime Electronic Record (VLER)—a joint 

effort of DoD and VHA—overcame a major hurdle in 

2010 when DoD and VHA agreed to use a common personal identifier. Slated for VHA-wide implementation in 

2012, the VLER is a single electronic record that would 

be used to manage comprehensive administrative and 

medical information for service members throughout 

their lives, from enlistment to death, regardless of health 

care provider. 

Current record-sharing goals for VHA and DoD extend 

to a broader effort with the private sector, the Nationwide 

Health Information Network (NwHIN).23 This group of 

federal agencies and private organizations has agreed to 

securely share patients’ health information electronically 

among providers and health care systems by defining 

standards, services, and policies. Pilot projects for 

NwHIN are under way; veterans who agree to participate 

allow their public- and private-sector health care providers to share specific health information. 

CBO’s Analytical Approach to VHA Data

In this study, CBO presents data on the use of VHA’s 

health care services between fiscal years 2004 and 2009 

by OCO veterans who received a diagnosis of PTSD or 

TBI.24,25 CBO also presents estimates of the costs that 

VHA has incurred to treat OCO veterans with PTSD, 

TBI, or both during that period and compares them with 

the costs of providing care to OCO patients who do not 

have PTSD or TBI.26 CBO’s estimates are based on 

VHA’s cost data and do not include expenditures by other 

federal providers of health care or private insurers, out-ofpocket costs, forgone earnings, or other losses to society 

associated with the two conditions.27

CBO’s primary analysis focused on VHA patients who 

had not been treated at specialized polytrauma facilities, 

which provide care for veterans who suffer from more 

than one complex physical or mental trauma. That analysis examined the use of VHA’s health care services and 

cost of providing those services for 496,800 OCO veterans in four mutually exclusive groups: 

 103,500 patients with PTSD (but not TBI); 

 8,700 patients with TBI (but not PTSD); 

 26,600 patients with both PTSD and TBI; and 

 358,000 patients with neither of those two conditions.28

Patients in the PTSD group did not have TBI, but many 

had other conditions; similarly, patients in the TBI group 

did not have PTSD, but many had other conditions. 

None of the groups includes 500 polytrauma patients, 

many with PTSD and TBI, who were analyzed separately. 

The data include 99 percent of all OCO veterans seen by 

VHA from 2004 to 2009. To protect patients’ confidentiality, VHA did not provide CBO with data on individual 

23. NwHIN is led by the Department of Health and Human Services. 

For more information, see http://healthit.hhs.gov/portal/server.pt/

community/healthit_hhs_gov__nhin_exchange/1407.

24. VHA did not provide CBO with data from the start of overseas 

contingency operations in 2001. However, the number of OCO 

veterans entering VHA before 2004 was relatively small: Roughly 

10,000 veterans who deployed to Iraq and Afghanistan had sought 

VHA’s health care services by the end of 2003.

25. Vet Centers provided PTSD services to 42,000 OCO veterans 

through June 2011; among those veterans, 27,000 were also seen 

for PTSD at a VHA medical center. The data that CBO analyzed 

do not include information on the 15,000 veterans seen only at 

Vet Centers.

26. In the information that it provided to CBO, VHA converted its 

cost data to fiscal year 2009 dollars on the basis of annual 

increases in the average cost of a primary care visit from 2004 to 

2009. CBO then indexed those costs to 2011 dollars using the 

implicit price deflator for gross domestic product.

27. Initial hospitalizations for the more severe cases of TBI are not 

included in VHA’s costs because those individuals were still on 

active duty at the time of initial injury and would have been 

treated within DoD.

28. TBI describes an injury event, but the term TBI may also refer to 

symptoms that persist beyond the acute period. In this study, TBI 

patients are OCO veterans who, when examined at VHA facilities, exhibited symptoms attributed to a TBI.
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 9

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patients. Because VHA did not identify the date of 

patients’ first diagnosis or entry, CBO was not able to 

calculate the use or the cost of health care for patients 

entering VHA treatment in any given fiscal year.

For the first three groups, CBO presents data on the use 

of services and costs of treatment for the first year of care 

(treatment year 1) and for up to three additional years 

following initial diagnosis.29 Data on patients with no 

diagnosis of PTSD or TBI are presented for comparison 

purposes following their initial visit for any VHA care. 

CBO did not receive detailed clinical data and thus was 

not able to construct a comparison group that was similar 

in all observed ways to the three groups apart from their 

diagnosis of PTSD, TBI, or both. The patients with and 

without PTSD or TBI were roughly similar in age, sex, 

and military experience, but they differed in certain characteristics, particularly injuries sustained while deployed 

in overseas contingency operations. In general, service 

members who had PTSD or TBI were more likely to have 

received other injuries, so the costs of care for the PTSD 

and TBI groups probably would have been higher even 

without the costs of care for PTSD and TBI. The polytrauma group, which consisted of patients with multiple 

complex injuries requiring extended inpatient stays for 

rehabilitation at VHA, is examined separately later in the 

study; it was a very small group whose average medical 

costs were far higher than those of the four other groups.

CBO’s analysis is based on data from VHA’s administrative records from 2004 through 2009. Because some 

patients started using VHA’s services partway through the 

sample period, not all patients were observed for the full 

six years. Indeed, CBO used only the first four years of 

data even when six years were available because data for 

that longer span existed for only a small minority of veterans. When fewer than four years of data existed, CBO 

included all of the years available. Consequently, when 

CBO examined patients’ first year of treatment, those 

who entered the VHA system in 2008 and 2009 were 

included, but when CBO examined later years of treatment, those patients were not included, having entered 

the system too late in the sample period. 

Not only do patients entering VHA in 2008 and 2009 

have fewer years of treatment data available, they are also 

different from those who entered in earlier years in two 

other ways. First, more veterans entering the VHA system 

in those later years had experienced longer deployments 

and multiple deployments. Second, starting in 2008, 

VHA extended enhanced eligibility from two years to five 

years for OCO veterans (see Box 1 on page 2). That 

extension enabled veterans with delayed-onset PTSD or 

other combat-related conditions for which they had not 

previously sought treatment to enter the VHA system 

and receive care at no cost. However, CBO does not 

believe that those two differences substantially affected 

the number or severity of PTSD or TBI cases or, more 

generally, the injuries or other medical conditions treated 

at VHA in 2008 and 2009.30

While screening and treatment for PTSD were consistent 

across the years, VHA’s clinical practices for TBI changed 

during the data period (2004 to 2009): The agency initiated comprehensive screening for mild, symptomatic 

TBI in 2007. As a consequence, the characteristics of TBI 

patients are likely to be different across treatment years. 

Patients whom VHA diagnosed with TBI before 2007 

were more likely to have had moderate to severe TBI than 

those diagnosed in 2007 or after. The study period ended 

before the newly identified mild cases could accumulate 

four treatment years. Therefore, moderate and severe 

cases are more common among TBI patients in treatment 

years 3 and 4 than in treatment years 1 and 2. Because 

CBO did not have information on TBI severity (mild, 

moderate, or severe), it was not possible to separate the 29. To determine the group to which a patient belonged, each OCO 

patient’s administrative record was checked for any diagnosis code 

of PTSD or TBI, and the patient was assigned to the relevant 

group. Any patient with both codes was classified as having both 

PTSD and TBI. No patient could be included in more than one 

diagnosis group; once classified, patients remained in the same 

group for the entire sample period. The sample included all PTSD 

and TBI cases among OCO veterans diagnosed at VHA, regardless of whether those conditions were sustained while deployed. 

The share of veterans who acquired PTSD or TBI unrelated to 

deployment (for example, injury from an automobile accident 

after returning from Iraq or Afghanistan) is unknown but is probably a small portion of CBO’s sample.

30. Veterans who became part of CBO’s sample in those later years are 

more likely to have remained in the military longer after deployment than those who entered in the early years of 2004 and 2005. 

Any health conditions that veterans who entered VHA in 2008 

and 2009 developed during deployment, therefore, were more 

likely to have been treated by DoD before those service members 

transferred to VHA. The extension of enhanced eligibility in 2008 

appears to have had a minimal effect on entry into the VHA system. VHA provided CBO with data showing that both before and 

after the policy change, most veterans who used VHA services did 

so within two years of separation from active duty.
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use of services and costs by severity. The costs of treating 

mild TBI, however, are likely to be substantially lower 

than the costs of treating moderate and severe TBI. As 

a result of the policy change, use and costs in later 

treatment years grow for TBI patients and are almost as 

high in treatment year 4 as in treatment year 1. Without 

the policy change, use and costs for those patients probably would have been highest during the first year of care 

and then declined and stabilized thereafter, as occurred in 

the other groups.

VHA provided CBO with aggregate use and cost data for 

groups of OCO veterans based on their demographic 

characteristics, medical condition, and medical services 

used.31 Because data were provided at the group level, 

CBO can only present information on averages for those 

groups and not on the distribution of use or cost within 

groups. (For additional information about the data and 

methodology used in this analysis, see Appendix B.) 

CBO calculated total and average costs for patients who 

accessed VHA’s services at least once, for up to four years 

after their PTSD or TBI diagnoses or, in the absence of 

those diagnoses, average costs for up to four years after 

their entry into the VHA system. Diagnostic tests and 

pharmacy use were included and categorized as part of 

outpatient costs. As with all analyses based on administrative data, errors and nonstandardized coding may affect 

the results presented here. 

Occurrence and Prevalence of 

PTSD and TBI 

In the VHA data provided to CBO regarding 496,800 

OCO veterans treated by VHA between 2004 and 2009, 

veterans with a diagnosis of PTSD (but not TBI) 

accounted for 21 percent (103,500) of the total, and 

those with a diagnosis of TBI (but not PTSD) accounted 

for 2 percent (8,700). In addition, veterans with diagnoses of both PTSD and TBI accounted for about 5 percent 

(26,600). Thus, three out of four OCO veterans with a 

diagnosis of TBI had a concurrent PTSD diagnosis.32 In 

total, approximately 26 percent (130,100) had at least 

one diagnosis of PTSD, and 7 percent (35,300) had at 

least one diagnosis of TBI.33 More than 70 percent 

(358,000) of OCO veterans treated by VHA were not 

diagnosed with either PTSD or TBI. Other mental 

health conditions besides PTSD are common within the 

OCO veteran population. (For a brief description of 

other mental health conditions and suicide in that population, see Box 2.)

The occurrence of PTSD and TBI among OCO veterans 

who use the VHA system—which is measured by the 

diagnosis rates just described—does not necessarily reflect 

the prevalence of those conditions in the entire OCO 

population. If service members who have separated from 

the military are more likely to have service-connected 

health problems than those who have remained on active 

duty, then the rate of diagnosis among VHA patients 

will be higher than the proportion of the entire OCO 

population that has those problems. If, however, sufficient numbers of veterans with PTSD or TBI were either 

being treated for the condition elsewhere or not being 

treated at all, the rate in the overall OCO population 

could be greater than the rate diagnosed among VHA 

patients. For example, some veterans have employmentbased health insurance; others seek care from other 

sources that are not connected to their military service, 

perhaps because providers are located more conveniently 

or are perceived to be more private; and still other veterans forgo care altogether. For PTSD, the effect of stigma 

associated with a positive screening or diagnosis has not 

31. VHA computes costs on the basis of its internal reporting systems. 

Costs for treating PTSD and TBI in the civilian population and 

veterans treated at VHA are unlikely to be comparable because of 

differences in cost allocation methodologies, the populations 

treated, and the mechanisms of injury. Also, while VHA data measure the costs of care, private-sector estimates are often based on 

insurance reimbursements to private providers, which are not 

identical to costs. 

32. VHA researchers examining OCO veterans treated at VHA have 

reported rates of concurrent diagnoses that are similar to CBO’s; 

however, some researchers drawing from broader samples of OCO 

service members and veterans find lower rates of concurrent TBI 

and PTSD. In the three studies with the largest sample sizes, 

between 33 percent and 39 percent of OCO veterans with mild 

TBI also screened positive for PTSD. See Kathleen F. Carlson 

and others, “Prevalence, Assessment, and Treatment of Mild 

Traumatic Brain Injury and Posttraumatic Stress Disorder: A 

Systematic Review of the Evidence,” Journal of Head Trauma 

Rehabilitation, vol. 26, no. 2 (March–April 2011), pp. 103–115.

33. If the threshold is raised to include only veterans who had two or 

more visits coded with a diagnosis of PTSD or TBI, the rates that 

CBO estimates drop to 20 percent and 3 percent, respectively. 

(Some researchers consider a two-visit measure a more definitive 

indicator of a condition, although that more-stringent threshold 

will miss those veterans who have PTSD or TBI but leave the 

VHA system after the initial diagnosis.)
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been measured well, but it is likely to reduce the number 

of people who admit to problems associated with PTSD 

and then screen positive. For those reasons, the prevalence—that is, the estimate of the proportion of cases in a 

population, whether or not the individual has received a 

clinical diagnosis from a medical professional—of PTSD 

and TBI in the OCO population probably differs from 

the percentage of patients in the VHA system diagnosed 

with those conditions.

Many researchers have estimated PTSD and TBI prevalence among different groups of service members 

and veterans who deployed to operations in Iraq and 

Afghanistan, but there is no consensus as to the prevalence rate among the entire OCO population.34

Researchers generally have reported prevalence rates ranging between 5 percent and 25 percent for PTSD among 

different groups of service members who deployed to 

overseas contingency operations, with generally higher 

rates in studies of infantry brigades or combat teams. 

Researchers have found that the proportion of service 

members who experienced a TBI, including those who 

no longer had symptoms, ranged from 15 percent to 

23 percent, and that the proportion of service members 

who had symptomatic TBI after returning from deployment ranged from 4 percent to 9 percent. Thus, the 

percentage of OCO veterans whom VHA clinicians 

have diagnosed with PTSD (26 percent) is at the top 

of the range of prevalence reported in published studies, 

whereas the percentage they have diagnosed with 

symptomatic TBI (7 percent) is in the middle of the 

reported range. The estimates of symptomatic TBI 

remain uncertain because there are no clinically validated 

diagnostic criteria for that condition, and connecting 

self-reported persistent symptoms to the initial injury is 

problematic. Published estimates of PTSD and TBI during deployment vary widely because the assessment tools 

used to identify the conditions, the criteria used to identify cases, and the subgroup of service members sampled 

differ among studies. (For a detailed discussion of those 

issues, see Appendix C.)

The gold standard for determining prevalence would be 

to evaluate each person in a representative sample of the 

OCO population using validated clinical interviews; 

achieving that ideal, however, would be expensive and 

difficult. Instead, some researchers use administrative 

data on diagnoses to measure the number of cases of 

PTSD and TBI; others use clinical screening tools to 

assess cases. Administrative data on diagnoses understate 

prevalence in a population because not everyone seeks 

care. Some researchers who use screening tools to identify 

PTSD and TBI apply low thresholds for assessing those 

conditions. In so doing, however, they may also generate 

many false positives and overestimate the number of 

cases. Conversely, researchers employing more restrictive 

thresholds could underestimate cases.

In addition, most studies to date, including some that 

attempt to be population-based, have oversampled certain groups; applying rates from nonrandom samples 

without the proper weighting is unlikely to yield an accurate measurement of prevalence. On the one hand, estimates based on combat units, which experience higher 

rates of physical and psychological trauma than other 

types of military units, may lead to prevalence estimates 

that are too high to apply to the general population of 

service personnel in a combat region, which includes support units. On the other hand, samples based on returning, uninjured troops may lead to estimated prevalence 

rates that are too low. 

Another shortcoming with published studies, which 

applies also to diagnosis rates within VHA, is that service 

members and veterans may not accurately report their 

symptoms. The stigma associated with screening positive 

for PTSD, the perceived inconvenience of undergoing 

additional evaluation, or a lack of confidence in treatment effectiveness may lead to an underreporting of 

symptoms of mental health problems or TBI and thus 

an underestimate of prevalence. 

Finally, using estimates of TBIs that occur during deployment is problematic because even a confirmed clinical 

diagnosis when or shortly after an injury is sustained does 

not reveal the frequency of persistent postconcussive 

symptoms. DoD reports that, although a small minority 

of service members has ongoing symptoms, most cases of 

TBI are mild, often resolving within weeks and almost 

always improving within three months. 

34. Those studies included papers that reported frequencies of possible cases of PTSD or TBI regardless of whether the objective of 

the study was to estimate the prevalence in the broader OCO 

population.
12 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

Continued

Use of VHA’s Services 

Through September 2011, VHA reported that the number of OCO veterans who had used VHA at least once 

totaled nearly 740,000, or 53 percent of OCO veterans. 

The OCO population using VHA’s services tends to be 

male (88 percent), is young (46 percent are younger 

than 32), consists predominantly of former soldiers in 

the Army (61 percent), and is slightly more likely to be 

veterans of active-duty units (56 percent) than reserve 

components. 

Future spending on OCO patients will change according 

to the mix of conditions diagnosed and the number of 

Box 2.

Suicide and Mental Illness Among OCO Veterans

Just over half of veterans of overseas contingency 

operations (OCO) treated by the Veterans Health 

Administration (VHA) have a diagnosis of a mental 

illness. Mental health problems can affect all aspects 

of life. Suicide among service members and veterans, 

an infrequent but devastating outcome of mental illness, is of particular concern to policymakers and 

others. 

Suicide

In 2009, the suicide rate for military members serving on active duty was 18.3 per 100,000, the highest 

since 1980. The following year, that rate dropped to 

17.0. In the general population, by comparison, the 

suicide rate in 2007 was 20.8 among males ages 20 to 

24 and 20.7 among males ages 25 to 34.1

 From 2003 

to 2010, the Department of Defense (DoD) confirmed nearly 2,000 suicides among active-duty service members, 300 of which occurred during deployment. Roughly 50 percent of suicides in 2010 

occurred among military members who had deployed 

to overseas contingency operations. Suicide rates were 

higher in the Army and Marine Corps than in other 

branches of the military.

Suicides among service members who deployed to 

overseas contingency operations also occur after they 

leave military service. Studies of Vietnam veterans 

reveal that deployment to a war zone is associated 

with suicide in the years immediately following 

deployment.2

 However, information on suicides 

among veterans is less complete than it is for activeduty personnel, and no nationwide surveillance 

system exists for tracking the incidence of suicides in 

that population. 

The Centers for Disease Control and Prevention 

(CDC) compiles national statistics on suicide, 

but veteran status and the cause of death are not 

always reported correctly on death certificates or 

summarized accurately by local health officials. 

CDC estimates that about 35,000 suicides occurred 

in the U.S. population in 2007. A separate system, 

the CDC’s National Violent Death Reporting 

System—which maintains more comprehensive data 

on violent deaths but operates in only a limited 

number of states—estimates that veterans accounted 

for 20 percent of the suicides in those states in 2005. 

The CDC and Department of Veterans Affairs have 

ongoing initiatives to tabulate all suicides among 

veterans. 

Statistics from VHA’s suicide-prevention coordinators indicate that in fiscal year 2009 there were nearly 

11,000 suicide attempts among veterans receiving 

care from the agency; 6.2 percent were documented 

as fatal. Among VHA’s patients in 2007, the rate of 

suicide was 35 per 100,000, a rate higher than that 

found in the general population. However, that rate is 

not adjusted for the demographics of VHA’s user 

population. Veterans who use VHA, moreover, may 

do so because they have more medical conditions, 

including mental health conditions, than other veterans or members of the general population.

1. Historically, rates of death for all causes have been lower 

among service members than in the general population.

2. Institute of Medicine, Gulf War and Health, vol. 6,

Deployment-Related Stress and Health Outcomes (Washington, 

D.C.: National Academies Press, 2007).
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 13

CBO

patients treated.35 CBO’s estimates of diagnosis rates are 

useful in projecting VHA’s future costs, but the usefulness 

depends on the extent to which the prevalence of those 

conditions and veterans’ likelihood to seek treatment at 

VHA remain the same. If outreach services motivate 

more veterans to seek care, for example, the rate at which 

veterans use VHA’s services would tend to increase over 

time. Combat exposure should decline with OCO troop 

Box 2. Continued

Suicide and Mental Illness Among OCO Veterans

As part of VHA’s expansion of mental health services, 

the agency’s suicide-prevention program is wideranging.3

 Initiatives include screening OCO veterans 

for selected mental health conditions; establishing 

suicide-prevention programs in each VHA hospital 

and large community-based outpatient clinic; operating a 24-hour suicide-prevention hotline staffed by 

VHA mental health professionals; and developing a 

system for flagging the records of patients at high risk 

of suicide.

Mental Illness

Among OCO veterans using VHA’s services from 

October 2001 through June 2011, 21 percent were 

diagnosed with a depressive disorder. Other mental 

health conditions commonly diagnosed among 

OCO veterans are anxiety and drug or alcohol abuse. 

OCO patients with mental health conditions often 

have multiple conditions of this type. 

Treatment for mental illness is provided at local 

facilities in broad consultation with VHA’s Office 

of Mental Health Services, which has been implementing recommendations from its comprehensive 

five-year Mental Health Strategic Plan. That plan, 

which focused on gaps in mental health care for veterans, had several goals, which included addressing 

the mental health needs of OCO veterans and preventing suicide. One of the steps being taken to 

achieve those goals is to better integrate mental 

health treatment and primary care. For fiscal year 

2010, VHA obligated $5.2 billion for mental health 

programs—more than a tenth of its total spending 

for medical care; obligations are slated to exceed 

$6 billion by 2012.4

 Available services consist of outpatient specialty programs, inpatient psychiatric care, 

residential and vocational rehabilitation, substance 

use disorder care, and various local initiatives.

VHA provided CBO with information on the use of 

VHA’s health care services and the costs of providing 

those services for 73,000 OCO veterans who had a 

mental health diagnosis other than PTSD (and no 

diagnosis of TBI). When compared with OCO 

veterans with no mental health diagnosis, patients 

with mental health disorders other than PTSD made 

greater use of VHA’s health services in treatment 

year 1 as measured by inpatient hospital days (0.6 per 

year compared with 0.08 per year for veterans with 

no mental health diagnosis), annual outpatient visits 

(16 versus 8), and prescriptions filled (9 versus 3). 

When compared to OCO patients with PTSD, 

patients with other mental health conditions spent 

the same share (one-quarter) of their hospital days in 

psychiatric care but used less health care overall. For 

the first year of treatment, VHA spent $350 million 

on patients with other mental health diagnoses. The 

average cost of care during the first year of treatment 

($4,300) was more than double that for OCO 

patients with no mental health diagnoses ($2,000) 

but only half the average cost of treating OCO 

patients with PTSD.

3. See the Joshua Omvig Veterans Suicide Prevention Act (P.L. 

110-110, 38 U.S.C. 1720F).

4. An obligation is a commitment that creates a legal liability 

on the part of the government to pay for goods and services 

ordered or received. Such payments may be made immediately or in the future. Obligations during any year may 

exceed appropriations provided during that year because 

an agency may obligate funds that were provided in an 

earlier year.

35. For a discussion of future spending on health care for OCO veterans, see Congressional Budget Office, Potential Costs of Veterans’ 

Health Care (October 2010).
14 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

levels, however, so fewer service members are likely to 

develop PTSD or TBI in the future. In addition, an 

increasing share of veterans who do seek care from VHA 

in the future will have deployed several years earlier and 

are more likely to have sought care through DoD or to 

have had their symptoms resolve than was the case for 

veterans who sought care from VHA before 2010. For 

those reasons, future veterans enrolling in VHA’s health 

care system are less likely to seek treatment for PTSD or 

TBI. 

CBO measured the use of services by the number of 

patients who used VHA’s services after a diagnosis of 

PTSD or TBI and by the frequency of their use after 

those diagnoses. CBO measured VHA’s services in three 

categories: inpatient care (in days), outpatient care (in 

number of clinic visits), and pharmacy services (in 30-day 

equivalent prescriptions filled). CBO calculated the average use by service type in each treatment year for veterans 

who ever used VHA’s services.

Patients who had PTSD, TBI, or both conditions used 

the VHA system much more in any given year and were 

more likely to use VHA’s services than were patients with 

neither diagnosis. (This section of the analysis focuses on 

all health care services provided to patients in each group, 

regardless of whether a particular service was related to a 

PTSD or TBI diagnosis.) CBO found the highest average 

use of all health care services among patients who were 

treated for both PTSD and TBI. The use of services by 

TBI patients was roughly comparable to that of PTSD 

patients in the first two treatment years, but TBI patients 

(probably those with moderate to severe TBI) had markedly higher inpatient and outpatient use in treatment 

years 3 and 4. With the implementation of comprehensive screening for mild TBI in 2007, patients with 

moderate to severe TBI accounted for a larger share of 

cases in treatment years 3 and 4. Veterans with neither 

condition used VHA the least, with little change over the 

four treatment years. Use of services for most groups was 

highest in the first year of care. 

Number of Patients Using VHA’s Services 

The share of veterans who continued to access care at 

VHA declined in the years following their initial use of its 

services; however, the rate of decline differed among the 

groups CBO analyzed. The largest decrease occurred in 

the group that had no diagnosis of either PTSD or TBI; 

less than half (42 percent) of those veterans continued to 

use VHA four years after initial use (see Figure 1).

Figure 1.

Continuation of Use of VHA’s Services by 

OCO Veterans

(Percent)

Source: Congressional Budget Office based on data from the 

Department of Veterans Affairs, Veterans Health 

Administration.

Notes: For treatment years 2 through 4, the share of patients 

treated by VHA represents the number of patients using 

VHA’s services divided by the number of potential 

patients—those who were diagnosed with the condition 

in treatment year 1 and who remain in the sample 

(see Table D-1). 

Data cover fiscal years 2004 to 2009 for up to the first four 

years of treatment. Data exclude about 500 patients, many 

with PTSD and TBI, who entered VHA at Polytrauma 

Rehabilitation Centers. 

VHA = Veterans Health Administration; OCO = overseas 

contingency operations; PTSD = post-traumatic stress 

disorder; TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had 

other conditions.

b. Patients in the TBI group did not have PTSD, but many had other 

conditions.

By contrast, at least two-thirds of veterans in the other 

three groups continued to use VHA for some of their 

health care four years after initial diagnosis. Those 

patients might have had more clinically complicated conditions that took longer to resolve. In addition, those 

patients’ more intensive initial use of services might have 

predisposed them to continue pursuing care. Because of 

their conditions, moreover, some patients could also have 

had limited opportunities for employment, a common 

source of alternative health care options.

Treatment

Year 1

Treatment

Year 2

Treatment

Year 3

Treatment

Year 4

0

20

40

60

80

100

120

PTSDa

No PTSD or TBI

Both PTSD and TBI

TBIb
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 15

CBO

Figure 2.

Use of VHA’s Health Care Services by OCO Patients

(Average number)

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude about 500 patients, many with PTSD and 

TBI, who entered VHA at Polytrauma Rehabilitation Centers. 

Average annual use is based on the number of OCO patients who were ever seen at VHA, regardless of whether they were treated in a 

given year.

VHA = Veterans Health Administration; OCO = overseas contingency operations; PTSD = post-traumatic stress disorder; 

TBI = traumatic brain injury.

a. “Prescriptions filled” includes all pharmacy services, such as dispensing of pharmaceuticals and over-the-counter drugs (measured in 

30-day equivalents), as well as related supplies.

b. Patients in the PTSD group did not have TBI, but many had other conditions. 

c. Patients in the TBI group did not have PTSD, but many had other conditions.

Frequency of Use

OCO veterans using any health care services at VHA at 

least once, for up to four years after diagnosis or entry 

into the system, were included in the calculations. Generally, OCO patients used VHA’s services most intensively 

in the first year of treatment, after which use declined and 

stabilized (see Figure 2). The most notable exception was 

for patients with TBI (including those with both PTSD 

and TBI); their average use in each service category 

increased in treatment years 3 and 4. Patients who had 

neither a diagnosis of PTSD nor a diagnosis of TBI averaged many fewer inpatient days, outpatient visits, and 

pharmacy prescriptions than members of the other 

groups.36

Inpatient Care. Inpatient care for patients who had neither a PTSD nor a TBI diagnosis averaged less than one 

No PTSD

or TBI

PTSDb TBIc Both PTSD

and TBI

0

1

2

3

4

5

6

7

Year 1 Year 2 Year 3 Year 4

No PTSD

or TBI

PTSDb TBIc Both PTSD

and TBI

0

5

10

15

20

25

30

35

40

45

No PTSD

or TBI

PTSDb TBIc Both PTSD

and TBI

0

5

10

15

20

25

30

35

Inpatient Days Outpatient Visits Prescriptions Filleda

36. Veterans enrolled in the VHA system usually have other sources of 

health care available to them and use VHA’s services for a minority 

of their care. Because CBO has no data on OCO veterans’ use of 

health care outside of VHA, it cannot determine differences in the 

total health care services used by the different groups. Consequently, OCO veterans with no diagnosis of PTSD or TBI may 

receive a higher or lower portion of their care from VHA than the 

other groups.
16 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

day in all of the years following their first visit.37 The 

largest single category of inpatient care for this group in 

treatment year 1 was medical or surgical care (accounting 

for 41 percent). By contrast, the PTSD group averaged 

about two inpatient days in treatment year 1: 44 percent 

of those days were for residential rehabilitation (often 

treatment for mental health and substance abuse that 

focuses on community reintegration), and 27 percent 

were for psychiatric care. The TBI group averaged about 

three inpatient days in treatment year 1: 33 percent of 

those days were for rehabilitation medicine (treatment for 

physical impairments and disability), and 27 percent were 

for medical or surgical care. That distribution changed 

dramatically in the later years. The small number of 

TBI patients receiving VHA care in treatment year 4 

(400 patients) were resource intensive: Inpatient hospital 

days for TBI patients doubled from about three in 

treatment year 1 to about six in treatment year 4. By 

treatment year 4, nursing home care, which was concentrated among fewer than 10 percent of TBI patients 

seeking care in that year, accounted for 82 percent of 

that group’s inpatient days. The final group—those with 

both PTSD and TBI diagnoses—averaged nearly four 

inpatient days in year 1. Their inpatient use was most 

similar to that of the PTSD group, with 39 percent of 

inpatient days for residential rehabilitation and 

21 percent for psychiatric care. 

Outpatient Care. The PTSD group’s use of outpatient 

care in treatment year 1 was more than three times as 

high (29 visits) as that of OCO veterans with neither 

PTSD nor TBI but fell by about half (to 14 visits) in the 

following year and then leveled off.38 Although the TBI 

group had approximately the same number of outpatient 

clinic visits as the PTSD group in treatment years 1 and 

2, the average number of visits for the TBI group rose 

again in treatment years 3 and 4. By treatment year 4, the 

average number of visits for the TBI group (24 visits) 

was close to the number in the initial year of treatment 

(28 visits). Again, that pattern was most likely caused by 

the change in screening for TBI that led to more patients 

with mild TBI appearing in these data in earlier treatment years than later ones. Average use of outpatient 

care by the group with both PTSD and TBI diagnoses 

decreased sharply after treatment year 1 (from 44 visits 

to 27 visits in treatment year 2) and then rose a little 

thereafter. 

In the first treatment year, one-quarter of the PTSD 

group’s outpatient visits took place in mental health clinics, and an additional 8 percent of visits were in specialty 

PTSD clinics. For the group with TBI, 30 percent of 

outpatient care was provided in the aggregated, nonspecific category of “other clinics” (which included 

rehabilitation clinics), and 28 percent was provided in 

diagnostic testing venues; less than 1 percent of their outpatient care was provided in TBI clinics. For the group 

with both PTSD and TBI, 22 percent of outpatient visits 

in treatment year 1 occurred in mental health clinics. 

Data provided to CBO for this study did not include sufficient information on individual clinical encounters to 

report the initiation or completion of a course of therapy. 

Pharmacy Services. The group with neither a PTSD nor 

TBI diagnosis averaged four prescriptions annually in all 

treatment years.39 The other groups had considerably 

more pharmacy services in the first year, from four to 

seven times as many as the group with no PTSD or TBI 

diagnosis. Although pharmacy services for the other three 

groups—those diagnosed with PTSD, TBI, or both—

decreased between treatment years 1 and 2, that decline 

was reversed in later years. Indeed, the group of patients 

with both PTSD and TBI not only had more pharmacy 

services, on average, in treatment year 4 than in treatment 

year 1 but also had the highest average number of prescriptions (30 in treatment year 4).

Costs of VHA’s Services

Costs generally followed the same patterns as use of services. Thus, the highest average costs were for patients 

treated for both TBI and PTSD. Average costs for all 

groups of OCO patients dropped in the second year of 

37. Inpatient care includes medical or surgical care, rehabilitation 

medicine, residential rehabilitation, inpatient PTSD care, 

inpatient psychiatric care, PTSD residential rehabilitation, 

and nursing home care. Because only one or two categories of 

inpatient care generally accounted for a substantial share of treatment, only the largest categories are reported here.

38. Outpatient care includes care provided in various types of clinics: 

primary care, medical/surgical care, mental health, PTSD, TBI, 

polytrauma, and a more general type denoted as “other.” Diagnostic tests are also included in outpatient care. Because only one or 

two categories of outpatient care typically accounted for a substantial share of treatment, only the largest categories are reported 

here.

39. The number of prescriptions filled includes the dispensing of 

pharmaceuticals and over-the-counter drugs (as measured in 

30-day equivalents), as well as related supplies.
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 17

CBO

treatment and, for most groups, stabilized or declined 

thereafter. A notable exception was the group of patients 

treated for TBI; the average costs for those patients grew 

substantially in treatment years 3 and 4. That apparent 

anomaly most likely reflects the changing composition of 

the TBI group during the four-year treatment period. 

Because the data included veterans using VHA both 

before and after comprehensive TBI screening was implemented, patients with mild TBI probably accounted for a 

larger share of cases during the first two treatment years, 

and patients with moderate or severe TBI represented a 

greater share of cases during the latter two treatment 

years. Because VHA did not provide data that would 

enable CBO to separate mild cases of TBI from moderate 

or severe cases, CBO’s ability to examine this issue further 

is limited.

CBO used two different approaches to analyze VHA’s 

costs of treating veterans with PTSD, TBI, or both. The 

first method captures the total costs to VHA of treating 

those patients but overstates costs related solely to PTSD 

or TBI. The second method attempts to attribute costs 

for services directly to a diagnosis of PTSD or TBI, which 

yields costs that are lower than those estimated using the 

first method. However, the PTSD- and TBI-specific costs 

can be considered only rough approximations.

In the first approach, CBO calculated the total cost of 

all health care provided to OCO patients diagnosed 

with PTSD and TBI, regardless of whether that care was 

directly related to those conditions. If patients were 

treated for a back injury or hearing loss, for example, 

those treatment costs were included in CBO’s estimates. 

All costs were included because determining which care 

is related to a specific condition requires subjective 

decisions. Furthermore, patients with PTSD or TBI 

frequently develop other conditions that may be caused 

or exacerbated by the presence of PTSD or TBI and thus 

may be considered additional, indirect costs of PTSD 

and TBI. 

The second approach that CBO used to compute costs 

was to examine only PTSD- and TBI- specific care using 

the diagnostic codes identified by VHA’s clinicians. 

Determining the cost of treating a particular condition 

(rather than the cost of treating a patient with the condition) requires subjective decisions that attribute a medical 

encounter and a specific portion of the cost of that 

encounter to a particular condition. Computing PTSDand TBI-specific costs, therefore, provides a rough estimate of how much VHA spends on treating those particular conditions. (See Appendix B for a description of 

CBO’s methodology.)

Costs of All Health Care

In calculating total costs of all health care for patients 

with a particular diagnosis, CBO examined up to four 

years of data. CBO included all patients in the average 

cost calculations, whether those patients accessed VHA 

once or many times in the four years. (For an alternative 

method of examining average costs, see Appendix D.) 

Because the data are through 2009, patients that enrolled 

in 2007, 2008, and 2009 were not able to accumulate 

four years of treatment (see Appendix B). 

Total Costs. During fiscal years 2004 through 2009, 

VHA spent $3.7 billion for the first four years of treatment on the OCO patients analyzed by CBO.40 CBO 

estimates that VHA spent 60 percent of that sum 

($2.2 billion) on patients with PTSD, TBI, or both. 

The group with neither a PTSD nor a TBI diagnosis—

the largest group, with more than 350,000 patients—had 

the highest total costs: $860 million in treatment year 1 

and about $1.5 billion in total costs from 2004 through 

2009 (see Table 1). Total spending in those years for the 

PTSD patients was almost as high ($1.4 billion), 

although the PTSD group had many fewer patients. 

The share of total costs devoted to inpatient care varied 

by treatment group but was fairly stable over the first four 

years of treatment for all groups except TBI patients. For 

most groups, the share of total costs devoted to inpatient 

care was less than 25 percent. For TBI patients, however, 

the portion of total costs assigned to inpatient care was 

40 percent in treatment year 1 and 50 percent in treatment year 4. A small percentage of TBI patients were 

responsible for those costs: Fewer than 10 percent of TBI 

patients in treatment year 4 used nursing home care, but 

at an average cost of approximately $147,000 per nursing 

home patient.

40. See Appendix B for a description of CBO’s methodology. VHA 

has reported the number of OCO patients and their associated 

costs in the various editions of the agency’s annual budget documentation. VHA treated 508,000 OCO veterans from 2002 

through 2009. The data that VHA supplied to CBO encompassed 

98 percent of that population and, because some overhead costs 

were not included, about 92 percent of the total costs.
18 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

Table 1.

Total Costs for VHA’s Health Care Provided to OCO Patients

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude about 500 patients, many with PTSD and 

TBI, who entered VHA at Polytrauma Rehabilitation Centers. 

VHA converted costs provided to CBO to fiscal year 2009 dollars on the basis of annual increases in the average cost of a primary care 

visit from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the implicit price deflator for gross domestic product.

VHA = Veterans Health Administration; OCO = overseas contingency operations; PTSD = post-traumatic stress disorder; 

TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had other conditions. 

b. Patients in the TBI group did not have PTSD, but many had other conditions.

Average Costs. In treatment year 1, the average costs per 

patient diagnosed with PTSD ($8,300), TBI ($11,700), 

or both ($13,800) were much higher than the average 

costs for those with neither PTSD nor TBI ($2,400) (see 

Table 2 and Figure 3 on page 20).41 Although patients 

with PTSD, TBI, or both had higher average costs, those 

costs may not be solely attributable to those two conditions. If patients with PTSD or TBI have worse health 

overall (they may be more likely to have combat injuries, 

for example) than patients without those conditions, 

their costs will be higher. The group with both PTSD 

and TBI included patients with persistent symptoms 

from multiple conditions, which helps explain why their 

use of medical services and the costs of those services were 

greater than those for patients with PTSD or TBI alone.

For all groups, the average cost of all health care was highest in treatment year 1 (see Figure 3). For three of the 

four groups, costs largely stabilized or continued to drop 

in the third and fourth treatment years. TBI patients were 

different. After dropping below the treatment year 1 level 

in years 2 and 3, costs rebounded to $11,100 in treatment year 4. That pattern can be attributed to the composition of the TBI sample in later treatment years. As 

discussed earlier, the change in TBI screening implemented in 2007 means that the sample of patients analyzed here had a larger share with moderate or severe TBI 

in later treatment years.42 Thus, this result does not imply 

that new TBI patients will tend to require higher expenditures for treatment in later years. 

Costs of PTSD- and TBI-Specific Care

To provide a rough estimate of how much VHA spent on 

treatment specific to PTSD and TBI, CBO also presents 

Treatment Group

PTSD or TBI

PTSDa 1,420 660 46

TBIb 130 50 38

Both PTSD and TBI 670 380 57 _____ ____

All PTSD and TBI 2,220 1,090 49

No PTSD or TBI 1,450 0 0

All OCO Patients 3,670 1,090 30

Share of Total Costs Attributed to

(Percent)

Total Costs PTSD- and TBI-Specific Care PTSD- and TBI-Specific Care

Total Costs Attributed to 

(Millions of dollars) (Millions of dollars)

41. By contrast, VHA projects that spending per veteran user for all 

eras will be an estimated $9,100 in 2011.

42. In the data provided to CBO, TBI patients who used VHA’s services for four years were diagnosed before 2007, when VHA began 

comprehensive screening of OCO veterans for mild TBI. Consequently, the portion of the sample drawn before 2007 was much 

smaller and probably included relatively more cases of moderate 

or severe TBI than later cohorts, making costs for patients with 

four treatment years unreliable in predicting future spending.
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 19

CBO

Table 2.

Average Costs for All of VHA’s Health Care and VHA’s PTSD- and TBI-Specific Care 

Provided to OCO Patients

(Dollars)

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude about 500 patients, many with PTSD and 

TBI, who entered VHA at Polytrauma Rehabilitation Centers. 

Average annual costs are based on the number of OCO patients who were ever seen at VHA, regardless of whether they were treated

in a given year.

VHA converted costs provided to CBO to fiscal year 2009 dollars on the basis of annual increases in the average cost of a primary care 

visit from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the implicit price deflator for gross domestic product.

VHA = Veterans Health Administration; PTSD = post-traumatic stress disorder; TBI = traumatic brain injury;

OCO = overseas contingency operations.

a. Patients in the PTSD group did not have TBI, but many had other conditions. 

b. Patients in the TBI group did not have PTSD, but many had other conditions.

tabulations of the costs of care that had an accompanying 

diagnosis code of PTSD, TBI, or both. CBO reports two 

types of costs for patients in the years after diagnosis: total 

costs and average costs for PTSD- or TBI-specific care. 

The costs calculated using this method are lower than 

those presented earlier because they represent only a portion of health care costs for patients, not all costs.

Costs in this section should be considered a rough 

approximation of the costs of treating PTSD or TBI; they 

may be either too high or too low. When multiple diagnoses were made during an inpatient stay or outpatient 

visit that also included a PTSD or TBI diagnosis, VHA 

attributed all costs for that visit to PTSD or TBI. In 

addition, CBO attributed all costs for prescriptions and 

diagnostic tests to either PTSD or TBI for patients with 

those diagnoses (although VHA’s clinical information 

systems do not associate diagnosis codes with those services).43 That approach may overstate the costs to treat 

those conditions. Conversely, patients with PTSD and 

TBI often have other medical problems that may be 

related to their PTSD or TBI and that pose indirect costs 

not included; in such instances, the estimates may be too 

low. In addition, oversights on the part of care providers 

or medical coders may have resulted in missing PTSD or 

TBI diagnosis codes, which also could produce estimates 

that are too low. 

Total Costs. While PTSD and TBI accounted for a sizable 

part of total health care costs, OCO veterans with PTSD 

or TBI also received a considerable amount of care for 

other conditions, even in the first year of treatment. 

VHA spent $1.1 billion for PTSD- and TBI-specific care 

during the 2004–2009 period for the first four years of 

Treatment Group

PTSD or TBI

PTSDa 8,300 4,200 3,900 3,800

TBIb 11,700 4,600 7,300 11,100

Both PTSD and TBI 13,800 8,400 8,800 9,800

No PTSD or TBI 2,400 1,100 1,000 1,000

PTSD 4,100 2,100 1,900 1,900

TBI 5,000 1,600 2,500 4,400

Both PTSD and TBI 8,000 4,900 5,300 5,700

Average Costs per Patient for PTSD- and TBI-Specific Care

 Treatment Year 3 Treatment Year 4

Average Costs per Patient

 Treatment Year 1 Treatment Year 2

43. If diagnostic and pharmacy costs were excluded, the average costs 

would be approximately 20 percent to 35 percent lower than 

reported here.
20 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Figure 3.

Average Costs for All of VHA’s 

Health Care Provided to OCO Patients

(Thousands of dollars)

Source: Congressional Budget Office based on data from the 

Department of Veterans Affairs, Veterans Health 

Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first 

four years of treatment. Data exclude about 500 patients, 

many with PTSD and TBI, who entered VHA at Polytrauma 

Rehabilitation Centers. 

Average annual costs are based on the number of OCO 

patients who were ever seen at VHA, regardless of whether 

they were treated in a given year.

VHA converted costs provided to CBO to fiscal year 2009 

dollars on the basis of annual increases in the average cost 

of a primary care visit from 2004 to 2009. CBO then indexed 

those costs to 2011 dollars using the implicit price deflator 

for gross domestic product.

VHA = Veterans Health Administration; OCO = overseas 

contingency operations; PTSD = post-traumatic stress 

disorder; TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had 

other conditions.

b. Patients in the TBI group did not have PTSD, but many had other 

conditions.

treatment, with more than half of that amount spent 

on patients in their first year (see Table 1 on page 18). 

For the PTSD group, PTSD-specific care averaged almost 

half (46 percent) of total health care costs over four years. 

The share was somewhat less (38 percent) for TBIspecific care for the TBI group. More than half 

(57 percent) of the care provided to the group with both 

PTSD and TBI was directly related to those specific 

diagnoses.

Average Costs. CBO’s estimates of average annual costs 

for treating PTSD or TBI or both in patients with those 

diagnoses can be regarded only as rough estimates 

because of the broad classification of treatments attributable to PTSD or TBI. Following the initial year of treatment for patients with PTSD, which cost $4,100 per 

patient for PTSD-specific care, those costs fell by about 

half (see Table 2). Average costs of treating veterans with 

both PTSD- and TBI-specific care in year 1 ($8,000 per 

patient) were almost double those for veterans with 

PTSD alone, and $3,000 higher than the average costs of 

treating patients with TBI alone. Between treatment year 

1 and treatment year 4, the average costs of care for 

PTSD and combined PTSD and TBI declined by 54 percent and 29 percent, respectively, but the average costs of 

TBI care decreased by only 12 percent during that 

period. As noted above, the pattern of costs for veterans 

with TBI is distorted by the change in screening during 

the sample period. 

Other Studies of the Costs of Treating PTSD and TBI

CBO reviewed other studies on the costs of treating 

people with PTSD and TBI. CBO focused on studies 

examining those conditions in the OCO population, in 

part because costs experienced by the civilian population 

are unlikely to be comparable to those for the military 

population.44 While studies of the costs to treat OCO 

veterans have been limited, more research is becoming 

available. CBO reviewed two studies of VHA costs, neither of which attempted to examine the costs of care 

related specifically to PTSD or TBI.

No PTSD

or TBI

PTSDa TBIb Both PTSD

and TBI

0

2

4

6

8

10

12

14

16

Year 1 Year 2 Year 3 Year 4

44. Reliable, up-to-date estimates of the total costs of PTSD and 

TBI are not available for the general population. In addition, 

cost estimates for civilians would not be comparable to those for 

the military partly because the mechanism of injury is different. 

Among OCO veterans, most TBIs are the result of explosions; 

military PTSD is typically related to combat. 
THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 21

CBO

One study compared the costs of treating OCO veterans 

with PTSD or TBI with the costs of treating OCO 

veterans without those conditions.45 In fiscal year 2008, 

the average cost for patients with PTSD alone was 

between $6,000 and $8,000 (expressed in 2011 dollars), 

and the average cost for patients with TBI totaled about 

$5,000. (TBI cases in that study were identified through 

VHA’s screening and therefore were more likely to have 

been mild and less expensive to treat.) The corresponding 

cost for patients with both PTSD and TBI was $10,300. 

For veterans with neither condition, the average cost was 

$2,500, very similar to CBO’s estimate for treatment year 

1. Compared with CBO’s estimates, most costs reported 

in the study for fiscal year 2008 are lower, but CBO’s data 

contained a different mix of cases that included more 

severe ones.

A second study examined the average costs in fiscal year 

2009 for VHA to treat OCO patients who had used any 

outpatient services in that year. The cost estimates, therefore, were for patients who first sought care in 2009, as 

well as those who had been treated for several years. The 

authors found that the median annual cost per patient 

with PTSD was $2,800 (expressed in 2011 dollars); the 

mean was $5,300. For patients with TBI, the median cost 

was $3,400, and the mean was $7,300. For veterans with 

both PTSD and TBI, the median cost was $7,300, and 

the mean was $12,300.46 Those average values for fiscal 

year 2009 are all lower than CBO’s estimates of all health 

care costs for such patients for the first treatment year.

Another study, by the RAND Corporation, examined 

costs of treating service members who deployed to overseas contingency operations, but its focus on societal costs 

makes it dissimilar to CBO’s analysis of VHA’s costs.47

Polytrauma Patients

Polytrauma patients at VHA are those with multiple 

severe injuries. Patients categorized as polytrauma for 

purposes of this analysis first enrolled in the VHA system 

as inpatients at one of the Polytrauma Rehabilitation 

Centers; about 500 OCO veterans were identified as 

polytrauma patients. Some patients with multiple traumas were included in other groups in CBO’s analysis, 

however, because their first encounters with VHA were 

not at a Polytrauma Rehabilitation Center, but rather at 

some other facility. 

After initial entry into the polytrauma system, those 

patients continued to access VHA’s health care system. In 

any given treatment year, at least 95 percent used VHA 

and had some PTSD- and TBI-specific care. Like 

patients in the other groups, polytrauma patients used 

significantly more resources in treatment year 1 than in 

later years (see Table 3). The average hospital stay in 

treatment year 1 was close to two months, with 73 percent of that care delivered in rehabilitation medicine. 

In subsequent years, the average annual length of an 

inpatient stay declined dramatically. Outpatient clinic 

visits for polytrauma patients were close to half the initial 

45. Ann Hendricks and others, “Screening for Mild Traumatic Brain 

Injury in OEF/OIF Deployed Military: An Empirical Assessment 

of the VHA Experience,” (paper presented at the National 

Conference of VA’s Health Services Research and Development 

Service, Washington, D.C., February 16–18, 2011). 

46. Brent Taylor and others, “Prevalence and Costs of Co-Occurring 

TBI, Psychiatric Disturbance, and Pain Among OEF/OEF VA 

Users,” (paper presented at the National Conference of VA’s 

Health Services Research and Development Service, Washington, 

D.C., February 16–18, 2011).

47. In RAND’s Invisible Wounds of War, researchers estimated the 

2005 societal costs, including the costs from unemployment and 

suicide, of treating service members who deployed to overseas 

contingency operations. The researchers found that the costs of 

PTSD ranged from $5,900 to $10,300 for two years. Using Medicare reimbursement rates and other data, the researchers reported 

that the societal costs of TBI for one year ranged from $26,000 to 

$31,000 for mild cases and from $252,000 to $383,000 for moderate and severe cases. Because the data undercounted the number 

of mild TBIs and overcounted the number of hospitalizations 

attributable to those mild cases, the reported costs for mild TBI 

are likely to be substantially overstated. RAND’s estimates of 

societal costs should not be compared with CBO’s numbers, 

which focus only on VHA’s costs. (Unlike RAND’s estimates, 

CBO’s estimates of the costs of treating TBI exclude the initial 

hospitalizations of the more severe cases because those individuals 

were still on active duty at the time of initial injury and hospitalization and therefore would have been treated within DoD.) 

See Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of 

War: Psychological and Cognitive Injuries, Their Consequences, 

and Services to Assist Recovery (Santa Monica, Calif.: RAND 

Corporation, 2008).
22 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Table 3.

Use and Costs of VHA’s Health Care Provided to OCO Polytrauma Patients

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment.

Average annual use and costs are based on the number of OCO patients who were ever seen at VHA, regardless of whether they were

treated in a given year.

VHA converted costs provided to CBO to fiscal year 2009 dollars on the basis of annual increases in the average cost of a primary care 

visit from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the implicit price deflator for gross domestic product.

VHA = Veterans Health Administration; OCO = overseas contingency operations.

a. “Prescriptions filled” includes all pharmacy services, such as the dispensing of pharmaceuticals and over-the-counter drugs (measured in 

30-day equivalents), as well as related supplies. 

number by treatment year 4. Pharmacy use declined 

36 percent in treatment year 2, but as with other groups 

analyzed in this study, increased thereafter. 

The pattern of use was reflected in the costs of treatment. 

The average cost of all health care per polytrauma patient 

in treatment year 1 was $136,000, or nearly 10 times the 

average cost for the group with both PTSD and TBI. 

Average annual health care costs dropped to about 

30 percent of their first-year amount in treatment year 2 

and to about 20 percent of that amount by year 4. 

PTSD- and TBI-specific care accounted for 60 percent 

($55 million) of total health care costs for polytrauma 

patients during the 2004–2009 period, a percentage 

similar to that for the group with both PTSD and TBI.48

In total, health care costs for the roughly 500 polytrauma 

patients treated between 2004 and 2009 exceeded 

$91 million.

 Treatment Year 1 Treatment Year 2 Treatment Year 3 Treatment Year 4

Inpatient Days 56 17 8 11

Outpatient Visits 77 66 60 43

Prescriptions Filleda 45 29 31 33

Health Care 136,000 42,000 27,000 28,000

Average Costs per Patient (Dollars)

Average Use per Patient 

48. Because polytrauma patients have many other medical conditions, 

it is difficult to attribute a portion of their total costs of care 

specifically to PTSD and TBI. The relatively high average costs 

credited to PTSD- and TBI-specific care is probably an artifact of 

how such costs are allocated. See Appendix B. 
CBO

Appendix A:

Background on PTSD and TBI

Post-traumatic stress disorder (PTSD) is an anxiety 

disorder induced by exposure to a traumatic event.

Although the psychological effects of combat have long 

been recognized (in previous wars, the symptoms now 

associated with PTSD were known as “shell shock” or 

“battle fatigue”), the American Psychiatric Association 

did not codify PTSD as a separate mental disorder until 

1980. Traumatic brain injuries (TBIs) are defined as a 

blow, jolt, or penetrating injury to the head that interrupts the functioning of the brain, at least momentarily. 

Medical intervention varies considerably. During military 

combat operations, some mild TBIs may go untreated 

when there are no physical head wounds or neurological 

signs of impairment. Medical personnel may not detect 

injury, especially when more obvious, life-threatening 

injuries require attention, and service members may not 

seek care for a TBI if the injury does not appear acute. 

Moderate and severe TBIs, however, are generally apparent clinically through changes in consciousness or neurological impairment.

Criteria for a PTSD Diagnosis

According to current diagnostic criteria for PTSD, a person must experience a traumatic event—involving death 

or serious injury, or a threat to the physical integrity of 

self or others—and react to the trauma with intense horror, fear, or helplessness.1

 Sometime after that trauma, the 

person must also develop symptoms that cause clinically 

significant distress or impairment lasting for more than 

one month. Those symptoms must be from each of the 

following three symptom clusters: 

 Reexperiencing the traumatic event, such as having 

recurring and distressing recollections or nightmares; 

 Avoidance of stimuli associated with the trauma, such 

as thoughts, feelings, and conversations, along with 

diminished responsiveness and loss of interest in activities; and 

 Hyperarousal, such as irritability, anger, hypervigilance, insomnia, or difficulty with concentration.

For example, a person who experienced nightmares about 

the trauma and had lost interest in daily activities but had 

no symptoms of hyperarousal would not have PTSD, 

according to those diagnostic criteria.

There are various forms of PTSD. Acute PTSD occurs 

when the duration of symptoms is between one and three 

months. Patients with symptoms extending for more 

than three months are considered to have chronic PTSD. 

Delayed-onset PTSD occurs when symptoms begin at 

least six months after the trauma.

1. For more detail, see the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th ed., rev. (Arlington, Va.: American Psychiatric Publishing, 2000). In previous editions, the DSM required 

that the trauma be outside the range of usual human experience 

but set no requirement for impairment. More recently, according 

to the committee revising the DSM, the requirement that the 

trauma result in horror, fear, or helplessness may be eliminated in 

the 5th edition of the DSM, scheduled for release in 2013. 
24 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Course of PTSD

Among people who develop PTSD, the symptoms and 

their intensity may differ over the course of the disorder.2

Some people recover without medical intervention; others experience chronic symptoms persisting for years, 

even decades; and still others have sporadic symptoms. 

For most people who develop PTSD, symptoms appear 

soon after the trauma, although the time between exposure and symptoms sufficient for a clinical diagnosis of 

PTSD varies. 

Studies of Vietnam veterans who developed PTSD have 

found that, for most veterans, the onset of PTSD 

occurred during the first few years following combat 

trauma, with the number of symptoms increasing rapidly 

during that period. A study by Schnurr reported that 

more than 60 percent of Vietnam veterans who 

developed PTSD did so less than two years after entry 

into the combat theater; fewer than 10 percent experienced an onset of PTSD more than six years after entering the combat theater.

Researchers have found that a substantial portion of 

PTSD patients develop chronic PTSD. Two studies—

one by Breslau and one by Kessler and others—indicate 

that, for 20 percent to 40 percent of PTSD cases, symptoms abate within one year. According to Kessler and others, as well as Conner and Butterfield, symptoms do not 

improve substantially in more than one-third of PTSD 

cases even after several years. (Because the populations, 

treatment, and timing of treatment in those studies differ 

from those in CBO’s analysis, the rates of remission 

reported in the studies may not be applicable to more 

recent combat veterans.) 

Risk and protective factors for experiencing PTSD and 

for subsequent recovery include demographic characteristics, socioeconomic status, psychiatric history, and social 

support. Among Vietnam veterans, women were more 

likely than men to develop PTSD. Research also shows 

that lower educational attainment, lower income, and 

minority status place individuals at greater risk.3

 The 

presence of social networks and social support after a 

stressor serves to protect against PTSD, particularly for 

combat veterans. Finally, more frequent and intense 

exposure to combat is strongly associated with the development of PTSD.

Clinical Definition of TBI 

The Centers for Disease Control and Prevention defines 

TBI as an injury to the head arising from blunt or penetrating trauma or from acceleration-deceleration forces 

that result in one or more of the following: 

 decreased level of consciousness;

 amnesia regarding the event itself or events preceding 

or following the injury;

 skull fracture;

 a neurological or neuropsychological abnormality such 

as disorientation, agitation, or confusion; or 

 an intracranial lesion such as a traumatic intracranial 

hematoma, cerebral contusion, or penetrating injury.4

Neurologists classify the severity of the TBI at the time of 

the injury as mild, moderate, or severe. Mild TBIs 

2. Information for this section was compiled from the following 

sources: Institute of Medicine, Gulf War and Health, vol. 6, Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related 

Stress (Washington, D.C.: National Academies Press, 2008); J.D. 

Bremner and others, “Chronic PTSD in Vietnam Combat Veterans: Course of Illness and Substance Abuse, American Journal of 

Psychiatry, vol. 153, no. 3 (1996), pp. 369–375; Naomi Breslau 

and others, “Trauma and Posttraumatic Stress Disorder in the 

Community,” Archives of General Psychiatry, vol. 55, (July 1998), 

pp. 626–632; Naomi Breslau, “Outcomes of Posttraumatic Stress 

Disorder,” Journal of Clinical Psychiatry, vol. 62, supplement 17 

(2001), pp. 55–59; Ronald C. Kessler and others, “Posttraumatic 

Stress Disorder in the National Comorbidity Survey,” Archives of 

General Psychiatry, vol. 52 (December 1995), pp. 1048–1060; 

Kathryn M. Connor and Marian I. Butterfield, “Posttraumatic 

Stress Disorder,” Focus, vol. 1, no. 3 (Summer 2003), pp. 247–

261; and Paula P. Schnurr and others, “A Descriptive Analysis of 

PTSD Chronicity in Vietnam Veterans,” Journal of Traumatic 

Stress, vol. 16, no. 6 (December 2003), pp. 545–553; Karestan C. 

Koenen and others, “Risk Factors for Course of Posttraumatic 

Stress Disorder Among Vietnam Veterans: A 14-Year Follow-Up 

of American Legionnaires,” Journal of Consulting and Clinical Psychology, vol. 71, no. 6 (2003), pp. 980–986.

3. For a more detailed discussion about risk and protective factors, 

see Institute of Medicine, Gulf War and Health, vol. 6, Physiologic, 

Psychologic, and Psychosocial Effects of Deployment-Related Stress.

4. Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Center for Injury Prevention 

and Control, Traumatic Brain Injury in the United States: A Report 

to Congress (December 1999).
APPENDIX A THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 25

CBO

account for the vast majority of such injuries. Definitions 

of mild TBI, also known as a concussion, vary within the 

neurology community, but a generally accepted definition from the American Congress of Rehabilitation 

Medicine specifies at least one of the following symptoms 

after a blow to the head:

 Loss of consciousness for no more than 30 minutes;

 Loss of memory, lasting no longer than 24 hours, of 

events immediately before (retrograde amnesia) or 

after (posttraumatic amnesia) the injury;

 Any alteration in mental state (being dazed, disoriented, or confused, for example) at the time of the 

injury; or

 A score of 13 to 15 on a Glasgow coma scale (an 

assessment of neurological functioning).5

Injuries above any of those thresholds are moderate 

to severe TBIs. The continuation of multiple symptoms 

may be labeled as postconcussional disorder or postconcussive syndrome (PCS); however, those terms are 

problematic because there is no single clinically validated 

definition of the condition.6

 Short- or long-term impairment may affect memory, reasoning and problem solving, 

language, speech, motor skills, physical functions, and 

psychosocial behavior. 

Course of TBI 

Although the effects of, and recovery from, TBI differ 

among individuals, impairment tends to be greater for 

those with moderate or severe TBIs than for those with 

mild TBIs. Moderate and severe TBIs are usually associated with damage to the brain that can be detected when 

imaged.7

 For people with moderate or severe TBI, 

injuries to the brain—swelling of brain tissue, insufficient 

blood flow, and pressure within the skull, for example—

may require surgery or medication. Recovery from 

moderate or severe TBI ranges from full rehabilitation 

to significant disability. Survivors of moderate or severe 

TBI may suffer lasting consequences such as seizures, 

nerve damage, behavioral abnormalities, and cognitive 

and language difficulties.

Research findings on the course of recovery after mild 

TBI vary widely, partly because of the difficulty in making causal associations between the initial injury and 

physical or cognitive problems following the injury.8

Frequently reported problems following a mild TBI 

include headache, fatigue, dizziness, depression, and difficulties with memory and concentration. However, many 

problems associated with mild TBIs are nonspecific or 

common to many conditions and widely experienced by 

5. T. Kay and others, “Definition of Mild Traumatic Brain Injury,” 

Journal of Head Trauma Rehabilitation, vol. 8, no. 3 (September 

1993), pp. 86–87. Criteria by the Department of Veterans Affairs 

and the Department of Defense for severity are largely consistent 

with the above guidance, although they have one additional criterion for mild TBI: Brain imaging results must be normal. Service 

members who meet the other criteria for mild TBI but have 

abnormal brain imaging results are rated as having moderate TBIs. 

Service members who meet the criteria for more than one severity 

level are rated at the higher severity. See Department of Veterans 

Affairs and Department of Defense, VA/DOD Clinical Practice 

Guideline for Management of Concussion/Mild Traumatic Brain 

Injury, April 2009.

6. The DSM-IV and ICD-10 (International Classification of Diseases, 

10th ed.) define the condition differently, which often results in 

diagnostic disagreement. In addition, controversy surrounds the 

diagnosis of the condition—specifically, whether symptoms that 

occur after an injury can be unequivocally attributed to mild TBI, 

as opposed to other conditions. See Corwin Boake and others, 

“Diagnostic Criteria for Postconcussional Syndrome After Mild 

to Moderate Traumatic Brain Injury,” Journal of Neuropsychiatry 

and Clinical Neuroscience, vol. 17, no. 3 (Summer 2005), 

pp. 350–356; and Linda J. Carroll and others, “Methodological 

Issues and Research Recommendations for Mild Traumatic Brain 

Injury: The WHO Collaborating Centre Task Force on Mild 

Traumatic Brain Injury,” Journal of Rehabilitation Medicine, 

vol. 36, supplement 43 (February 2004), pp. 113–125. The 

Department of Veterans Affairs and the Department of Defense’s 

clinical guidelines for diagnosing and treating mild TBI do not 

endorse either the DSM’s or ICD’s definition of PCS. 

7. For more information on the effects of TBI, see Institute of 

Medicine, Gulf War and Health, vol. 7, Long-Term Consequences of 

Traumatic Brain Injury (National Academies Press: Washington, 

D.C., 2008).

8. See Linda J. Carroll and others, “Prognosis for Mild Traumatic 

Brain Injury: Results of the WHO Collaborating Centre Task 

Force on Mild Traumatic Brain Injury,” Journal of Rehabilitation 

Medicine, vol. 36, supplement 43 (February 2004), pp. 84–105; 

Heather G. Belanger and others, “The Veterans Health Administration System of Care for Mild Traumatic Brain Injury: Costs, 

Benefits, and Controversies,” Journal of Head Trauma Rehabilitation, vol. 24, no. 1 (January–February 2009), pp. 4–13; Charles 

Hoge and others, “Care of War Veterans with Mild Traumatic 

Brain Injury—Flawed Perspectives,” New England Journal of 

Medicine, vol. 360 (April 16, 2009), pp. 1588–1591.
26 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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the general population. Consequently, there is no objective way of determining whether ongoing problems are 

caused by an earlier mild TBI or arise from other 

conditions. 

Most people with mild TBI report one or more symptoms or problems immediately after the injury; however, 

medical evidence suggests that recovery typically occurs 

within a matter of weeks or months, with improvement 

most pronounced in the first months.9

 In addition, some 

studies indicate that between 5 percent and 20 percent of 

people who experience a mild TBI remain symptomatic 

after 12 months, although some researchers have reported 

rates that exceed 20 percent, and others have argued 

that rates are at the lower end of the range at most.10 

Generally, studies report that a small subset of patients 

experience one or more symptoms or limitations for years 

after the injury. Repeated incidents of mild TBI (as may 

occur from wartime explosions or in contact sports such 

as football or hockey) may lead to more significant longterm health problems. 

Several studies have attempted to identify preinjury and 

postinjury factors that may alter the course of recovery 

from mild TBI.11 Researchers have found that the severity 

and duration of symptoms can be reduced by providing 

reassurance to patients and by providing education to 

patients on both the course of TBI and expected recovery 

from the condition. Few other factors have consistently 

been shown to facilitate recovery from mild, symptomatic 

TBI.

9. See Carroll and others, “Prognosis for Mild Traumatic Brain 

Injury”; Michael P. Alexander, “Mild Traumatic Brain Injury: 

Pathophysiology, Natural History, and Clinical Management,” 

Neurology, vol. 45, no. 7 (July 1995), pp. 1253–1260; and 

Thomas W. McAllister, “Mild Brain Injury and the Postconcussion Syndrome,” in Jonathan M. Silver, Thomas W. 

McAllister, and Stuart C. Yudofsky, eds., Textbook of Traumatic 

Brain Injury (Arlington, Va.: American Psychiatric Publishing, 

2004), pp. 279–309.

10. See Michael A. McCrea, Mild Traumatic Brain Injury and 

Postconcussion Syndrome: The New Evidence Base for Diagnosis and 

Treatment (New York: Oxford University Press, 2008); Alexander, 

“Mild Traumatic Brain Injury,” pp. 1253–1260; Heather G. 

Belanger and others, “Factors Moderating Neuropsychological 

Outcomes Following Mild Traumatic Brain Injury: A MetaAnalysis,” Journal of the International Neuropsychological Society, 

vol. 11, no. 3 (2005), pp. 215–227; and Grant L. Iverson, 

“Outcome from Mild Traumatic Brain Injury,” Current Opinion 

in Psychiatry, vol. 18, no. 3 (May 2005), pp. 301–317.

11. See Heather Belanger and others, “The Veterans Health 

Administration System of Care for Mild Traumatic Brain Injury: 

Costs, Benefits, and Controversies”; also see Carroll and others, 

“Prognosis for Mild Traumatic Brain Injury.” 
CBO

Appendix B: 

Data and Methods

The Veterans Health Administration (VHA) provided the Congressional Budget Office (CBO) with 

information on the frequency and costs of various health 

care services for veterans of overseas contingency operations (OCO) for fiscal years 2004 through 2009. VHA 

identified patients using a roster of OCO veterans that 

was derived from the Department of Defense’s (DoD’s) 

list of separated service members eligible for VHA benefits. The roster is based on a combination of pay and 

operational records and contains data fields describing 

both general demographic characteristics and military 

service information such as branch, rank, and deployment dates. 

VHA data included virtually all OCO veterans seen at 

VHA during fiscal years 2004 to 2009; fewer than 1 percent of patients were deleted from the data set because 

their information was incomplete. VHA provided the 

data to CBO in groups organized by sex, age interval, 

year of treatment, clinical service use, and clinical diagnoses. The diagnosis groups were defined to be mutually 

exclusive, so that no patient was included in more than 

one diagnosis group during the first year of treatment at 

VHA; once classified, patients remained in the same 

group for the entire sample period. A patient was identified as having post-traumatic stress disorder (PTSD) or a 

traumatic brain injury (TBI) if he or she had at least one 

medical encounter with VHA in which PTSD or TBI 

was listed as a primary or secondary diagnosis. The identification of PTSD and TBI was broad, in that not all 

patients with those diagnoses sustained those conditions 

while deployed and, even among those who did sustain 

the conditions while deployed, the conditions were not 

necessarily related to combat. Patients who did not 

receive a diagnosis of PTSD or TBI were also followed 

from their first visit to VHA. From the time of the initial 

clinic visit or inpatient stay, all patients were followed in 

12-month increments. Service use and costs were aggregated into totals by year of treatment.

CBO subsequently combined all patients into four mutually exclusive cohorts: no documented diagnosis of PTSD 

or TBI, a diagnosis of PTSD and not TBI, a diagnosis of 

TBI and not PTSD, or diagnoses of both PTSD and 

TBI.1

 Polytrauma patients were analyzed separately as a 

fifth group because their usage was greater and their costs 

substantially higher than those of other OCO patients. 

Small cohort size was an issue in later treatment years: 

CBO restricted its analysis to the first four years of treatment for each entry group. As overseas contingency operations have continued, increasing numbers of service 

members have deployed and separated from the military 

and become eligible for VHA care; therefore, many 

patients in CBO’s analysis entered the VHA system in the 

last two years of the sample period (2008 and 2009), and 

data accrued for them only for treatment years 1 or 2 (see 

Figure B-1). Consequently, each group had fewer patients 

in treatment year 4 than in treatment year 1. Because 

CBO did not have data at the patient level, only group 

totals and weighted averages were calculated. The lack of 

patient-level data made it impossible to separate groups 

by the year in which patients first used VHA’s services, 

preventing CBO from following groups of patients during the specific fiscal years in which they were treated.

VHA extracted data on patients’ use of services mainly 

from its National Patient Care Database, which includes 

1. Because of small sample sizes for female veterans and some age 

groups, CBO does not report analyses along those dimensions.
28 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

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Figure B-1.

Years of Potential Use of VHA’s Services, by OCO Patient’s Year of Entry

Source: Congressional Budget Office.

Notes: VHA = Veterans Health Administration; OCO = overseas contingency operations.

information on patients from all of its clinical information systems. Information on the use of various medical 

services was available for 16 detailed categories, not all 

of which were well populated. To provide a general overview, CBO classified the use of services as inpatient, 

outpatient, or outpatient pharmacy. Use was measured in 

days of inpatient hospital care and outpatient clinic visits. 

A veteran may have had several outpatient visits on a single day, each tallied separately. Pharmacy services were 

measured as the number of 30-day equivalent prescriptions filled. 

The primary source of the cost data provided to CBO 

was the cost-accounting system of VHA’s Decision 

Support Service (DSS); a second source, the Fee Basis 

database, included the cost of outside care paid for by 

VHA. VHA combined those separate sources of cost 

data, which captured most of the costs of services covered 

by VHA, into unified data for CBO. Costs reflected 

medical center-specific expenditures. Approximately 

8 percent of total costs were not included, such as those 

for capital, depreciation, the central office of the Department of Veterans Affairs (VA), and some national programs. Because of those exclusions, the data used by 

CBO were slightly different from the DSS data available 

to most VHA researchers; therefore, other researchers 

may not be able to reproduce the same results precisely. 

The DSS system takes clinical and financial information 

from other VHA databases and uses algorithms that 

merge data and allocate costs across functional units. 

Cost estimates of individual health care encounters are 

also produced. Those costs include both direct and 

indirect (overhead) components. Because the accuracy of 

those costs depends on the quality of the feeder databases, 

DSS data are subject to auditing at regular intervals. DSS 

data are longitudinal and retrospective. VHA uses DSS 

information extensively, including for the purpose of 

financial allocation, and considers the data to be highly 

reliable. 

DSS computations to derive patient-level costs require 

several steps. First, cost data from VHA’s core financial 

and payroll systems are fed into DSS. Those cost data 

reflect VHA’s actual outlays for salaries, supplies, and 

contract services, as well as imputed costs for depreciation. At that level, expenditures are differentiated by type 

of expense (labor category or supplies and equipment) 

and by administrative service (nursing or laboratory 

tests). Next, DSS assigns costs to functional cost centers 

that involve either the direct provision of health care or 

2004

2005

2006

2007

2008

2009

2006

2007

2008

2009

4

4

2005

2006

2007

2008

2009

4

2007

2008

2009

3 2008

2009 2 2009 1

year

Year

Year of Entry

Years of Treatment Analyzed by CBO

Number of Years of Treatment Analyzed by CBO

Years of Treatment Not Analyzed by CBO
APPENDIX B THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 29

CBO

indirect support for health care. Cost centers that provide 

care directly include primary care clinics and psychiatric 

wards, whereas cost centers that provide indirect support 

for health care include information technology support 

and security. Using a standardized methodology, those 

indirect costs are then allocated to departments providing 

care directly within each facility. After all costs have been 

assigned by function, unit costs for intermediate products 

are constructed. Intermediate products are goods and 

services used in providing care, such as blood draws, laboratory tests, or doctors’ time during primary care visits. 

Finally, all intermediate products and their prices are 

assigned to individual patients to estimate the cost of 

health care encounters.2

CBO categorized cost data as inpatient and outpatient, 

with outpatient pharmacy costs included in the outpatient category. VHA converted the costs provided to 

CBO to fiscal year 2009 dollars on the basis of annual 

increases in the average cost of a primary care visit 

between fiscal years 2004 and 2009. CBO then indexed 

those costs to 2011 dollars using the implicit price deflator for gross domestic product. 

Using those data, CBO calculated average costs per 

patient with PTSD or TBI, or both, of health care services for each treatment year by dividing costs in that year 

(the numerator) by the number of patients who had ever 

been diagnosed for PTSD or TBI and remained in the 

sample that year (the denominator). Average costs for 

those without PTSD or TBI were calculated using a similar method. Patients who used care from VHA for only a 

single year or a single time were included in the denominator for all subsequent years, even years for which they 

had no costs. In other words, CBO counted the entire 

population of veterans diagnosed with PTSD or TBI 

regardless of whether they continued to use VHA's services after their first visit. That approach shows VHA's 

average cost per patient to treat the entire population of 

veterans in each diagnosis group (those diagnosed with 

PTSD, TBI, both, or neither). 

In calculating the average costs of PTSD- and TBIspecific care, CBO used a similar methodology. VHA 

provided two additional cost categories: “all PTSD care” 

and “all TBI care,” which were used as the numerator. 

The tallies of those categories should be viewed as rough 

approximations of the costs of treating PTSD and TBI. 

VHA assigned all costs associated with a medical encounter (for example, an inpatient stay or outpatient visit) as 

“PTSD care” or “TBI care” whenever there was a primary 

or secondary diagnosis of either condition. For the group 

with both PTSD and TBI, if an encounter had both diagnosis codes, all the costs for that encounter were counted 

in both categories—that is, they were assigned to the 

costs of “PTSD care” and also to those of “TBI care”—so 

estimates of dollars spent for the treatment of PTSD and 

TBI are not mutually exclusive. For all groups, the total 

cost of an entire visit was attributed to PTSD or TBI (or 

both) even if there were several other diagnoses. 

CBO used VHA’s “all PTSD care” and “all TBI care” cost 

categories and, in addition, attributed the costs of diagnostic tests and pharmacy use, to which VHA does not 

assign diagnosis codes, to PTSD or TBI care, according 

to the group to which patients had been assigned. Inclusion of diagnostic tests and pharmacy services increased 

the costs for the subtotals for “all PTSD care” and “all 

TBI care” by between 20 percent and 35 percent. 

2. Although some researchers have used Medicare reimbursement 

data to estimate health care costs, those data would not have been 

useful for CBO’s analysis, which focuses solely on VHA’s costs. 

VHA’s costs and Medicare reimbursement rates are structurally 

different and therefore not directly comparable. As a health insurance system, Medicare reimburses providers on the basis of a price 

schedule for various services classified by diagnosis codes; negotiated prices presumably reflect the providers’ costs, but they are not 

equal to those costs. By contrast, VHA is a direct health care provider with an accounting system designed to measure the direct 

and indirect costs of each health care encounter. In addition, services are not necessarily comparable. For example, VHA hospital 

stays include the costs of services provided by physicians; by contrast, Medicare’s reimbursements to hospitals for inpatient stays 

do not. 

CBO

Appendix C: 

Interpreting Published Estimates of the 

Prevalence of PTSD and TBI

Prevalence estimates for post-traumatic stress disorder 

(PTSD) and traumatic brain injury (TBI) vary substantially. Changes in diagnostic criteria over time, as well as 

differences in the populations studied, diagnostic tools 

used to identify cases, and the methodologies employed 

all contribute to that variation. 

PTSD Prevalence Among Current 

Service Members Who Deployed to 

Overseas Contingency Operations and 

Veterans of Those Operations

PTSD was first included in the American Psychiatric 

Association’s Diagnosis and Statistical Manual of Mental 

Disorders in 1980; for a diagnosis of PTSD, a person 

must have experienced a traumatic event and certain 

symptoms related to that trauma. A number of studies 

have addressed PTSD in service members or veterans. 

Estimates of the proportion of service members with 

PTSD generally range between 5 percent and 25 percent, 

depending on the study’s methodology and the population sampled.1

Some observers have looked to the prevalence of PTSD 

among veterans of the Vietnam War. Widely quoted is 

the National Vietnam Veterans Readjustment Study 

(NVVRS), an extensive survey and analysis of mental 

health problems among Vietnam War veterans. Researchers using those data estimated that 15 percent of male 

Vietnam-theater veterans had combat-related PTSD at 

the time of the survey (1988), and 31 percent had experienced combat-related PTSD at some point in their lives 

prior to the survey.2

 A more recent reanalysis of a subsample of the NVVRS data found lower prevalence rates of 

9 percent and lifetime prevalence of 19 percent as of 

1988. The decrease in prevalence rates in the second analysis was largely attributed to a change in the methodology 

used to identify a case of PTSD.3

 While prevalence rates 

among Vietnam War veterans are important for estimating the resources that group might require for future 

treatment, those rates are not good indicators of the likely 

prevalence rates for military members who have served in 

the Iraq and Afghanistan conflicts. Previous research 

shows that various factors—demographics, educational 

attainment, social support, combat intensity and injuries, 

1. The range includes studies that reported frequencies of PTSD 

regardless of whether the study objective was to estimate the 

prevalence in a population of service members or veterans. For 

a survey of the literature, see Rajeev Ramchand and others, 

“Disparate Prevalence Estimates of PTSD Among Service Members Who Served in Iraq and Afghanistan: Possible Explanations,” 

Journal of Traumatic Stress, vol. 23, no. 1 (February 2010), 

pp. 59–68.

2. Richard A. Kulka and others, The National Vietnam Veterans 

Readjustment Study: Tables of Findings and Technical Appendices

(New York: Brunner/Mazel, 1990); and Richard A. Kulka and 

others, Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study

(New York: Brunner/Mazel, 1990).

3. Bruce Dohrenwend and others, “The Psychological Risks of 

Vietnam for U.S. Veterans: A Revisit with New Data and Methods,” Science, vol. 313, no. 979 (August 18, 2006), pp. 979–982. 

The diagnostic tool and methodology used in the reanalysis of the 

NVRRS differed from those used in the earlier study. The change 

in the diagnostic tool alone reduced the estimated prevalence of 

PTSD by 3 percentage points. Adjusting for changes in the clinical definition of PTSD and using additional data from personnel 

records decreased the prevalence rate an additional 3 percentage 

points.
32 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

and past psychiatric history, among others—affect 

whether service members will develop PTSD, and 

Vietnam veterans differ from veterans recently discharged 

from the military in some of those respects.4

Several recent studies have estimated the prevalence of 

PTSD among those who deployed to overseas contingency operations in Iraq and Afghanistan. Many have 

relied on the commonly used 17-item PTSD Checklist 

(PCL), in which veterans report their own symptoms, to 

screen for PTSD; relatively few of those studies surveyed 

members of all four military services or included reserve 

and National Guard as well as active-duty personnel.5

 A 

2008 RAND study based on a telephone survey of 1,965 

service members and veterans who had returned from 

overseas contingency operations found that 14 percent 

screened positive for PTSD. Within that group, higher 

rates were observed among Army soldiers and National 

Guard and reserve personnel than among other groups; 

higher rates were observed for those with longer deployments; and higher rates were observed for those seriously 

injured during their deployment.6

 A separate study by 

Smith and others reported new cases of PTSD in as few 

as 1 percent to 4 percent of deployed service members 

in the Air Force who did not experience combat exposure, but up to 9 percent for Army soldiers who had 

experienced certain combat-related traumas or exposures.7

 Other studies have estimated the prevalence of 

PTSD from data on service members’ responses to the 

Department of Defense’s (DoD’s) screening test for that 

condition.8

 Some estimates based on that test were on the 

higher end of the spectrum. For example, a study by 

Milliken and others found that between 6 percent and 

12 percent of active Army personnel and between 6 percent and 13 percent of Army reservists screened positive 

for PTSD immediately upon returning from deployment 

to the Iraq war. The same study showed that assessments 

conducted three to six months after deployment yielded 

positive screening rates between 9 percent and 17 percent 

for active soldiers and between 14 percent and 25 percent 

for reserve soldiers.9

Issues in Reporting PTSD Prevalence Rates

There are two main problems in applying the published 

rates of PTSD to the entire population of OCO veterans. 

First, the studies relied on screening tools to establish a 

case of PTSD, and those instruments may not produce 

accurate estimates of the prevalence of the underlying 

condition. Second, the samples used in the studies were 

seldom representative of all personnel who deployed. 

Screening Tools to Estimate PTSD Prevalence Rates.

Although studies usually estimate rates of possible 

PTSD using a screening questionnaire, those tools do 

not replace a clinician-determined diagnosis. Screening 

questionnaires are not comprehensive and do not determine whether all relevant criteria for a diagnosis have 

been met.10 Also, different researchers may use more or 

less stringent criteria to estimate the number of PTSD 

cases, which would result in dissimilar estimates even if 

the researchers used the same sample of service members 

and the identical screening tool.11 Finally, because screen4. For example, recent veterans are more likely to have completed 

high school than were draftees during the Vietnam War. Also, 

American society may be more supportive of its returning service 

members now than it was during the Vietnam War.

5. Researchers may use different methods to determine whether an 

individual screens positive using the PCL. Under the cluster 

method, personnel screened positive if they reported at least one 

intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms at the moderate level or higher. An alternate 

method requires assigning a number to the severity of each 

symptom (“not at all” = 0 points through “extremely bothered” = 

5 points). To screen positive for PTSD, a score of at least 50 on a 

scale of 17 to 85 is often required. 

6. Terri Tanielian and Lisa Jaycox, eds., Invisible Wounds of War: 

Psychological and Cognitive Injuries, Their Consequences, and 

Services to Assist Recovery, (Santa Monica, Calif.: RAND Corporation, 2008).

7. Tyler C. Smith and others, “New Onset and Persistent Symptoms 

of Post-Traumatic Stress Disorder Self Reported After Deployment and Combat Exposures: Prospective Population Based U.S. 

Military Cohort Study,” British Medical Journal, vol. 336, 

no. 7640 (February 16, 2008), pp. 366–371.

8. Upon service members’ completion of their deployment, DoD 

administers the four-question Primary Care PTSD screen (PCPTSD) in the Post-Deployment Health Assessment and, again, 

generally three to six months later, in the Post-Deployment 

Health Reassessment.

9. Charles S. Milliken and others, “Longitudinal Assessment of 

Mental Health Problems Among Active and Reserve Component 

Soldiers Returning from the Iraq War,” Journal of the American 

Medical Association, vol. 298, no. 18 (November 14, 2007), 

pp. 2141–2148. The prevalence estimates presented in that study 

are based on the DoD-administered Post-Deployment Health 

Assessment. The range in rates is the result of two alternate 

methods for determining PTSD: The lower rate reflects service 

members’ endorsement of three or more symptom clusters from 

the four-item screening instrument, and the higher rate reflects 

the positive endorsement of two or more symptom clusters.
APPENDIX C THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 33

CBO

ing tools are imperfect, they generate false positives and 

false negatives; the resulting prevalence estimates, therefore, may diverge from the true prevalence rates. For 

conditions in which the underlying prevalence in the 

population is relatively low, a screen may be more likely 

to overestimate the number of cases, particularly when 

used as a clinical tool designed to capture as many potential cases as possible.12

Subsamples of the OCO Population. Most of the published studies on PTSD have examined a subsample of 

service members who have deployed to overseas contingency operations, often combat troops in the Army or 

Marine Corps, and excluded the more numerous support 

personnel (such as truck drivers or supply handlers) or 

personnel from the Navy and Air Force. Although those 

results may be important for estimating the prevalence of 

PTSD in the highest-risk units, they cannot be directly 

applied to the entire deployed force. Other military 

occupations and service branches are likely to see lower 

levels of combat when deployed and consequently to 

experience lower levels of PTSD than the Army and 

Marine ground combat forces that have deployed, all else 

being equal. Even studies that attempt to survey the 

entire deployed force may not be representative because 

some service members may be more likely than others to 

respond to a survey. Furthermore, service members may 

not respond truthfully if they are concerned that reporting could result in stigma and possibly jeopardize their 

careers or delay their return home.13 In addition, methodological attempts to mitigate effects of unrepresentative 

samples may not be wholly successful. Because of those 

factors, the samples analyzed may either understate or 

overstate the prevalence of PTSD among service members who deployed to overseas contingency operations.

TBI Prevalence Among Current Service 

Members Who Deployed to Overseas 

Contingency Operations and Veterans 

of Those Operations

Measuring TBI in the OCO population also presents 

challenges. TBI results from an injury to the head, and 

the symptoms that follow the injury vary substantially. 

Research on the prevalence of TBI has been limited by 

inconsistent case definitions for TBI and the absence of 

ongoing population surveillance systems before the 

1990s. Even now, the number of TBIs attributable to 

service in overseas contingency operations is difficult to 

measure. Many cases of TBI may never be recorded 

because medical attention may not have seemed necessary 

at the time of injury and because the Veterans Health 

Administration and the Department of Defense did not 

institute their population-based screening programs until 

2007 and 2008, respectively. 

Although investigation of the prevalence of TBI has not 

been as extensive as that for PTSD, some researchers have 

estimated the number of OCO service members who 

10. For example, the PCL (17-item checklist) and the PC-PTSD 

(four-item screen) do not explicitly establish significant distress or 

impairment in social, occupational, or other areas of functioning. 

In addition, the PCL does not ask whether the person was exposed 

to a traumatic event. 

11. Milliken presented data using two thresholds: answering positively 

to two or more questions and, alternatively, to three or more questions on the four-question PC-PTSD. Using the higher threshold 

almost halved (to 6 percent) the number of PTSD cases for active 

Army soldiers immediately after deployment. 

12. A 2004 study by Annabel Prins and others estimated that the 

PC-PTSD had a sensitivity of 0.77 and a specificity of 0.85 using 

a three-out-of-four question threshold. Those values imply that 

77 percent of service members with PTSD screen positive (sensitivity equals 0.77), and 15 percent of those without the disease 

also screen positive (specificity equals 0.85). CBO estimates that, 

if the true population prevalence is 15 percent and 1,000 people 

are screened, a total of 244 people (24 percent) would be expected 

to test positive: 116 of the 150 people (77 percent) who have the 

disease, and 128 of the 850 people (15 percent) who do not (the 

false positives). In that case, the rate of screening positive is about 

60 percent higher than the true prevalence of the disease. See 

Annabel Prins and others, “The Primary Care PTSD Screen 

(PC-PTSD): Development and Operating Characteristics: Corrigendum,” Primary Care Psychiatry, vol. 9, no. 4 (2004), p. 151; 

Artin Terhakopian and others, “Estimating Population Prevalence 

of Posttraumatic Stress Disorder: An Example Using the PTSD 

Checklist,” Journal of Traumatic Stress, vol. 21, no. 3 (June 2008), 

pp. 290–300; and Heidi Golding and others, “Understanding 

Recent Estimates of PTSD and TBI from Operations Iraqi Freedom and Enduring Freedom,” Journal of Rehabilitation Research 

and Development, vol. 46, no. 5 (2009), pp. vii–xiii.

13. One study by McLay and others illustrates that type of reporting 

problem. Using a sample of medical personnel within the Department of Defense, the study found that delivering the PCL anonymously generated double the rate of positive PTSD cases than 

found in PCL results that become part of a service member’s medical record. However, generalizing those results is problematic 

because the respondents to the anonymous screen were a small 

subset of the larger population and may not have been representative. See Robert N. McLay and others, “On-the-Record Screenings Versus Anonymous Surveys in Reporting PTSD,” American 

Journal of Psychiatry, vol. 165, no. 6 (June 2008), pp. 775–776.
34 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

screen positive for TBI or continue to have symptoms of 

TBI. Researchers generally estimate that the proportion 

of service members deployed to overseas contingency 

operations who experienced a TBI (including those who 

were no longer symptomatic) is between 15 percent and 

23 percent, depending on the study’s methodology and 

sample; their estimates of the portion of service members 

who continue to experience symptoms over the longer 

term (that is, who continue to have symptomatic TBI) 

range from 4 percent to 9 percent.

A study by Hoge and others found that 15 percent of 

soldiers in two Army infantry brigades returning from 

deployment to Iraq screened positive for experiencing 

a mild TBI.14 A 2008 RAND study that was based on a 

telephone survey of OCO service members and veterans 

reported a probable TBI prevalence of almost 20 percent.15 A paper by Terrio and others estimated that 

23 percent of soldiers in an Army brigade combat team 

returning from a one-year deployment to Iraq had experienced a TBI while deployed.16 That paper also examined 

the frequency of continued medical complaints that may 

be attributed to TBI, including headache, irritability, dizziness, balance problems, and memory difficulties. The 

authors found that 9 percent of personnel within the brigade reported at least one ongoing symptom potentially 

related to TBI, and 4 percent reported a minimum of two 

ongoing symptoms at the time of the screening, a few 

days after returning home from deployment. By comparison, VHA researchers have found that 7 percent of OCO 

veterans who are screened receive a diagnosis of symptomatic TBI.17 In part because there are no validated 

clinical criteria for symptomatic TBI, estimates from 

these studies are not comparable.

Issues in Reporting TBI Prevalence Rates

The rates of TBI reported in those published studies 

should not be interpreted as the prevalence for the whole 

population of service members deployed in support of the 

conflicts in Iraq and Afghanistan. Estimates of TBI in 

those studies are problematic for several reasons: Studies 

use different sets of diagnosis codes to approximate the 

number of TBI cases; they rely on screening instruments 

for TBI rather than clinical diagnoses at or near the time 

of injury; and they use samples that are not representative 

of the entire deployed force. Furthermore, even if the 

prevalence of TBI could be precisely determined, the 

extent of impairment and consequent need for continuing medical care are unknown.

Diagnosis Codes to Estimate TBI Prevalence Rates.

Studies that provide estimates of TBI frequency based on 

diagnosis codes are problematic. For one thing, not 

everyone with a TBI will seek treatment and receive a 

diagnosis, which leads to underestimates. For another, 

there is no single diagnosis code to identify TBIs. The 

codes identify several types of injuries to the head, distinguished by the section of the head injured rather than by 

the severity of injury to the brain itself. Researchers have 

employed different collections of codes to estimate the 

number of TBIs.

Screening Tools to Estimate TBI Prevalence Rates.

Studies have generally relied on screening tools or questions that are based on the Brief Traumatic Brain Injury 

Screen (BTBIS) to identify possible TBIs.18 The BTBIS 

does not replace a clinician-determined diagnosis at the 

time of injury. Indeed, the accuracy of the BTBIS is not 

known because it has not been psychometrically validated 

against clinicians’ diagnoses at or near the time of injury. 

14. Charles W. Hoge and others, “Mild Traumatic Brain Injury in 

U.S. Soldiers Returning from Iraq.” New England Journal of 

Medicine, vol. 358, no. 5 (January 31, 2008), pp. 453–463.

15. Tanielian and Jaycox, eds., Invisible Wounds of War.

16. Heidi Terrio and others, “Traumatic Brain Injury Screening: 

Preliminary Findings in a U.S. Army Brigade Combat Team,” 

Journal of Head Trauma Rehabilitation, vol. 24, no. 1 (January–

February 2009), pp. 14–23.

17. Ann Hendricks and others, “Screening for Mild Traumatic Brain 

Injury in OEF-OIF Deployed Military: An Empirical Assessment 

of the VHA Experience” (paper presented at the National Conference of VA’s Health Services Research and Development Service, 

Washington, D.C., February 2011).

18. To view the questionnaire, see “3 Question DVBIC TBI Screening Tool Instruction Sheet,” available at www.dvbic.org/images/

pdfs/3-Question-Screening-Tool.aspx. That screening tool asks 

service members to identify injuries that occurred during deployment by certain mechanisms such as an explosion or a fall; it asks 

whether any injuries resulted in a change in consciousness, such as 

“seeing stars,” immediately following the event; and it also asks the 

respondents, “Are you currently experiencing any of the following 

problems that you think might be related to a possible head injury 

or concussion?” It does not ask whether symptoms may be related 

to other causes. RAND researchers considered the test positive for 

TBI if the individual endorsed any of the injuries listed in the first 

question and reported any alteration of consciousness detailed in 

the second question. Terrio used the same screening criteria but 

followed up with a clinical assessment. Hoge queried soldiers on a 

smaller set of changes in consciousness than the BTBIS offers.
APPENDIX C THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 35

CBO

When the BTBIS is compared with a structured clinical 

interview that may occur several months after the injury, 

VHA researchers have found that the screen correctly 

identifies the vast majority of OCO veterans who remain 

symptomatic but also falsely identifies a large number of 

people.19 Because the screen was designed as a clinical 

tool to identify as many cases of TBI as possible, studies 

relying on that tool are likely to overestimate, perhaps 

significantly, the prevalence of both TBI and TBI with 

persistent symptoms. Also, the timing of the screening 

may result in substantially different responses in the same 

population.20 

Sample Selection. Sample selection is also problematic 

when estimating the prevalence of TBI, much as it is for 

PTSD. Studies have tended to focus on combat troops 

returning to their units. Even in the few studies that did 

survey active-duty personnel from all four branches of 

service, not just Army soldiers, certain groups of service 

members were either undersampled or oversampled. 

Although combat troops are much more likely to 

experience a TBI (and thereby inflate estimates of TBI 

prevalence), a sample of soldiers who return to their units 

does not include severely injured service members who 

have been medically evacuated from the combat theater; 

excluding medical evacuees from the sample underestimates the prevalence of TBI.

Extent of Impairment. Finally, even if the number of 

TBIs sustained in combat theater could be accurately 

determined, an important issue remains in understanding 

the impact of TBI on the health care needs of the OCO 

population: The degree of impairment is unknown. Even 

a clinical diagnosis at or shortly after a TBI occurs indicates only that an injury was sustained; it does not reveal 

the persistence or intensity of symptoms at the time of 

the diagnosis. Indeed, the literature indicates that the vast 

majority of individuals who experience a mild TBI 

recover spontaneously over a period of a few weeks or 

months. In addition, for some who remain symptomatic, 

many of the neurological and physiological indicators 

and limitations arising from TBI (headaches, memory 

difficulties, sleep problems) are not specific to the injury 

and may be caused by either the TBI or other conditions, 

complicating clinical assessment of TBI.21 Studies that 

report rates of symptomatic TBI show substantially lower 

rates than studies that measure the number of service 

members who sustained a TBI during deployment to a 

combat theater. 

19. Kerry T. Donnelly and others, “Reliability, Sensitivity, and 

Specificity of the VA Traumatic Brain Injury Screening Tool,” 

Journal of Head Trauma Rehabilitation, vol. 26, no. 6 (November–

December 2011), pp. 439–453; also see Karen A. Schwab and 

others, “Screening for Traumatic Brain Injury in Troops Returning from Deployment in Afghanistan and Iraq: Initial Investigation of the Usefulness of a Short Screening Tool for Traumatic 

Brain Injury,” Journal of Head Trauma Rehabilitation, vol. 22, 

no. 6 (November-December 2007), pp. 377–389. 

20. One study found that the self-reported concussion rate was 9 percent about one month before soldiers returned home from deployment but jumped to 22 percent when the same sample was 

surveyed one year after deployment. See Melissa A. Polusny and 

others, “Longitudinal Effects of Mild Traumatic Brain Injury and 

Posttraumatic Stress Disorder Comorbidity on Postdeployment 

Outcomes in National Guard Soldiers Deployed to Iraq,” Archives 

of General Psychiatry, vol. 68, no. 1 (January 2011), pp. 79–89. 

21. See Heather Belanger and others, “The Veterans Health Administration System of Care for Mild Traumatic Brain Injury: Costs, 

Benefits, and Controversies,” Journal of Head Trauma Rehabilitation, vol. 24, no. 1 (2009), pp. 4–13; also see Charles W. Hoge 

and others, “Care of War Veterans with Mild Traumatic Brain 

Injury—Flawed Perspectives,” New England Journal of Medicine, 

vol. 360, no. 16 (April 16, 2009), pp. 1588–1591. 

CBO

Appendix D: 

VHA’s Average Annual Costs for 

OCO Veterans Who Continue to Seek Care

In this study, the Congressional Budget Office (CBO) 

calculated average costs per patient of health care services 

for each treatment year by dividing costs in that year (the 

numerator) by the number of patients who ever used 

VHA’s services and remained in the sample that year (the 

denominator). (For the denominator for each treatment 

year, see the number of potential patients in Table D-1.) 

That method yields costs for specific groups of new OCO 

veterans, including some who used VHA only once and 

others who used VHA more frequently or even continually. Those results are presented in the main text of this 

study.

An alternative way to calculate average costs in a treatment year is to include in the denominator only those 

patients who continued to receive health care in each subsequent year. (For the denominator for each treatment 

year using that method, see the number of patients using 

VHA in Table D-1.) That method will produce higher 

annual average costs per patient, because the total cost for 

treating patients each year is divided by the number of 

patients who used services in that year (consequently, the 

denominator is smaller). In this appendix, CBO presents 

average costs using the second method. The first 

approach provides the cost for treating a given group of 

veterans; the second approach provides the cost for treating a group of veterans who are continually seeking care. 

After the first year of treatment, average annual costs for 

patients using VHA were higher than for potential 

patients, because some of the potential patients had no 

VHA costs associated with them (see Table D-2). Differences in average costs for the two samples were most pronounced for patients who had neither PTSD nor TBI. 

For that category of patients, the average cost of treatment in year 4 for patients using VHA ($2,300) was 

more than twice the cost for potential patients ($1,000, 

shown in Table 2 on page 19). Because so many veterans 

with PTSD and with both PTSD and TBI continued to 

use VHA care, differences in average cost between the 

two samples were much smaller for veterans diagnosed 

with those conditions. By treatment year 4, the average 

cost for patients using VHA with PTSD ($5,100) was 

34 percent more than for potential patients with PTSD 

($3,800). For veterans with both PTSD and TBI, the 

average annual cost for patients using VHA was only 

$400 more than the cost for potential patients. 
38 THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS

CBO

Table D-1. 

Sample Sizes

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude 500 patients, many with PTSD and TBI, 

who entered VHA at Polytrauma Rehabilitation Centers. 

VHA = Veterans Health Administration; PTSD = post-traumatic stress disorder; TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had other conditions.

b. Patients in the TBI group did not have PTSD, but many had other conditions.

Treatment Group

PTSD or TBI

PTSDa 103,500 103,500 100 

TBIb 8,700 8,700 100 

Both PTSD and TBI 26,600 26,600 100

No PTSD or TBI 358,000 358,000 100

PTSD or TBI

PTSDa 69,100 55,600 80 

TBIb 3,600 2,800 78 

Both PTSD and TBI 17,500 18,600 94 

No PTSD or TBI 124,100 248,800 50 

PTSD or TBI

PTSDa 43,800 33,600 77 

TBIb 1,200 800 67 

Both PTSD and TBI 10,000 10,600 94

No PTSD or TBI 77,400 177,800 44

PTSD or TBI

PTSDa 24,600 18,600 76 

TBIb 600 400 67 

Both PTSD and TBI 5,300 5,500 96 

No PTSD or TBI 48,600 115,300 42 

(Percent)

Share of Patients Using VHA

Patients Using VHA

 Treatment Year 3

 Treatment Year 4

 Treatment Year 1

Treatment Year 2

Potential Patients in Group
APPENDIX D THE VETERANS HEALTH ADMINISTRATION’S TREATMENT OF PTSD AND TRAUMATIC BRAIN INJURY AMONG RECENT COMBAT VETERANS 39

CBO

Table D-2. 

Alternative Calculation of Average Costs for All of VHA’s Health Care 

Provided to OCO Patients

(Dollars)

Source: Congressional Budget Office based on data from the Department of Veterans Affairs, Veterans Health Administration.

Notes: Data cover fiscal years 2004 to 2009 for up to the first four years of treatment. Data exclude about 500 patients, many with PTSD and 

TBI, who entered VHA at Polytrauma Rehabilitation Centers. 

Average annual costs are based on the number of OCO patients who sought treatment in a given year.

VHA converted costs provided to CBO to fiscal year 2009 dollars based on annual increases in the average cost of a primary care visit 

from 2004 to 2009. CBO then indexed those costs to 2011 dollars using the GDP deflator.

VHA = Veterans Health Administration; OCO = overseas contingency operations; PTSD = post-traumatic stress disorder; 

TBI = traumatic brain injury.

a. Patients in the PTSD group did not have TBI, but many had other conditions.

b. Patients in the TBI group did not have PTSD, but many had other conditions. 

Treatment Group

PTSD or TBI

PTSDa 8,300 5,200 5,100 5,100

TBIb 11,700 6,000 10,800 18,300

Both PTSD and TBI 13,800 8,900 9,300 10,200

No PTSD or TBI 2,400 2,300 2,300 2,300

 Treatment Year 1 Treatment Year 2 Treatment Year 3 Treatment Year 4