When the U.S. invaded Iraq early in 2003, and later that year when the insurgency arose, it wasn't just soldiers in the field who were hurting. Something was happening to young veterans back home—they were hurting not physically, but mentally. That was the finding of a recent study by researchers at the DMS-affiliated VA Medical Center in White River Junction, Vt.

Many more young veterans (age 18 to 44) who use the VA health system reported poor mental health in 2003 than in 2000, the team discovered. Their analysis was based on the results of an annual national survey by the Centers for Disease Control and Prevention (CDC).

Group: "Nobody else reported more distress, just this particular group," says researcher Alan West, Ph.D., who coauthored the study with psychiatrist William Weeks, M.D. West and Weeks found no significant increases in any other group—not in nonveterans, older veterans, nor veterans who receive their care outside the VA system.

In 2000, about 17.5% of veterans aged 18 to 44 who were under VA care reported at least five days of poor mental health in the previous month. In 2003, that number jumped to 29%. When West and Weeks probed deeper, by dividing the calendar year into three periods, the results were even more striking. In the first third of the year (January to April), the percentages for this group were 21% in 2000 and 36% in 2003. The second third of the year showed no significant difference between 2000 and 2003. But the final third of the year showed another spike, from 16% in 2000 to 32% in 2003.

As West and Weeks explain in their paper, published in the journal Psychiatric Services, "the first period [of 2003] involved the buildup and launching of Operation Iraqi Freedom, which was televised widely, perhaps inducing considerable anticipatory anxiety among these veterans. With the occupation of Iraq, hostilities subsided during the summer months. However, during the last third of the year, U.S. casualties increased between the suicide bombing of the Baghdad United Nations headquarters in late August and the capture of Saddam Hussein in December. The reality of a protracted war and its casualties may have first become apparent to the post- Vietnam veterans at this time."

The authors speculate that the reason older veterans didn't show the same effect is because the current war may be "more emotionally salient to younger veterans," a third of whom had served in Desert Storm—in the same combat theater. Other studies, West and Weeks note, have shown that "perceived similarity to victims increases a remote observer's distress in response to news of traumatic events."

To West and Weeks's dismay, 2000 and 2003 were the only years that the CDC survey, known as the Behavioral Risk Factor Surveillance System (BRFSS), asked two questions key to their study: "Are you a veteran?" and "Do you use the VA health system?" Without answers to those questions, West and Weeks cannot expand their analysis to other years—at least not using BRFSS data. They hope the CDC will include those questions in future surveys.

Novel findings: In addition to the study's novel findings about veterans' mental health in 2003, the study also demonstrated a new approach for VA research. Veterans' health issues are often studied by comparing various groups or populations of veterans. When veterans are compared to the general population, it is rare that the data for each group is collected in the same way and at the same time, Weeks explains. Comparing veterans to nonveterans "in real time, with the exact same questions done with the same methodology," says Weeks, "gives you a great opportunity to contextualize your findings."

For example, in previous studies, Weeks showed that rural veterans are in poorer health than their urban and suburban counterparts. But "I didn't know if that was a rural veteran issue or a rural issue," says Weeks, who is an associate professor of psychiatry and of community and family medicine.

Comparison: Another study he recently published with West answered that question. VA patients in rural areas have poorer physical and mental health than nonveterans (no matter where they live) and than veterans in urban and suburban areas. "This study is the first direct comparison of veterans in VA medical care to other veterans or nonveterans in a national survey of health problems, health-related functional limitations, and health-care access," West and Weeks wrote in the Journal of Rural Health. That study also suggests that the poor health of rural veterans may be an access problem, such as having to travel long distances to reach the nearest VA medical center.

Using data from surveys of the general population that distinguish between veterans and nonveterans is "a very cost-efficient way" of assessing both veterans' health and VA health care, says Weeks. Such data can provide "a really nice objective view of [VA] performance," he adds. And, as the Psychiatric Services paper demonstrates, lead to compelling findings.