Journal of Anxiety Disorders 31 (2015) 98–107

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

Review

The prevalence of posttraumatic stress disorder in Operation

Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans:
A meta-analysis♦
Jessica J. Fulton a,b,c,∗ , Patrick S. Calhoun a,b,c , H. Ryan Wagner a,b,c , Amie R. Schry a,b,c ,
Lauren P. Hair a , Nicole Feeling a,c , Eric Elbogen a,b,d , Jean C. Beckham a,b,c
a
Durham VA Medical Center, Durham, NC 27705, United States
b
VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center, Durham, NC 27705, United States
c
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, United States
d
Department of Psychiatry, UNC-Chapel Hill, Chapel Hill, NC 27516, United States

a r t i c l e i n f o a b s t r a c t

Article history: Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and
Received 29 September 2014 Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is
Received in revised form necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33
25 December 2014
studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence
Accepted 9 February 2015
was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active
Available online 19 February 2015
duty participants explained significant variability in prevalence across studies. PTSD remains a concern
for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among
Keywords:
Posttraumatic stress disorder
OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of
Prevalence PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with
Veterans randomly selected, representative samples administered diagnostic interviews. Significant financial and
Iraq mental health resources are needed to promote recovery from PTSD.
Afghanistan Published by Elsevier Ltd.
Meta-analysis

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2.1. Selection of studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2.2. Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
2.3. Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
2.4. Publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.1. Study and participant characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.2. Primary analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.3. Moderator analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
3.4. Investigation of publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
4.1. Limitations of current research on prevalence of PTSD among OEF/OIF veterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
4.2. Limitations of this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

♦ The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the U.S. Government. Since the authors are
employees of the U.S. Government and contributed to this manuscript in part as part of their official duties, the work is not subject to U.S. copyright.
∗ Corresponding author at: Durham VA Medical Center (116B), Durham, NC 27705, United States. Tel.: +1 919 491 2011.
E-mail address: jessica.j.fulton@gmail.com (J.J. Fulton).

http://dx.doi.org/10.1016/j.janxdis.2015.02.003
0887-6185/Published by Elsevier Ltd.
 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107 99

5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Acknowledgments and disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Appendix B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

1. Introduction compensation for any type of disability (e.g., physical injury, med-
ical condition, mental health condition; Department of Veteran
In recent years, several reviews have examined posttraumatic Affairs Benefits Administration, 2012). Furthermore, knowledge of
stress disorder (PTSD) prevalence estimates among U.S. service the base rate of a condition in the population can improve the
members deployed to Iraq and/or Afghanistan (Gates et al., 2012; accuracy of our diagnostic and conclusions (Meehl & Rosen, 1955).
Kok, Herrell, Thomas, & Hoge, 2012; Ramchand et al., 2010; Accordingly, the purpose of the current investigation was to present
Richardson, Frueh, & Acierno, 2010; Sundin, Fear, Iversen, Rona, & a systematic and quantitative review of PTSD prevalence among
Wessely, 2010). Across studies in these reviews, PTSD prevalence U.S. OEF/OIF veterans separated from military service. A secondary
estimates ranged from 1.4% to 60%. The authors identified factors aim was to investigate potential causes for the variability across
that may contribute to variability in PTSD prevalence estimates prevalence estimates.
among military personnel, including sampling strategy (e.g., ran-
dom versus non-random), method of PTSD diagnosis, anonymity 2. Method
of reporting, level of combat exposure, military component (e.g.,
active duty versus reserve), and military context (e.g., operational 2.1. Selection of studies
infantry unit samples).
Although these reviews represent considerable progress in our PubMed, PsycINFO, and PILOTS (Published International Liter-
understanding of the epidemiology of PTSD among military per- ature on Traumatic Stress) databases were searched for the terms
sonnel, studies with samples of deployed and returning service “OEF OR Afghanistan OR Iraq OR OIF” combined with the terms
members may not adequately capture the mental healthcare needs “post traumatic OR posttraumatic OR posttraumatic stress OR post-
of veterans who have separated from military service. Research traumatic stress disorder” and “veteran” between October 7, 2001
suggests that early symptoms of psychological distress and PTSD and May 31, 2013. The reference lists of recently published review
are not good predictors of long-term adaptation. A review of studies articles (Gates et al., 2012) and articles included in the meta-
of military service members deployed to Iraq found that although analysis were also searched. These combined searches yielded 1369
few studies have examined rates of PTSD longitudinally post- references. After excluding all duplicates, the literature searches
deployment, the few studies that do exist on this topic suggest that identified 857 studies. To be included in the meta-analysis, studies
rates of PTSD increase through at least 12 months post-deployment had to (a) be written in English, (b) be published in a peer-reviewed
(Sundin et al., 2010). In addition, service members may face unique outlet, (c) provide a PTSD prevalence estimate for veterans who
barriers to endorsing mental health problems and seeking men- served in support of OEF or OIF and were separated from military
tal health treatment including concerns that seeking mental health service, and (d) have a sample size greater than or equal to 1000.
treatment could affect how they are perceived by military leader- The first author initially screened and eliminated studies that
ship and their unit (Hoge et al., 2004). Such concerns may contribute clearly did not meet inclusion criteria (e.g., animal studies, stud-
to underreporting of mental health symptoms among military ies without PTSD prevalence estimate). For those studies in which
service members who have not yet separated. Accordingly, preva- inclusion in the meta-analysis was questionable, the first author
lence estimates among service members may not be representative and at least one other author reviewed the article and reached con-
for veterans. sensus regarding inclusion/exclusion. Fig. B.1 provides a flowchart
A better understanding of PTSD prevalence among U.S. veterans depicting the study selection process. The meta-analysis included
is important for informing public policy decisions regarding alloca- 33 studies published between 2007 and 2013 with a total of
tion of mental healthcare resources. Widely discrepant prevalence 4,945,897 veterans.
estimates have limited utility for informing treatment efforts and
projecting healthcare needs. The cost of underestimating rates 2.2. Coding
and undertreating is high particularly because PTSD is associated
with increased rates of psychiatric and medical comorbidity, health Data abstraction was performed by one reviewer and con-
care utilization, disability, substance abuse, and suicide (Breslau, firmed by a second; disagreements were resolved by discussion
2001; Calhoun, Bosworth, Grambow, Dudley, & Beckham, 2002; or a third reviewer. Methods of data abstraction were specified in
Cohen, Marmar, Ren Bertenthal, & Seal, 2009; Frayne et al., 2004; advance and documented in a protocol that can be accessed by
Kessler, Chiu, Demler, & Walters, 2005; Perkonigg, Kessler, Storz, contacting the corresponding author. The studies were coded for
& Wittchen, 2000). Moreover, once veterans manifest protracted publication year, sample size, mean age of participants, percent-
adaptation difficulties, PTSD symptoms tend to remain chronic age of female participants, percentage of Caucasian participants,
across the lifespan (Prigerson, Maciejaewski, & Rosenheck, 2002) percentage of married participants, percentage of participants
and become resistant to treatments that have demonstrated effi- who were active duty (versus reserve) prior to military separa-
cacy with acute PTSD symptomatology (Schnurr, Lunney, Sengupta, tion, method of PTSD assessment (i.e., record review of medical
& Waelde, 2003). In contrast, overestimating PTSD prevalence chart including International Classification of Diseases and Related
among OEF/OIF veterans could also have significant costs. A higher Health Problems, Revision 9 [ICD-9] diagnostic codes, questionnaire,
percentage of OEF/OIF veterans are seeking compensation fol- semi-structured interview), sample type (VA versus non-VA), and
lowing military service than veterans of earlier eras (Marchione, catchment area (national versus regional). All diagnoses based
2012; McNally & Frueh, 2013). During the 2012 fiscal year, PTSD on a medical record review were based on ICD-9 diagnostic
was the third most prevalent disability among veterans receiving codes in the patients’ medical records. Multiple VA providers
100 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107
(e.g., physician, nurse, psychologist) can enter a diagnosis of PTSD
into a patient’s medical record, and the basis for diagnosis may
vary across providers. Information about the basis of the diag-
nosis (e.g., screening questionnaire versus unstructured interview
versus structured interview) was not available in nearly all cases
and therefore could not be abstracted for analysis. To avoid depend-
ency effects between studies, one prevalence estimate per sample
was included. Therefore, weighted prevalence estimates were com-
bined to obtain a single index of prevalence for studies that derived
estimates separately for men and women (e.g., Haskell et al., 2009).
2.3. Analyses
Analyses were performed using the R-based metaphor package
(Viechtbauer, 2010). The primary outcome measure was based
on the proportion of participants within each study sam-
ple with a diagnosis of PTSD. For calculations, proportions
were variance-stabilized using the Freeman–Tukey double-arcsine
transformation (Freeman & Tukey, 1950); resulting statistics were
reverse-transformed for ease of interpretation. Given that method-
ological differences across studies could affect outcomes, the
significance of heterogeneity was estimated using random-effects
models; mixed-effects models were used when evaluating puta-
tive moderators. Tests for residual heterogeneity (QE ) and tests
of model-based moderator effects (QM ) were based on standard
chi-square Q (QE ) tests. Moderator models were estimated using
Freeman–Tukey transformed prevalence estimates and tested for
both residual heterogeneity (QE ) and for the reduction in het-
erogeneity associated with the tested moderator (QE ). A final
model was estimated to include individual moderators identified
by reduced model heterogeneity with inclusion criterion based on
a QM p-value of p = 0.10 or less. Graphic presentation of effect sizes
across studies was assessed by forest plot (Lewis & Clarke, 2001).
2.4. Publication bias
Possible publication bias was investigated graphically using fun-
nel plot (Sterne & Egger, 2001) and empirically using a regression
test (Egger, Smith, Schneider, & Minde, 1997) or rank test (Begg
& Mazumdar, 1994). A funnel plot is a scatterplot of variance (or
some transformation thereof) against effect size and is based on the
assumption that studies with small and/or non-significant findings
are less likely to be included in a meta-analysis thereby resulting in
an asymmetric plot. The regression test assesses systematic asso-
ciation between variance and effect size by regressing the latter on
the former.
3. Results
3.1. Study and participant characteristics
Across studies, 85.3% of the participants were male. Racial group
membership of participants was reported in 28 studies, with 66.7%
of participants in those studies being Caucasian. The average age of
participants was reported in 9 of the studies; the weighted average
age of participants across the remaining 24 studies was 32.2 years.
Forty-one percent of participants were married in the 23 stud-
ies that reported marital status data. Seventeen studies reported
participants’ military component status, with 53.2% of participants
being active duty prior to military separation. Among the thirteen
studies that provided data on enlistment (versus commissioned
officer status), 92.2% of participants were enlisted personnel prior
to military service separation.
The majority of studies included in this meta-analysis collected
data from national VA database samples (k = 21). The meta-analysis
also included eight regional VA database samples and four non-
VA samples. Twenty-five studies determined PTSD diagnosis based
on medical record review, two studies used a version of the PTSD
Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993), and
three studies utilized the Primary Care PTSD Screen (Bliese et al.,
2008; Prins et al., 2004). One study used a semi-structured clini-
cal interview, and one study used a structured clinical interview,
the Structured Clinical Interview for DSM Disorders (First, Spitzer,
Gibbon, & Williams, 1996). When available, study and participant
data are presented in Table A.1.
3.2. Primary analyses
Analyses were based on 33 studies selected as discussed above
and described in more detail in Table A.1. Mean and median propor-
tions of participants with diagnoses of PTSD were 23.1 ± 8.4% and
24.0%, respectively. Prevalence estimates (weight-adjusted) ranged
from a minimum of 5.8% to a maximum of 41.3%; inter-quartile
range extended from 19.2% to 29.0%.
Results from an intercept-only random effects model estimated
on Freeman and Tukey (1950) transformed proportions indicated
substantial heterogeneity based on the associated Q statistic (QE
[df = 32] = 932; p < 0.0001). Repeating the analysis using the actual
proportions (without transformation) yielded an intercept term of
23.0 ± 1.5% in close agreement with the mean estimate reported
above. Results are displayed graphically (Fig. B.2) with the propor-
tion of participants with PTSD diagnoses plotted by sample size.
3.3. Moderator analyses
A series of moderator variables was subsequently tested
to investigate between-study heterogeneity. These variables
included age, percentage of Caucasian participants, percent-
age of male participants, percentage of married participants,
dichotomized (yes/no) medical records-based diagnosis, publi-
cation year, percentage of enlisted participants, percentage of
active duty participants, dichotomized (yes/no) VA utilizing cohort,
dichotomized (national versus regional) sample type, and sample
size (log transformed). Results are presented in Table A.2.
Of the individually tested moderators, heterogeneity within
studies was significantly reduced by higher percentages of Cau-
casian participants (R2 = 27.9%), more recent publication date
(R2 = 13.9%), and higher percentages of participants who were on
active duty prior to service separation (R2 = 34.9%). Heterogeneity
was also marginally reduced in studies with a higher percentages
of male participants (R2 = 9.3%). Changes in PTSD prevalence based
on derived coefficients indicated a decrease in prevalence of 0.25%
for each one unit increase in the percentage composition of Cau-
casian participants, an increase of 2.10% with each publication year
increase, an increase of 0.76% for each one unit increase in the per-
centage composition of active duty participants, and an increase of
0.15% for each one unit increase in the percentage composition of
male participants. No other moderator effects attained significance.
Furthermore, no moderator was able to account for overall hetero-
geneity. That is, QE , the test for overall heterogeneity, remained
significant even when any moderator was added to the model. A
final composite model comprised of all moderators with signif-
icance levels of p ≤ 0.10 resulted in a reduction in heterogeneity
of 65%, yet the overall test for heterogeneity remained significant
(QE = 27.02; p < 0.0001).
3.4. Investigation of publication bias
Publication bias was investigated graphically by funnel plot
(Fig. B.3) and by rank test (Begg & Mazumdar, 1994) and regression
test (Egger, Smith, Schneider, & Minde, 1997). In each instance, the
Table A.1
Description of studies with PTSD prevalence estimates for veterans of Operation Enduring Freedom and Operation Iraq Freedom.

Studya,b Nc Sample characteristics Percent Percent Mean age Diagnosis PTSD

male Caucasian (SD) method estimate %

National VA database samples

Bangerter et al. (2010) 286,868 Veterans with military discharges through 12/07 who had VA health 87.6 – 34.7 (–) Record 25.4
service use data between 10/1/04 and 9/30/07 review
Blackstock, Haskell, Brandt, 445,319 Veterans with 1+ inpatient or outpatient VHA visits between 10/1/01 87.9 69.1 – Record 22.9
and Desai (2012) and 9/30/09 review
Cohen, Marmar, Ren, 303,223 New users of VA health care between 10/7/01 and 9/30/08 88.0 – 31.0 (9.0) Record 24.0
Bertenthal, and Seal review
(2009)a
Cohen et al. (2010)a 249,440 New users of VA health care between 10/7/01 and 3/31/07 who were 87.3 66.8 31.0 (9.0) Record 21.5
followed until 3/31/08 review
Cohen et al. (2012)a 71,504 New female users of VA health care after 10/7/01 who were followed 0.0 39.7 29.3 (8.2) Record 21.4
until 12/31/10 review
Evans et al. (2013) 170,681 Veterans who (1) were members of the OEF/OIF Roster, (2) had 87.5 72.1 32.9 (–) Record 17.6

J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107

separated from the military after 9/11/01 and before 9/30/08, (3) review
sought inpatient or outpatient care at VA medical facilities from
4/14/07 to 9/30/08 and (4) indicated that they had been deployed to
Afghanistan and/or Iraq
Frayne et al. (2011) 90,558 Male veterans with 1+ face-to-face VHA outpatient visits in both FY06 100.0 65.5 – (–) Record 34.8
(10/1/05–9/30/06) and FY07 (10/1/06–9/30/07) with a valid service review
end date between 9/11/01 and 9/30/06
Haskell et al. (2009) 153,212 Veterans with military discharges between 10/1/01 and 11/30/07 who 88.0 66.9 32.3 (–) Record review 11.1
had (1) enrolled for or received VA services before 1/1/08; (2) had 1+
visits to a VA clinic most likely to obtain pain scores; and (3) had 1 year
of observation after their last deployment end date
Haskell et al. (2011) 163,812 Veterans with military discharges between 10/1/2007 and 11/30/07 88.0 67.0 31.8 (–) Record review 9.5
who (1) either enrolled for or received VA services before 1/1/08 and
(2) had an encounter within 1 year
Ilgen et al. (2012) 309,108 Veterans with an inpatient or outpatient encounter in the VHA health 87.5 – 32.7 (9.6) Record review 21.3
system between 10/1/06 and 9/30/08 and who were alive at the start
of FY08 (10/1/07)
Kimerling et al. (2010) 125,729 Veterans with 1+ OEF or OIF deployments who separated from military 86.0 65.9 – (–) Record review 31.1
service by 9/30/06 and used VA mental health or primary care services
between 10/1/01 and 9/30/07
Maguen, Lau, Madden, and 1549 (1400) Veterans with a first-level TBI screen between 4/1/07 and 1/8/10 who 89.6 42.3 30.2 (8.4) PC-PTSD ≥ 3 41.3
Seal (2012) had not previously received a TBI diagnosis
Maguen, Madden, Cohen, 603,221 New users of VA healthcare between 10/7/01 and 12/31/10 with 88.0 48.7 30.3 (9.3) Record review 26.3
Bertenthal, and Seal complete demographic (with the exception of race) and military
(2014) service information
Maguen, Ren, Bosch, 329,049 Veterans not enrolled in VA prior to OEF/OIF conflicts who had 1+ visit 87.6 67.0 31.2 (9.0) Record review 21.2
Marmar, and Seal (2010) to a VA facility between 4/1/02 and 3/31/08
+
Mattocks et al. (2010) 43,078 Female veterans enrolled in VHA health care between 10/1/01 and 0.0 54.0 28.87 (–) 1 inpatient or 9.8
4/30/08 who (1) had 1+ VHA visits and (2) were of childbearing age 2+ out-patient
(up to 50 years old)
Record review
Nazarian, Kimerling, and 73,720 Veterans with military service ending between 9/01 and 9/06 who (1) 85.0 62.7 – (–) Record review 34.6
Frayne (2012) had 2+ primary care visits in FY06 (10/1/05–9/30/06) and FY07
(10/1/06–9/30/07) and (2) 1+ visits occurred in FY06 providing 1+
years of observation
Seal, Bertenthal, Miner, 103,788 Veterans who (1) first used VA health care between 10/1/01 and 87.0 69.0 – (–) Record review 13.0
Sen, and Marmar (2007)b 12/31/05, (2) had been seen at a VA facility by 9/30/05, and (3) were
included in the OEF/OIF Roster as of 11/1/05

101
 102
Table A.1 (Continued)

Studya,b Nc Sample characteristics Percent Percent Mean age Diagnosis PTSD

male Caucasian (SD) method estimate %

Seal et al. (2011)b 456,502 Veteran who first used VA care between 10/15/01 and 9/30/09 and 88.0 46.0 – (–) Record review 26.0
were followed for 90+ days until 1/1/10; veterans killed in action or
who first entered VA within 90 days of 1/1/10 were excluded
Seal et al. (2009)b 289,328 Veterans who were included in OIF/OEF Roster and first used VA 88.0 68.0 – (–) Record review 21.8
health care between 10/1/01 and 1/31/08; veterans killed in action,
seen within the first180 days after 10/1/01, or enrolled VA veterans
who had not had a clinical visit prior to 3/31/08 were excluded
Stecker, Fortney, Owen, 293,861 Veterans enrolled in VA services between 10/1/01 and 9/30/06 88.0 66.0 34.4 (–) Record review 11.9
McGovern, and Williams
(2010)
Taylor et al. (2012) 327,388 Veterans who used inpatient or outpatient VHA care between 1/1/08 88.0 44.0 35.3 (9.7) Record review 28.0
and 9/30/09
Regional VA database samples

J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107

Anderson, Wade, 4416 Veterans with primary care visit in VISN 2 between 9/11/01 and 89.0 85.0 29.0 (8) Record review 24.6
Possemato, and 12/31/07; veterans with war or combat experience before 9/11/01 or
Ouimette (2010) who entered VA system before 9/11/01 were excluded
Barber, Bayer, Pietrzak, and 1553 Veterans with 1+ documented PTSD or depression screens between 86.6 – 32.6 (8.8) PC-PTSD ≥ 2 27.0
Sanders (2011) 10/1/06 and 3/31/08 at the West Haven VA
Carlson et al. (2010) 13,201 Veterans in VISN 23 who received a TBI screen between 4/1/07 and 90.0 82.0 32.5 (9.3) Record review 25.8
10/20/08 and who did not report or have a documented TBI diagnosis
before screen
Haskell et al. (2010) 1229 Veterans who received Primary Care or the Women’s Health Clinic 84.0 64.0 32.0 (–) PC-PTSD ≥ 3 31.1
services at VA Connecticut from 10/1/01 to 5/7/07
Hosain, Latini, Kauth, Goltz, 4755 Male veterans who sought inpatient and outpatient care at the MED 100.0 45.9 31.5 (8.3) Record review 33.1
and Helmer (2013) VAMC between 9/1/07 and 8/31/09
Lemaire and Graham 1740 (1716) Veterans registered at Houston VAMC who underwent routine mental 87.3 49.6 29.4 (–) Semi- 28.9
(2011) health screening between 5/24/04 and 3/26/08 structured
interview
Possemato et al. (2012) 4463 Veterans with a primary care visit in VISN 2 between 9/11/01 and 89.0 78.0 30.0 (9.0) Record review 29.0
1/1/08
Sayer, Nelson, and Nugent 15,973 Veterans screened for TBI in VISN 23 between 4/1/07 and 10/20/08 89.5 80.2 31.9 (–) Record review 5.84
(2011) who had no TBI diagnosis before 4/1/07
Non-VA database samples
Elbogen et al. (2012) 1388 National sample of veterans with military service after 9/11/01 who 84.4 70.0 36.1 (10.1) DTS > 48 20.0
were either separated from active duty or in the Reserves/National
Guard between 7/09 and 4/10
Iverson, Pogoda, Gradus, 2348 Veterans with 1+ OEF or OIF deployments who responded to a national 48.5 74.2 35.66 (–) PCL-M ≥ 50 19.3
and Street (2013) mail survey conducted between 9/09 and 11/10
McClernon et al. (2013) 1691 Veterans recruited from VISN 6 VA facilities who participated between 79.8 42.3 37.5 (0.2) SCID 32.0
11/05 and 9/11 in an ongoing MIRECC Registry Database for the Study
of Post-Deployment Mental Health
Schneiderman, Braver, and 2235 Veterans living in northern Virginia, Maryland, Washington, DC, or 86.0 – – (–) PCL ≥ 50 11.2
Kang (2008) eastern West Virginia who left combat theaters by 9/30/04 and
responded to a national survey mailed during 2/2005

Notes: DTS, Davidson Trauma Scale; FY, Fiscal Year; MED, Michael E. DeBakey; MIRECC, Mid-Atlantic Mental Illness Research, Education and Clinical Center; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; PCL,
PTSD Checklist; PCL-M, PTSD Checklist-Military Version; PC-PTSD, Primary Care PTSD Screen; PTSD, Posttraumatic Stress Disorder; SCID, Structured Clinical Interview for DSM Disorders; TBI, Traumatic Brain Injury; VA, Veterans
Affairs; VAMC, Veterans Affairs Medical Center; VHA, Veterans Health Administration; VISN, Veterans Integrated Service Networks.
a
Studies include potentially overlapping samples.
b
Studies include potentially overlapping samples.
c
When the total sample size and the sample size used to estimate the PTSD prevalence differ, the sample size used for estimating the prevalence appears in parentheses.
 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107 103

logic of the test regresses the effect size measure on a predictor vari-
able that can variously include study size, standard error, variance,
or inverse sample size. Significant association of sample size with
any of the putative predictors is taken as evidence that publication
is associated with sample size and/or effect size. Neither inspection
of the funnel plot nor the results of either the rank test (Kendall’s
tau = −0.04, p = 0.70) nor the regression test (t (31) = −0.50, p = 0.62)
supported a bias for prevalence estimates to be associated with
sample size.
4. Discussion
In the decade since the OEF and OIF conflicts began, numerous
epidemiological studies with returning military service members
have been published, improving our understanding of the scope
of mental health concerns in this cohort and of the character-
istics of those at highest risk. Previous reviews have examined
PTSD prevalence among active service members (e.g., Ramchand
et al., 2010) and mixed samples of both active service members
and veterans (e.g., Gates et al., 2012). This review is unique in
its focus on the synthesis of PTSD rates among veterans sepa-
rated from military service, and the purpose of the review was
twofold. First, it was conducted to estimate the overall prevalence
of PTSD among samples of OEF/OIF veterans. However, character-
istics of the included studies (e.g., primarily VA database samples,
PTSD prevalence estimated from ICD-9 codes in medical charts)
limited the generalizability of the results of this meta-analysis pri-
marily to prevalence of PTSD among OEF/OIF Veterans using VA
healthcare services. Second, it was designed to investigate potential
causes for variability in prevalence across studies. Therefore, stud-
ies from peer-reviewed, English language outlets were included
if they assessed and reported an estimate of PTSD in a sample of
OEF/OIF veterans.
The average PTSD prevalence among OEF/OIF veterans in the
studies included in this meta-analysis was 23%, confirming that
PTSD is a problem of considerable magnitude among this cohort
of veterans. The racial composition of the study sample was a
significant predictor of prevalence estimate; specifically, as the
percentage of Caucasian participants in the sample increased, the
prevalence estimate of PTSD decreased. This finding may suggest
that non-Caucasian veterans are more likely to have a diagnosis of
PTSD than Caucasian veterans. The percentage of male veterans was
positively associated with PTSD prevalence, which suggests PTSD
is more prevalent among male veterans than female veterans. This
finding is surprising as a previous meta-analysis examining gen-
der differences in PTSD found that women were approximately
two times more likely to meet diagnostic criteria for PTSD than
men (Tolin & Foa, 2006), but this previous meta-analysis was not
Table A.2
specific to veterans. Furthermore, a recent study on gender dif-
ferences among OEF/OIF veterans found that the prevalence of
probable PTSD did not differ between male and female veterans;
however, prevalence varied by type of stressful events (e.g., sex-
ual harassment, combat exposure) occurring during deployment
(Street, Gradus, Giasson, Vogt, & Resick, 2013).
Publication year was also a significant predictor of PTSD esti-
mates, as more recent publications reported higher rates of PTSD.
Prevalence also significantly differed based on percent of veter-
ans in the sample who had served in active duty units (versus
reserve units). In contrast to research which has found higher PTSD
rates among military service members in reserve units (Milliken,
Auchterlonie, & Hoge, 2007), results from the present review indi-
cated an increase in prevalence as the proportion of veterans with
service in active duty units increased. This finding may reflect dif-
ferences in combat exposure level, which has been consistently
associated with PTSD diagnosis (Ramchand et al., 2010). Level of
combat exposure was not reported in many studies included in
this review. Thus, its effect on prevalence estimates could not be
examined.
4.1. Limitations of current research on prevalence of PTSD among
OEF/OIF veterans
Specific patterns in the extant research were brought to light
in the current meta-analysis. First, the majority of studies in this
review examined samples of veterans using VA healthcare ser-
vices. Although it is important to understand the prevalence of
PTSD among help-seeking veterans, many OEF/OIF veterans do
not use VA healthcare services, and it is possible that data from
Records identified through
database searching
(n = 1,369)
Records after duplicates removed
(n = 857)
Records screened Non-relevant records excluded
(n = 857) during abstract screening
(n = 415)
Full-text articles excluded,
with reasons
Full-text articles assessed
(n = 409)

..
Moderator analyses examining between-study heterogeneity. for eligibility
(n = 442) Non-English (n = 4)
B estimate ± SE% R2

..
QM p
No PTSD estimate (n = 7)
Age 0.90 ± 0.75 0.04 0.8491 0.0016 Reviews (n = 7)
Caucasian %
Male %
Married %
−0.25 ±
0.15 ±
−0.20 ±
0.11
0.09
0.26
4.67
3.14
0.55
0.0307
0.0763
0.4578
14.26%
9.25%
2.41%
Studies included
in meta-analysis
.. Sample size < 1,000 (n = 8)
Overlapping sample (n = 10)
Editorials, commentaries, letters (n
Enlisted %
Active duty %
Record review (yes/no)
0.47 ±
0.76 ±
−4.26 ±
0.67
0.26
3.29
0.04
9.13
1.55
0.5167
0.0025
0.2127
3.15%
34.89%
4.46%
(n = 33)
. = 84)
Treatment study or pre-selected on
basis of mental health symptoms
VA sample (yes/no)
National sample (yes/no)
Sample size
3.22 ±
−2.53 ±
−2.15 ±
5.57
3.11
1.47
0.34
0.47
1.72
0.5627
0.4897
0.1894
0.99%
1.41%
4.91%
. (n = 112)
No veterans (n = 177)

Publication year 2.10 ± 0.90 5.29 0.0215 13.85%

Composite model – 27.62 <0.0001 64.54%

Note: QM , Test of reduction in heterogeneity attributable to moderator(s); p, Prob-

ability of that the decrease in heterogeneity is significantly greater than zero;
R2 , Percentage of residual heterogeneity accounted for by the moderator(s). Fig. B.1. PRISMA 2009 flowchart for included studies (Liberati et al., 2009).
104 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107

help-seeking samples skew prevalence estimates upward. Future
research with OEF/OIF veterans who are not help-seeking and/or
who are not using VA healthcare services would complement exist-
ing literature and provide a more comprehensive understanding of
PTSD rates in this cohort.
Second, although it is reasonable to assume that large adminis-
trative database studies provide accurate PTSD estimates among
help-seeking veterans utilizing VA care, even among large (e.g.,
n > 100,000) national samples of VA patients included in the
present review, evidence of significant heterogeneity emerged
with observed prevalence estimates ranging from 9.5% to 41.3%.
Although percentage of male participants, percentage of partic-
ipants with active duty status, and publication year explained
some of the variance in estimates across studies, heterogeneity in
the results is also likely in part due to the widely varying selec-
tion criteria and associated sample characteristics of the studies
reviewed (see Table A.1, sample characteristics). Given the signif-
icant methodological differences across studies and heterogeneity
between observed PTSD estimates, the aggregate estimate of PTSD
prevalence should be interpreted with caution (Petitti, 2001).
Third, 20 of the 21 national VA administrative database samples
used ICD-9 codes from medical chart reviews as method of identi-
fying individuals with a PTSD diagnosis. The use of medical chart
review to determine diagnostic status is potentially problematic, as
providers within VA can use widely varying methods to establish
diagnosis and determine whether to list a diagnosis of PTSD in the
medical chart. Additionally, a recent study of the validity of chart
diagnoses of PTSD for veterans of the Iraq and Afghanistan conflicts
revealed that diagnostic status for current PTSD was discordant
for 26.8% to 27.7% of the sample depending on what information
in the medical record was used (Holowka et al., 2014). Whereas
17.5% to 19.1% of participants had a diagnosis of PTSD based on
record review but did not meet criteria for current PTSD on the
SCID, 8.6% to 9.3% of participants met criteria for current PTSD on
the SCID but did not have a diagnosis of PTSD based on the medical
record review. The fact that the vast majority of studies provid-
ing information on the prevalence of PTSD in OEF/OIF veterans
is based on medical record review is a limitation of the current
literature and reflects a need for additional research using other
assessment methods. Other studies in this review used self-report
data from screening measures such as the PTSD Checklist or the
Primary Care PTSD screen as method of PTSD diagnosis. A recent
review (McDonald & Calhoun, 2010) documented the limitations
of using self-report screening measures to assess PTSD when the
population prevalence is unknown. Additionally, there is a need to
validate existing screening measures in diverse samples of OEF/OIF

Fig. B.2. Forest plot of PTSD prevalence stratified by the study sample size. Note: The area of each square is proportional to the study’s weight in the meta-analysis, and
each line represents the confidence interval around the estimate. The diamond represents the aggregate estimate, and its lateral points indicate confidence intervals for this
estimate.
 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107
veterans. In the current review, only 1 out of the 33 studies
(McClernon, Calhoun, Hertzberg, Dedert, & Beckham, 2013) used
a structured clinical interview to assess PTSD. Structured clinical
interviews are considered the gold standard assessment method-
ology for psychiatric diagnosis given their increased reliability and
validity (Rogers, 2001; Segal & Coolidge, 2003). Thus, the absence of
studies using clinical interviews to examine the prevalence of PTSD
in representative population-based samples of OEF/OIF veterans
represents a significant gap in the current literature.
4.2. Limitations of this review
This meta-analysis is the first quantitative review to examine
prevalence of PTSD among OEF/OIF veterans. The findings of this
review must be considered in light of its limitations. First, only 33
studies met inclusion criteria for this meta-analysis. Additionally,
moderator data was not reported in some studies and was subse-
quently unavailable for inclusion in the current analyses. Therefore,
ability to detect effects in analyses of moderator variables was
limited by low power. Also, time since trauma exposure, as well as
moderators shown to influence risk of PTSD in military samples,
including prior traumatic experiences (e.g., childhood trauma),
trauma severity, and social support post-trauma (see Gates et al.,
2012 for a review), could not be evaluated in this meta-analysis
because no studies reported this information. Furthermore, the
majority of studies included in this meta-analysis were from VA
national samples. While selection criteria varied by study, it is likely
that at least some participants were included in multiple samples.
It was impossible, however, to determine the degree of overlap,
and the assumption of independent samples was likely not met
for these studies. The inclusion of dependent samples in the anal-
yses may have reduced heterogeneity in estimates; however, it
Fig. B.3. Funnel plot to assess publication bias across prevalence studies.
105
should be noted that when only the VA samples were examined,
heterogeneity was still significant (results not presented). Finally,
while it was hoped that differences among studies using differ-
ent techniques to determine PTSD diagnostic status (e.g., medical
chart review, questionnaires, structured or semi-structured inter-
view) could be examined as a moderator with multiple categories
to determine whether these different methods affect prevalence
estimates, this variable had to be dichotomized (i.e., medical chart
review versus other) because so few studies involved self-report or
clinician-administered assessment of PTSD.
5. Conclusions
In conclusion, this review highlights the need for researchers,
clinicians, and policy-makers to consider methodological differ-
ences across studies, including sample characteristics and selection
criteria, when gauging and comparing PTSD prevalence among
OEF/OIF veterans. While the findings must be interpreted in light
of the high heterogeneity in studies and specific limitations of the
extant literature, the estimated prevalence of PTSD in OEF/OIF vet-
erans from the current comprehensive meta-analysis suggests that
approximately 23% of those who served in the military during the
past decade are suffering from a potentially debilitating mental
health disorder. This rate is less than that reported for Vietnam
era veterans (i.e., 30%; Kulka et al., 1990) and far above the rate of
PTSD in the general population (Kessler, Sonnega, Bromet, Hughes,
& Nelson, 1995). Accordingly, financial and mental health care
resources are needed to provide early and evidence-based inter-
vention to this large portion of veterans from the current war era to
promote recovery from PTSD and to optimize veterans’ adjustment
to civilian life and community re-integration.
106 J.J. Fulton et al. / Journal of Anxiety Disorders 31 (2015) 98–107
Conflict of interest
The authors have no conflicts of interest to declare.
Acknowledgments and disclosures
Amie Schry’s contributions to this manuscript were partially
supported by the Department of Veterans Affairs Office of Aca-
demic Affiliations Advanced Fellowship Program in Mental Illness
Research and Treatment, the Durham Veterans Affairs Medical Cen-
ter, and the Department of Veterans Affairs Mid-Atlantic Region
Mental Illness Research, Education, and Clinical Center (MIRECC).
Appendix A
See Tables A.1 and A.2
Appendix B
See Figures B.1–B.3
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References marked with an asterisk indicate studies included in the meta-
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