Effect of Center-Based Counseling for Veterans and Veterans Families on Long-Term Mental Health Outcomes

MILITARY MEDICINE, 178, 12:1328, 2013 Effect of Center-Based Counseling for Veterans and Veterans Families on Long-Term Mental Health Outcomes Meaghan O Donnell, PhD*; Tracey Varker, PhD*; Desmond Perry, PhD ; Andrea Phelps, PhD* ABSTRACT The Veterans and Veterans Families Counselling Service (VVCS), established by the Australian government, plays a pivotal role in providing mental health services to veterans and their families. This research explored the impact of center-based psychological counseling on depression, anxiety, stress, and alcohol use severity. A stratified sample of VVCS clients were invited to participate in this study. Data were collected on intake to the program, at the fifth counseling session, and 12 months after the commencement of counseling. Repeated-measures general linear model analyses were conducted to examine the impact of center-based counseling on depression, anxiety, stress, and alcohol severity over time. VVCS center-based counseling resulted in a significant reduction in depression, anxiety, stress, and alcohol use severity after five sessions, and these improvements were maintained over the next 12 months. Despite these improvements, however, participants continued to report moderate-to-severe levels of mental health problems. VVCS center-based counseling successfully reduced depression, anxiety, stress, and alcohol use symptom severity of veterans and their families. However, the clinical profiles of this population are often complex and challenges remain in terms of addressing the mental health needs of this group. INTRODUCTION It has been widely recognized that military personnel may experience mental health issues following deployment. Although much attention is paid to post-traumatic stress disorder (PTSD), evidence suggests that depression, anxiety, and alcohol use disorders are just as common. 1 After the Vietnam War the Australian government established the Vietnam Veterans Counselling Service (VVCS). This service aimed to provide psychological care for veterans who were experiencing physical and emotional difficulties as a consequence of their military service. Today, VVCS is a primary provider of Australian community-based mental health services to veterans and their families. The service was recently renamed the Veterans and Veterans Families Counselling Service in recognition of the broader client group including contemporary (post-vietnam) veterans and family members. VVCS operates within the Department of Veteran Affairs mental health policy framework focusing on improving access to a comprehensive range of mental health services for veterans and their family members. 2 There are currently 15 VVCS centers across Australia that provide both individual counseling and group programs to Australian veterans, their families, and eligible Australian Defence Force personnel. Services are provided for a wide range of war- and service-related issues such as relationships and family problems, alcohol and other drugs problems, and psychological problems such as PTSD, depression, anxiety, problematic anger, and sleep difficulties. Access to these *Australian Centre for Posttraumatic Mental Health and Department of Psychiatry, University of Melbourne, Level 1, 340 Albert Street, East Melbourne, VIC 3002, Australia. Veterans and Veterans Families Counselling Service, Department of Veterans Affairs Australia, Level 6, 280 Elizabeth Street, Surry Hills 2010, GPO Box 3994, Sydney, NSW 2001, Australia. doi: 10.7205/MILMED-D-13-00058 services is based on self/family member referral, or medical practitioner referral. Counseling is provided by registered psychologists or social workers across a range of programs that include individual therapy, couples/family therapy, and case management. Informal client feedback indicates that the counseling interventions provided by VVCS are effective, but there has never been an independent, longitudinal examination of the impact of these VVCS center-based counseling services on mental health outcomes. The aim of this study was to examine the outcomes of VVCS center-based counseling practiced under naturalistic conditions. These conditions include usual providers, patients, payment mechanisms, and patient/provider choice of treatment. The aim of this study was also to explore whether VVCS center-based psychological counseling resulted in sustained improvements in the mental health of veterans and their family members across time. METHOD The study protocol was approved by the Department of Veterans Affairs Human Research Ethics Committee. The study used data routinely collected by VVCS on intake to counseling and at session five, as well as data collected for this study at 12-months after counseling. The preexisting decision to routinely collect data at session five was based on earlier VVCS data that had shown that the average period of engagement of VVCS clients was five sessions, and to standardize the time at which post-treatment data were collected and VVCS decided to choose session five. Participants Participants met entry criteria for this study if they presented to VVCS with moderate-to-severe symptoms of depression or anxiety, or alcohol misuse, and if they completed at least five sessions of VVCS center-based counseling. 1328

A total of 4,327 veterans and their family members met entry criteria and completed the intake questionnaire between August 2009 and August 2010. Of these, 685 completed at least 5 sessions of intervention and provided data at this time point, and 312 (46%) completed the 12-month follow-up questionnaire (Fig. 1). Demographic information of the final group of 312 participants is presented in Table I. A two-staged completer analysis was conducted to inform the generalizability of the study results. In the first analysis, those in the final group (moderate/severe self-reported depression, anxiety, or alcohol symptoms at intake, and completion of the session five assessment and 12-month follow-up assessment, n = 312) were compared to those who failed to complete outcome measures at the fifth session or 12-month follow-up (n = 4,015). The two groups differed on era of service ( c 2 (1, N = 4,327) = 29.80, p < 0.001) with a smaller proportion of contemporary veterans in the study sample (52%), relative to the noncompleter group (67%). Completers also had significantly higher levels of self-reported intake anxiety than noncompleters (t(4,325) = 2.66, p < 0.01), and higher levels of self-reported stress at intake relative to noncompleters (t(4,325) = 2.32, p < 0.05). There were no differences between the two groups in regards to gender or self-reported depression severity or alcohol use severity. In the second completer analysis, those who completed all three assessments were compared to those who completed the intake and session five assessment but not the 12-month follow-up. Participants who completed the 12-month follow-up assessment did not differ from those who did not complete it in terms of self-reported intake depression, anxiety, and alcohol TABLE I. Demographic Characteristics of the Sample (N = 312) n (%) Gender Male 170 (54) Female 162 (46) Status Veterans 128 (41) Partners 89 (29) Sons/Daughters 59 (19) Defence Referred a 19 (6) Other b 17 (5) Age M = 51.29 (SD = 14.63) Employment Currently Employed 128 (41) Not Currently Employed 184 (59) Days Worked Per Week for Those M = 4.46 (SD = 1.42) Who Are Employed Type of Therapy Provided by VVCS Individual Therapy 284 (91) Couples Therapy 26 (8) Average Number of Counseling Sessions M = 11.35 (SD = 6.30); Median = 10; Range = 2 40 a Australian Defence Force members who had been referred via the Defence Memorandum of Understanding. b Those who were granted services for compassionate reasons. use scores. Participants who completed the 12-month follow-up assessment had significantly higher levels of self-reported stress at intake (t(683) = 2.35, p < 0.05). Measures Mental Health The Depression Anxiety Stress Scales (DASS-21; see Reference 3), a 21-item self-report measure used to assess severity of depression, anxiety, and stress, was administered at intake, session five, and 12-month follow-up. Individuals were required to indicate the presence of a symptom over the previous week. Good levels of reliability and validity were reported, with Cronbach s a of 0.94, 0.87, and 0.91 reported for the three subscales. 4 Alcohol use was assessed using the Alcohol Use Disorders Identification Test (AUDIT; see Reference 5). The AUDIT is a 10-item, self-report instrument developed by the World Health Organization as a screening tool sensitive to early detection of risky and high-risk drinking. 5 A score of eight or more is associated with harmful or hazardous drinking and a score of 13 or more in women or 15 or more in men is likely to indicate alcohol dependence. 5 FIGURE 1. Flow chart of clients progression through the study. Procedure VVCS counselors administered the intake assessment and the assessment at the end of the fifth session of counseling. The study researchers sent a self-report questionnaire that contained the DASS-21 and the AUDIT at 12 months following completion of the study (session five). Questionnaires were returned in a replied paid envelope. 1329

Design and Statistical Analyses In this study we used a single group design with pre-, post-, and follow-up assessments. Four sets of repeated-measures general linear model (GLM) analyses were conducted to examine whether there were changes in outcome following center-based VVCS counseling in the short term, and whether these changes were maintained over time. Outcomes for these four sets of analyses were severity of depression, stress, anxiety, and alcohol use. The primary analyses looked at differences in symptoms across time (n = 312). Secondary analyses were conducted to investigate the role of gender, client status, and era of service on changes in symptoms across time and to compare the VVCS counseling sample s 12-month depression, stress, and anxiety follow-up results to community norms. To examine the characteristics of those with moderateto-severe symptoms who responded to VVCS center-based treatment and those who did not, we conducted further exploratory analyses. A total score for affective distress was calculated (i.e., the sum of the three DASS-21 subscales), and an affective distress change score was calculated for each participant. The change score was the difference between the intake DASS-21 total score and the 12-month follow-up DASS-21 total score. To explore the degree to which participants levels of affective distress improved in a clinically reliable way, we categorized participants in terms of treatment responders and treatment nonresponders. Clinically reliable treatment response was defined as a decrease in DASS-21 severity score of at least 15 points at 12-month follow-up (relative to intake). This reliable change index was calculated using Devilly s 6 reliable and clinical change generator, which is based on the formula of Jacobson and Traux. 7 These authors suggest that a reliable change index larger than 1.96 (p < 0.05) is unlikely to occur without actual change in the individual. Reliability data for DASS-21 severity used in the reliable change calculations were obtained from the thesis of McGrail, 8 because of the fact that reliability for the total DASS-21 score has not been previously reported by the authors of this measure. RESULTS Depression Severity As can be seen in Table II, depression severity changed significantly over time from intake to 12-month follow-up (F(2,620) = 116.00, p < 0.001), with effect size analyses indicating that this represented a moderate-to-large clinical effect (Hedges g^ = 0.75). Within-subjects contrasts showed that the significant decrease in depression severity took place between intake and the fifth session (F(1,310) = 218.51, p < 0.001), with some of the treatment gains lost by the 12-month follow-up (F(1,310) = 5.41, p < 0.05). Despite this, however, participants were still less depressed at 12-month follow-up than when they originally started counseling. Repeated-measures GLM analyses revealed a significant main effect for era of service (F(1,145) = 4. 40, p < 0.05). This showed that contemporary veterans were significantly less depressed than older veterans. The level of depression in the overall VVCS client group 12 months after treatment, however, was significantly greater than that of depression in a non-treatment-seeking community sample (see Table III). Anxiety Severity Anxiety severity declined significantly over time (F(2,620) = 81.00, p < 0.001), and this represented a moderate clinical effect (Hedges g^ = 0.63). Within-subjects contrasts showed that there was a significant decline in level of anxiety between intake and the fifth session (F(1,310) = 128.33, p < 0.001), with these improvements being maintained over time (between the fifth session and 12-month follow-up). Analyses identified a significant interaction effect for gender on anxiety severity outcomes (see Table II), with females reporting greater improvements in anxiety severity over time (Hedges g^= 0.84) than males (Hedges g^= 0.46) (see Table IV). Further analyses revealed a significant main effect for era of service (F(1,145) = 6.30, p < 0.05). Repeated-measures analyses of variance showed that contemporary veterans had much greater improvements in anxiety severity over time (Hedges g^ = 0.72) compared to older veterans (Hedges g^ = 0.36). Although this suggests that contemporary veterans as a whole were experiencing less anxiety than older veterans, generally VVCS clients had significantly greater anxiety severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III). Stress Severity Stress severity changed significantly over time (F(2,620) = 114.93, p < 0.001), and this represented a significant moderateto-large clinical effect (Hedges g^ = 0.76). Within-subjects contrasts showed that there was a significant decline in level of stress between intake and the fifth session (F(1,310) = 201.93, p < 0.001), and this was maintained between the fifth session and 12-month follow-up. Further analyses revealed a significant main effect for era of service (F(1,145) = 4.13, p < 0.05), with contemporary veterans experiencing less stress than older veterans. In addition, contemporary veterans had far greater improvements in stress severity over time (Hedges g^= 1.00) compared to older veterans (Hedges g^= 0.58). In spite of these improvements, however, overall clients had significantly greater stress severity at 12-month follow-up than a non-treatment-seeking community sample (see Table III). Alcohol Severity The GLM analysis showed that alcohol use severity declined significantly over time (F(2,622) = 13.63, p < 0.001), although this difference was not clinically significant (Hedges g^= 0.12). Within-subjects contrasts showed that there was a significant decrease in alcohol use severity between intake and the fifth 1330

TABLE II. Repeated-Measures GLMs for Changes in Depression, Anxiety, Stress, and Alcohol Use Severity Score Over Time n Intake M (SD) Time Fifth Session M (SD) 12-Month Follow-up M (SD) (df)f Analysis Effect Size (Between T1 and T3) Hedges g^ Depression (Whole Sample) 311 23.20 (10.84) 13.41 (10.77) 14.99 (11.10) Time (2,620) = 116.00** 0.75 Males 169 23.73 (10.69) 14.00 (10.63) 16.01 (11.31) Time (2,618) = 115.52** Females 142 22.66 (11.01) 12.72 (10.96) 13.77 (10.76) (1,309) = 2.62 Time (2,618) = 0.40 Veterans 147 23.61 (10.55) 13.51 (10.22) 15.03 (10.90) Time (2,618) = 115.52** Other 164 22.91 (11.10) 13.33 (11.30) 14.95 (11.31) (1,309) = 2.62 Time (2,618) = 0.40 Contemporary Veterans 63 22.73 (10.55) 12.03 (9.07) 12.70 (10.50) Time (2,290) = 57.95** Older Veterans 84 24.26 (10.56) 14.62 (10.93) 16.79 (10.92) (1,145) = 4.50* Time (2,290) = 0.79 Anxiety (Whole Sample) 311 17.46 (10.39) 11.24 (9.66) 11.19 (9.57) Time (2,620) = 81.00** 0.63 Males 169 16.54 (10.96) 11.54 (10.05) 11.74 (9.79) Time (2,618) = 84.63** Females 142 18.55 (9.63) 10.97 (9.19) 10.54 (9.29) (1,309) = 0.01 Time (2,618) = 4.54* Veterans 147 16.18 (10.67) 10.91 (9.72) 11.10 (9.43) Time (2,618) = 79.65** Other 164 18.61 (10.05) 11.61 (9.61) 11.27 (9.72) (1,309) = 1.45 Time (2,618) = 2.20 Contemporary Veterans 63 15.33 (10.85) 8.44 (7.75) 8.48 (7.88) Time (2,290) = 33.42** Older Veterans 84 16.81 (10.54) 12.76 (10.65) 13.07 (10.04) (1,145) = 6.30** Time (2,290) = 2.58 Stress (Whole Sample) 311 26.48 (9.72) 17.84 (10.52) 18.77 (10.50) Time (2,620) = 114.93** 0.76 Males 169 26.83 (9.96) 18.25 (10.65) 19.87 (10.96) Time (2,618) = 115.00** Females 142 26.06 (9.45) 17.35 (10.37) 17.45 (9.81) (1,309) = 2.23 Time (2,618) = 1.07 Veterans 147 26.52 (9.67) 17.59 (10.38) 18.82 (10.87) Time (2,618) = 114.50** Other 164 26.44 (9.80) 18.06 (10.67) 18.72 (10.19) (1,309) = 0.1 Time (2,618) = 0.13 Contemporary Veterans 63 26.10 (8.79) 15.81 (8.45) 16.32 (10.58) Time (2,290) = 60.53** Older Veterans 84 26.83 (10.33) 18.93 (11.26) 20.69 (10.78) (1,145) = 4.13* Time (2,290) = 2.09 Alcohol Use (Whole Sample) 312 7.59 (7.86) 6.22 (6.90) 6.67 (6.86) Time (2,622) = 13.63** 0.12 Males 170 10.12 (8.55) 8.16 (7.72) 8.45 (7.62) Time (2,620) =12.42** Females 142 4.56 (5.62) 3.90 (4.86) 4.54 (5.08) (1,310) = 40.93** Time (2,620) = 5.36** Veterans 147 9.27 (8.15) 7.56 (7.20) 7.89 (7.43) Time (2,620) = 14.03** Other 165 6.10 (7.30) 5.03 (6.42) 5.58 (6.13) (1,310) = 12.87** Time (2,620) = 1.38 Contemporary Veterans 63 7.90 (7.00) 5.92 (5.94) 6.90 (6.65) Time (2,290) = 10.72** Older Veterans 84 10.29 (8.82) 8.79 (7.82) 8.63 (7.92) (1,145) = 3.94* Time (2,290) = 1.06 *p < 0.05; **p < 0.001. session (F(1,311) = 32.99, p < 0.001), and this was maintained between the fifth session and 12-month follow-up. As can be seen in Table II, gender had a substantial effect on alcohol use severity, with males having greater improvements in alcohol use severity over time and females reporting low levels of alcohol use consistently over time (F(2,620) = 5.36, p < 0.05). At 12-month follow-up, however, the mean male alcohol severity score was 8.45 (Table II), which is a level associated 1331

TABLE III. Unpaired t-tests Comparing Client Depression, Stress, Anxiety, and Alcohol Severity at 12-Month Follow-up, to a Normal Sample VVCS Center-Based Counseling (n = 311) M(SD) Normal Sample a (n = 1,771) M(SD) (df) t, p Depression 14.99 (11.10) 5.55 (7.48) (2,080)18.90, <0.001 Anxiety 11.19 (9.57) 3.56 (5.39) (2,080)13.32, <0.001 Stress 18.77 (10.50) 9.27 (8.04) (2,080)18.28, <0.001 a Crawford JR, Henry JD: The Depression Anxiety Stress Scales (DASS): normative data and latent structure in a large non-clinical sample. Br J Clin Psychol 2003; 42: 111 13. TABLE V. Percentage of Clients Who Had a Clinically Reliable Improvement in Affective Distress From Intake to 12-Month Follow-up Affective Distress No Change/ Deteriorated% (n) Responded to Treatment% (n) All Clients Combined (n = 312) 40 (124) 60 (187) Males (n = 170) 46 (78) 54 (91)* Females (n = 142) 32 (46) 68 (96) Veterans (n = 147) 43 (63) 57 (84) Other Clients (n = 165) 38 (61) 62 (103) Contemporary Veterans (n = 63) 33 (21) 67 (42)* Older Veterans (n = 84) 50 (42) 50 (42) *p < 0.05. with harmful or hazardous drinking. There was also a significant main effect for client type (older veteran, contemporary veteran, family member) (F(1,310) = 12.87, p < 0.001), and era of service (F(1,145) = 3.94, p < 0.05). This suggested that veterans had significantly greater levels of alcohol use at all three time points, in comparison to other clients and that contemporary veterans in particular were experiencing lower levels of alcohol use, when compared to older veterans. Treatment Responders Overall, 60% of clients responded to treatment (see Table V). c 2 -Tests revealed that there was a significant difference TABLE IV. Repeated-Measures Analyses of Variance for Changes in Depression, Anxiety, Stress, and Alcohol Use Severity Score Over Time n Intake M (SD) Time 12-Month Follow-up M (SD) (df) F Analysis Effect Size (Between T1 and T3) Hedges g^ Depression Males 169 23.73 (10.69) 16.01 (11.31) (1,336) = 41.59** 0.70 Females 142 22.66 (11.01) 13.77 (10.76) (1,282) = 47.35** 0.81 Veterans 147 23.61 (10.55) 15.03 (10.90) (1,292) = 47.03** 0.80 Other 164 22.91 (11.10) 14.95 (11.31) (1,327) = 41.38** 0.71 Contemporary Veterans 63 22.73 (10.55) 12.70 (10.50) (1,124) = 28.61** 0.95 Older Veterans 84 24.26 (10.56) 16.79 (10.92) (1,166) = 20.31** 0.69 Anxiety Males 169 16.54 (10.96) 11.74 (9.79) (1,336) = 18.03** 0.46 Females 142 18.55 (9.63) 10.54 (9.29) (1,282) = 50.89** 0.84 Veterans 147 16.18 (10.67) 11.10 (9.43) (1,292) = 18.71** 0.50 Other 164 18.61 (10.05) 11.27 (9.72) (1,326) = 45.20** 0.74 Contemporary Veterans 63 15.33 (10.85) 8.48 (7.88) (1,124) = 16.44** 0.72 Older Veterans 84 16.81 (10.54) 13.07 (10.04) (1,166) = 5.55* 0.36 Stress Males 169 26.83 (9.96) 19.87 (10.96) (1,336) = 37.33** 0.66 Females 142 26.06 (9.45) 17.45 (9.81) (1,282) = 56.74** 0.89 Veterans 147 26.52 (9.67) 18.82 (10.87) (1,292) = 41.18** 0.75 Other 164 26.44 (9.80) 18.72 (10.19) (1,326) = 48.90** 0.77 Contemporary Veterans 63 26.10 (8.79) 16.32 (10.58) (1,124) = 31.85** 1.00 Older Veterans 84 26.83 (10.33) 20.69 (10.78) (1,166) = 14.21** 0.58 Alcohol Use Males 170 10.12 (8.55) 8.45 (7.62) (1,338) = 3.61 Females 142 4.56 (5.62) 4.54 (5.08) (1,282) = 0.001 Veterans 147 9.27 (8.15) 7.89 (7.43) (1,292) = 2.30 Other 165 6.10 (7.30) 5.58 (6.13) (1,328) = 0.49 Contemporary Veterans 63 7.90 (7.00) 6.90 (6.65) (1,124) = 0.68 Older Veterans 84 10.29 (8.82) 8.63 (7.92) (1,166) = 1.65 *p < 0.05; **p <0.001. 1332

between males and females, with a greater proportion of females responding to treatment compared to males (c 2 (1, n = 311) = 6.09, p = 0.014). Similar results were noted for contemporary veterans compared to older veterans ( c 2 (1, n = 311) = 4.08, p = 0.014). DISCUSSION The study investigated whether the current center-based counseling practices used by VVCS resulted in sustained changes to mental health problems, for veterans and their family members with moderate-to-severe depression, and anxiety symptoms or problematic alcohol use who completed at least five sessions of counseling. The findings indicated that VVCS center-based counseling resulted in a significant reduction in depression, anxiety, stress, and alcohol misuse severity measured after five sessions of counseling, and these improvements were generally maintained over the next 12 months. Overall, 60% of the treatment completers had a clinically reliable improvement in affective distress over the 12-month period. This result is consistent with research on psychological treatment for depression and anxiety, which shows that the average patient who receives an active treatment is substantially better off than the average control patient at the end of treatment, supporting the utility of these treatments in reducing psychological distress. 9 Despite the improvement in the study sample, participants continued to report moderate-to-severe levels of anxiety, depression, stress, and alcohol use (males only) at 12-months follow-up, suggesting that a degree of mental health problems persisted for a substantial portion of participants. These findings are consistent with results from analyses of other Australian veteran data such as those from PTSD group programs. 10 The finding that VVCS clients improve significantly but still maintain a relatively high level of symptomatology after interventions may speak to the chronicity and complexity of the problems experienced by veterans. Examination of between-group differences showed that in respect to the impact of gender, female clients respond particularly well to center-based VVCS counseling, lowering their anxiety scores over time at a significantly greater rate than males. Females were also significantly more likely to have clinically reliable improvements in their overall distress levels. This finding is consistent with the treatment response literature that finds that generally females respond better to psychological treatments than males (e.g., see Reference 11 ). It should be noted, however, that only a very small proportion of female clients were female veterans, and as such it was not possible to explore any differences between female veterans and other female VVCS clients. It may be possible that female veterans respond differently to psychological treatments, as compared to other female clients who are partners or daughters of veterans. In general, contemporary veterans presented for treatment with lower levels of depression, anxiety, and alcohol use symptom severity relative to older veterans, but they were also the only group who dropped below threshold into a lowto-moderate symptom group across time after treatment. There was, however, no interaction effect, which may indicate that the small sample size of contemporary and older veterans was not powerful enough to produce significant results. Examination of response to treatment results showed that contemporary veterans responded significantly better to treatment than older veterans, with a greater proportion of contemporary veterans having a clinically reliable decrease in their level of affective distress, in comparison to older veterans. This is supported by the large effect sizes that were seen for improvements in anxiety and stress symptom severity for contemporary veterans in comparison to older veterans. Therefore, it could be concluded from these findings that contemporary veterans with moderate-to-severe symptoms at intake responded particularly well to VVCS counseling. These results need, however, to be interpreted with the recognition that contemporary veterans were less likely to complete data collection, so the group of contemporary veterans who participated in this study may be a subset of (and therefore different to) the larger group of contemporary veterans who commence VVCS counseling. The client-type analyses showed no significant differences between veterans and their family members in terms of anxiety, depression, or stress symptoms. This is an interesting finding that suggests that military deployment experiences alone do not account for the higher levels of anxiety, depression, and stress symptoms in veterans compared to community norms. Nonveteran family members reported severe levels of anxiety and depression, which dropped to moderate levels after counseling. These improvements in mental health are not as great as previously found in community samples (e.g., see References 12 and 13) and may indicate that the particular difficulties experienced by veterans families are on some level unique to this group. Their mental health difficulties are often embedded within a multiproblem family system, with ongoing stressors that contribute to poor outcomes. It suggests mental health services that target veterans families are dealing with complex, treatment-resistant problems. The current findings must be considered in light of the following limitations. First, this study was a naturalistic study, using data routinely collected by VVCS. The design of this study lacked a control group, and did not have a randomization procedure required by a highly rigorous randomized controlled trial. As an evaluation of a service, however, the study has some level of rigor. Second, the current study was conducted on a very small group of eligible VVCS clients. Of those who met entry criteria for high levels of anxiety, depression, stress, or alcohol use at intake, only 16% had fifth session data. Thus the 312 participants who completed all data collection points represent only 7% of the original sample. This group is, however, representative of the larger group on nearly all aspects measured in the study and 1333

suggests that the findings would generalize to other veterans who present to VVCS. The results, may not, however, generalize to those with mild symptoms, or contemporary veterans who were less likely to participate in the study. It is also a limitation of the study that participants had to score highly on only one measure, meaning there is a chance that they could have scored low on the other measures. Because of the fact that the DASS was used in this study, it was not possible to investigate whether participants changed in terms of diagnosis. Lastly, it was not possible to obtain information on the therapeutic approach that was used by counselors within VVCS who treated the participants in this study or on whether participants were receiving pharmacotherapy. Thus, although it can be said that client outcomes improved as a function of receiving VVCS counseling, it is not possible to comment on what practices facilitated this improvement. However, extrapolating from an analysis of what constitutes treatment as usual among the same clinician group in the treatment of PTSD in veterans, 14 cognitive behavioral therapy is likely to be the most commonly used approach. This naturalistic longitudinal study demonstrated that for those who commenced treatment with moderate-to-severe symptoms, VVCS center-based counseling led to an improvement in depression, anxiety, stress, and alcohol symptom severity over time. Differences were observed in the symptom severity of some groups of clients, and in the ways in which some groups of clients responded to treatment. VVCS centerbased counseling, therefore, should continue to be tailored to the client s individual needs. Contemporary veterans, and their families in particular, represent a specific group that require more research investigation, with the key challenge appearing to be retaining this client group in treatment. ACKNOWLEDGEMENTS We thank all the participants involved in this study. This study was funded by the Department of Veterans Affairs Applied Research Program (project number 08/2010). REFERENCES 1. Ikin JF, Sim MR, Creamer MC, Forbes AB, McKenzie DP, Kelsall HL, et al: War-related psychological stressors and risk of psychological disorders in Australian veterans of the 1991 Gulf War. Br J Psychiatry 2004; 185: 116 26. 2. Department of Veterans Affairs. Veterans and Veterans Families Counselling Service. 2011; Available at http://www.dva.gov.au/health/vvcs; accessed September 26, 2012. 3. Lovibond SH, Lovibond PF: Manual for the Depression Anxiety Stress Scales, Ed 2. Sydney, Psychology Foundation, 1995. 4. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP: Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psych Assess 1998; 10(2): 176 81. 5. Babor T, de la Fuente J, Saunders J, Grant M: The Alcohol Use Disorders Identification Test: guidelines for use in primary health care. Geneva, World Health Organization, Division of Mental Health, 1989. 6. Devilly GJ: ClinTools software for Windows, Version 4.1 [computer program], Melbourne, Australia 2007. 7. Jacobson NS, Traux P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Cons and Clin Psychol 1991; 59: 12 19. 8. McGrail J: An Investigation into the Treatment of Posttraumatic Stress Disorder with Comorbidity. Melbourne, University of Melbourne, 2006. 9. Westen D, Morrison K: A multidimensional meta-analysis of treatments for depression, panic, and generalised anxiety disorder: an empirical examination of the status of empirically supported therapies. J Cons Clin Psychol 2001; 69(6): 875 99. 10. Creamer M, Elliott P, Forbes D, Biddle D, Hawthorne G: Treatment for combat-related posttraumatic stress disorder: two year follow-up. J Trauma Stress 2006; 19(5): 675 85. 11. Bisson J, Ehlers A, Matthews R, Pilling S, Richards D, Turner S: Psychological treatments for chronic post-traumatic stress disorder: systematic review and meta-analysis. Br J Psychiatry 2007; 190: 97 104. 12. Chen S, Jordan C, Thompson S. The effect of cognitive behavioral therapy (CBT) on depression: the role of problem-solving appraisal. Res Soc Work Prac 2006; 16(5): 500 10. 13. Ree M, Craigie MA: Outcomes following mindfulness-based cognitive therapy in a heterogenous sample of adult outpatients. Behav Change 2007; 24(2): 70 86. 14. Forbes D, Lloyd D, Nixon RD, Elliott P, Varker T, Perry D, et al: A multisite randomized controlled effectiveness trial of cognitive processing therapy for military-related posttraumatic stress disorder. J Anx Dis 2012; 26(3): 442 52. 1334