This scoping review summarizes the research literature on justice-involved veterans and their health and healthcare. The majority of studies focused on mental health conditions, and over 90% used an observational research design. Few studies examined medical conditions, psychosocial factors, healthcare delivery and organization, or long-term care and aging in this vulnerable population. Randomized clinical trials aimed at improving health outcomes, rather than simply observing and documenting outcomes, were rare. Half of studies did not report a funding source or were unfunded, 28% of studies were funded by the VHA, and 27% were supported by other government funding.

PTSD, military service, and criminal justice involvement

Mental health conditions, particularly PTSD and substance use disorders, were the foci of most articles published in the justice-involved veterans’ scientific literature. PTSD was consistently linked to more legal problems among US veterans (Backhaus et al., 2016; Black et al., 2005; Saxon et al., 2001). PTSD and combat exposure were significantly associated with violent offending among military veterans in the UK (MacManus et al., 2013). Similarly, among US veterans, PTSD and “anger hyperarousal symptoms” (derived from the Davidson Trauma Scale question that asked in the past week “Have you been irritable or had outbursts of anger?”) were found to predict family violence across a one-year study period (Sullivan & Elbogen, 2014). Among US veterans who served in Iraq or Afghanistan, military sexual trauma was linked with higher predicted probability of legal problems (Backhaus et al., 2016). Prosecutors offered more diversion programs to veterans with PTSD and thought they were less criminally culpable than veterans without PTSD (Wilson, Brodsky, Neal, & Cramer, 2011).

Combat exposure – and related PTSD from such experiences – was examined to explain the link between military experience and criminal justice involvement, though results were mixed. Combat experience has been associated with lower odds of non-violent offending (Bennett et al., 2018), and serving in wartime has been linked with lower odds of incarceration (Culp et al., 2013). However, greater combat exposure has also been associated with higher odds of unlawful behavior, including “having been arrested”, “being on probation or parole”, or “driving a car or other vehicle after having too much to drink” (Larson & Norman, 2014). While neither causal nor conclusive, this body of research on PTSD and combat exposure suggests that systems serving veterans should increase access to evidence-based trauma treatment for justice-involved veterans and develop prevention programs to attenuate their risk for violence and justice involvement.

Other aspects of military service were examined in relation to criminal justice involvement and were similarly inconclusive. Compared to enlisted soldiers, officers had lower odds of being incarcerated (Black et al., 2005) or of violent offending (MacManus et al., 2013). In most studies, period of service was either not specified or included veterans from multiple periods of service without examining differences by service era. One exception was a study that compared veterans from Iraq/Afghanistan, Gulf War, and Vietnam eras: Veterans who served during the Iraq/Afghanistan era had a lower rate of incarceration than veterans from the other eras of service (Fontana & Rosenheck, 2008). Branch of service was mentioned in a few studies. For example, a higher percentage of veterans incarcerated in jail served in the Army or Marines compared to veterans who were not incarcerated (Greenberg & Rosenheck, 2009). Length of service was examined with longer military service associated with fewer lifetime arrests among veterans incarcerated in prison (Brooke & Gau, 2018). However, examination of aspects of military service and links with criminal justice involvement were rare.

Although more research is needed to explore the link between military service and criminal justice involvement, results will have implications for the Department of Defense in their treatment of active duty personnel. For example, if combat trauma is determined to be a mechanism that causes later criminal justice involvement, designing post-deployment treatment programs that comprehensively address PTSD and trauma experienced while personnel are still serving in the military will be an important practice change. The VHA could use the reviewed studies to estimate the number of veterans who may become justice-involved and allocate treatment services to help reduce criminal behavior.

Knowledge gaps and informing policy, practice, and research

The scoping review uncovered numerous gaps in the literature on the health and healthcare of justice-involved veterans. These gaps include studies of different sociodemographic groups, and research on veterans’ medical conditions and the impact of managing multiple medical, mental health, and substance use disorder conditions. Gaps were also apparent for studies of interventions to improve the health and healthcare of justice-involved veterans, especially studies using randomized trials. Differences in health and healthcare by type of criminal justice involvement were understudied. Conceptual models were rarely used to guide studies’ analyses or interpretation of results, and there was little consistency across studies that used conceptual models. The identified gaps provide guidance on areas for future research.

Medical conditions

Needed are studies focused on medical conditions, especially conditions such as traumatic brain injury, which may disproportionately affect veterans and be related to their justice involvement (To et al., 2015). Research on traumatic brain injury in veterans will also be relevant to both veterans and non-veterans with justice involvement as this condition is prevalent among justice-involved populations (Durand et al., 2017). Although hypertension is the most common medical condition among veterans served at the VHA (Frayne et al., 2014), only one study touched on this topic (Howell et al., 2016). Other chronic medical conditions, such as diabetes, were unaddressed in the studies we reviewed and need attention in future research. Studies on suicide and suicide risk will inform programming by the VHA Office of Suicide Prevention. Other important topics that need research include mortality, and the impact of civil legal issues on criminal issues and health. For example, studies on medical-legal partnerships (Tsai, Middleton, et al., 2017) may shed light on the types of civil legal issues that are most effectively addressed among veterans, allowing legal providers to be strategic with their time and resources.

Management of multiple conditions

Even though chronic mental health or addiction conditions, including depression and alcohol use disorder, were examined in a number of studies, the long-term management of these conditions in clinical practice among justice-involved veterans is an area of untapped investigation. A subset of studies examined multiple medical, mental health, and substance use disorder conditions, however, most lacked in-depth analysis on the topic, only reporting the prevalence of such conditions and health services utilization. Some studies examined the interaction of these conditions. However, given that 35–58% of justice-involved veterans served by VHA outreach programs have co-occurring mental health and substance use disorders (Finlay et al., 2017; Finlay, Smelson, et al., 2016) and many have medical conditions (Brown & Jones, 2015), more studies are needed that examine the cumulative effect of managing multiple conditions to inform clinical practice and policy. Studies that investigate how cycling in and out of incarceration impacts management of multiple conditions are also important. Furthermore, many justice-involved veterans who have mental health and addiction conditions struggle with homelessness and unemployment. Although the VHA and community programs provide comprehensive housing and employment training services to some justice-involved veterans, the impact of these programs, especially for veterans with multiple chronic mental health and addiction conditions, is unknown. Efforts to identify and evaluate approaches to meeting housing and employment needs across the spectrum of justice-involved veterans will be critical to improving the health of this population by means of improved clinical practice and evolving policy decisions.

Sociodemographic differences

The scoping review highlights that we need to know more about sociodemographic groups within the justice-involved veteran population, such as women, people of color, rural veterans, veterans with disabilities, and veterans from different periods of service and service branches. Only a few studies examined women veterans separately from men (Finlay et al., 2015; Stainbrook et al., 2016) and only one study was of transgender compared to non-transgender veterans (Brown & Jones, 2015). To inform clinical practice and policy, research is needed to examine the extent to which these underrepresented veterans differ from white male veterans living in urban areas, who have predominated in most justice-related studies, what unique programmatic needs they may have, and the effectiveness of tailored intervention programs.

Intervention studies

Along with studies on sociodemographic groups, intervention studies focused on addressing the unique and additional treatment needs of justice-involved veterans and preventing or reducing their criminal justice involvement are needed. There is a robust literature examining the link between criminal justice involvement and mental health and addiction issues (e.g., Baillargeon, Binswanger, Penn, Williams, & Murray, 2009; Binswanger et al., 2012), and the effectiveness of interventions to improve outcomes among the general population of justice-involved individuals (e.g., Cusack, Morrissey, Cuddeback, Prins, & Williams, 2010; Kinlock et al., 2007). Borrowing from this literature to inform policy and practice with veterans, as well as developing this body of research among veterans will help move the field of justice-involved veterans research forward. Expanding the study designs used to include more randomized controlled trials, qualitative studies such as interviews or focus groups, and more rigorous observational studies that allow for propensity score analysis and other sophisticated statistical tests are needed.

Although 30% of studies focused on veterans in non-VHA settings, information on the quality of health and healthcare of justice-involved veterans in non-VHA treatment setting is lacking, as is best practices for how to coordinate between VHA and non-VHA treatment settings. The lack of studies in non-VHA settings may be partially because most healthcare provided to veterans occurred at VHA facilities. However, in 2014, Congress enacted the Veterans Access, Choice, and Accountability Act, known as the Veterans Choice Program, which enabled the VHA to substantially expand the purchase of community care for veterans. Primary care and mental health care, including substance use disorder care, were among the top five types of community care used by veterans (Vanneman et al., 2017). In 2018, the VA MISSION Act continued funding for the Veterans Choice Program and an additional 640,000 veterans are estimated to move into community care annually in the early years of the program (Rieselbach, Epperly, Nycz, & Shin, 2019). Understanding what impact purchased care has on justice-involved veterans and coordination between VHA and non-VHA treatment is important to ensuring they are receiving high quality care (Liu et al., 2010).

Type of criminal justice involvement

Distinctions in the health and healthcare among veterans involved in different aspects of the criminal justice system are difficult to draw because the majority of articles did not examine differences by criminal justice type. Most articles asked about current (Backhaus et al., 2016; Cook et al., 1996) or past criminal justice involvement, such as lifetime legal problems measured by the Addiction Severity Index (Anderson et al., 2017; Benda et al., 2003a; Bennett et al., 2018; Cacciola, Rutherford, Alterman, & Snider, 1994), and results were not reported by type of criminal justice involvement. Studies also examined veterans in jail diversion programs (Clark, Barrett, Frei, & Christy, 2016; Hartwell et al., 2014), courts (Clifford, Fischer, & Pelletier, 2014; Gallagher, Nordberg, & Gallagher, 2016; Hoyt et al., 2014), or jails (Davis, Baer, Saxon, & Kivlahan, 2003; Greenberg & Rosenheck, 2009; Saxon et al., 2001), but these studies often lacked comparison groups.

There were several articles that studied veterans incarcerated in prison, but samples were limited to US state prisons only with no comparisons with US federal prisons (Boivin, 1987; Brooke & Gau, 2018; Luallen & Corry, 2017; Stacer & Solinas-Saunders, 2015; Tsai & Goggin, 2017) or it was not stated where the incarceration occurred (Black et al., 2005). One exception was a study found that a higher percentage of jail incarcerated veterans had current indicators of mental health problems and more previous mental health problems than prison incarcerated veterans (Bronson et al., 2015). From the broader criminal justice literature, limited evidence suggests that individuals incarcerated in prisons have similar or greater medical needs (Maruschak, Berzofsky, & Unangst, 2015), but have fewer mental health needs compared to individuals in jails (Bronson & Berzofsky, 2017). Individuals in prison also may have greater access to healthcare than those in jails or under community supervision, including medical care (Maruschak et al., 2015) and substance use treatment (Taxman, Perdoni, & Harrison, 2007), which likely is related to being in a confined environment for longer sentences. However, given that the majority of justice-involved individuals are under community supervision (71%) (Kaeble, Glaze, Tsoutis, & Minton, 2016), future work should identify and better understand potential differences in health and healthcare by criminal justice status.

Conceptual models

Although the majority of studies in our scoping review lacked a conceptual model, a few studies drew from conceptual models across a variety of fields. One study grounded their research in criminology models, including the importation model and the functionalist model (Stacer & Solinas-Saunders, 2015). Conceptual models drawn from psychology included psychosocial rehabilitation (Elbogen, Johnson, Wagner, et al., 2012), ecological theory and cross-cultural approaches (Clifford et al., 2014), and a survivor mode coping model (Wilson & Zigelbaum, 1983). Two health services studies used the Gelberg-Andersen Behavioral Model for Vulnerable Populations (Gabrielian et al., 2016; Petrovich et al., 2014). Finally, the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was used in an implementation science study (Blonigen et al., 2018). The field of justice-involved veterans draws from different disciplines with their own conceptual models, but the lack of a common framework is a notable gap. Convening an interdisciplinary research consortium to develop a unifying conceptual model will help integrate these disciplines and guide future research.

Limitations of the scoping review

This scoping review was designed to provide a broad overview of the literature on the health and healthcare of justice-involved veterans and how these articles add to our general understanding of criminal justice involved populations. We did not provide an in-depth analysis of the topics covered in the reviewed studies, the quality of these studies, or an investigation of bias; thus, we were limited in the conclusions we could draw about the research we reviewed. We did not conduct a second review of all full-text articles; rather, a second review was conducted on only a subset of articles. Finally, we limited our search to healthcare databases. Additional articles relevant to our review may have been published in other fields, such as law journals, and not every relevant article may have been identified using our search strategy. Articles not available in English that may have been relevant were also excluded due to limitations on the availability of translation. However, the search strategy used likely identified most key studies available in English and the findings likely reflect the scope of healthcare issues related to justice-involved veterans currently in the literature. Many of the articles we excluded focused on legal aspects of veterans’ experiences in the criminal justice system, such as recidivism and legal rationales for considering PTSD when charging a veteran. Criminal justice outcomes were included in some of the studies in our scoping review, though we did not summarize those outcomes here. We instead focused our review on health and healthcare outcomes, but a more comprehensive review of the literature including health, law, and other related areas, such as sociology, may be needed to fully understand the experiences of justice-involved veterans.