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Veterans with Hoarding Disorder Face High Service Utilisation and Low Diagnosis Rates

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Veterans with hoarding disorder (HD) face significant challenges in receiving proper medical and psychiatric care, according to a recent study by researchers at the VA San Diego Healthcare System. The study, published in the journal Psychiatry Research, highlights the low diagnosis rates and high service utilisation among veterans with HD, suggesting a significant unmet need within the Veterans Health Administration (VHA) system.

Hoarding disorder is a debilitating neuropsychiatric condition characterised by persistent difficulty in discarding possessions, leading to severe clutter and functional impairment. According to the American Psychiatric Association, HD affects approximately 2–6% of the general population, with prevalence increasing with age. The condition often co-occurs with other psychiatric disorders, including major depressive disorder, anxiety disorders, and obsessive-compulsive disorder (OCD).

Over an eight-year period, Dr Jessica Zakrzewski and colleagues’ study examined medical records from the VA San Diego Healthcare System. Researchers aimed to determine the rate of HD diagnoses and compare it to the expected prevalence in the general population. They found that the diagnosis rate for HD among veterans was significantly lower than expected, at only 0.04%. In contrast, the community prevalence rate of HD is estimated to be between 2 and 6%.

Furthermore, the study revealed that the majority of HD diagnoses were made by a specialised research and clinical team, rather than by general medical or psychiatric providers. This finding suggests that many veterans with HD may go undiagnosed and, therefore, untreated. The authors noted that low confidence among general providers in diagnosing and treating HD and related disorders likely contributes to the under-detection of this condition.

Despite the low diagnosis rate, veterans with HD utilised medical and psychiatric services at significantly higher rates than those with OCD, another under-diagnosed condition within the VHA system. Veterans with HD were found to have higher rates of hospital admissions, longer hospital stays, and more frequent interactions with homelessness services and the suicide prevention team. They also had higher Care Assessment Needs (CAN) scores, which indicate a greater risk for hospitalisation or death.

The study also identified a high burden of comorbidities among veterans with HD. These individuals were more likely to suffer from medical conditions such as cardiovascular disease, neurological disorders, and chronic pain. Psychiatric comorbidities were also common, with higher rates of PTSD, major depressive disorder, and substance use disorders compared to veterans with OCD.

One of the critical issues highlighted by the study is the lack of routine screening for HD within the VHA system. Unlike OCD, which has some established screening protocols, HD is often not systematically assessed, leading to significant under-diagnosis. The authors recommend the implementation of validated screening tools, such as the Hoarding Rating Scale-Self Report, to improve detection rates. This tool has been shown to be effective in identifying individuals with clinical levels of HD symptoms through self-report.

The study emphasises the need for better education and training for VHA providers in diagnosing and managing HD. Enhancing provider knowledge and confidence in addressing HD could lead to more accurate diagnoses and timely interventions, ultimately improving the quality of life for veterans affected by this condition.

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