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Witness Testimony of Karen H. Seal, M.D., MPH, Staff Physician, Medical Service, San Francisco Department of Veterans Affairs Medical Center, Veterans Health Administration, U.S. Department of Veterans Affairs, and Associate Professor in Residence of Med

Executive Summary

Mental Health Problems in OEF/OIF Veterans in VA Healthcare

PTSD rates in OEF/OIF Veterans in VA healthcare have increased steadily since the conflicts began, followed by increasing rates of depression.  Younger active duty Veterans appear to be at particularly high risk for PTSD; older National Guard and Reserve Veterans are at higher risk for PTSD and depression.  Rates of depression, anxiety, and eating disorders are higher in women than men; female Veterans who experienced military sexual trauma are at heightened risk for developing PTSD. Appreciating subgroup differences in the prevalence and types of mental health disorders can help guide more targeted interventions and treatments, as well as future research efforts.

Mental Health Services Utilization in OEF/OIF Veterans

The majority (80%) of OEF/OIF Veterans that received new PTSD diagnoses attended at least one VA mental health follow-up visit in the first year of diagnosis.  However, less than 10% with new PTSD diagnoses attended a minimum number of mental health sessions within a time frame required for evidence-based PTSD treatment.  Being young (under age 25) and male, having received a mental health diagnosis from a non-mental health clinic (ie: primary care), and living far from a VA facility (> 25 miles) were associated with failing to receive adequate PTSD treatment.  Because adequate evidence-based PTSD treatment may prevent chronic PTSD, VA must continue to develop interventions designed to improve retention in mental health treatment.  In contrast, despite underutilization of mental health services, those with mental health disorders disproportionately used VA primary care medical services.  Thus, models that integrate primary care and mental health services may improve engagement in mental health treatment, and, at the same time, address co-occurring physical complaints. 

Barriers to VA Mental Health Care

Patient barriers to mental health care among OEF/OIF Veterans include stigma, logistical barriers, and even the symptoms of the mental health disorders themselves.  Avoidance in PTSD, apathy in depression, and denial and self-medication with drugs and alcohol may prevent Veterans from seeking care.  In addition, VA has not always been able to keep pace with the demand for mental health services.  System barriers include shortages of mental health personnel trained in evidence-based treatments and lack of universal access to telemental health care, particularly in rural VA facilities.  While information technology security is important, excessive concerns may be impeding the development of more novel internet and telephone-based mental health treatment options. Privacy concerns about the Department of Defense’s access to Veterans’ electronic medical records have discouraged some Veterans from coming forward and disclosing symptoms.

Improving Access to and Retention in Mental Health Treatment for OEF/OIF Veterans

Capitalizing on the propensity for OEF/OIF Veterans with mental health problems to receive care in VA primary care settings, VA might consider further restructuring VA services such that more specialty mental health providers trained in evidence-based mental health treatments are embedded within primary care.  In addition, new clinical resources available through Patient Aligned Care Teams (PACT) in VA primary care (i.e. Nurse Care Managers) could be leveraged to facilitate enhanced engagement of Veterans in mental health treatment.  For instance, PACT nurses could act as motivational coaches or could help provide Veterans access to new technologies such as the VA internet site, “My HealtheVet” or smart phone applications such as “PTSD Coach” to enhance access to online mental health treatments or treatment adjuncts.  There also a need for more research to develop and test modified evidence-based treatments for PTSD and other mental health problems that are better suited to primary care settings.

Conclusions

OEF/OIF Veterans have extremely high rates of accruing military service-related mental health problems. Despite this large burden of mental illness, many OEF/OIF Veterans do not access or receive an adequate course of mental health treatment.  Veterans with mental health disorders disproportionately use VA primary care medical services. Recognizing the advances that VA has already made in VA Primary Care-Mental Health Integration, and more recently, the Patient-Aligned Care Team (PACT) model, VA is poised to address many of the remaining system barriers to mental health care for OEF/OIF Veterans by incorporating more specialty mental health care within VA primary care to meet the growing needs of this current generation of men and women returning from war.


It has been nearly 10 years since the current conflicts began and over 2.1 million service members have served in OEF and OIF.  Of these, over 1.2 million have separated from active duty service and have become eligible for VA services. Many soldiers have endured multiple tours of duty and most have experienced combat. Making the transition from warzone to home has been challenging, especially for veterans who have sustained physical injuries, as well as for those who have developed mental health problems. Based on prior DoD, VA, and nationally representative samples of OEF/OIF Veterans, the prevalence of mental health disorders has steadily increased: between 19 percent and 42 percent of OEF/OIF veterans have been estimated to suffer from deployment-related mental health problems (Milliken et al., 2007;Tanielian & Jaycox, 2008). The most recent data released from the VA Environmental Epidemiology Service (January 18, 2011) indicate that 331,514 (51 percent) of 654, 348 VA-enrolled Veterans have received mental health diagnoses and 177,149 (27 percent) have received posttraumatic stress (PTSD) diagnoses. These data confirm that the burden of mental health diagnoses has continued to increase since the conflicts began in 2001.

The mental health prevalence estimates our research group provides are based on data our group has acquired from VA national administrative databases which contain mental health diagnostic codes associated with VA clinical visits. The use of diagnostic codes has been shown to be a valid proxy for estimating disease prevalence, but is subject to reporting biases and some misclassification errors. Our findings are based on the entire population of OEF/OIF veterans who sought VA healthcare nationwide and thus, are not based on a nationally representative sample of OEF/OIF Veterans.  Of note, our findings have been consistent with other published studies of nationally representative samples of OEF/OIF Veterans.

In one of our earlier studies (Seal et. al, 2009), of 289,328 Iraq and Afghanistan Veterans who were first-time users of VA healthcare after separation from OEF and/or OIF military service, we found that new mental health diagnoses increased 6-fold from 6 percent in April 2002 to 37 percent by March 31, 2008. Thus, by 2008 over 1 of every 3 Veterans had received one or more mental health diagnoses.  Moreover, with each additional year of follow-up, we observed the accrual of additional mental health diagnoses in individual Veterans. Similarly, Milliken and colleagues demonstrated increases in mental health problems among OEF/OIF soldiers who were screened again several months after returning home compared to rates immediately after returning (Miliken et al., 2007). There are several factors that contribute to delayed onset of mental health diagnoses. There may be stigma leading to reluctance to disclose mental health problems until those problems interfere with functioning (Hoge et al., 2004).  Some military service-related mental health problems only appear months to years after combat (Solomon et al., 2006) and somatization or co-morbidity often confound accurate mental health diagnosis (Kessler et al., 1995).  The VA policy change that extended free VA military service-related health care to 5 years from 2 years post-discharge has likely increased our ability to detect mental illness in OEF/OIF Veterans. Now our challenge is to engage Veterans with mental health problems in care.

Several other key findings regarding the prevalence of mental health disorders have emerged from our recently published studies (Seal et al., 2009; Maguen et al., 2010; Seal et al., 2011):

  • Among the 106,726 OEF/OIF Veterans with mental health diagnoses, by study end (2008), two thirds had more than one co-occurring mental health diagnosis: approximately one-third had two mental health diagnoses and another third had 3 or more different mental health diagnoses, increasing diagnostic complexity and complicating treatment.
  • Overall, from 2002 to 2008, the rate of PTSD had increased from 0.2 percent to 22 percent (62,929); with a rapid increase in PTSD in the first quarter of 2003 following the invasion of Iraq.  Greater combat exposure was associated with higher risk for PTSD in active duty Veterans.
  • Age and component type mattered: Active duty Veterans less than age 25 years had 2 to 5 times higher rates of PTSD, alcohol and drug use disorder diagnoses compared to active duty Veterans over age 40.   In contrast, among National Guard/Reserve Veterans, risk for PTSD and depression were significantly higher in Veterans over age 40 compared to their younger counterparts less than age 25
  • Rates of depression diagnoses in OEF/OIF Veterans paralleled increases in PTSD with 50,432 (17 percent) Veterans diagnosed with depression by 2008.  PTSD and depression were highly comorbid with as many as 70 percent of Veterans suffering from both conditions.
  • Women OEF/OIF Veterans were at significantly higher risk for depression than men; women Veterans were also at significantly higher risk for anxiety disorders and eating disorders than their male counterparts.
  • 31 percent of women with PTSD compared 1 percent of men with PTSD screened positive for a history of military sexual trauma (MST). Women Veterans with MST were over four times more likely to develop PTSD than OEF/OIF female Veterans without MST.
  • Overall, over 11 percent of OEF/OIF Veterans received substance use disorder diagnoses. Male Veterans had over twice the risk for substance use disorders as female Veterans. Among Veterans with substance use disorders, 55–75 percent had comorbid PTSD or depression.

In summary, PTSD rates in treatment-seeking Veterans in VA healthcare have increased steadily since the conflicts began, closely followed by increasing rates of depression diagnoses. Particular subgroups of OEF/OIF Veterans appear at higher risk for mental health diagnoses.  Younger active duty Veterans appear to be at particularly high risk for PTSD likely due to higher combat exposure. Older National Guard and Reserve Veterans were at higher risk for PTSD and depression than younger National Guard/Reserve Veterans.  Further investigation of the causes of mental health diagnoses in older Guard/Reserve Veterans is warranted because measures of greater combat exposure were not consistently associated with mental health diagnoses. One explanation is that when called to arms, older Guard/Reserve members are more established in civilian life and may be less well prepared for combat, making their transition to warzone and home again more stressful. Regarding the relatively low prevalence rates of drug use disorders in OEF/OIF Veterans in our sample, stigma, fear of negative repercussions, and lack of universal screening for illicit substances in VA may have reduced the number of drug use disorders reported and detected.  Finally, there are pronounced gender differences in military service-related mental health disorders: Rates of depression, anxiety and eating disorders were elevated in women compared to men; female Veterans who experienced MST were at extremely high risk for developing PTSD. Appreciating subgroup differences in the prevalences and types of mental health disorders can help guide more targeted interventions and treatments, as well as future research efforts.

Mental Health Services Utilization in OEF/OIF Veterans

Overview

The Department of Veterans Affairs (VA) healthcare system is the single largest provider of healthcare for OEF/OIF Veterans with over 50 percent of all returned combat Veterans enrolled.  This is historically high for VA; only 10 percent of Vietnam Veterans enrolled in VA healthcare (Kulka et al., 1990).   Since 2001, the VA had provided OEF/OIF Veterans 2 years of free military service-related health care from the time of service separation, a benefit which was extended to 5 years in 2008 ("National Defense Authorization Act of 2008").  Most of the over 150 VA medical centers in the United States offer a complete spectrum of mental health services, including  over 140  PTSD specialty clinics. For rural Veterans living far from a VA medical center, over 900 VA community-based outpatient clinics offer basic health care and some offer basic mental health services. After the 5-year period of combat-related health coverage, OEF/OIF Veterans are eligible to continue to use VA healthcare services without charge (if service-connected) or are assessed a nominal co-pay scaled to income.  Of note, OEF/OIF Veterans who have health insurance through employment, school or otherwise, may seek non-VA healthcare services in their communities, and VA data systems do not capture non-VA healthcare utilization.

Early, adequate evidence-based mental health treatment has been shown to prevent mental health disorders, such as PTSD, from becoming chronic (Bryant et al., 2003).  Multiple studies of Veterans and civilians reveal however that a substantial proportion of those suffering from mental health problems either do not access, delay, or fail to complete an adequate course of specialty mental health treatment (Hoge et al., 2004; Tanielian & Jaycox, 2008; Wang et al., 2005). Studies have shown that mental health disorders other than PTSD, such as depression and substance use disorders may be managed in primary care as opposed to specialty mental health (Batten & Pollack, 2008). Some specific symptoms of PTSD, such as insomnia, may be managed by primary care clinicians in primary care.  However, consistent with the Institute of Medicine’s finding that only two mental health therapies have demonstrated efficacy for PTSD, Cognitive Processing Therapy and Prolonged Exposure Therapy, the VA recommends that Veterans with a PTSD diagnosis receive definitive treatment by mental health providers trained in these evidence-based therapies, which usually occurs in mental health clinics (Institute of Medicine’s Committee on Treatment of Posttraumatic Stress Disorder, 2007). Evidence-based PTSD treatments typically require a minimum of 9 or more sessions, ideally spaced at weekly intervals ( Foa et al, 2007; Monson et al., 2006).

Mental Health Services Utilization in OEF/OIF Veterans using VA healthcare (2002-2008)

Of nearly 50,000 OEF/OIF Veterans with newly-diagnosed PTSD, 80 percent compared to 49 percent of Veterans receiving mental health diagnoses other than PTSD had at least one VA mental health visit in the first year of diagnosis. Nevertheless, only 9.5 percent with new PTSD diagnoses attended 9 or more follow-up sessions in 15 weeks or less after receiving their diagnosis. When the follow-up period was extended to one year, a larger proportion, 27 percent attended 9 or more mental health sessions. Among OEF/OIF Veterans receiving mental health diagnoses other than PTSD (e.g. depression), only 4 percent attended 9 or more follow-up sessions in 15 weeks or less and slightly more, 9 percent attended 9 or more sessions when the follow-up period was extended to one year. Our study was limited in that we lacked information about non-VA mental health treatment utilization and the specific type of mental health treatment received. Thus, we can draw no firm conclusions about the adequacy and intensity of mental health care for OEF/OIF Veterans since we lack data on care received outside the VA system.  Nevertheless, VA is currently the single largest provider of healthcare for OEF/OIF Veterans and, of those with new PTSD diagnoses, in the first year of diagnosis, under 10 percent appear to have received what would approximate evidence-based mental health treatment for PTSD at a VA facility, and those with other mental health diagnoses received an even lower intensity of VA care.

Our study revealed that factors such as being young (under age 25) and male, factors linked to a greater likelihood of receiving a PTSD diagnosis, were also associated with a failure to receive minimally adequate PTSD treatment. These findings may reflect the symptoms of PTSD itself, including avoidance, denial and comorbid disorders such as depression and substance abuse.  In young male Veterans, stigma likely also plays a major role (Hoge et al., 2004).  In addition, we found that having received a mental health diagnosis from a non-mental health clinic (i.e. primary care) and living far from a VA facility (> 25 miles) were associated with failing to receive adequate PTSD treatment. Veterans who receive PTSD diagnoses from VA primary care may be less symptomatic than those receiving diagnoses from mental health clinics and less in need of specialty mental health treatment or prefer primary care-based treatments.  Indeed, many mental health problems of OEF/OIF Veterans other than PTSD, such as depression, may be effectively managed in primary care. In fact, we found that among OEF/OIF Veterans receiving mental health diagnoses other than PTSD, more than 85 percent had attended at least one primary care visit in the year following diagnosis, the majority of which were coded to indicate that a mental health concern had been discussed.  It is also possible that Veterans who receive PTSD diagnoses from non-mental health clinics or who live far from VA services fall through the cracks in the referral for specialty mental health care. In sum, our research findings support ongoing implementation efforts by VA leadership to  promote expanded access and adherence to specialty mental health care, especially for rural Veterans (Zeiss & Karlin, 2008).

Our results suggest that OEF/OIF Veterans may, in fact, be more likely than Vietnam-era Veterans to have had at least one initial VA mental health follow-up visit after receiving a new mental health diagnosis.  In the National Vietnam Veterans Readjustment Study (NVVRS), a nationally representative sample of Vietnam-era Veterans, a much lower proportion of Vietnam Veterans (30 percent) reported having sought any mental health treatment and only 7.5 percent used VA mental health services (Kulka et al., 1990). A more recent study demonstrated that after adjustments for potential confounding, variables such as age and the complexity of mental health disorders were more important predictors of whether Veterans received mental health treatment as opposed to which era they served (Harpaz-Rotem & Rosenheck, 2011). 

It stands to reason that OEF/OIF Veterans would be more likely than prior-era Veterans to have had at least an initial mental health visit. In comparison to Vietnam-era Veterans, a higher proportion of OEF/OIF Veterans has experienced “front-line” combat exposure and has survived their injuries (Gawande, 2004), which has been associated with the development of mental health disorders and increased need for mental health services (Hoge et al., 2007).  Unlike in prior eras, Congress extended health coverage for OEF/OIF Veterans to five years after service separation. Many newly returned OEF/OIF Veterans facing economic hardship have taken advantage of blanket VA healthcare coverage and have used VA services. Also, different from prior eras, the Department of Defense, in an effort to reduce stigma, now openly discusses combat-related stress with active duty service members. Similarly, widespread media attention focused on mental health disorders in Iraq and Afghanistan Veterans has lowered the threshold for recently returned Veterans to seek care. Finally, both the VA and the military have implemented population-based post-deployment mental health screening programs and routinely refer Veterans who screen positive for further mental health assessment and/or treatment (Hoge et al., 2006; Seal et al., 2008), all factors which support initial VA mental health services utilization.

Nevertheless, despite initial use of VA mental health services among OEF/OIF Veterans, retention in VA mental health services appears less robust.  The strongest predictor of retention in VA mental health treatment services in our study, as in others, was “need” for mental health treatment (Spoont et al., 2010). Veterans receiving PTSD diagnoses (as opposed to other mental health diagnoses) and those receiving additional comorbid mental health diagnoses in conjunction with PTSD were more likely to remain in care and receive minimally adequate PTSD treatment. Unfortunately, compared to studies of civilians however, retention in VA mental health treatment appears inferior.  For instance, the National Comorbidity Survey Replication Study, a population-based survey of 9,282 US civilian adults, found that 48 percent of patients with any mental disorder (including PTSD) reported having received at least “minimally adequate therapy,” defined by evidence-based national mental health treatment guidelines, within the first year of diagnosis (Wang et al., 2005).  In contrast, similar to our findings, a RAND Corporation study reported that a much lower proportion, 25 percent of a nationally representative sample of OEF/OIF Veterans with PTSD and depression, received “minimally adequate therapy” within the first year of diagnosis (Tanielian & Jaycox, 2008).

In summary, we found that the majority of OEF/OIF Veterans that received new mental health diagnoses, including PTSD, attended at least one mental health follow-up visit in the year after mental health diagnosis. However, the vast majority of OEF/OIF Veterans with new PTSD diagnoses failed to attend a minimum number of mental health sessions within a recommended time frame required for evidence-based PTSD treatment.  Because early, evidence-based PTSD treatment may prevent chronic PTSD, it will be important that the VA, in its mission to provide the best care for returning combat Veterans, continue to develop and implement interventions to improve retention in mental health treatment, with particular attention to the needs of more vulnerable OEF/OIF Veterans.

Utilization of VA Primary Care in OEF/OIF Veterans with Mental Health Problems

Despite underutilization of mental health services, those with mental health disorders disproportionately use VA primary care medical services compared to OEF/OIF Veterans without mental health problems. Frayne et al. examined non-mental health medical care among 90,558 Veterans from 2005 through 2006 and found that those with a diagnosis of PTSD had more medical diagnoses and greater primary care service utilization than those without a mental health diagnosis (Frayne et al., 2010).  Another article published by Cohen et al. in our group, found an increased prevalence of cardiovascular risk factors (i.e. hypertension, high cholesterol, smoking, and obesity) in OEF/OIF Veterans with PTSD compared to Veterans with mental health conditions other than PTSD, or no mental health conditions (Cohen et al., 2010). In a related study, Cohen et al. reported that Veterans with PTSD consumed almost twice as much primary medical care as those without a mental health diagnosis (Cohen et al., 2010). There are several possible explanations for these findings: The traumatic events that caused PTSD might have also caused physical injury requiring medical attention; somatic symptoms and stigma associated with PTSD may have motivated Veterans to seek VA primary care; PTSD may be associated with high-risk behaviors (e.g. alcohol abuse) leading to physical health problems, and finally, increased contact with the medical system through PTSD treatment, may have led to increased detection of other physical problems. To the extent that we fail to retain Veterans in an adequate course of mental health treatment, we may continue to grapple with pervasive and chronic comorbid physical and behavioral problems in VA primary care clinics. Because most individuals with PTSD, including OEF/OIF Veterans, pursue medical treatment in primary care, models that integrate primary care and mental health treatment may improve both engagement and retention of patients in mental health care, while simultaneously addressing co-occurring physical complaints.   

Barriers to VA Mental Health Care 

Patient Barriers

There have been numerous reports of barriers to mental health care for OEF/OIF Veterans. Our data and the work of others indicate that while there are indeed barriers to access and initiation of mental health treatment, longer-term retention in mental health treatment is far more problematic (Seal et al., 2010; Seal et al., 2011, in press; Spoont et al., 2011; Harpaz-Rotem & Rosenheck, 2011).  Barriers to engagement in mental health treatment have generally been categorized into patient-related barriers and system barriers. Patient barriers have been well-described and include: (1) Stigma regarding mental illness-concerns about being perceived as weak by family, friends, colleagues, or within one’s culture for coming forward with mental health problems, (2) “Battlemind”-not recognizing or believing that behaviors such as hypervigilence that were adaptive in the warzone are now maladaptive in civilian life, and thus not seeking or accepting mental health treatment, (3) Beliefs and attitudes that mental health treatment, including psychoactive medication, is not effective or even dangerous, (4) Logistical barriers such as job, school, family obligations, geographical distance, and lack of transportation, (5) Symptoms of mental health disorders themselves, such as avoidance in PTSD, apathy in depression, and denial in drug and alcohol abuse, and (6) Self-medication with drugs and alcohol that may temporarily mask symptoms.

VA System Barriers

The Institute of Medicine (IOM) identified six aims for improvement of the quality of mental health care. These included safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (Institute of Medicine, 2006). Consistent with these aims, the VA has made numerous strides toward improving the delivery of mental health treatment for OEF/OIF Veterans by greatly increasing mental health capacity and services.  For instance, in order to improve identification and treatment of Veterans with mental health disorders, since 2004, the VA has conducted universal post-deployment mental health screening of OEF/OIF Veterans who receive care at VA facilities (Seal et al., 2008)  In addition, in 2007, the VA initiated an expansion of mental health services capacity, which included an increase in the number of mental health staff assigned to more rural VA clinics, an increase in the use of video-teleconferencing services (“telemental health”) to increase access to specialty mental health care for rural Veterans, and the implementation of the Primary Care Mental Health Integration initiative to co-locate mental health providers in primary care settings (Zeiss & Karlin, 2008). Indeed, the new VA primary care Patient Aligned Care Team (PACT) model is consistent with IOM principals to improve the quality of mental health care by identifying a mental health provider that is associated with each of the primary care PACT teams to provide timely and efficient mental health care to Veterans within primary care.

Nevertheless, with ever-increasing numbers of OEF/OIF Veterans presenting with mental health problems, VA has not always been able to keep pace with the demand for services, particularly in more rural VA facilities.  From my perspective, there are several VA system barriers which are remediable and require our attention:

  • There are shortages of mental health staff (psychologists and social workers) who are trained in evidence-based therapies for PTSD, particularly in more rural VA community-based outpatient clinics.
  • There is a lack of universal access to telemental health services for Veterans receiving care at more rural VA community-based outpatient clinics to provide access to specialty mental health clinicians based at VA medical centers.
  • Information technology (IT) security is important, yet excessive concerns about IT security may be slowing the development and use of more novel internet and telephone-based mental health treatment options that may appeal to younger Veterans.
  • Veterans continue to complain about difficulties navigating the VA system to schedule appointments, long wait times for appointments, and shortages of drop-in appointments, which limit access to care. 
  • Limited mental health treatment resources for families and children of Veterans, as well as the lack of childcare limits mental health treatment options for Veterans and their families; particularly affecting Women Veterans. 
  • ·In an effort to enhance information exchange between the Department of Defense (DoD) and the VA, there is concern that Veterans’ confidential electronic medical records will be viewed by DoD, causing some Veterans to be reticent about disclosing sensitive mental health concerns such as substance abuse issues, interpersonal violence, and sexual identity issues, which limits their ability to receive treatment for these problems at VA.

Enhancing Access to and Retention in Mental Health Treatment for OEF/OIF Veterans

Capitalizing on the propensity for OEF/OIF Veterans to receive care in VA primary care settings, one strategy to further enhance engagement in mental health services is to further co-locate and integrate specialty mental health services, such as evidence-based PTSD treatment, within primary care. Despite the VA Primary Care Mental Health Integration initiative, even in model programs, these embedded mental health providers (many of whom are social workers) typically provide further assessment of positive mental health screens, specialty mental health referrals, medication management, and brief supportive therapies, but rarely provide evidence-based mental health treatments (Possemato et al., 2011).  Use of specialty mental health services has been associated with greater retention in mental health treatment, and in turn, improved clinical outcomes (Wang et al., 2005). There are several ways to provide greater access to specialty mental health treatment through primary care. Below are a few possible suggestions:

  • Restructure VA services such that specialty mental health providers trained in evidence-based mental health treatments are co-located and fully integrated within primary care.  This requires a new holistic paradigm for VA primary care that views mental health care as part of primary care. This may even involve infrastructure changes to existing medical clinics to accommodate the co-location of more mental health providers in primary care.  These structural change could literally “break down walls” that exist between medical and mental health services, overcome stigma, and narrow the gap between primary care and mental health.  For instance, pre-scheduling mental health visits to occur at the same time as primary care visits, as we do in our one-stop Integrated Care Clinic at the San Francisco VA Medical Center, will make it more likely that patients will attend and be retained in mental health.
  • Leverage new clinical resources available through Patient Aligned Care Teams (PACT) in VA primary care. Nurse Care Managers in primary care PACT teams are currently being trained nationwide through the VA National Center for Prevention to conduct motivational coaching through a new VA program called “TEACH” (Tuning in, Evaluation, Assessment, Communication and Honoring the patient).  Primary care PACT nurses could conceivably conduct brief telephone motivational coaching sessions to remind and motivate Veterans to attend their mental health appointments. As an alternative to the telephone, nurses could use the new VA internet application, “My HealtheVet” to securely e-mail Veterans about upcoming mental health visits, a communication modality that particularly appeals to younger Veterans. In addition, consistent with the evidence-based collaborative care model for depression treatment, nurses could feedback relevant clinical information from patients to mental health and primary care providers to promote more efficient, coordinated, and effective care.
  • Exploit new technologies to deliver mental health treatment through VA primary care in rural settings where there are limited or no specialty mental health services. For instance, PACT nurses could coordinate telemental health visits at VA community-based outpatient clinics with specialty mental health providers based at VA medical centers.  For patients who need care, but are unable to travel to any VA facility, VA might give serious consideration to newer technologies that bring mental health care into patients’ homes.  Examples include the delivery of evidence-based mental health treatments over the telephone or through “Skype,” the use of smart phone applications such as “PTSD Coach” as an adjunct to mental health treatment, and the use of the internet to deliver mental health treatments through VA sites such as “My HealtheVet”  or other state-of-the- art DoD-sponsored websites such as www.afterdeployment.org, which provides on-line evidence-based mental health treatment. These internet-based treatments could be facilitated by VA therapists who could conduct regular telephone check-ins with patients.  These innovations will require re-visiting some of VA’s current IT security policies.
  • Support further research to develop and test the implementation of modified evidence-based treatments for PTSD and other mental health problems in primary care. There is a need to develop and test PTSD treatments that are briefer and better suited for primary care. In addition, there is a need to develop and test integrated treatments for PTSD that simultaneously address substance abuse or other behavioral (e.g. smoking) or physical health problems (e,g, chronic pain) in the context of PTSD treatment, since PTSD is highly comorbid with other mental and physical health problems.  In this vein, the incorporation of complementary and alternative modalities in the treatment of PTSD, such as exercise, yoga, and acupuncture can be used to help motivate engagement in mental health treatment and may help to improve symptoms and overall physical and emotional well-being of Veterans suffering with mental illness.

Conclusion

In summary, OEF/OIF Veterans have extremely high rates of accruing military service-related mental health problems. Despite this large burden of mental illness, because of patient and system barriers to VA mental health care, many OEF/OIF Veterans do not access or receive an adequate course of mental health treatment.  In contrast, despite underutilization of mental health services, combat Veterans with mental health disorders disproportionately use VA primary care medical services. Recognizing the advances that VA has already made in VA Primary Care-Mental Health Integration, and more recently, the Patient-Aligned Care Team (PACT) model, VA is poised to address many of the remaining system barriers to mental health care for OEF/OIF Veterans by incorporating more specialty mental health care within VA primary care. VA has been a pioneer in our national healthcare system, learning and growing through vast clinical experience and the enterprise of VA health services research.  Given the current epidemic of mental health problems in OEF/OIF Veterans, coupled with budgetary constraints, we will again need to challenge ourselves to “think outside of the box” to develop and implement new systems of care, new technologies, and new services to meet the needs of this current generation of men and women who have served our Country.


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