VA Mental Health Services Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses

Abstract:

“Little is known about mental health services utilization among Iraq and Afghanistan veterans receiving care at Department of Veterans Affairs (VA) facilities. Of 49,425 veterans with newly diagnosed posttraumatic stress disorder (PTSD), only 9.5% attended nine or more VA mental health sessions in 15 weeks or less in the first year of diagnosis. In addition, engagement in nine or more VA treatment sessions for PTSD within 15 weeks varied by predisposing variables (age and gender), enabling variables (clinic of first mental health diagnosis and distance from VA facility), and need (type and complexity of mental health diagnoses). Thus, only a minority of Iraq and Afghanistan veterans with new PTSD diagnoses received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis.”

Implications

For Practice

Although the initial use of VA mental health services has increased among veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), few of these veterans have actually attended VA mental health treatment sessions as often as is suggested by health professionals. Frequency of attendance at these mental health sessions was also found to vary by diagnosis. Among OEF and OIF veterans, only 4% with non-PTSD mental health diagnoses and 10% with a PTSD diagnosis attended nine or more VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Although the percentages of veterans attending nine or more sessions increased once the researchers expanded the time interval to one year, still less than one-third of veterans with a PTSD diagnosis attended nine or more mental health treatment sessions. Male veterans, and those under the age of 25, were less likely to engage in sustained mental health treatment, possibly due to the social stigma associated with a mental health diagnosis. Veterans with a PTSD diagnosis combined with other diagnoses utilized services more frequently than those only diagnosed with PTSD, reflecting the greater urgency for treatment associated with multiple conditions. Because many patients are more comfortable receiving mental health care from primary care physicians with whom they have already established bonds of trust, additional training in addressing mental health issues should be provided to VA primary care physicians who would be interested in providing these kinds of care to long term patients. More than 85% of the OEF and OIF veterans receiving non-PTSD mental health diagnoses and attending none or one or two mental health treatment sessions had at least one primary care visit, many of which were coded to indicate that a mental health concern may have been addressed during the visit. However, the results of this study show that veterans who received a mental health diagnosis from VA primary care or specialty clinics, as opposed to a mental health clinic, were less likely to receive the recommended dose of treatment. Therefore, primary care physicians should be especially careful to follow-up with treatment regimens for these patients. There is also a gap in services for veterans living far from VA facilities, so physicians and administrators should be sure these individuals do not fall through cracks in the referral process and should work with veterans and their families to arrange access to care.

For Policy

Compared to veterans from earlier eras, OEF and OIF veterans have a higher usage of VA mental health services. Policy makers should note interventions that may have increased mental health care utilization in the past in order to continue to encourage veterans to seek out needed health care services. Although the U.S. Congress originally only mandated two years of free military service-related health care coverage, that coverage has since been increased for OEF and OIF veterans to five years of care, adjusted from the date of service separation. In addition to the extension in years of coverage, the Department of Defense has taken steps to reduce stigma associated with seeking mental health care by openly discussing combat-related stress with active duty members. The VA and military have also implemented mental health screening programs for veterans post-deployment, referring those who screen positive for further mental health assessment and treatment, if necessary. These policies are especially important in addressing the needs of the OEF and OIF population, as compared to Vietnam-era veterans, a higher proportion of these veterans have experienced front-line combat exposure, survived their injuries, and sustained mild traumatic brain injury. These factors have all been associated with the development of mental health disorders, and the increased use of mental health services, creating a greater need for mental health care for OEF and OIF veterans. VA policies expanding access to service have been successful thus far, including extended mental health clinic hours, telephone-administered mental health care by nurse case managers, Internet-based mental health treatment options, and increased mental health specialists in more rural areas. However, these efforts should continue and should be expanded in rural areas where veterans live farther from VA facilities, as veterans in these areas are less likely to access mental health treatment as frequently as is necessary.

For Future Research

Further research should focus on the intensity of mental health treatment in VA primary care, and whether methods of treatment vary between mental health and primary care clinicians. Some studies suggest that patients may prefer their primary care physicians for mental health care, as they have already established bonds of trust with these physicians. Because of this, the quality of mental health treatment programs may differ based on the patient’s relationship with their physician, so further research could address variations in care provided and mental health outcomes based on physician relationship as well. Because this study is based on a population of OEF and OIF veterans who sought out care and were enrolled in VA health care, future studies can investigate diagnoses and treatments for PTSD in more diverse populations of veterans, especially those using non-VA health services. Researchers should also investigate the needs of veterans who live farther from VA facilities. In this study, distance from VA facilities was found to be significantly related to fewer mental health care visits, so this population has a clear unmet need for services that can be addressed if researchers and policy makers work with veterans to find viable solutions.

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