Matt Boucher, VA Pittsburgh social worker, at left, listens as Korean War veterans Lindy Malignani, Tom Miller, Wil Jones, Eddie Peters, Hugh Riscoe and Norm Crease discuss their experiences with PTSD. The veterans meet weekly at the VA Pittsburgh Healthcare System's H.J. Heinz campus.
VA photo.

AMES, IA — A new report gave the VA high marks for the quality of mental health care provided to veterans of the conflicts in Iraq and Afghanistan, according to the National Academies of Sciences, Engineering and Medicine. Issues remain with providing and publicizing access to the services in all locations, however.1

Congress mandated the report in response to epidemiological studies that showed that veterans of Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn had significantly higher rates of mental illness and suicide than the general population.

Overall, the VA compared well against other public and private providers, and veterans who used the VA’s mental health services reported high rates of satisfaction. The researchers attributed the high quality of mental health services to a combination of VA-specific characteristics and to better implementation of recommendations for quality care than seen in most other settings.

“Veterans prefer to be treated by professionals who ‘understand’ them,” explained Alicia Carriquiry, chair of the report committee and distinguished professor of liberal arts and sciences in the department of statistics at Iowa State University in Ames, IA. “Providers in the VA are able to offer culturally appropriate care because a sizeable portion of them are veterans themselves.”

As U.S. Medicine reported last month, a recent RAND report found that many private providers fail to ask whether their patients are veterans, and few have had training in conditions common to the veteran population, such as post-traumatic stress disorder and traumatic brain injury. That report noted that the shortage of culturally aware and trained providers was especially acute in mental health fields.

“Mental health providers in the VA benefit from in-house research and training and tend to be at the head of the curve when it comes to new practices and technologies. The VA is the largest trainer of mental health professionals in the country (and probably the world),” Carriquiry told U.S. Medicine.

In addition, the VA’s commitment to providing fully integrated care in one location also leads to better care, overall, as veterans with mental health needs frequently have co-morbidities which may bring them into the system, she said. The patient-centered, team approach of the VA and centralized health record help all providers work together to address the whole patient.

The VA also has led the nation in the use of evidence-based practice and complementary and integrative health-based practices, Carriquiry added.

Barriers to Care

Improving access and providing the same quality mental health care across the entire VA system continue to pose challenges, however, the researchers found. Veterans’ lack of awareness of their own mental health needs and their concerns about receiving mental health care also create barriers to care.

“The VA has pioneered the use of technology such as telemedicine, which enables veterans in remote areas or with crippling anxiety disorders or others who find it difficult to visit a clinic to receive high-quality mental health care,” Carriquiry said. Younger veterans are more receptive to using the internet, phone or other technology to receive mental health care, according to a survey conducted as part of the study. Still, the report noted that transportation issues and distance to VA facilities can make it difficult for veterans to make in-person appointments.

Staffing issues and lack of space often constrain the number of appointments available, making timely delivery of services difficult and keeping some facilities from meeting quality of care standards. “If evidence-based practice says a patient should see her provider every other week, but for staffing or other reasons, the provider an only see her once per month” that would deviate from best quality care, Carriquiry explained.

“Many of these issues can be resolved by more strategic distribution of resources (human and other), by more deliberate use of telemedicine and other such technology, and by fixes such as improving the patient scheduling system and simplifying the hiring process,” she said. Still, Carriquiry estimated that 80% to 90% of VA facilities provide high-quality mental health care.

The report identified a notable gap, however, between the number of veterans who receive mental health services at the VA and the number who need mental health care. “The No. 1 barrier to seeking care appears to be the fact that veterans are either not aware that the VA offers mental health services or incorrectly believe that they are ineligible or know that the services are available but do not know how to navigate the system,” Carriquiry said.

Women veterans in particular did not know they were entitled to mental health care services through the VA. Carriquiry noted that women veterans more frequently have private insurance than men, so some of them might not have considered seeing a VA provider. On the other hand, she said a number of women veterans reported that they feel they constantly have to prove that they are veterans themselves and not spouses of male veterans, so some may have internalized the perception that they do not qualify for the same benefits men receive.

Other veterans who need services do not seek them. More than half of veterans with a diagnosis of post-traumatic stress disorder, substance use disorder or depression did not see a need to receive mental health services, the report committee found. Veterans with family members or friends who support and encourage treatment used VA services at a far higher rate than those without such individuals in their lives.

Some veterans who knew they needed services worried that receiving treatment would negatively affect their lives. A number of veterans indicated in surveys that they feared that taking time off from work for mental health appointments might damage their careers by leading to a loss of security clearances or reduced respect in the workplace. Others reported concerns that seeking mental health treatment could be used against them in custody hearings or visitation agreements or might limit their ability to keep guns or received medical or disability benefits.