conduct monthly standardized medical-record reviews of outpatient care as part of the External Peer Review Program and uses the data to monitor according to national performance measures. In addition, much of the data on implementation and monitoring of evidenced-based practices included in this chapter comes from an independent evaluation of the quality of VA mental-health and substance-use care. VA commissioned the RAND Corporation and Altarum Institute to perform the evaluation, which they conducted between 2006 and 2010 (Watkins and Pincus, 2011). The study was authorized by the Government Performance and Results Act of 1993 and Title 38 of the US Code, which require independent evaluations of large government programs. In general, studies have shown that the health care that VA provides for a number of conditions, such as diabetes and heart disease, is on par with or better than care provided in non-VA settings (Jha et al., 2003; Trivedi et al., 2011). However, as discussed in this chapter, VA’s performance in mental health is not as strong, given the variation found among service networks and the low rate of delivery of some evidence-based practices (Watkins et al., 2011).

DOD has an extensive centralized Military Health System–wide database for population health management called the Military Health System Population Health Portal.3 However, clinical performance measures in the dataset do not address mental-health care. In 2010, the Defense Health Board recommended to the assistant secretary of defense for health affairs that “evidence-based metrics for processes of mental health care” should be developed and monitored to address questions of mental health care quality and adequacy of clinical capacity/resources (Defense Health Board, 2010). The Defense Health Board added that DOD should evaluate clinician competence in providing evidence-based treatment and patience adherence to treatment.

As VA and DOD continue to advance their efforts to evaluate mental-health care services, they face a number of challenges, such as the lack of validated clinical performance measures that assess the full array of psychologic health services and the lack of appropriate benchmarks that VA and DOD can use to compare their performance. Measurement of clinical performance is not as advanced in mental health as it is in other types of care (Pincus et al., 2011; Watkins et al., 2010). That potentially presents opportunities for VA and DOD to collaborate with each other and with others in the field to advance clinical performance measurement aimed at improving the quality of mental health care and care for brain injury.


The chapter is organized in six main sections: TBI, PTSD, MDD, SUDs, suicidal ideation, and comorbid conditions. By structuring the chapter according to each condition, the committee does not mean to suggest that it is always the case that a single diagnosis can account for all symptoms or that a single set of clinical guidelines and evidenced-based treatments will address all symptoms. Many patients, particularly in military settings, present with complex problems that do not fall neatly into single diagnostic categories. Comorbid, co-occurring, and dual diagnosis are terms used to indicate that more than one disorder is occurring in the same person, simultaneously or sequentially, and that associated interactions between the illnesses affect the course and prognosis of each. This chapter uses the terms comorbid and co-occurring.


3The Military Health System Population Health Portal contains administrative health care data on TRICARE Prime/Plus enrollees who receive care through military treatment facilities and contracted providers.

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