Evaluation of the Department of Veterans Affairs Mental Health Services (2018) / Chapter Skim
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6 Department of Veterans Affairs Mental Health Services: Need, Usage, and Access and Barriers to Care
6 Department of Veterans Affairs Mental Health Services: Need, Usage, and Access and Barriers to Care
Pages 103-166
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From page 103... ...
, and Operation New Dawn (OND) began in 2001, 2003, and 2010, respectively, an increasing number of veterans from this era have been receiving health care services through the Department of Veterans Affairs (VA)
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• What factors may influence the future use of mental health services? ELIGIBILITY AND PRIORITY FOR DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SERVICES The VA serves 8.76 million veterans per year at more than 1,700 health care sites throughout the United States (VA, 2015e)
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received an OTH discharge, making them potentially ineligible to receive VA health care services. This finding is consistent with findings of a 2016 report by the congressionally appointed Commission on Care, which reported that many former service members who received an OTH discharge as a result of a regulatory bar (which could be the result of behavioral misconduct related to a serviceconnected mental health condition)
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• Veterans receiving VA pension benefits • Veterans eligible for Medicaid programs Priority Group 6 • Compensable 0 percent service-connected veterans • Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki • Project 112/SHAD participants • Veterans who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 • Veterans of the Persian Gulf War who served between August 2, 1990 and November 11, 1998 • Veterans who served on active duty at Camp Lejeune for not fewer than 30 days beginning Au gust 1, 1953 and ending December 31, 1987* • Veterans who served in a theater of combat operations after November 11, 1998 as follows: in 2017 VA Secretary David Shulkin announced that the VA would offer emergency mental health care to veterans with an OTH discharge status as part of its ongoing efforts to prevent veteran suicides (VA, 2017e)
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for their resident location and who agree to pay copays Priority Group 8 • Veterans with gross household income above the VA and the geographically-adjusted income limits for their resident location and who agree to pay copays Veterans eligible for enrollment Noncompensable 0 percent service-connected: • Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this sub priority due to changed eligibility status • Subpriority b: Enrolled on or after June 15, 2009 whose income exceeds the current VA or geo graphic income limits by 10 percent or less Nonservice-connected and: • Subpriority c: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/or placed in this sub priority due to changed eligibility status • Subpriority d: Enrolled on or after June 15, 2009 whose income exceeds the current VA or geo graphic income limits by 10 percent or less Veterans not eligible for enrollment Veterans not meeting the criteria above: • Subpriority e: Noncompensable 0 percent service-connected (eligible for care of their SC condi tion only) • Subpriority g: Nonservice-connected NOTES: At the end of this enhanced enrollment priority group placement time period veterans will be assigned to the highest priority group their unique eligibility status at that time qualifies for.
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This number is lower than the number of other-era enrollees who use VA health services, which is about 72 percent. KEY CHARACTERISTICS OF THE OPERATION ENDURING FREEDOM, OPERATION IRAQI FREEDOM, AND OPERATION NEW DAWN COHORT WHO USE AND DO NOT USE VETERANS HEALTH ADMINISTRATION SERVICES Mental health conditions are the third most frequently diagnosed category of conditions at the VA, for both men and women (Frayne et al., 2014; VA, 2015b)
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SOURCE: Adapted from personal communication, Stacy Gavin, Department of Veterans Affairs, May 25, 2017. health services, many may not need mental health services.
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Allowing for missing responses to the survey question, 10 to 11 percent of the OEF/OIF/OND veterans surveyed do not have health insurance. The descriptive statistics in Table 6-1, which are estimates derived from the committee's survey, are reasonably comparable to estimates produced by the VA for the OEF/OIF/OND veteran population (VA, 2017c)
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Missing includes skipped items. SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
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112 EVALUATION OF THE DEPARTMENT OF VETERANS AFFAIRS MENTAL HEALTH SERVICES TABLE 6-2 Survey Estimates of the Military Characteristics of the OEF/OIF/OND Veteran Population (population size about 4.1 million) Military Experience Characteristics Unweighted n Weighted N Weighted % Standard Error % Total 4,180 4,179,998 100% Military status Active 3,409 3,302,287 79.0% 0.9% Reserve/Guard 751 843,162 20.2% 0.8% Refused 2 3,271 0.1% 0.1% Missing 18 31,278 0.7% 0.2% Branch of service Army 2,000 1,903,401 45.5% 0.8% Marine Corps 382 385,290 9.2% 0.5% Navy/Coast Guard 727 806,405 19.3% 0.7% Air Force 816 842,734 20.2% 0.7% Multiple branches 239 214,173 5.1% 0.4% Refused 1 320 0.0% 0.0% Missing 15 27,675 0.7% 0.2% Rank Officer 751 831,056 19.9% 0.9% Enlisted 3,411 3,319,462 79.4% 0.8% Refused 4 6,784 0.2% 0.1% Don't know 1 463 0.0% 0.0% Missing 13 22,231 0.5% 0.1% Total length of deployments No deployment 1,195 1,925,786 46.1% 0.7% 1 to 12 months 1,317 1,053,685 25.2% 0.7% More than 12 months 1,643 1,173,158 28.1% 0.7% Refused 10 8,822 0.2% 0.1% Missing 15 18,546 0.4% 0.1% Number of deployments to combat area None 1,643 2,473,530 59.2% 0.5% One 1,170 762,825 18.2% 0.5% More than one 1,330 909,445 21.8% 0.6% Refused 11 5,331 0.1% 0.0% Missing 26 28,865 0.7% 0.1% Location of deployments among the deployed Iraq only 942 577,324 25.9% 0.9% Afghanistan only 325 224,833 10.1% 0.6% Other combat area 472 360,752 16.2% 0.8% Multiple combat areas 765 511,755 23.0% 0.9% No combat deployments 450 546,537 24.5% 1.1% Missing 6 5,643 0.3% 0.1% Exposure to combat and aftermath of battle Low 3,007 3,380,131 80.9% 0.5% Moderate 868 599,552 14.3% 0.4% High 214 147,050 3.5% 0.3% Don't know 1 583 0.0% 0.0% Missing 90 52,681 1.3% 0.1%
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of the veterans reported having been in treatment for a physical condition during the previous 24 months. Geographic Distribution of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Veterans The committee's survey was not designed to describe the geographic distribution of OEF/OIF/OND veterans.
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account for an estimated 40 percent of the total OEF/OIF/OND veteran population. TABLE 6-3 Percent of U.S Armed Forces Veterans by Service Era Service Era % of Total Surviving Veterans Total 100% OIF/OEF/OND 16.7% Persian Gulf War 19.3% Vietnam War 36.0% Korean War 9.5% WW II 5.0% All other periods 13.5% NOTE: Population estimates from the 2015 American Community Survey.
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validated mental health screeners included in the survey, and (2) a survey question about having received a mental health diagnosis from a health care provider in the past 24 months.
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SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017. Results from the individual mental health screeners in the committee's survey showed 23 percent of the veterans screened positive for PTSD, 16 percent screened positive for major depression, and 13 percent screened positive on the Kessler six-item measure of general psychological distress.
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That is, the latter are all more likely to be among those with no need for mental health services. To summarize Tables 6-5 to 6-7, the survey data demonstrate several important relationships between the need for and use of mental health care services among OEF/OIF/OND veterans.
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TABLE 6-6 Percentage of OEF/OIF/OND Veterans by Mental Health Need,* Service Use, and Demographic Characteristics 118 All OEF/OIF/OND Veterans Mental Health Need No Mental Health Need Demographic Characteristics Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Total 4,180 4,179,998 100% – 2,007 1,705,168 100% – 2,157 2,453,388 100% – Mental health service use No use 2,915 3,296,850 79.3% 0.6% 890 941,504 55.2% 1.2% 2,025 2,355,346 96.0% 0.6% VA use 913 515,925 12.4% 0.4% 849 476,654 28.0% 0.9% 64 39,270 1.6% 0.3% Non-VA use only 308 317,086 7.6% 0.5% 256 272,799 16.0% 1.2% 52 44,287 1.8% 0.4% Missing 28 28,694 0.7% 0.2% 12 14,210 0.8% 0.3% 16 14,484 0.6% 0.2% Gender Male 2,946 3,303,305 79.0% 0.8% 1,359 1,312,186 77.0% 1.1% 1,572 1,969,877 80.3% 1.2% Female 1,220 859,250 20.6% 0.8% 642 386,589 22.7% 1.1% 577 472,461 19.3% 1.2% Missing 14 17,442 0.4% 0.1% 6 6,393 0.4% 0.2% 8 11,050 0.5% 0.2% Race/Ethnicity Non-Hispanic white only 2,636 2,762,440 66.1% 0.8% 1,187 1,071,175 62.8% 1.3% 1,441 1,681,093 68.5% 1.0% Non-Hispanic black only 644 537,059 12.8% 0.5% 371 254,662 14.9% 0.8% 271 280,705 11.4% 0.7% Hispanic 503 490,740 11.7% 0.6% 263 223,566 13.1% 1.1% 238 265,738 10.8% 0.5% American Indian/Alaska 109 108,708 2.6% 0.4% 69 54,395 3.2% 0.5% 40 54,313 2.2% 0.5% Native Other or multiple races 240 247,127 5.9% 0.6% 92 86,354 5.1% 0.6% 144 152,630 6.2% 0.7% Missing 48 33,924 0.8% 0.1% 25 15,015 0.9% 0.2% 23 18,909 0.8% 0.2% Education Less than a 4-year 2,204 2,218,603 53.1% 1.0% 1,233 1,086,043 63.7% 1.2% 960 1,117,194 45.5% 1.4% college degree 4-year college degree or 1,969 1,956,133 46.8% 1.0% 770 617,723 36.2% 1.2% 1,194 1,332,334 54.3% 1.4% more Refused 1 796 0.0% 0.0% – – – – 1 796 0.0% 0.0% Don't know 1 463 0.0% 0.0% 1 463 0.0% 0.0% – – – – Missing 5 4,002 0.1% 0.1% 3 938 0.1% 0.0% 2 3,064 0.1% 0.1%
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SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
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who have a positive screen or a reported diagnosis did not perceive a need for mental health services, it seems likely that a major reason for veterans not seeking care is that they personally do not perceive a need for such services. While a veteran's perceptions about whether he or she needs mental health services are not the same as assessed need according to a clinician's diagnosis or a positive result on a screening test, veterans' perceptions are reasonably well correlated with assessed need, in the following sense.
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Columns and rows may not sum to totals due to rounding or due to missing values in perceived need or mental health need. SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
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Sixty percent of veterans with two or more positive screeners or one or more positive screeners and a reported diagnosis perceived a need for mental health care. Logistic regression analysis was used to examine how demographic characteristics and experiences affect the likelihood of having a mental health care need and the perception of a mental health care need, while adjusting for other factors such as race/ethnicity, age, and sex.
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(The regression models discussed later use additional independent variables, which are shown in Table 6-20.) The combat-exposure variable was based on the DRRI Combat Exposure subscale that is discussed in more detail in Chapter 5.
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separately, whether he or she screened positive for specific disorders -- PTSD, depression, alcohol use disorders, and drug use disorders.4 An additional six logistic regression models were fitted using perceived need as the dependent variable; those results are discussed in the next section. 4 Results from the Kessler Screening Scale for Psychological Distress were not included in the regressions because it is not a screener for any specific condition but rather for general psychological distress.
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for the odds ratios. 4,180 unweighted cases initially available, 613 unweighted cases excluded due to missing responses.
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This model included the continuous scores on five screener variables: psychological distress, PTSD, depression, alcohol use disorder, and drug use disorder. These variables were included to examine whether veterans with specific mental health symptoms are more or less likely to have a perceived need, as this likely affects the decision to seek TABLE 6-13 Among All OEF/OIF/OND Veterans, Adjusted Odds Ratios of Having a Perceived Mental Health Care Need (statistically significant variables only)
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Table 6-12 shows the unadjusted odds ratios for the relationship between the continuous screener scores and perceived need. All of the odds ratios are positive and statistically significant, indicating that higher screener scores are associated with a higher probability of perceived need for mental health treatment.
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The site visit interviews reinforced the supposition that a veteran needs to have a significant amount of information to successfully enroll with the VA, starting with the understanding that he or she is, indeed, a "veteran": [It] took me a very, very long time to realize I even qualify as a veteran.
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" Understanding the Veterans Health Administration and the Veterans Benefits Administration Understanding how various benefits and services are organized within the VA system is a major hurdle for many veterans seeking VA care. Across all the sites visited, veterans conveyed confusion about the differences between the VBA and the Veterans Health Administration (VHA)
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Each user group reported on various topics: Among users of VA mental health services • Reasons for using VA services • Experiences with the VA Among non-users of VA mental health services • Reasons for not using VA services Among all veterans who have a mental health need • Ease of use • Availability of mental health services • Obstacles to obtaining services • Attitudes about mental health treatment Users' Perspectives The survey asked VA users of mental health services who have a mental health need about the reasons they use VA mental health services. Table 6-14 summarizes these reasons.
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and a similar percentage (30 percent) did not feel they deserved to receive mental health care benefits from the VA.
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obstacles to getting care, and attitudes about getting mental health treatment. Table 6-16 shows accessibility (measured as travel distance, travel time, and ease of transport)
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SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
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indicated that they lived more than 1 hour from such a facility. While the majority of veterans surveyed live reasonably close to the nearest VA facility offering mental health care, the committee found on its site visits that transportation can be a significant challenge and a barrier for veterans in rural locations.
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SE = standard error of percentage. aPercentage among those estimated 436,969 veterans who had tried to get an appointment with a VA mental health provider in the past 24 months.
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These included age, marital status, employment status, the branch of service, deployment time, and combat exposure. Refer to Table 6-10 above for a list of the core independent variables used in the regression models, including the reference categories for those variables.
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Case management 270 149,124 31.3% 1.6% 146 88,589 18.6% 1.6% 13 5,970 1.3% 0.4% NOTES: Responses may not sum to 100% due to rounding or due to the omission of the percentages of missing or refused in the table. SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
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138 TABLE 6-19 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Used VA Mental Health Services by Opinion Rating with Aspects of VA Mental Health Care Aspects of VA Very or Somewhat Negative Somewhat or Very Positive Refused or Missing Total Mental Health Care Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Wgt N Unwgt n Availability of 279 161,822 33.9% 1.7% 363 203,751 42.7% 1.6% 207 111,081 23.3% 1.5% 476,654 849 needed services Privacy and 88 49,209 10.3% 1.1% 549 306,577 64.3% 1.9% 211 120,597 25.3% 1.9% 476,654 849 confidentiality of medical records Ease of using 239 140,221 29.4% 1.9% 428 236,069 49.5% 2.0% 181 100,093 21.0% 1.8% 476,654 849 VA mental health care Mental health 160 92,679 19.4% 1.5% 468 261,843 54.9% 1.9% 221 122,132 25.6% 2.3% 476,654 849 care staff's skill and expertise Staff's courtesy 140 78,043 16.4% 1.5% 569 319,881 67.1% 2.0% 140 78,731 16.5% 1.9% 476,654 849 and respect toward patients NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted. SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
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Only the independent variables that were statistically significant at the bivariate, or the full-model stage, were included in the final model. Four responses to accessing mental health care survey items were selected as dependent variables for logistic regression analysis: (1)
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, having been encouraged to get help, disability rating, and deployment time. TABLE 6-22 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Adjusted Odds Ratios of Responding That It Is Never Easy to Get Appointments with a VA Mental Health Provider (statistically significant variables only)
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That is, veterans with higher levels of depression or PTSD and those who reported more barriers to care were less satisfied with availability of VA mental TABLE 6-24 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Adjusted Odds Ratios of Responding That They Are Somewhat/Very Dissatisfied with Period of Time from VA Appointment Request to Appointment Date (statistically significant variables only) Variable Variable Value Odds Ratio Lower CL Upper CL Standard Error Age 50+ years old 0.293*
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SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017. TABLE 6-26 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Statistically Significant Predictors of Higher Satisfaction with Availability of Mental Health Providers at the VA Variable Variable Value Estimate Standard Error t-score p-value Depression score Continuous −0.106*
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For items with a "not applicable" response option, Table 6-28 shows results calculated with and without "not applicable" responses in the total N Veterans' attitudes toward the effectiveness of mental health treatment and seeking professional mental health care may be another barrier to getting help.
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concerns that having a documented mental health issue would either cause them to lose their current job, or prevent them from obtaining employment in the future. As shown in Table 6-28 above, among those who indicated the item was applicable to them, 37 percent of the veterans in the committee's survey who had mental health needs reported that seeking mental health services could harm their careers, 36 percent indicated that seeking care would lead to co-workers having less confidence in them if they found out, and 35 percent indicated that it would result in supervisors losing respect or treating them differently.
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SE = standard error of percentage; Unwgt = unweighted; Wgt = Weighted. Rows may not sum to 100% due to the omission of the percentages of missing or refused in the table.
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(For more details about mental health treatment and access to VA health care among National Guard and Reserve forces serving in Iraq and Afghanistan see IOM, 2013, 2014.) Similar to the gun ownership issue discussed below, it is difficult to tease out reality from the rumors that circulate in the veteran community.
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, 21 percent saw this as an obstacle to use VA mental health services. Similarly, interviewees in many site visit locations expressed concern that seeking care and receiving a mental health diagnosis would result in the veteran not being able to own or purchase firearms.
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. Gun Laws and Veteran Treatment Seeking As explained above, under federal and state law a mental health diagnosis absent an involuntary hospitalization or a judicial order does not result in loss of gun ownership rights.
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In particular, Table 6-8 shows that among those veterans with an assessed mental health need and who have a perceived need (19 percent of all veterans, an estimated 800,000) , slightly more TABLE 6-30 Percentage of OEF/OIF/OND Veterans by Mental Health Need and User Group Who Are Somewhat Likely, Likely, and Very Likely to Use VA Mental Health Services in the Future Use of VA Mental Health Services Unweighted n Weighted N Weighted % Likely Standard Error % Need/VA Users (N=473,466)
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Overall, there are no significant differences by user group in the ratings of the importance of ease of the appointment process, better quality services, and better quality customer service, but there are some modest differences between VA users and non-users on the other three variables: VA users consistently rate greater availability of services or facilities as important, and they rate closer and nicer facilities as less important than non-users. While the importance ratings of non-VA users show the same general trends, the sample size for this group is too small to draw reliable conclusions.
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SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted. SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
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, 46 percent of 30- to 39-year-old veterans, and 50 percent of 40- to 49-year-old veterans reported they were willing to use the Internet TABLE 6-33 The Percentage of OEF/OIF/OND Veterans by the Importance of Select Changes the VA Could Make Important Not Important Changes the VA Could Make Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Total 4,180 4,179,998 100% – 4,180 4,179,998 100% – Easier appointment process 3,395 3,331,735 79.7% 0.9% 622 689,116 16.5% 0.9% Better quality services 3,273 3,252,381 77.8% 1.0% 730 755,576 18.1% 0.9% Better quality customer service 3,222 3,200,648 76.6% 0.9% 787 805,185 19.3% 0.8% More available services or facilities 3,177 3,139,848 75.1% 0.9% 835 869,074 20.8% 0.9% Closer facilities 2,663 2,656,245 63.5% 0.6% 1,352 1,353,561 32.4% 0.6% Nicer facilities 2,294 2,331,728 55.8% 1.0% 1,698 1,661,128 39.7% 0.9% NOTES: Weighted % important includes responses of very and moderately important. Weighted % not important includes responses of slightly and not at all important.
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Easier appointment process 726 746,952 79.3% 1.6% 118 143,630 15.3% 1.7% Better quality services 687 723,961 76.9% 1.8% 147 160,366 17.0% 1.8% Better quality customer service 672 706,063 75.0% 1.8% 165 179,504 19.1% 1.7% More available services or facilities 658 694,299 73.7% 1.7% 181 190,960 20.3% 1.7% Closer facilities 567 606,545 64.4% 1.9% 271 280,893 29.8% 1.7% Nicer facilities 464 509,800 54.1% 2.2% 370 375,180 39.8% 2.1% NOTES: Weighted % important includes responses of very and moderately important. Weighted % not important includes responses of slightly and not at all important.
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SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted. SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
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SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted. SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
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Interestingly, longer deployments tended to be associated with lower odds of mental health treatment among those who needed mental health services. The odds of service use decline in a monotonic fashion from the reference group of veterans who were never deployed through categories with a deployment TABLE 6-37 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Adjusted Odds Ratios of Mental Health Service Use (statistically significant variables only)
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for the odds ratios. 1,105 unweighted cases initially available, 257 unweighted cases excluded due to missing responses.
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, and therefore, because many OEF/OIF/OND veterans are males and still quite young, it is conceivable that they may now have a predisposition toward not accessing any health care services at all, including mental health care. A study by Maguen et al.
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Key Characteristics of the Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn Cohort Who Use and Do Not Use the Department of Veterans Affairs Services • Important demographic differences exist between the OEF/OIF/OND veteran population and the overall veteran population (that is, veterans from all eras)
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Need for and Use of the Department of Veterans Affairs Mental Health Care Services • Evidence from the committee's survey suggests the OEF/OIF/OND veteran population potentially has a substantial need for mental health care services. the estimated 4.2 million OEF/OIF/OND veterans, 41 percent screen positive on at least Of one of the mental health screening measures used in the survey or reported that they were told by a health professional that they have a mental health condition.
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Veterans who have a mental health need but do not have a disability rating are substantially less likely to be receiving mental health services than those who do have a disability rating. • OEF/OIF/OND veterans who have a mental health need are more likely to use VA mental health care services than to use non-VA mental health care services.
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of VA users with a mental health care need find the process of getting mental health care to be very or somewhat burdensome. Regression analysis shows that predictors for finding the process of getting mental health care to be very or somewhat burdensome are having insurance, having PTSD, and having a higher barriers score.
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Future Use of the Department of Veterans Affairs Mental Health Services • It is estimated that nearly two-thirds of OEF/OIF/OND veterans indicated that they might use VA mental health care services in the future, although the committee believes that this finding may be overstating future use because only about one-third of veterans who have mental health care need and perceive that they need care use the VA for mental health care services. • Among OEF/OIF/OND veterans who do not plan to use VA mental health care services, the reasons for not doing so include that they prefer to see a non-VA mental health provider (61 percent)
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2014. Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment.
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2014. Prevalence of mental health problems among Iraq and Afghanistan veterans who have and have not received VA services.
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