Evaluation of the Department of Veterans Affairs Mental Health Services (2018) / Chapter Skim
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11 Effective Mental Health Care
11 Effective Mental Health Care
Pages 233-252
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provides evidence-based mental health treatments to veterans, this chapter examines the availability of evidence-based practices in the VA system, the quality of mental health providers, and the provision of mental health care to veterans. The section dealing with that third issue examines whether veterans are receiving adequate treatment, the factors associated with receiving treatment, and patient engagement in care.
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recommended in various VA and Department of Defense (DoD) clinical practice guidelines for the management of veterans seeking VA care for posttraumatic stress disorder (PTSD)
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In addition to OSI, the VA is implementing a new clinical practice guideline to evaluate, treat, and manage patients with chronic pain who are on or being considered for long-term opioid therapy. The VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain, Version 3.0 -- 2017 is based on evidence reviewed through December 2016 and replaces the 2010 VA/DoD guideline for opioid therapy (Opioid Therapy Chronic Pain Work Group, 2017)
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DELIVERY OF MENTAL HEALTH CARE IN THE VETERANS HEALTH ADMINISTRATION Despite the availability of effective treatments, millions of Americans who might benefit from treatment are not seeking treatment or are not receiving adequate treatment. Studies show that gaps in the use of effective treatments exist in both general health care and mental health care and in both the civilian and veteran health systems (Cook and Wiltsey-Stirman, 2015; Farmer et al., 2016; Harpaz-Rotem and Rosenheck, 2011; Watkins et al., 2015)
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. In these evaluations, the common treatment standards used were the VA/DoD clinical practice guidelines (refer to Chapter 4)
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Summarized below are findings from studies the committee reviewed that assess the degree to which patients are receiving evidence-based care as well as factors associated with initiation and retention in treatment. Posttraumatic Stress Disorder Spoont et al.
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The VA Clinical Practice Guidelines for SUD (VA and DoD, 2009) state that "addiction-focused pharmacotherapy should be considered, available, and offered if indicated for all patients with opioid dependence and/or alcohol dependence." Another study of 4,270 veterans who were 18 to 30 years of age and treated at VA Palo Alto Health Care System found that only 31 percent of veterans receiving prescription opioids underwent drug testing while on the drugs (Wu et al., 2010)
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Vietnam veterans, even after controlling for differences in the treatment presentation. Other factors that have been found to predict treatment initiation, retention, or greater concordance with guidelines include being white, being female, living less than 30 miles from a facility, having a recent major health event, having three or more medical comorbidities, having greater PTSD symptom severity, having depressive symptoms, having more severe alcohol use disorder comorbid with traumatic brain injury and PTSD, and having low social support (Grossbard et al., 2013; Harpaz-Rotem et al., 2014; Morgan et al., 2012; Pfeiffer et al., 2011; Zivin et al., 2009)
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(2008) studied perceived barriers to mental health treatment among veterans with schizophrenia, bipolar disorder, and major depression.
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Similar to the Harpaz-Rotem and Rosenheck study cited above, being older and Caucasian was found to be predictive of retention. Marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity were not predictive of retention.
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relating to patients' satisfaction with their relationships with treatment providers as well as findings from the site visits suggest that VA users generally experience positive treatment relationships with their providers. However, it was apparent from some site visit data that factors external to the treatment relationship (for example, frustrations with parking, limitations on the frequency of treatment sessions, frequent provider changes)
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. In the site visit interviews, VA clinical staff reported implementing evidence-based treatments "with flexibility" in an effort to retain veterans in therapy.
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(2012) found that the dissemination of a clinical reminder along with a brief intervention for alcohol misuse was associated with increased adoption of brief intervention for veterans who screened positive for alcohol misuse.
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These data are useful for studies examining the impact of treatment on health status and other patient outcomes. In addition, the VA has a goal for 2016–2018 to complete the development of and to release phase I of the Mental Health Quality and Clinical Outcomes Reporting System, a comprehensive tracking system that will allow providers to track the flow of their patients through mental health care and monitor their outcomes with standardized patient-reported outcome measures (VA, 2016)
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Positive outcomes reported in site visit interviews are echoed in our survey results in which 63 percent of survey respondents who used VA mental services indicated that their VA mental health providers helped them either some or a lot, and 65 percent reported that they found the effect of care on their quality of life at least a little helpful. Additional details regarding veteran perspectives on outcomes of care are reported in Chapter 10, Table 10-1.
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to monitor individual health status, but systematic clinical outcomes data are not collected for many mental health conditions, and data on functional outcomes are not systematically collected from veterans at all. • The VA recently implemented a clinical progress template in the medical record to advance efforts to systematically assess treatment delivery, treatment fidelity, and patient outcomes.
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2013. Follow-up care for alcohol misuse among OEF/OIF veterans with and without alcohol use disorders and posttraumatic stress disorder.
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2011. Perceived barriers to care among Veterans Health Administration patients with posttraumatic stress disorder.
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2014. Implementation of evidence based psychotherapies for posttraumatic stress disorder in VA specialty clinics.
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