Evaluation of the Department of Veterans Affairs Mental Health Services (2018) / Chapter Skim
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13 Equitable Mental Health Care
13 Equitable Mental Health Care
Pages 265-292
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From page 265... ...
DISPARITIES IN DIAGNOSIS A 2007 systematic review of racial and ethnic disparities in the VA health care system noted findings from several studies that black and Hispanic patients were more frequently diagnosed with and treated for psychotic disorders (for example, schizophrenia) , while white veterans were more frequently diagnosed with and treated for affective disorders (for example, bipolar disorder and depression)
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Other differences included American Indian and Alaskan Native (AI/AN) male veterans who were more likely to be diagnosed with alcohol and drug use disorders than white veterans.
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This finding is supported by other research on the topic, which has found that black veterans are more likely than white veterans to not adhere to antidepressants (Chermack et al., 2008) and that among civilians, minority groups (other than AI/AN)
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From page 268... ...
. Access for Women Veterans In response to the growing number of female veterans, the VA has instituted a policy that helps address the needs of women seeking mental health services.
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. Women veterans with delayed care were more likely to be OEF and OIF veterans and were more likely to have experienced military sexual trauma (MST)
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. The committee also analyzed data from its survey of veterans to assess the obstacles to using mental health care services reported by OEF/OIF/OND veterans who had mental health needs but did not use mental health services.
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Many female veterans reported being "cat-called" while in VA facilities. Unwanted sexual attention can be particularly unsettling for female veterans who have been traumatized by MST.
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Interactions with office staff were worse for Hispanic, AI/AN, and A/PI veterans than for white veterans, indicating that these veterans may be at particular risk for poor interpersonal experiences while interacting with VA staff at their appointments. Black veterans reported more positive experiences with self-management support than did white veterans, suggesting that PCMH providers may be better engaging some minorities in that domain.
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From page 273... ...
Also compared to non-Hispanic white veterans, a higher percentage of non-Hispanic black veterans indicated they were not aware of VA mental health care benefits and that they did not know how to apply for VA mental health care benefits were reasons for not using the VA. The committee also analyzed data from its survey of veterans to assess obstacles to using mental health care services reported by non-Hispanic white, non-Hispanic black, and Hispanic OEF/OIF/OND veterans who had mental health needs but reported they did not use any mental health services.
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From page 274... ...
274 TABLE 13-2 Among OEF/OIF/OND Veterans Who Have Mental Health Needs and Do Not Use Mental Health Services, the Percentage Who Agreed with Various Reasons for Not Using VA Services by Race/Ethnicity (selected races) Non-Hispanic White Only Non-Hispanic Black Only Hispanic Reasons Veterans Do Not Use VA Mental Health Services Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Unwgt n Wgt N Wgt % SE % Total 729 792,537 – – 174 157,266 – – 146 159,142 – – Do not know how to apply for VA 247 311,947 39.4% 2.4% 75 75,340 47.9% 3.8% 56 69,742 43.8% 5.7% mental health care benefits Do not believe entitled or eligible for 217 307,401 38.8% 2.1% 55 56,121 35.7% 4.6% 53 67,359 42.3% 4.3% VA mental health care benefits Use other sources of mental health care 236 271,274 34.2% 1.8% 45 39,510 25.1% 4.1% 47 48,222 30.3% 4.1% Not aware VA offer mental health care 174 227,887 28.8% 2.5% 62 69,909 44.5% 5.6% 44 57,858 36.4% 5.3% benefits Do not need care 222 246,698 31.1% 1.9% 41 44,534 28.3% 5.0% 45 55,115 34.6% 4.7% Feel do not deserve to receive mental 170 230,426 29.1% 1.8% 41 39,802 25.3% 4.3% 47 54,558 34.3% 3.3% health care benefits from the VA Do not trust the VA 223 224,366 28.3% 1.9% 52 44,528 28.3% 5.4% 48 49,490 31.1% 4.9% Some other reason 192 194,731 24.6% 2.1% 54 45,201 28.7% 3.8% 49 44,498 28.0% 4.8% Had a bad prior experience at the VA 176 170,298 21.5% 1.6% 46 34,687 22.1% 5.1% 45 42,278 26.6% 4.1% Do not feel welcome at the VA 122 121,315 15.3% 1.6% 37 34,947 22.2% 4.8% 40 41,672 26.2% 4.0% Do not want assistance from the VA 130 135,362 17.1% 1.1% 30 26,157 16.6% 3.6% 30 29,418 18.5% 3.4% NOTES: All response options and missing are included in the denominators of the percentages.
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From page 275... ...
Even after the authors adjusted for differences in veterans' PTSD severity, service characteristics, physical functioning, age, gender, education, medical comorbidities, combat exposure, and sexual assault status, the difference still held up -- 43 percent of black veterans in the study received a service-connected disability rating versus 56 percent of white veterans (p = 0.003)
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. AIAN veterans have 1.9 higher odds of being uninsured than non-Latino white veterans (Johnson et al., 2010)
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of veterans who had received a mental health diagnosis and had used primary or mental health outpatient care between 2001 and 2012. Black women and men used emergency services at a higher rate than their white counterparts, while Asian/Pacific Islander men and women veterans used emergency services at a lower rate than white veterans.
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From page 278... ...
Past-year use was predicted by female gender, positive service connection, positive screen for PTSD and depression, lower physical functioning, a history of at least one military interpersonal trauma during military service related to LGB status, and having no history of stressful experiences initiated by the military regarding LGB status. Nearly 75 percent of those who reported never seeking services from the VA said that they had other health insurance (Simpson et al., 2013)
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. Military sexual trauma is a well-documented risk factor for PTSD, depression, and substance abuse in women and men (Kimerling et al., 2011; Suris and Lind, 2008)
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Disproportionately from the Vietnam era, homeless veterans were likely to be male, of older age, and to have multiple comorbidities (mental, physical, substance abuse) that made support services an essential component of the program (Tsai and Rosenheck, 2015)
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The higher use of services among the homeless group suggests that homelessness is a barrier to care in that the homeless veterans in this cohort were more likely to delay or defer the treatment of both medical and mental health conditions than the housed veterans (O'Toole et al., 2013)
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. In the site visit interviews, veterans reported stigma associated with seeking medical care, particularly for mental health issues, that is a carryover from active duty.
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The 812 participants who were included in the analysis averaged 28.26 years old. The authors found that those veterans who associated seeking care with greater levels of public stigma were less likely to take part in mental health treatments.
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. A 2015 literature review showed, however, that National Guard and Reservists tend to report lower rates of stigma related to seeking mental health care than their active-duty counterparts (Sharp et al., 2015)
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which demonstrated a similar association between a positive screen for a psychiatric disorder and greater reported stigma and barriers to care among OEF/OIF veterans. REDUCING STIGMA Veterans with mental health conditions often encounter or perceive stigma that may affect their use of mental health services.
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From page 286... ...
• Select population groups, including women, racial and ethnic minorities, and homeless veterans face unique barriers to care compared with male, white, and housed veterans. • Women veterans are generally in better health than their male counterparts, and they tend to seek care at a higher rate than men.
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From page 287... ...
• Compared to non-Hispanic white veterans, a higher percentage of both non-Hispanic black and Hispanic veterans indicated that they did not use VA mental health services because they did not feel welcome at the VA. • While the findings showed some variation, minority veterans may be less likely to use services and they may be more likely to report worse experiences obtaining services than white veterans.
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From page 288... ...
2016. The association between military sexual trauma and use of VA and non-VA health care services among female veterans with military service in Iraq or Afghanistan.
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2007. Assisting American Indian veterans of Iraq and Afghanistan cope with posttraumatic stress disorder: Lessons from Vietnam veterans and the writings of Jim Northrup.
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2011. Military sexual trauma and patient perceptions of Veterans Health Administration health care quality.
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2012. Gender differences in military sexual trauma and mental health diagnoses among Iraq and Afghanistan veterans with posttraumatic stress disorder.
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2012b. Healthcare inspection: Inpatient and residential programs for female veterans with mental health conditions related to military sexual trauma.
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