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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Evaluation of the Department of Veterans Affairs Mental Health Services Committee to Evaluate the Department of Veterans Affairs Mental Health Services Board on Health Care Services Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by Contract/Grant No. VA77713A0009 between the National Academy of Sciences and the U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13:  978-0-309-46657-8 International Standard Book Number-10:  0-309-46657-1 Digital Object Identifier:  https://doi.org/10.17226/24915 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Vet- erans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24915. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies. org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and on the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-reviewed process, and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event con- vened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE TO EVALUATE THE DEPARTMENT OF VETERANS AFFAIRS MENTAL HEALTH SERVICES ALICIA L. CARRIQUIRY (Chair), Iowa State University F. JAY BREIDT, Colorado State University DENNIS M. DONOVAN, University of Washington SUSAN V. EISEN, Boston University School of Public Health (retired) CONSTANTINE GATSONIS, Brown University School of Public Health ROBERT C. GRESEN, Medical College of Wisconsin STEVEN HEERINGA, University of Michigan KENNETH W. KIZER, University of California, Davis JOHN W. KLOCEK, Baylor University (through August 19, 2016) RICHARD A. KULKA, Consultant, Statistical, Survey and Social Research, Raleigh, NC BRUCE G. LINK, University of California Riverside SUSAN M. PADDOCK, RAND Corporation DEBORAH K. PADGETT, New York University BETHANY J. PHOENIX, University of California, San Francisco ROBERT L. SANTOS, The Urban Institute JEANNETTE E. SOUTH-PAUL, University of Pittsburgh THANH V. TRAN, Boston College PETER M. YELLOWLEES, University of California, Davis Study Staff LAURA AIUPPA DENNING, Study Co-Director ABIGAIL MITCHELL, Study Co-Director MARC MEISNERE, Associate Program Officer HEATHER L. CHIARELLO, Research Associate (through October 2016) JOSEPH GOODMAN, Senior Program Assistant CHRISTIE BELL, Financial Officer ROBERT POOL, Editor FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations (through July 2016) SHARYL NASS, Director, Board on Health Care Services (from January 2017) v PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their di- verse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the de- liberative process. We thank the following individuals for their review of this report: Margarita Alegría, Harvard Medical School and Massachusetts General Hospital, Disparities Research Unit Robert A. Barish, University of Illinois at Chicago Jonaki Bose, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services John Boyle, ICF International Babette Brumback, University of Florida Eric Goplerud, NORC at the University of Chicago Joel B. Greenhouse, Carnegie Mellon University Ronald C. Kessler, Harvard Medical School Richard C. Larson, Massachusetts Institute of Technology Richard A McCormick, MetroHealth/Case Western Reserve University Bernadette Mazurek Melnyk, The Ohio State University Harold A. Pincus, Columbia University Terri Tanielian, The RAND Corporation Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final vii PREPUBLICATION COPY—Uncorrected Proofs

viii REVIEWERS draft before its release. The review of this report was overseen by Dan G. Blazer, Duke University School of Medicine, and Bradford H. Gray, The Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Preface Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. Shortly after troops started returning from their deployments, some active-duty service members and veterans began experiencing mental health problems. Given the stressors associated with war, it is not surprising that some service members developed such mental health conditions as posttraumatic stress disorder, depression, and substance use disorder. Subsequent epidemiologic studies conducted on military and veteran populations that served in the operations in Afghanistan and Iraq provided scientific evidence that those who fought were in fact being diagnosed with mental illnesses and experiencing mental health–related outcomes—in particular, suicide—at a higher rate than the general population. Media reports also brought to the nation’s attention problems that veterans were having obtaining timely health care appointments and high-quality care through the Department of Veterans Affairs (VA) health system (that is, the Veterans Health Administration, VHA). Addressing the health needs of the large influx of veterans presented a substantial challenge to the VHA. In the National Defense Authorization Act of 2013, Congress included a mandate for the National Academies of Sciences, Engineering, and Medicine (the National Academies) to conduct a study to assess the VHA’s mental health care services and provide recommendations to assist the VHA with improving its services. The report that follows details the work of the National Academies’ study committee that was appointed to carry out this task. Gathering the evidence on which the committee developed its findings, conclusions, and recom- mendations was an enormous task. We on the committee used a multipronged approach to build the evidence base necessary to complete our work by conducting a survey of veterans who served in the operations in Afghanistan and Iraq; visiting 21 areas of the country to talk with veterans and their fami- lies, VHA employees, and others who work with the veteran population; conducting multiple literature searches; holding public meetings; and obtaining performance data collected by the VA on its mental health services. Those of us on the committee could not have accomplished its task without the assistance of the many people who provided valuable information about the VA and the agency’s mental health services. First and foremost, I would like to thank all of the veterans and their families who took time to tell us ix PREPUBLICATION COPY—Uncorrected Proofs

x PREFACE their stories and about their experiences getting health care at VHA facilities. Their input was critical to the committee’s understanding of their health-related needs. I would like to extend my sincere thanks to several individuals at the VA who assisted us by respond- ing to our many requests for information. Stacy Gavin from the Office of Mental Health and Suicide Prevention effectively coordinated our requests with others at the VA to send us the information we needed in a timely manner. Rani Hoff from the Northeast Program Evaluation Center compiled a complex set of data for the committee from several groups within the VA so that we could conduct the survey of veterans. Dawne Vogt from the VA’s National Center for PTSD assisted the committee with developing a brief instrument to measure combat exposure to include in the committee’s survey of veterans. Over the course of the study, the committee held several public meetings to obtain information from subject-matter experts. We committee members are grateful to have heard from the following people and I thank them for taking time to meet with us: David Carroll, Office of Mental Health and Suicide Prevention, VA Carolyn Clancy, Veterans Health Administration, VA Mike Davies, Access and Clinic Administration Program, VA Peter Duffy, Colonel, US Army (Ret), The National Guard Association of the United States John Fairbank, VISN 6 Mental Illness Research, Education and Clinical Center, VA Warren Goldstein, The American Legion Rani Hoff, Northeast Program Evaluation Center, VA Joy Ilem, Disabled American Veterans Kenneth Jones, Office of Academic Affiliations, VA Daniel Kivlahan, Seattle VA Medical Center Laura Krejci, Office of Patient Centered Care and Cultural Transformation, VA Harold Kudler, Durham VA Medical Center David Latini, Office of Academic Affiliations, VA Thomas Lynch, Veterans Health Administration, VA Jacqueline Maffucci, Iraq and Afghanistan Veterans of America Jennifer Patterson, Office of Patient Centered Care and Cultural Transformation, VA Andrew Pomerantz, Integrated Services, Mental Health Services, VA Stacy Pommer, Office of Academic Affiliations, VA Paula Schnurr, National Center for PTSD, VA Mary Schohn, Office of Mental Health and Suicide Prevention, VA Howard Somers and Jean Somers, Coronado, CA Jodie Trafton, Program Evaluation and Resource Center, VA Janet Vertrees, Office of Patient Centered Care and Cultural Transformation, VA Kendra Weaver, Mental Health Clinical Operations, VA The committee worked closely with Westat, an independent research corporation, on the conduct of the survey of veterans and the site visits. We appreciate the hard work put forth by Westat team members to produce the array of technical products necessary to support the committee’s work. I thank the Westat project director, Shelley Perry, along with her team members. I was honored to chair the committee and lead a group of very knowledgeable and hardworking individuals. Their dedication to this study, which took place over 4 years, is commendable. I would like to thank Thomas Horvath for his committee service during the initial period of the study. I also would like to thank the staff from the National Academies who guided the committee through the study process. PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xi Laura Aiuppa and Abigail Mitchell directed the study and kept us on task. Heather Chiarello and Marc Meisnere assisted the committee with research and with writing the report. Joseph Goodman provided administrative support and handled the logistics for our committee meetings; he made sure that all 16 meetings ran smoothly. Constance Citro, Director of the National Academies’ Committee on National Statistics, and Krisztina Marton provided valuable input on the committee’s survey. Finally, I thank the VA for providing support for this study. We hope that the committee’s recom- mendations will help the VHA to improve mental health care for veterans. Alicia L. Carriquiry, Chair Committee to Evaluate the Department of Veterans Affairs Mental Health Services PREPUBLICATION COPY—Uncorrected Proofs

Contents PREFACE�����������������������������������������������������������������������������������������������������������������������������������������������ix ABBREVIATIONS AND ACRONYMS������������������������������������������������������������������������������������������� xxiii SUMMARY���������������������������������������������������������������������������������������������������������������������������������������������1 Committee’s Approach to Its Charge ������������������������������������������������������������������������������������������������2 Key Findings��������������������������������������������������������������������������������������������������������������������������������������2 Conclusions and Recommendations��������������������������������������������������������������������������������������������������4 1 INTRODUCTION���������������������������������������������������������������������������������������������������������������������������13 Committee’s Charge ������������������������������������������������������������������������������������������������������������������������15 Committee’s Approach to Its Charge ����������������������������������������������������������������������������������������������15 Organization of the Report��������������������������������������������������������������������������������������������������������������16 References  ���������������������������������������������������������������������������������������������������������������������������������������17 2 THE VETERANS HEALTH ADMINISTRATION������������������������������������������������������������������������19 Transition from Active Duty to Veteran Status �������������������������������������������������������������������������������19 Eligibility and Enrollment���������������������������������������������������������������������������������������������������������������20 The Veterans Health Administration Organizational Structure�������������������������������������������������������21 Mental Health Services in the Broader U.S. Health Care Sector Compared   to the Veterans Health Administration ����������������������������������������������������������������������������������������22 References  ���������������������������������������������������������������������������������������������������������������������������������������24 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS 3 THE VETERANS HEALTH ADMINISTRATION’S MENTAL HEALTH SERVICES���������������27 Mental Health–Related Programs and Services������������������������������������������������������������������������������29 Programs and Centers Supporting Quality of Mental Health Services�������������������������������������������35 Summary������������������������������������������������������������������������������������������������������������������������������������������40 References ���������������������������������������������������������������������������������������������������������������������������������������41 4 CLINICAL MANAGEMENT OF MENTAL HEALTH CONDITIONS AT THE VETERANS HEALTH ADMINISTRATION ������������������������������������������������������������������45 Mental Health Conditions in Operation Enduring Freedom, Operation Iraqi Freedom, and   Operation New Dawn Veterans ���������������������������������������������������������������������������������������������������46 Screening, Assessment, and Treatment �������������������������������������������������������������������������������������������58 Summary������������������������������������������������������������������������������������������������������������������������������������������71 References����������������������������������������������������������������������������������������������������������������������������������������71 5 METHODOLOGY ��������������������������������������������������������������������������������������������������������������������������79 Approach  �����������������������������������������������������������������������������������������������������������������������������������������79 Survey Methods�������������������������������������������������������������������������������������������������������������������������������80 Site Visit Methods ���������������������������������������������������������������������������������������������������������������������������91 Literature Review Methods�������������������������������������������������������������������������������������������������������������99 Study Limitations ����������������������������������������������������������������������������������������������������������������������������99 References  �������������������������������������������������������������������������������������������������������������������������������������102 6 DEPARTMENT OF VETERANS AFFAIRS MENTAL HEALTH SERVICES: NEED, USAGE, AND ACCESS AND BARRIERS TO CARE���������������������������������������������������103 Eligibility and Priority for Department of Veterans Affairs Health Care Services�����������������������104 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���������������������������������������������������������������������������108 Need for and Use of Department of Veterans Affairs Health Care Services ��������������������������������116 Barriers and Facilitators to Service Use����������������������������������������������������������������������������������������127 Barriers: Individual Factors�����������������������������������������������������������������������������������������������������������143 Factors That May Influence Future Use����������������������������������������������������������������������������������������149 Summary����������������������������������������������������������������������������������������������������������������������������������������159 References  �������������������������������������������������������������������������������������������������������������������������������������163 7 DIMENSIONS OF QUALITY IN MENTAL HEALTH CARE���������������������������������������������������167 Defining Health Care Quality��������������������������������������������������������������������������������������������������������167 Integrated Systems Approach to Quality���������������������������������������������������������������������������������������168 System Transformation in the Department of Veterans Affairs�����������������������������������������������������170 Report Framework ������������������������������������������������������������������������������������������������������������������������170 References  �������������������������������������������������������������������������������������������������������������������������������������172 8 MENTAL HEALTH WORKFORCE AND FACILITIES INFRASTRUCTURE ������������������������175 Mental Health Workforce��������������������������������������������������������������������������������������������������������������175 Physical Infrastructure�������������������������������������������������������������������������������������������������������������������189 Geographic Access ������������������������������������������������������������������������������������������������������������������������192 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xv Summary����������������������������������������������������������������������������������������������������������������������������������������194 References  �������������������������������������������������������������������������������������������������������������������������������������195 9 TIMELY ACCESS TO MENTAL HEALTH CARE���������������������������������������������������������������������199 Wait Times and Scheduling Care at the VA ����������������������������������������������������������������������������������199 Programs to Improve Timely Access to VHA Care ����������������������������������������������������������������������209 Practices to Facilitate Timely Access��������������������������������������������������������������������������������������������216 Summary����������������������������������������������������������������������������������������������������������������������������������������218 References��������������������������������������������������������������������������������������������������������������������������������������219 10 PATIENT-CENTERED CARE AND THE VETERAN EXPERIENCE���������������������������������������221 Patient-Centered Care at the Veterans Health Administration ������������������������������������������������������222 Veteran Experiences with Receiving Mental Health Care at the   Veterans Health Administration�������������������������������������������������������������������������������������������������224 Summary����������������������������������������������������������������������������������������������������������������������������������������230 References  �������������������������������������������������������������������������������������������������������������������������������������231 11 EFFECTIVE MENTAL HEALTH CARE ������������������������������������������������������������������������������������233 Availability of Evidence-Based Practices for Mental Health in the   Department of Veterans Affairs�������������������������������������������������������������������������������������������������233 Delivery of Mental Health Care in the Veterans Health Administration ��������������������������������������236 Summary����������������������������������������������������������������������������������������������������������������������������������������247 References  �������������������������������������������������������������������������������������������������������������������������������������248 12 EFFICIENT MENTAL HEALTH CARE��������������������������������������������������������������������������������������253 Mental Health Workforce Tracking and Efficiency�����������������������������������������������������������������������253 Care Integration and Collaboration�����������������������������������������������������������������������������������������������254 Findings from the Committee’s Site Visits �����������������������������������������������������������������������������������260 Summary����������������������������������������������������������������������������������������������������������������������������������������262 References  �������������������������������������������������������������������������������������������������������������������������������������263 13 EQUITABLE MENTAL HEALTH CARE �����������������������������������������������������������������������������������265 Disparities in Diagnosis�����������������������������������������������������������������������������������������������������������������265 Treatment Disparities���������������������������������������������������������������������������������������������������������������������266 Access to Mental Health Care Services for Select Populations����������������������������������������������������267 The Department of Veterans Affairs Office of Health Care Equity ����������������������������������������������282 Stigma��������������������������������������������������������������������������������������������������������������������������������������������282 Reducing Stigma ���������������������������������������������������������������������������������������������������������������������������285 Summary����������������������������������������������������������������������������������������������������������������������������������������286 References��������������������������������������������������������������������������������������������������������������������������������������287   14 HEALTH TECHNOLOGY FOR MENTAL HEALTH CARE�����������������������������������������������������293 Electronic Health Record ��������������������������������������������������������������������������������������������������������������293 Telemedicine����������������������������������������������������������������������������������������������������������������������������������294 Other Health Technology in Use at the Department of Veterans Affairs��������������������������������������301 Technological Barriers in the Department of Veterans Affairs �����������������������������������������������������305 PREPUBLICATION COPY—Uncorrected Proofs

xvi CONTENTS Summary����������������������������������������������������������������������������������������������������������������������������������������306 References��������������������������������������������������������������������������������������������������������������������������������������307 15 QUALITY MANAGEMENT��������������������������������������������������������������������������������������������������������311 Quality Measurement���������������������������������������������������������������������������������������������������������������������311 Mental Health Care Quality Measurement in the Department of Veterans Affairs System����������313 Quality Improvement Innovations�������������������������������������������������������������������������������������������������317 Summary����������������������������������������������������������������������������������������������������������������������������������������318 References��������������������������������������������������������������������������������������������������������������������������������������319 16 FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS���������������������������������������������������321 Key Findings ���������������������������������������������������������������������������������������������������������������������������������321 Conclusions and Recommendations����������������������������������������������������������������������������������������������326 References �������������������������������������������������������������������������������������������������������������������������������������334 APPENDIXES A SUPPORTING DOCUMENTATION FOR THE SURVEY����������������������������������������������������������335 B SUPPORTING DOCUMENTATION FOR THE SITE VISITS���������������������������������������������������417 PREPUBLICATION COPY—Uncorrected Proofs

Boxes, Figures, and Tables BOXES 6-1 Department of Veterans Affairs Priority Groups 106 12-1 Integration Framework 255 12-2 Stepped-Care Model for Mental Health at the VHA 258 FIGURES 3-1 Algorithm to determine appropriate placement of veterans within the system of mental health care at the Department of Veterans Affairs. 28 5-1 Flowchart of questionnaire modules. 85 5-2 Data collection plan as originally designed. 87 5-3 Map showing approximate Department of Veterans Affairs medical center location for each site visit. 95 5-4 Number and percentage of interviews and group discussions by venue. 96 5-5 Number and percentage of participants by type. 97 5-6 Number and percentage of veteran participants by service branch. 98 6-1 Number of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans versus number of non-OEF/OIF/OND veterans enrolled in each Department of Veterans Affairs (VA) priority group in FY 2016. 108 xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii BOXES, FIGURES, AND TABLES 6-2 Number of OEF/OIF/OND veterans enrolled in each VA priority group versus number of OEF/OIF/OND veterans enrolled and using VA health care services in FY 2016. 109 6-3 Veteran population by Veterans Integrated Service Network, FY 2015. 114 9-1 Actual versus VA calculated wait time for mental health appointments. 204 11-1 Average number of veteran mental health visits for fiscal years 2013–2017. 242 12-1 Continuum of VA mental health services. 259 15-1 VHA Mental Health Management System Framework. 315 TABLES 3-1 MIRECCs in the VHA 36 3-2 VA Centers of Excellence 37 3-3 National Center for Posttraumatic Stress Disorder Focus Areas by Division 39 4-1 Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for PTSD 48 4-2 Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for Substance Use Disorders (SUDs) 50 4-3 Prevalence of Mental Health Conditions and Suicide Rates in Veteran and Non-Veteran Populations 52 4-4 Example of the Scope of Mental Health Practice for Five Main Types of Health Care Providers 59 4-5 Mental Health Screening in the VA 61 5-1 Second-Phase Stratification and Sample Sizes 82 5-2 Timeline of Actual Data Collection Activities 88 5-3 Final Survey Status at End of Data Collection 88 5-4 Final Survey Completes, by User and Need Status 89 5-5 Five Raking Cells 91 5-6 Site Visit Data Collection Modality and Location by Respondent Type 93 5-7 Sites and Dates of Site Visits (in Order by VISN Number) 94 6-1 Survey Estimates of the Demographic Characteristics of the OEF/OIF/OND Veteran Population (population size about 4.1 million) 111 6-2 Survey Estimates of the Military Characteristics of the OEF/OIF/OND Veteran Population (population size about 4.1 million) 112 6-3 Percent of U.S. Armed Forces Veterans by Service Era 114 6-4 Six States with Largest Populations of OEF/OIF/OND Veterans 115 6-5 Percentage of OEF/OIF/OND Veterans Who Have a Mental Health Need by Screener and/or Received a Mental Health Diagnosis 116 6-6 Percentage of OEF/OIF/OND Veterans by Mental Health Need, Service Use, and Demographic Characteristics 118 PREPUBLICATION COPY—Uncorrected Proofs

BOXES, FIGURES, AND TABLES xix 6-7 Description of Service Use Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Use Mental Health Services 120 6-8 Percentage of OEF/OIF/OND Veterans by Mental Health Need, Perceived Need, and User Group 121 6-9 Perceived Need for Mental Health Care Among OEF/OIF/OND Veterans Who Screened Positive on a Mental Health Screener or Who Reported a Mental Health Diagnosis 123 6-10 Core Independent Variables Used in the Multivariate Analyses 124 6-11 Among All OEF/OIF/OND Veterans, Adjusted Odds Ratios of Having a Mental Health Care Need (statistically significant variables only) 125 6-12 Among All OEF/OIF/OND Veterans, Unadjusted Odds Ratios of Having a Perceived Mental Need by Mental Health Screener Scores (statistically significant variables only) 126 6-13 Among All OEF/OIF/OND Veterans, Adjusted Odds Ratios of Having a Perceived Mental Health Care Need (statistically significant variables only) 126 6-14 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Use VA Services, the Percentage Who Strongly or Somewhat Agree with Reasons for Using VA Services 131 6-15 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Do Not Use VA Services (Users of Non-VA Services and Nonusers of Any Mental Health Services), the Percentage Who Agreed with Various Reasons for Not Using Services 132 6-16 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Geographic Accessibility to the Nearest VA Facility That Offers Mental Health Services 133 6-17 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Use VA Mental Health Services (an estimated 476,654 veterans), Attitudes on Access to Care and Availability of Mental Health Care 135 6-18 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Used VA Mental Health Services Satisfaction with Availability of Mental Health Providers and Services at the VA 137 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 138 6-20 Additional Independent Variables Included in the Regression Models 139 6-21 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Adjusted Odds Ratios of Responding That the Process of Obtaining Mental Health Care Through the VA Is Very/Somewhat Burdensome (statistically significant variables only) 140 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) 140 6-23 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Adjusted Odds Ratios of Responding That They Are Never Able to Get VA Mental Health Care on Evenings, Weekends, or Holidays (statistically significant variables only) 141 PREPUBLICATION COPY—Uncorrected Proofs

xx BOXES, FIGURES, AND TABLES 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) 141 6-25 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Statistically Significant Predictors of Higher Satisfaction with Availability of Primary Care, General Mental Health, and Specialized Mental Health Services at the VA 142 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 142 6-27 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, Statistically Significant Predictors of Higher Satisfaction with Availability of Mental Health Services at the VA (medication management, psychotherapy, group therapy, emergency services, case management) 142 6-28 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, the Percentage Reporting Obstacles to Using Mental Health Services 144 6-29 Among OEF/OIF/OND Veterans Who Have a Mental Health Need, the Percentage Who Agree or Disagree with Statements About Getting Mental Health Care 145 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 149 6-31 Among OEF/OIF/OND Veterans Who Are Not at All Likely to Use VA Mental Health Services in the Future Even If in Need, the Percentage Who Agree with Select Reasons by Use Groups 151 6-32 Among OEF/OIF/OND Veterans Who Have a Mental Health Need and Not at All Likely to Use VA Mental Health Services in the Future Even If in Need, the Percentage Who Agree with Select Reasons 152 6-33 The Percentage of OEF/OIF/OND Veterans by the Importance of Select Changes the VA Could Make 152 6-34 The Percentage of OEF/OIF/OND Veterans by the Importance of Select Changes the VA Could Make, by User Group 153 6-35 The Percentage of OEF/OIF/OND Veterans by Their Likelihood of Mode of Future VA Mental Health Service Use 154 6-36 The Percentage of OEF/OIF/OND Veterans Within Each Age Category by Their Likelihood of Mode of Future VA Mental Health Service Use 155 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) 156 6-38 Among OEF/OIF/OND Veterans Who Use Mental Health Care, the Adjusted Odds Ratios of Using the VA for Their Mental Health Care 157 7-1 MyVA 2016 Priorities 170 7-2 Types of Quality Assessment Questions  171 PREPUBLICATION COPY—Uncorrected Proofs

BOXES, FIGURES, AND TABLES xxi 8-1 VHA Mental Health Position Vacancy Rates 176 8-2 VA Mental Health Training Slots by Profession, Expansion Since 2013/2014 and Current Total (as of May 31, 2017) 180 8-3 Psychotherapies in VA Dissemination and Implementation Model 183 8-4 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, VA and Non-VA Users’ Experiences of Mental Health Care 186 8-5 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Perceived Local Availability of Mental Health Services 187 8-6 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Perceived Local Availability of Mental Health Services, by User Group 188 8-7 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, Reported Ability to See the Same Mental Health Provider, by User Group 188 8-8 Among OEF/OIF/OND Veterans Who Have Mental Health Needs, VA and Non-VA Users’ Perceptions of the VA Facility 191 10-1 Experience of Care Among OEF/OIF/OND Veterans Who Use VA Mental Health Services 225 10-2 Statistically Significant Predictors of Mental Health Outcomes 226 11-1 National Evidence-Based Psychotherapy Dissemination and Implementation Model in the Department of Veterans Affairs 235 13-1 Among Men and Women 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 Services 271 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) 274 PREPUBLICATION COPY—Uncorrected Proofs

Abbreviations and Acronyms A/PI Asian/Pacific Islander ACA Patient Protection and Affordable Care Act ACT acceptance and commitment therapy AI/AN American Indian/Alaska Native APPN advanced practice psychiatric nurse ATP asynchronous telepsychiatry AUDIT Alcohol Use Disorder Identification Test BHIP Behavioral Health Interdisciplinary Program CAPS Clinician-Administered PTSD Scale CBOC community-based outpatient center CBT cognitive behavioral therapy CCHT care coordination home telehealth CDC Centers for Disease Control and Prevention CIH complementary and integrative health CPG clinical practice guideline CPT cognitive processing therapy CVT clinical videoconferencing technology CWT compensated work therapy CWT-TR compensated work therapy-transitional residence DAST Drug Abuse Screening Test DBT dialectical behavior therapy DCHV domiciliary care for homeless veterans xxiii PREPUBLICATION COPY—Uncorrected Proofs

xxiv ABBREVIATIONS AND ACRONYMS DoD Department of Defense Dom SA domiciliary substance abuse DRRI Deployment Risk and Resilience Inventory DRRTP Domiciliary Residential Rehabilitation and Treatment Program DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition EBP evidence-based practice ECT electroconvulsive therapy ED emergency department EHR electronic health record FDA Food and Drug Administration FRCP Federal Recovery Coordination Program FTE full-time equivalent FY fiscal year GAD generalized anxiety disorder GAO Government Accountability Office GPD Grant and Per Diem HCHV Health Care for Homeless Veterans HCRV Health Care for Re-entry Veterans HUD Department of Housing and Urban Development HUD-VASH Department of Housing and Urban Development-Department of Veterans Affairs Supportive Housing ICD-9 International Classification of Diseases, Ninth Revision IOM Institute of Medicine IOP intensive outpatient program IPT interpersonal therapy IT information technology LCSW licensed clinical social worker LGBT lesbian, gay, bisexual, transgender LPC licensed professional counselor LRC local recovery coordinator MA matched attention (health education control intervention) MAOI monoamine oxidase inhibitor MDD major depressive disorder MFT marriage and family therapist MH RRTP Mental Health Residential Rehabilitation Treatment Program MHEE mental health education expansion MHICM mental health intensive case management MHIS Mental Health Information System MHMS Mental Health Management System PREPUBLICATION COPY—Uncorrected Proofs

ABBREVIATIONS AND ACRONYMS xxv MIRECC Mental Illness Research, Education, and Clinical Center MSA medical support assistant MST military sexual trauma NCPTSD National Center for Posttraumatic Stress Disorder NDAA National Defense Authorization Act NIAAA National Institute on Alcohol Abuse and Alcoholism NQF National Quality Forum NSDUH National Survey on Drug Use and Health OAT opioid-agonist treatment OEF Operation Enduring Freedom OHE Office of Health Equity OIF Operation Iraqi Freedom OMHSP Office of Mental Health and Suicide Prevention OND Operation New Dawn OPCC&CT Office of Patient Centered Care and Cultural Transformation OSI Opioid Safety Initiative OTH other than honorable (discharge) OTP opioid treatment program PACT Patient Aligned Care Team PAM Patient Activation Measure PC-PTSD Primary Care PTSD screen PC3 Patient-Centered Community Care PCL(-M) PTSD checklist (Military) PCMH patient-centered medical home PC-MHI primary care-mental health integration PCP primary care physician PCT present-centered therapy PDSI Psychotropic Drug Safety Initiative PE prolonged exposure (therapy) PERC Program Evaluation and Resource Center PET prolonged exposure therapy PHQ Patient Health Questionnaire PII personally identifiable information PRRC psychosocial rehabilitation and recovery center PRRTP Psychosocial Residential Rehabilitation Treatment Program PST problem-solving therapy PTSD posttraumatic stress disorder QI quality improvement QUERI Quality Enhancement Research Initiative RANGE Rural Access Network for Growth and Enhancement RCT randomized clinical trial PREPUBLICATION COPY—Uncorrected Proofs

xxvi ABBREVIATIONS AND ACRONYMS RRTP residential rehabilitative treatment program SAIL Strategic Analytics for Improvement and Learning SARRTP Substance Abuse Residential Rehabilitative Treatment Program SeRV-MH Services for Returning Veterans-Mental Health SIT stress inoculation training SMI serious mental illness SMITREC Serious Mental Illness Research and Evaluation Center SNRI serotonin norepinephrine reuptake inhibitor SoCRR Social and Community Reintegration Research SPAN Suicide Prevention Applications Network (of the VA) SSN Social Security number SSRI selective serotonin reuptake inhibitor SSVF Supportive Services for Veteran Families STEPS-UP Stepped Enhancement of PTSD Services Using Primary Care SUD substance use disorder TAP Transition Assistance Program TBI traumatic brain injury TCA tricyclic antidepressant TLC time-limited care (coordination intervention) TOP Telemedicine Outreach for PTSD UBHC Unified Behavioral Health Center VA Department of Veterans Affairs VABHS VA Boston Healthcare System VACO Department of Veterans Affairs Central Office VAMC Department of Veterans Affairs medical center VAR veteran appointment request VBA Veterans Benefits Administration VCCE VA Medical Center Call Center Expansion (project) VCL Veterans Crisis Line VCP Veterans Choice Program VHA Veterans Health Administration VISN Veterans Integrated Service Network VSE VistA Scheduling Enhancements WTU warrior transition unit PREPUBLICATION COPY—Uncorrected Proofs

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Evaluation of the Department of Veterans Affairs Mental Health Services Get This Book
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Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. Shortly after troops started returning from their deployments, some active-duty service members and veterans began experiencing mental health problems. Given the stressors associated with war, it is not surprising that some service members developed such mental health conditions as posttraumatic stress disorder, depression, and substance use disorder. Subsequent epidemiologic studies conducted on military and veteran populations that served in the operations in Afghanistan and Iraq provided scientific evidence that those who fought were in fact being diagnosed with mental illnesses and experiencing mental health–related outcomes—in particular, suicide—at a higher rate than the general population.

This report provides a comprehensive assessment of the quality, capacity, and access to mental health care services for veterans who served in the Armed Forces in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn. It includes an analysis of not only the quality and capacity of mental health care services within the Department of Veterans Affairs, but also barriers faced by patients in utilizing those services.

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