Equitable mental health care requires that different populations and subgroups of users be afforded equal access to care within a given system. Sociocultural barriers such as stigma and discrimination affect access for various populations, including racial, ethnic, and sexual minority groups and also groups with special needs, such as the homeless. For example, if a health system user or (potential user) perceives or experiences discrimination from a provider or from the public, the experience may discourage the user from seeking services. This chapter summarizes recent studies that examine racial and ethnic disparities in mental health diagnosis and treatment provided by the Department of Veterans Affairs (VA) as well as in adherence to care among veterans. It also addresses issues affecting women veterans. The chapter describes the access and stigma issues faced by various select population groups and relevant findings from this study’s survey and site visits.
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) (Saha et al., 2007). According to VA data, minority veterans also are more likely to have a posttraumatic stress disorder (PTSD) diagnosis than non-minorities (5.8 versus 5.0 percent) (VA, 2017b). A similar pattern among African Americans has been found in the civilian population (Gara et al., 2012). Reasons for these diagnostic and treatment differences are unclear; however, among veterans, the difference may be attributed to the fact that minorities are more likely to be exposed to trauma while serving in the military (VA, 2017b). The review notes, however, that black veterans might benefit from having black clinicians (Saha et al., 2007). Non-whites also were more skeptical of interventions and treatment plans, which in turn may make them less likely to adhere to the course of treatment. This skepticism may
be fueled by a lack of familiarity with interventions or past experiences of discrimination. Black and Latino veterans were less likely to have a primary care physician and are less likely to be adherent to treatment plans than whites. These disparities were attributed to variations in the quantity and quality of patient–provider communication, shared decision making, and patient participation (Saha et al., 2007).
In a large study of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans who received care at the VA between 2001 and 2013 (N = 792,663), Koo et al. (2015a) looked at differences across race/ethnicity and gender in mental health diagnoses. Most measures were the same across gender, but, with a few exceptions, most differed by race and ethnicity. White veterans were more likely than most racial/ethnic minority veterans to be diagnosed with anxiety disorders. This is consistent with previous research among non-veterans (Asnaani et al., 2010). The authors suggested that diagnostic criteria for anxiety disorders may not be culturally sensitive and consequently may not accurately capture the experiences of racial/ethnic minorities. 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. Furthermore, Asian and Pacific Islander (A/PI) men and women were less likely to have a mental health diagnosis than white veterans. The authors note that A/PI and AI/AN groups are often lumped together in studies that look at racial and demographic differences. The findings from this study suggest that the unique characteristics of these two groups may be lost when they are grouped together.
A retrospective study of OEF and OIF veterans who were engaged in PTSD treatment between 2007 and 2011 and had screened positive for PTSD at the start of treatment (N = 79,938) revealed differences in PTSD screening results across race/ethnic and gender groups (Koo et al., 2016). Notably, Asian/Pacific Islander women and black and Hispanic men were more likely to screen positive for PTSD at baseline than white veterans, indicating that perhaps the screens do a better job of detecting PTSD in these groups or that these groups may be more inclined to over-endorse symptoms on the screeners. These are speculative explanations, and further exploration is necessary to understand the differences in screening results between the groups (Koo et al., 2016).
Manhapra et al. (2016) looked at the characteristics of veterans that were associated with different treatments provided by the VA for opioid use disorder. The authors found that demographic (including racial) characteristics—rather than medical or psychiatric or service use differences—were associated with the choice of whether buprenorphine or methadone was offered for treatment. The authors looked at veterans with an opioid use disorder diagnosis who received VA services in 2012 and who were treated with only buprenorphine (N = 5,670), only methadone (N = 6,252), or both buprenorphine and methadone in the same year (N = 2,513). White veterans were more likely to be prescribed only buprenorphine than only methadone (relative risk [RR] 1.54), whereas African American veterans were far less likely to be prescribed buprenorphine only than they were methadone only (RR 0.30). Logistic regression analysis revealed that black race was associated with lower odds of receiving only buprenorphine versus only methadone (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.35–0.43). Differences in treatment received remained after controlling for age, income, and rural location.
In similar fashion, Quinones et al. (2014) examined race- and ethnicity-based differences in how veterans were treated for depression (antidepressants and psychotherapy). The authors used a large sample (62,095) of 2009–2010 medical record data of chronically depressed veterans. They examined how many received adequate antidepressant therapy (defined as sufficient prescriptions filled to take the medication for at least 80 percent of the days within the 6-month study period), how many received
adequate psychotherapy (at least 6 sessions during the 6-month study period), and how many received guideline concordant care (either adequate antidepressant therapy or psychotherapy or both). The rates of receiving adequate antidepressant therapy and guideline concordant care were lower for almost all non-white groups than for whites. The authors note these discrepancies were largely driven by differences in antidepressant therapy, a finding that is supported by other research on the topic (Davis et al., 2014). The results do not necessarily imply that minority veterans receive lower quality care since it is unclear whether patients are offered antidepressants but refuse them or whether the providers fail to offer them altogether. The reluctance to take antidepressants may be more common among African Americans and Hispanics than among whites (Cooper et al., 2003), and patients’ refusal to take antidepressants that are offered may be driving the difference. The rates of receiving adequate psychotherapy showed the opposite pattern, with that treatment being more commonly received by non-white veterans. This finding suggests that minorities may prefer or request psychotherapy more often than whites and possibly in lieu of pharmacotherapy. On the other hand, the difference in treatment could also have a totally different explanation. After adjusting for distance from the facility where the diagnosis was received, the racial and ethnic differences in psychotherapy received were no longer significant, suggesting that those who live farther away from the facility might have more trouble scheduling (or less interest in traveling for) psychotherapy sessions than those who live closer.
A recent study examined differences in mental health treatment adherence across racial and ethnic groups. Among a sample of 311 older veterans (60 or over), Kales et al. (2016) looked for predictors of antidepressant nonadherence. Overall, nonadherence was reported by 29 percent of the sample in an interview 4 months after receiving their diagnosis and antidepressant prescription. Nonadherence was significantly associated with being African American, with being single, and with having greater general comorbidity. 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) are less adherent than white veterans (Rossom et al., 2016).
In a prospective national cohort design Spoont et al. (2015) looked for disparities in PTSD treatment adherence in veterans recently diagnosed with PTSD across racial and ethnic groups (N = 6,788). The researchers used analyses of self-administered surveys and patient records and prescription records to examine treatment patterns in the 6 months following a PTSD diagnosis, controlling for treatment need, access factors, age, gender, and treatment beliefs. Their analyses revealed lower treatment retention for pharmacotherapy for Latino and African American veterans than for white veterans. African American veterans also had a lower odds of retention in treatment overall, suggesting that psychotherapy was not compensating entirely for low pharmacotherapy retention and consistent with the findings cited above for the treatment of depression and substance use (Kales et al., 2016; Quinones et al., 2014).
Tailoring treatment to a variety of select populations, including racial, ethnic, sexual minority (that is, lesbian, gay, bisexual, and transgender [LGBT]) and homeless groups is a challenge in the VA, as the population of patients receiving mental health care is diverse. While only a few mental health programs integrate racial, cultural, or ethnic group-specific programming, the VA has developed specific PTSD programming for American Indian veterans that considers their traditions and oftentimes rural location. For this program, providers may incorporate cultural traditions, such as the use of shamans, sweat lodges, and traditional medicines into treatment plans when appropriate (Gross, 2007; IOM, 2014). The VA also provides sensitivity and educational training to providers on cultural differences among black, Hispanic,
or Asian and Pacific Islander veterans (IOM, 2014). Additionally, homeless veterans have unique health needs that the VA is working to address (VA, 2016). LGBT veterans are another select population served by the VA. To address their needs, the VA has developed policies, provider-education programs, and services to ensure high-quality patient-centered care for LGBT veterans (VA, 2015b).
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. Every VA medical center (VAMC) has a women veterans program manager in place to advocate for and coordinate care for women seeking services. Studies of OEF and OIF female veterans suggest that they exhibit a higher need for mental health care than women who served during previous conflicts, with reports that 17 percent of female OEF/OIF veterans are diagnosed with PTSD (compared to other eras, in which 8 to 9 percent of women veterans were diagnosed with PTSD) and 23 percent are diagnosed with depression (Litz et al., 1997; Maguen et al., 2009; Schlenger et al., 1992). More recent data suggest that between one-half and one-third of women veterans indicate that they need counseling for depression (48 percent), relationship issues (38 percent), anxiety (36 percent), and anger management (30 percent) (Shekelle et al., 2011). In addition, a greater number of deployments common in OEF and OIF seem to be associated with women screening positive for mental health problems (Bean-Mayberry et al., 2011). Women also tend to prefer designated women’s services and the co-location of primary care and mental health services, suggesting that the women’s clinics that exist at many VA facilities help address these preferences (Kimerling et al., 2015). These preferences are stronger for many services among women veterans who are racial/ethnic minorities or sexual minorities. Women veterans who feel their veteran status is a central part of their identity are more likely to choose the VA for their health care (Di Leone et al., 2016).
Grossbard et al. (2013) used data from a large telephone survey (N = 27,471, 2.2 percent of which were veterans) to evaluate the relationship between veteran status and health indicators among men and women. Their analysis showed that women veterans were more likely than their male counterparts to have insurance, have a regular provider, and have had a routine checkup in the previous year. They were, however, more than twice as likely to report an anxiety disorder as male veterans (Grossbard et al., 2013), which is similar to the gender distribution of anxiety disorders in the civilian population.
Women Veterans’ Use of Mental Health Services
Maguen et al. (2012) conducted a retrospective study of gender differences in VA health care use in a national sample of newly returning OEF and OIF veterans with PTSD seeking care from 2001 to 2010. The study population consisted of 159,705 OEF and OIF veterans (15,303 women, 144,402 men) who had at least one clinical VA facility visit from 2001 through 2010 and who were diagnosed with PTSD. The mean numbers of visits for each type of use (three mental health outpatient visits per year) were similar for men and women with PTSD. There were a few small but statistically significant differences between men and women in initiating care and in the types of service they received. Women with PTSD initiating care were less likely than male veterans with PTSD to receive inpatient mental health hospitalization, more likely to use outpatient mental health services, more likely to use primary care, and more likely to use emergency care. These findings are consistent with research on women in the general (nonmilitary) population which shows that women use primary care and emergency services at higher rates than men (Bertakis et al., 2000).
Fox et al. (2015) evaluated how attitudes toward mental health conditions, treatment, and VA care affected VA service use among men and women OEF/OIF veterans with probable PTSD, depression, or alcohol abuse. Men and women had similar perceptions of VA care and of their fit1 within the VA health system. However, men viewed mental health treatment, treatment seeking, and mental health disorders more negatively than women and were more concerned about mental health–related stigma from loved ones than women. All these differences, while significant, showed small effect sizes. The authors also found that for women, positive perceptions of VA care were associated with a greater use of VA services. The authors caution, however, that it could be the use of VA services itself that increases positive perceptions of VA care (i.e., the positive view of VA services may be a result rather than a cause of the increased use of the services) (Fox et al., 2015).
Washington et al. (2006) conducted a study to identify the factors influencing women’s use of VA health care services. The most often cited reasons for VA use were affordability (67.9 percent), the availability of a women’s health clinic (58.8 percent), the quality of care (54.8 percent), and convenience (47.9 percent). The reasons for choosing non-VA care included having health insurance (71.0 percent), the greater convenience of non-VA care (66.9 percent), a lack of knowledge about VA eligibility and services (48.5 percent), and a perceived better quality of care outside of the VA health system (34.5 percent). Thus, a lack of information about VA health care, concerns about the quality of care provided by the VA, and inconvenience associated with using the VA reduced the use of VA health care among the study population.
Hamilton et al. (2013) examined reasons for attrition among women veterans who had previously sought health care from the VA health system. The data revealed that those who had left VA health care were in better health overall (p < 0.007) and had more resources to access health care in the private sector (private insurance, p < 0.001, and higher income, p < 0.001) than women veterans who remained in VA health care. Those who had left VA health care also had more negative perceptions of the VA and of the quality of the care they had received at the VA than those who had stayed in the VA health system (p < 0.001) (Hamilton et al., 2013).
The National Survey of Women Veterans, a national population-based telephone survey conducted in 2008–2009, also evaluated the use of VA health care. Of the 10,638 contacted households, 3,611 participants (33.9 percent) were eligible for and consented to enroll in the survey. Overall, 18.9 percent of that population had delayed or gone without needed health care in the prior 12 months, including 14.3 percent of insured and 54.6 percent of uninsured participants. Younger age was associated with delayed care or unmet need (35 percent of 18- to 34-year-olds). 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). In the study, 4.8 percent (N = 173) of the overall population sampled were OEF and OIF veterans, of which more than one-third (37.2 percent) reported an unmet need for care. The most commonly cited reason for unmet needs was not being able to afford medical care. The independent predictors of delayed or unmet needs for OEF and OIF women veterans health care were being uninsured (OR = 6.5; 95% CI = 3.0–14.0) and being under 35 (OR = 4.5; 95% CI = 1.8–11.3). After controlling for potential confounders, the other predictors of delayed care were having a history of MST and the perception that VA providers are not gender sensitive (Shekelle et al., 2011).
1 “Perceived fit” was measured using questions designed to assess participants’ perceptions that they deserved VA care and questions designed to assess participants’ perceived similarity to other VA users.
Lehavot et al. (2013) examined personal (not institutional) barriers to the use of care faced by women veterans with PTSD and depression with data from the National Survey of Women Veterans (N = 3,593); most of the veterans (80 percent) in that population were from the pre-OEF/OIF era. The authors evaluated unmet medical needs in the previous year, the reasons for unmet needs, and the barriers reported by women veterans who were not using VA health services. The authors compared these domains across four groups of women veterans: (1) those with a lifetime positive screen for PTSD, (2) those with current depressive symptoms, (3) those with both PTSD and depressive symptoms, and (4) those with neither PTSD nor depressive symptoms. Among the sample, 4 percent screened positive for depression and PTSD, 9 percent screened positive for PTSD only, 4 percent screened positive for depression only, and 83 percent did not screen positive for either PTSD or depression. Among the entire sample, 19 percent reported unmet medical needs in the past year. Among the different groups, adjusting for demographic differences, 46 percent of the PTSD-and-depression group reported unmet needs, compared with 25 percent of the PTSD-only group, 13 percent of the depression-only group, and 17 percent of the group without either diagnosis (p < 0.05). In terms of barriers to care among those with unmet medical needs, women were asked if the reasons for delaying or going without care were related to childcare responsibilities, work obligations, the affordability of care, transportation to care, or some other reason. The affordability of care was the most cited reason for delaying or going without care. It was also the only reason that differed significantly across the groups, with 69 percent of the PTSD- and-depression group citing this as a barrier to care compared with 42 percent in the PTSD-only group, 40 percent in the depression-only group, and 36 percent in the group with neither PTSD nor depression (p < 0.05). Not being able to take time off work was the second-most cited reason for not accessing care; there were no significant differences in that answer across the groups. Among the VA non-users and former users, over half of those in the PTSD-and-depression group (52 percent) and 34 percent of the PTSD-only group thought they were not eligible for VA health services. Similarly, only 3 percent of the PTSD-and-depression group and 4 percent of the PTSD-only group had insurance that covered care outside of the VA health system (Lehavot et al., 2013).
Data from the committee’s survey of veterans were analyzed to compare the reasons given for not using VA mental health care services by men versus women OEF/OIF/OND veterans who had mental health needs2 but did not use mental health services (see Table 13-1). In general, the women and men veterans in this analysis were similar in their awareness of VA mental health benefits and how to apply for them, in feeling that they deserved to receive mental health care from the VA, in their trust of the VA, and in feeling welcome at the VA. One difference was that women were significantly less likely to report having had bad experiences at the VA than men (16.1 percent of women versus 24.4 percent of men). Another major difference appears to be that the women were significantly more likely to believe that they were not entitled to or eligible for VA mental health care (52 percent of women versus 34 percent of men).
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. No substantial differences were found between men and women veterans in this analysis.
2 A veteran was classified as having a need for mental health care if the result on at least one mental health screener was positive, or reported receiving a mental health diagnosis from a health care provider in the past 24 months.
|Unwgt n||Wgt N||Wgt %||SE %||Unwgt n||Wgt N||Wgt %||SE %|
|Need, no use||625||736,784||258||196,380|
|You were not aware of VA mental health care benefits?||177||238,246||32.3%||1.8%||67||70,992||36.2%||4.2%|
|You do not know how to apply for VA mental health care benefits?||221||295,958||40.2%||1.8%||94||88,218||44.9%||4.1%|
|You do not feel you deserve to receive mental health care from the VA?||149||209,296||28.4%||1.5%||69||65,733||33.5%||3.4%|
|You do not believe you are entitled to or eligible for VA mental health care benefits?||174||251,186||34.1%||1.9%||92||102,503||52.2%||3.7%|
|You have had a bad prior experience at the VA?||167||179,521||24.4%||1.9%||58||31,690||16.1%||3.3%|
|You do not feel welcome at the VA?||125||146,108||19.8%||1.6%||46||33,301||17.0%||2.2%|
|You do not trust the VA?||203||232,716||31.6%||2.5%||67||46,393||23.6%||4.0%|
|You do not want assistance from the VA?||110||129,682||17.6%||1.5%||52||40,380||20.6%||3.7%|
|You use other sources of mental health care?||109||138,499||18.8%||2.0%||55||50,958||25.9%||3.5%|
|You do not need care?||237||292,598||39.7%||2.5%||74||63,661||32.4%||5.4%|
NOTE: SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
Site Visit Findings
Site visit teams recognized during the first few visits that there was an under-representation of female veteran interviewees and subsequently intensified efforts to engage this population. Such efforts included outreach to women’s veteran organizations, specific requests to VA staff and community-based organizations to recruit more women participants, and interviews with veterans at VA women’s clinics. Just under 20 percent of the OEF/OIF/OND veterans interviewed were women (women represent about 21 percent of OEF/OIF/OND veterans overall). Findings from the interviews indicate that women face unique barriers to mental health care at the VA, largely related to challenges associated with being a woman in a traditionally male-dominated system as well as issues that are specific to MST, one of the main reasons women seek mental health care from the VA.
Female veterans reported frustration with both having to prove they are veterans (it is often assumed that a female at the VA is a wife accompanying her husband) as well as a combat veteran. One female veteran in Cleveland, Ohio, explained what she goes through each time she goes to a VA facility: “As far as mental health, I always have to identify myself as a veteran. I always have to have my card. . . . They assume I’m a spouse.” Similarly, a veteran in Biloxi, Mississippi, relayed an interaction she had with an eligibility clerk: “I enrolled here for my healthcare and I had to educate the clerk. . . . I got put in as not a combat vet. I had to go back and say, ‘No, I am a combat vet. I’m a girl, but I had boots on the ground in Afghanistan.’ That’s frustrating.”
Women also reported feeling uncomfortable in VA health facility waiting rooms, which are often dominated by males. 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.
As one VA clinician in Cleveland noted, “The last thing [female veterans] want to do is go to the clinic or the medical center and sit around in a waiting room with a bunch of people who look like potential perpetrators.” Another clinician in East Orange, New Jersey, said, “I think there are many, many people who fall through the cracks and don’t want to come here because they associate it with the very culture that traumatized them. That’s a huge barrier to treatment.” A female veteran in El Paso, Texas, even went as far as to say she was “afraid to go to [to a VA facility].”
Additionally, obtaining childcare in order to attend medical appointments is particularly difficult for women, who often bear the majority of or the sole responsibility for taking care of children. One promising practice that is helping to eliminate this barrier for women veterans is the creation of child-friendly spaces at some VA facilities.
Racial and Ethnic Minorities
In 2014 approximately 24.8 percent of post-9/11 veterans were minorities, and the proportion of minority veterans is projected to grow in the coming decades (VA, 2017b). About 23 percent of patients receiving outpatient PTSD care are black, 10 percent are Hispanic, and 15 percent identify themselves as another non-white race or ethnicity (IOM, 2014).
There is a paucity of literature on disparities in health care in racial and ethnic minorities in the OEF/OIF/OND populations. Furthermore, many of the studies that do look at racial disparities in health rely on secondary and administrative VA data, which are often missing race and ethnicity information (Long et al., 2006). Nevertheless, the committee summarizes the literature on the topic in this section and also includes some studies on all minority veterans from beyond the OEF/OIF/OND service era.
In a large study of veterans (N = 65,930) with a recent mental health or substance use diagnosis receiving care from patient-centered medical homes (PCMHs), Jones et al. (2016) looked at differences in experiences across race and ethnicity. Race and ethnicity were factors across all of the domains the researchers examined. For example, black, Hispanic, AI/AN, and A/PI veterans reported worse experiences than white veterans with respect to access to timely appointments to care. 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.
Hebert and Hernandez (2016) note that because the PCMH model improves outcomes and because minority veterans tend to have worse outcomes than non-minorities, minorities may have the most to gain from the PCMH model. That said, if the PCMH model is not adopted equally across the system and is adopted at a higher rate in clinics that serve non-minority veterans, the expansion of PCMHs could, in fact, increase disparities between minorities and non-minorities. In a study looking at the implementation patterns of PCMHs for minorities, Hernandez et al. (2016) found just that—facilities with higher percentages of minorities were associated with lower levels of PCMH implementation across the VA system.
In a study from the beginning of the OEF/OIF service era, Harada et al. (2002) found that minority veterans who strongly self-associate with their veteran status and had used outpatient services in the previous year (VA or non-VA) prefer using the VA health system for outpatient services more than those who do not strongly associate with their veteran status. Likewise, black and Hispanic veterans, the authors found, were more than twice as likely to prefer the VA health system to other systems of care compared to white veterans. Hynes et al. (2007) similarly found that black veterans were more likely to rely on VA health care than non-black veterans.
In contrast, in a separate study Washington et al. (2005) used the same dataset as Harada et al. (2002) but looked at actual usage patterns by race and ethnicity (rather than preferences among users as Harada et al.  did). The study examined outpatient care usage among black, Hispanic, Asian/Pacific Islander, and white veterans (all male). Using survey data (3,227 completed interviews), the authors found that black veterans (OR = 05), Hispanic veterans (OR = 0.4), and Asian/Pacific Islander veterans (OR = 0.4) who were VA eligible were less than half as likely to have used VA outpatient services in the previous 12 months than white veterans. The most commonly cited barrier to VA usage among the ethnic minority groups was dissatisfaction with VA health care. The odds ratios for this complaint was significant among Hispanic (OR = 2.1) and Asian/Pacific Islander (OR = 5.8) participants, but not among black veterans (compared to whites). Furthermore, being white was a stronger predictor of VA health care use than was fair or poor health status (OR = 1.4) (Washington et al., 2005).
More recently, De Luca et al. (2016), in a telephone survey of both veterans and civilians, found that race and ethnicity were not associated with mental health treatment seeking (at the VA or elsewhere) among veterans. One study found that black and Hawaiian/Pacific Islander veterans were less likely to use mental health services than white veterans, but Latino veterans were not (Spoont et al., 2009).
In a review of the literature, Saha et al. (2007) found mixed results regarding racial and ethnic disparities in the use of VA mental health care. Race and ethnicity were related to the number of VA outpatient visits among veterans, with black and Latino veterans having more visits (reverse disparity) and Asian and Pacific Islanders having fewer visits (greater disparity) than non-Latino white veterans (Harada et al., 2002). Black, Latino, and Asian/Pacific Islander veterans were less likely than non-Latino white veterans to persist with health care services over a 12-month period (Washington et al., 2005), and non-white veterans were less active participants in their care, asked fewer questions, and in turn received less information from their providers. Finally, black and Latino veterans are more likely to use VA-only health services, while Asian/Pacific Islanders and non-Latino white veterans are more likely to seek help outside the VA health system (Washington et al., 2002).
Analysis of data from the committee’s survey of veterans compared reasons for not using VA mental health care services among non-Hispanic white, non-Hispanic black, and Hispanic OEF/OIF/OND veterans who have mental health needs but do not use mental health services (see Table 13-2). Responses to the variables in Table 13-2 were similar among the groups, except that, compared to non-Hispanic white veterans, a higher percentage of both non-Hispanic black veterans and Hispanic veterans reported not feeling welcome at the VA as a reason for not using the VA. 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. No statistically significant differences were found among these groups of veterans in this analysis.
African American Veterans
Grubaugh et al. (2006) examined usage patterns among black and white veterans and found few racial differences in the use of VA mental health services. The study did reveal some differences between white and black veterans in terms of their past experiences, with black veterans in the sample having a higher rate of combat exposure, but the two groups did not differ in rates of PTSD diagnosis or severity. Black veterans were more likely to have a diagnosis of dysthymia (although the difference was not significant
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)
|Reasons Veterans Do Not Use VA Mental Health Services||Non-Hispanic White Only||Non-Hispanic Black Only||Hispanic|
|Unwgt n||Wgt N||Wgt %||SE %||Unwgt n||Wgt N||Wgt %||SE %||Unwgt n||Wgt N||Wgt %||SE %|
|Do not know how to apply for VA mental health care benefits||247||311,947||39.4%||2.4%||75||75,340||47.9%||3.8%||56||69,742||43.8%||5.7%|
|Do not believe entitled or eligible for VA mental health care benefits||217||307,401||38.8%||2.1%||55||56,121||35.7%||4.6%||53||67,359||42.3%||4.3%|
|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 benefits||174||227,887||28.8%||2.5%||62||69,909||44.5%||5.6%||44||57,858||36.4%||5.3%|
|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 health care benefits from the VA||170||230,426||29.1%||1.8%||41||39,802||25.3%||4.3%||47||54,558||34.3%||3.3%|
|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. SE = standard error of percentage; Unwgt = unweighted; Wgt = weighted.
SOURCE: Committee to Evaluate VA Mental Health Services, Veteran Survey, 2017.
after adjusting for age) and of substance dependence or abuse (AOR = 2.48, CI = 1.04–5.92, p = 0.04). Black veterans were more likely to have used a substance abuse treatment center and to have made an urgent care visit than white veterans, but there were no racial differences in the likelihood of receiving VA benefits. Of the 84 veterans who were identified as having PTSD on the clinician-administered PTSD scale, only 30 had PTSD notated on their charts; there were, however, no significant age-adjusted or unadjusted racial differences found by the authors with this discrepancy. No additional racial differences were found regarding additional diagnoses, service use, or benefits (Grubaugh et al., 2006).
Murdoch et al. (2003) found that black veterans were less likely to be granted a service connection for PTSD than other veterans. 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). While the study surveyed veterans who applied for VA disability benefits between 1994 and 1998—pre-OEF/OIF service era—the results do suggest that black veterans, while they have similar rates of PTSD to white veterans (Grubaugh et al., 2006), may face more barriers to care than other veterans in the VA system.
In a qualitative study that included 49 African American veterans receiving mental health care from a VA facility, Eliacin et al. (2016) looked at patient perspectives on patient and provider barriers and on facilitators to engagement in VA mental health care. Patients suggested that providers should engage with patients and take their time to get to know them, particularly at the first meeting. Many stressed that if the provider is friendly, warm, and personal, it makes it easier for the participants to share their thoughts more openly. The veterans also identified some patient-related factors that help facilitate active engagement. These include self-awareness, assertiveness, willingness to seek help, and leadership skills. One participant said that his difficulty with self-awareness and willingness to seek help was associated with his African American identity and also with the general stigma associated with seeking mental health care in the African American community. The ability to identify personal emotions, behaviors, and thoughts and the ability to communicate them to providers were also identified as critical skills necessary to facilitating mental health treatment. Provider encouragement and ongoing reinforcement of these skills are essential, the participants stated.
In a review of the literature, Duke et al. (2011) looked for potential barriers to care among Latino veterans residing in rural locations. While Latino veterans report higher prevalence of PTSD and greater symptom severity than non-Hispanic Caucasians, they may avoid seeking VA medical care because of cultural norms among Latino families that value stoicism, downplay distress, and rely on family members to address problems. Rural-dwelling Latino veterans also face the logistical challenges that all rural-dwelling veterans face regarding unmet transportation needs and long travel distances to VA facilities. VA staff have reported that Latino veterans often have difficulty discussing personal matters. Latino veterans, on the other hand, have reported that the VA health system lacks the cultural competency to meet their needs, which may deter Latino veterans from seeking care (Duke et al., 2011).
A small study of Puerto Rican OEF and OIF veterans and family members following deployment examined unmet health needs. Hannold et al. (2011) found that Puerto Rican veterans tended to deny symptoms of stress and did not seek psychological examinations. The authors also found that the families of these veterans experienced emotional problems and expressed the need for family support groups. The veterans also indicated that they had physical problems and needed pain treatment. The authors concluded that there is a need for “veteran-centric” and family-focused health care.
Native American, Alaska Native Veterans
The Native American Indian, native Hawaiian, and Alaska Native (AIAN) populations serve at the highest per capita rates of any race or ethnicity in the Armed Forces (Holiday et al., 2006; Kramer et al., 2009); however, because of their relatively small absolute numbers, they make up less than 1 percent of veterans who served in OEF/OIF/OND (VA, 2012a). As of September 2012, there were 17,500 OEF/OIF/OND veterans who identified as AIAN (out of 2.4 million OEF/OIF/OND veterans overall). That said, nearly half of all Native veterans reside in rural locations on tribal or Alaska Native lands. According to the American Indian Vietnam Veterans Project, a community-based epidemiologic study, Native veterans have high rates of combat-related mental health disorders (31 percent current and 59 percent lifetime) and alcohol abuse and dependence (72 percent current, 84 percent lifetime). These figures are significantly higher than any other ethnic group (Beals et al., 2002). The rates of alcoholism, lifetime and current, are also higher than in civilian AIAN estimates (Brave Heart et al., 2016).
AIAN veterans have 1.9 higher odds of being uninsured than non-Latino white veterans (Johnson et al., 2010). They have a disproportionate amount of service-related military conditions, and they are more likely to use the Indian Health Service as opposed to the VA health system (Johnson et al., 2010; Kramer et al., 2009). A secondary data analysis of linked VA and Indian Health Service data (N = 64,746) found that 25 percent of AIAN veterans accessed care from both health systems; however, most used either the VA (28 percent) or the Indian Health Service (46 percent) exclusively. Among the users of both systems, most received their behavioral health care services from the VA and their primary care from the Indian Health Service (Kramer et al., 2009). The Indian Health Service, similar to the VA, has struggled historically to find and retain physicians, especially those who have the necessary cultural awareness (Brod et al., 1982; Fannin and Barnes, 2007; Hostetter and Felsen, 1975; Johnson and Cameron, 2001).
As with other rural veterans, the AIAN population experiences significant barriers in accessing care, including underfunded resources (that is, time, money, and transportation), a lack of culturally appropriate care, difficulties in recruiting and retaining health care professionals where many AIAN reside, and geographic access issues (Kaufman et al., 2010). AIAN veterans are more likely than their white counterparts to report delays in care because of not getting a timely appointment or not being able to reach a contact by phone or because of transportation problems (Johnson et al., 2010). Despite the growing evidence on telehealth effectiveness, acceptance and implementation among providers in the rural areas where these veterans reside remain a challenge (Barton et al., 2007; Grigsby et al., 2007; Spaulding et al., 2005). However, a study examining AIAN veterans’ acceptance of the administration of a mental health assessment by videoconference versus in person found that the veterans were comfortable with participating by videoconference (Shore et al., 2008). The veterans’ level of patient satisfaction and cultural acceptance were similar in both the videoconference and in-person interview groups.
Brooks et al. (2015) examined demographic differences in VA service use among Native veterans (including AIAN) (N = 84,269) and compared them to a random sample of non-Native veterans (N = 262,212). Both groups used outpatient services more than their non-Native counterparts (both primary care and mental health). Both groups also had more overall diagnoses and higher disability ratings than the non-Natives in the study, suggesting that Native veterans have a greater need for services than non-Native veterans. Native women were more likely to report MST than non-Native women. Reported MST was associated with mental health service use.
Asian American and Pacific Islander Veterans
According to National Survey of Veterans data from 2010, 1.5 percent of veterans identified themselves as Asian American/Pacific Islander (AA/PI), up from 0.4 percent a decade prior. This
rate of growth reflects the AA/PI growth in the general population, which is projected to continue for decades to come (Tsai et al., 2014). Furthermore, AA/PI veterans were more likely to be OEF or OIF veterans than veterans of all other racial/ethnic groups. They also had higher incomes than both black and Hispanic veterans. The data revealed no differences in perceived barriers or stigma related to health care among AA/PI veterans compared to other veterans. After adjusting for differences in sociodemographic and health characteristics, AA/PI veterans used both VA and non-VA outpatient, inpatient, and emergency services at a rate equal to the rates of other racial/ethnic groups (Tsai et al., 2014). This is in contrast to an earlier review of the literature that found that AA/PI veterans, while physically healthier than other groups, reported worse mental health and also used services less than other groups (Tsai and Kong, 2012). When analyzed separately, there were some differences between AA and PI veterans, suggesting that perhaps they should not be lumped together by the VA or in future studies (Tsai et al., 2014). For example, AA veterans reported higher income, fewer PTSD symptoms, and better mental health overall than PI veterans. PI veterans were more likely to live in rural locations, to have been deployed, to report lower income, and to have higher PTSD checklist scores than AA veterans (Tsai et al., 2014).
Racial and Ethnic Differences Among Women Veterans
In a review of the literature, Carter et al. (2016) looked for usage disparities among women veterans across racial and ethnic groups. The review was not mental health specific and included only two mental health–related studies. One of these studies found no difference across racial and ethnic groups among female veterans in the use of mental health services, although black women did report wanting mental health referrals more frequently than white women. The other mental health–related study included in the review reported that Native American women veterans were more likely than white women to receive treatment for alcohol use. Hispanic women and African American women received alcohol treatment from the VA health system at a rate level to that of white women.
Similarly, Koo et al. (2015b) compared usage by men and women by racial and ethnic group using a large sample (N = 309,050) 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. Hispanic women and men used primary care more than white women and men. American Indian women and Hispanic women veterans were both less likely to use outpatient mental health services than white veterans, whereas American Indian and Hispanic men were both more likely to use outpatient mental health care than white veterans. While black men were more likely to use mental health outpatient services than white men, usage did not differ significantly between black and white women.
Davis et al. (2014) examined gender and ethnic differences in VA mental health service use among OEF/OIF veterans diagnosed with depression. The authors used data from the VA Computerized Patient Record System (N = 1,556) to examine usage patterns for the 90 days following a depression diagnosis. Analysis revealed no gender or ethnic differences in the use of specialty mental health services following diagnosis. The authors noted that while these results are promising in that they suggest service use is equitable across gender and ethnicity, the data were drawn from a single VA network and participants were limited only to those with a depression diagnosis. Nevertheless, these results were similar to an earlier study that found no difference in use by race or ethnicity among women veterans (Grubaugh et al., 2008).
Lesbian, Gay, Bisexual, and Transgender Veterans
In 2012 the VA established an LGBT Health Program within the Office of Patient Care Services, led by two clinical psychologists and LGBT health care subject-matter experts (VA, 2017c). The program has led a series of activities that have led to recommendations for the VA to create a more welcoming environment for LGBT veterans, such as installing increased signage communicating LGBT awareness and sensitivity, providing LGBT resource information in waiting areas, and offering training webinars for providers regarding gender dysphoria and hormone evaluation. The VA has also created postdoctoral interprofessional psychology fellowships in LGBT health, and about half of those fellows accept VA positions upon graduation. Furthermore, since 2016 each facility has had a part-time LGBT care coordinator to assess the clinical needs of LGBT veterans at that facility and to address any gaps in the care of those veterans. Each Veterans Integrated Service Network (VISN) also has an LGBT lead. The LGBT care coordinator is tasked with creating a welcoming environment for LGBT veterans (VA, 2017c).
Data from the 2000 Census indicate that nearly 1 million veterans have same-sex partners (Gates, 2004), yet little is known about LGBT veterans’ usage of and barriers to VA care. A recent study evaluating the usage of VA health services by LGB veterans (transgender veterans were not included in the study) and the barriers they experience while accessing those services found that 45.8 percent of participants reported lifetime VA usage, and 28.7 percent reported having used the VA in the previous year. For mental health services, 6.2 percent reported usage in the previous 12 months (Simpson et al., 2013). By comparison, between October 2001 and March 2015, approximately 61 percent of OEF/OIF/OND veterans obtained some sort of health care (not just mental health care) at the VA (VA, 2015a), and in fiscal year 2014 about 30 percent of the total veteran population used the VA (Bagalman, 2014). Lifetime use was predicted by a positive service connection, a positive screen for both PTSD and depression, and a history of at least one interpersonal trauma during military service related to the veteran’s LGB status. 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).
Nearly one in eight respondents (11.8 percent) reported not using the VA because of concerns that the VA staff would not accept their sexual orientation. A smaller proportion (6.4 percent) reported concerns that other patients would not accept their sexual orientation as a reason for not using the VA. Over one-third of respondents (36.9 percent) who used the VA reported that their VA providers do not have knowledge of their sexuality. Almost one-third (32.8 percent) of respondents reported they sometimes or openly talk about their sexuality with VA staff (Simpson et al., 2013).
In 2011 a VA directive mandated medically necessary care for transgender veterans for the first time. The directive was updated in 2013 (VA, 2013). Interestingly, the directive positions the VA to provide care to transgendered veterans that is generally not covered by most private insurance providers (Johnson et al., 2016). The committee is aware of little research on this population and the barriers they may face seeking VA health care. The committee did find one study that evaluated VA data and found that between 2006 and 2013, 2,662 unique individuals had an International Classification of Diseases, Ninth Revision (ICD-9) code in their medical record related to transgender status (Kauth et al., 2014). Nearly 40 percent of the transgender diagnoses between 2006 and 2013 occurred in the 2 years following the 2011 VA directive, suggesting that the directive was effective in increasing access to care for transgendered veterans (Kauth et al., 2014).
In another study of transgender veterans, Brown and Jones (2016) sought to determine diagnostic disparities between transgendered veterans and veterans without an indication of transgender status on their health records. Transgender status was determined by ICD-9 codes in patient electronic health records. All records with eligible codes between 1996 and 2013 were included in the study (N = 5,135). The authors noted that this is a crude estimation of the size of transgender veteran population that uses VA services since gender-identity data are not collected by the VA, making it impossible to include veterans who self-identify as transgender but have not received a transgender-related diagnosis. The prevalences of a variety of diagnoses were compared between the transgender group and a matched group of non-transgendered veterans (N = 15,405). After adjusting for marital status, religious affiliation, and priority group, transgendered veterans were found to be more likely to be diagnosed with all behavioral health conditions included in the analysis. These included depression, PTSD, serious mental illness, suicidal ideation/attempt, alcohol abuse, and tobacco use. Moreover, transgendered veterans were more likely than non-transgendered veterans in the study to have ever experienced homelessness or experienced MST and more likely to have a service-connected disability. Use of and barriers to care were not evaluated in the study.
Veterans’ Access to Military Sexual Trauma Services
Recognizing the prevalence of military sexual trauma, VAMCs have a dedicated military sexual trauma coordinator, although the adequacy of MST services varies by facility (IOM, 2014). In cases of MST, facilities are strongly encouraged (but not required) to offer care from a provider that is the same gender as the veteran (or an opposite sex provider if a same-sex perpetrator committed the trauma) (VA, 2015c).
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). MST is reported in the VA based on a universal screening program—the VA requires all facilities to screen for MST and to provide services (even if the veteran is not eligible for other services) (VA, 2012b). In 2003, shortly after the implementation of VA screening, 21.5 percent of women and 1.1 percent of men reported having experienced MST (Kimerling et al., 2007). These estimates have remained fairly consistent, and as of 2008 those percentages translated into 48,106 women and 43,693 men screening positive for MST (Hyun et al., 2009). Department of Defense (DoD) estimates of MST report that as of 2008, the annual prevalence of being a victim of sexual assault was 6.8 percent among women and 1.8 percent among men (Lipari et al., 2008). A study of reservists examined sexual harassment and assault during military service and found that sexual assault was reported by 13.1 percent of the women and 1.6 percent of the men (Street et al., 2008).
There are mixed findings regarding the relationship between women’s health care use and sexual assault. Kelly et al. (2008) found MST to be associated with a greater use of VA care but less satisfaction with VA services. Another study found that women with a history of any form of sexual assault were more likely to meet the criteria for PTSD but accessed fewer health care services (Suris et al., 2004). After controlling for symptom severity, Di Leone et al. (2013) found that women who had experienced sexual harassment during deployment used VA mental health services at a greater rate than women who did not report having experienced sexual harassment. Another study found that women veterans who had experienced MST used VA mental health services at a higher rate than women who had not (27.6 versus 7.1 percent, p < 0.001) but that the difference was not significant after controlling for PTSD and depression symptoms (Calhoun et al., 2016). Women veterans who have experienced MST and who access health care report significant anxiety if treated by a male provider, particularly if subjected to an invasive exam, a concern with regard to aggravating mental health symptoms and accessing future health care (Bean-Mayberry et al., 2010).
In 2014, in a point-in-time count, the Department of Housing and Urban Development (HUD) estimated there were 49,933 homeless veterans (10 percent of the total homeless population). This number has dropped substantially since 2009, when there were an estimated 74,050 homeless veterans. Of the homeless veterans in 2014, 64 percent were sleeping in a shelter while 36 percent were in a place not meant for human habitation (Perl, 2014). Many of these veterans receive VA benefits and health services from VA facilities. Homelessness is associated with increased morbidity and mortality compared with housed individuals, and many homeless often defer or delay treatment which may complicate their health needs. Homeless individuals often receive their care from emergency departments, and thus they often do not receive chronic care management or preventative services (O’Toole et al., 2013).
The HUD-VA Supportive Housing (HUD-VASH) program began in 1992 as a joint effort by the VA and HUD to address rising homelessness among veterans. The program offers housing choice rental vouchers and supportive housing services to help veterans remain stably housed. 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).
The HUD-VASH program underwent a dramatic change in 2009 as veteran homelessness became a national priority and as veterans from the Afghanistan/Iraq wars were returning home to a troubled U.S. economy. Embracing the “housing first” approach, the program energetically made outreach to chronically homeless veterans, offering them ready access to housing without pre-conditions such as sobriety or medication compliance. With strong popular support from political leaders in all 50 states, Congress had authorized over 90,000 rental vouchers and $635 million for the program as of 2016 (U.S. Interagency Council on Homelessness, 2017).
Nevertheless, early adoption was challenging for many VA facilities, since the housing-first approach required VA clinicians to make substantial changes in their practice, including prioritizing home visits and harm reduction rather than abstinence requirements. Locating and furnishing apartments was also a novel challenge, and additional funds had to be appropriated to support these program components and hire additional case managers to assist in implementing them.
Considered the nation’s largest permanent housing initiative, HUD-VASH has proven to be a success in engaging and stably housing homeless veterans and their families. Overall numbers of homeless veterans have dropped by 56 percent since 2009, and as this is written, three states (Delaware, Virginia, and Connecticut) and 35 cities have announced an end to veteran homelessness in their jurisdictions (U.S. Interagency Council on Homelessness, 2017).
Compared to previous cohorts, veterans who served in OEF/OIF/OND operations are more likely to be younger, female, and a head of household. While still a minority of homeless veterans overall, OEF/OIF/OND veterans are likely to experience a rise in homelessness if HUD-VASH and other programs cannot accommodate their needs (which also include dealing with higher rates of MST and traumatic brain injury). Supportive Services for Veterans’ Families (SSVF) is a program begun in 2012 that is designed to prevent or intervene early in homelessness by providing short-term financial assistance to pay rent arrears or other expenses that threaten a veteran family with eviction. Early findings from evaluations of SSVF indicate that almost 100,000 persons have been assisted at an average household cost of $2,480 (Byrne et al., 2014).
O’Toole et al. (2013) compared service use over 6 months among newly enrolled homeless veterans (N = 127) and housed veterans (N = 106) in the medical home model. The groups were comparable in age and almost all had a chronic medical condition (92.1 percent of homeless veterans versus 96.2 percent of non-homeless veterans). The two groups also had similar proportions of mental health diag-
noses (59.1 percent of homeless veterans versus 52.8 percent of non-homeless veterans). Depression, anxiety disorder, PTSD, and bipolar were the most common conditions in both groups. Over 88 percent of homeless veterans used mental health services during the first 6 months of enrollment (averaging 12 visits per person), over 86 percent accessed specialty care, and over 37 percent accessed substance abuse treatment. Less than half of the cohort (48 percent) visited the emergency room during the 6-month period. Non-homeless veterans used all services at a lower rate than homeless veterans except for specialty services, which non-homeless and homeless veterans used nearly equally. Among the homeless group, 26 percent stopped going to the emergency room after 3 months of primary care enrollment. 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).
In a study comparing patient experiences across three models of care—non-VA primary care tailored for homeless patients, VA primary care tailored for homeless patients, and typical VA care—Kertesz et al. (2013) found that recently or currently homeless veterans preferred the non-VA services tailored to homeless patients over the other modes of care. Using a survey to measure recently and currently homeless veterans’ satisfaction with services, the researchers found the mean score at the tailored non-VA site to be greater than those at the three VA sites. The VA sites had 1.5 to 3 times greater odds than the non-VA sites of an unfavorable experience in the domains of patient–clinician relationship, cooperation, and access (Kertesz et al., 2013).
McGuire et al. (2009) evaluated access, use, and outcomes among homeless veterans receiving either integrated VA health care (homeless, primary care, and mental health care) or “usual” VA health care. The veterans in the study either had a serious mental illness or were substance abusers. Veterans in both groups were comparable in levels of social, psychiatric, and medical problems (N = 130 in both groups). Over the 18-month study, veterans in the integrated group received primary care appointments more quickly than the veterans in the standard care group. Similarly, they completed more primary care visits, received more preventative services, and made fewer emergency room visits. Despite the veterans in the integrated care group receiving more timely and frequent services, there was no difference in perceived health status between the two groups (McGuire et al., 2009).
During the site visits conducted as part of this study, the site visitors witnessed firsthand the success of the HUD-VASH program. They reached out to locations serving extremely low-income veterans, such as food banks and homeless shelters, and discovered that the veterans served in these locations were generally well connected with VA health services. Compared to their non-veteran counterparts, homeless veterans had far readier access to housing and services (rental vouchers being very difficult to obtain in the general population). Referring veterans to the VA services was a means of conserving scarce county or state resources targeted for homeless services. As one VA staff member said:
When a non-VA agency finds out someone’s a veteran, they almost burn the doors down trying to get the person into the VA . . . especially agencies that maybe survive on grants or United Way money. . . . It’s like, “Let’s get them to somebody that’s got the big pockets.” [Iowa City, Iowa]
Outreach workers are quick to make the appropriate referrals:
If they’re . . . homeless, it would be very hard for them not to interact with us because as soon as they went to any social service organization, they would say, “Oh, you’re a veteran?” Someone would probably literally come and connect with that person, if not that day, within a few days. [San Diego, California]
The VA’s Office of Health Equity (OHE) was established in 2012 and is charged with building cultural and military competence within the VA in order to eliminate health disparities (Commission on Care, 2016). OHE has successfully identified new areas of health care disparities among veterans and works with veterans groups and other VA entities, such as the Office of Diversity and Inclusion, to achieve its mission. In 2013, with a variety of stakeholders, the OHE developed the Health Equity Action Plan (HEAP) to ensure that veterans receive equitable health care irrespective of geography, gender, race, age, culture, or sexual orientation. HEAP focuses on awareness, leadership, health system and life experience, cultural and linguistic competency, and data in order to implement its mission (VA, 2015d).
In its recent assessment of the VA system, the Commission on Care asserted that the VA had not provided adequate resources or authority for OHE to achieve its mission and implement HEAP in full (Commission on Care, 2016). OHE lacks the adequate staff, resources, and support to effectively address issues of equity within the VA. Further compounding the challenges the OHE faces, the Commission on Care noted, the VA lacks high-quality data on vulnerable populations and health outcomes and lacks data on the impact of existing health equity initiatives. The Commission on Care recommended that the VA make health equity a strategic priority by directing the implementation of HEAP nationwide and designating an equity “clinical champion” within each VISN and VAMC. It also recommended fully staffing OHE and fully monitoring and evaluating the implementation of HEAP (Commission on Care, 2016).
In communications with the committee, the VA highlighted activities and research that OHE has completed in order to better understand mental health disparities. But the VA also acknowledged the Commission on Care findings and many of the challenges that OHE continues to face (VA, 2017a). Namely, the VA acknowledged that HEAP has not yet been fully implemented despite the Commission on Care recommendation. Furthermore, it reported that VA data are not reliably broken down by race and ethnicity despite OHE’s continued advocacy for that action. OHE has demonstrated how to reduce missing race and ethnicity data in specific instances. Finally, VA acknowledged that OHE continues to be understaffed, with only two full-time equivalent staff as of May 31, 2017 (VA, 2017a).
In the context of this report, stigma refers to the discrimination veterans might face from friends, family, employers, and others because of their mental health needs or treatment-seeking behavior. Stigma can be an actual or perceived barrier in that veterans may fear discrimination associated with their mental health and treatment-seeking behavior which may or may not actually materialize. Stigma is a sociocultural barrier affecting access; for example, if a health system user or (potential user) perceives or experiences discrimination from a provider or from the public, it may discourage the user from seeking services. While there are numerous studies that document stigma associated with mental health and with the use of mental health care in active-duty military populations (IOM, 2013), there is far less in the literature about stigma and how it affects veterans who have separated and are using or are eligible for VA mental health services. This section is a summary of the sparse literature on the topic.
Despite efforts reduce stigma in recent years, it is well documented that there is a strong stigma attached to seeking mental health care in the military (Acosta et al., 2014; Brown and Bruce, 2016; Hurtado et al., 2015; Kim et al., 2016; VanSickle et al., 2016) and veterans often carry this belief with them following separation (Chase et al., 2016; Kulesza et al., 2015). 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. Veterans across all branches reported that while serving, not only were they
discouraged from reporting medical issues, but any behaviors were severely chastised that demonstrated weakness or not “sucking it up and driving on” [West Haven, Connecticut]. This was particularly true with respect to mental health concerns.
The term “malingerer” gets thrown around a lot. To be the person that’s always going to medical or whatever for issues . . . you may get barred from the next operation . . . because then they’re like, “Oh. Well, you had been to medical prior for this and this and this. . . . We may have to replace you with somebody else.” [Iowa City, Iowa]
The military experience also taught veterans that reporting mental health concerns could end their careers. A provider who was an OEF/OIF/OND veteran offered this perspective:
The problem, it starts out within the military. There’s a huge stigma about mental health. If a soldier or service member goes to a mental health facility, then it’s almost like a career killer. A lot of veterans won’t report a lot of the symptoms . . . until they get to a point where they can’t control it. [Topeka, Kansas]
While stigma associated with mental health is also well documented in the civilian world (Corrigan et al., 2014), veterans may face levels of stigma not experienced by the civilian population. These stem from negative attitudes about seeking help in general, privacy concerns, an emphasis on “toughness” and self-reliance, and the belief that they will not be helped. Many veterans reported that even after they left active duty, they still had a hard time believing they could identify mental health concerns and not experience backlash. VA staff also identified this as a significant barrier. One clinician noted,
The tendency [in the military] was push down the emotions, push down the thoughts, just get on with it because they didn’t want to abandon their brothers. Now when they come back . . . I think a lot of the problem we have is getting them to come in. [Biloxi, Mississippi]
A 2015 study by Kulesza et al. (2015) looked at the association between treatment-seeking stigma and the use of mental health services among a sample of 812 young veterans. 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. Another particularly notable finding was that nearly half (44 percent) of the participants perceived that they would be negatively judged by others for seeking mental health care but only 12 percent reported they themselves would view others negatively for seeking treatment (whether they needed treatment themselves or not). This discrepancy is an example of how perception among veterans may not align with the reality—veterans may have a fear of being judged negatively by their peers for seeking mental health care when in fact very few veterans in this study viewed treatment seekers as weak or inferior for seeking care (Kulesza et al., 2015).
Brown and Bruce (2016) looked at how self-stigma, public stigma, and concerns about career-related consequences were related to treatment-seeking among OEF/OIF/OND soldiers and veterans. The authors surveyed 276 participants, 62 percent of whom were veterans and 38 percent of whom were active duty. Interestingly, the analysis differentiates stigma (negative beliefs about mental illness) from career worry and found that while some OEF/OIF/OND soldiers and veterans may not have negative beliefs about mental illness, they may avoid seeking care out of a fear that it could harm their careers. In fact, career worry was a stronger predictor of avoiding care than self-stigma or public stigma among the study population (Brown and Bruce, 2016).
In a 2011 review, Vogt looked at 15 studies of mental health beliefs and public stigma and how these factors affect the use of services among veterans and active-duty military. The author also sought to identify areas that have been neglected in the research that require additional attention. The review revealed
15 articles—12 quantitative and 3 qualitative—that focused on mental health–related beliefs or in which beliefs regarding mental health emerged from the data. Nearly all the quantitative papers found public stigma to be a barrier to care. While only two studies in the review addressed personal beliefs about mental health care as a barrier to care, those two showed that negative attitudes about seeking mental health care and the idea that individuals should be able to handle their own mental health were barriers to seeking mental health care. Vogt suggests that the topic of personal beliefs about mental health and mental health care should be studied further among military veteran populations. The current research on the topic is sparse, but it does suggest these are important factors affected health-seeking decisions (Vogt, 2011).
A small qualitative study of 16 OEF/OIF veterans receiving care for PTSD reported similar results (Mittal et al., 2013). All the participants reported that they were aware of stigmatizing labels for PTSD. Being “violent” or “dangerous” was perceived by participants to be the dominant stigmatizing stereotype for the condition. Being “crazy” was another stereotype that participants felt was common, particularly within their families. Only a few of the participants, however, self-stigmatized and felt that the PTSD stereotypes applied to themselves. However, these labels and the fear of being labeled did affect treatment seeking among the sample: several participants reported they avoided treatment for fear of being labeled with a negative stereotype. Of those who avoided treatment, most chose to cope with their symptoms on their own and, in some cases, with substance abuse. Many participants expressed that others with PTSD were the only people that truly understood their experience, suggesting to the authors that group therapy or peer counseling may be a good way to combat the effects of public stigma and reduce the incidence of self-stigma (Mittal et al., 2013).
In another study, Pyne et al. (2004) evaluated the relationship between perceptions of stigma and depression severity and treatment for depression. The authors used a convenience sample of depressed veterans from a VA outpatient clinic (N = 54) and never-depressed veterans from a VA primary care clinic (N = 50). The sample was not OEF/OIF/OND specific. The authors found that among those in treatment for depression, symptom severity was a strong predictor of perceived stigma. Subthreshold depression, however, was not a predictor of perceived stigma.
Rosen et al. (2011) evaluated a similar question among a sample of veterans with a PTSD diagnosis. The authors examined the relationships among symptom severity, stigma, and service use. The study sample included a total of 1,609 male and female veterans with a PTSD diagnosis, 482 of whom agreed and were eligible to participate (31 percent response rate). Of the sample, 243 were OEF/OIF veterans. About one-third (35 percent) of the sample said that stigma concerns were “moderately” or “very much” reasons to not seek care. However, contrary to the other research discussed in this section, persons who expressed stigma concerns were no less likely to actually initiate psychotherapy or counseling. While there was a low response rate among OEF/OIF veterans in the study, they were no less likely to initiate care than veterans from other service eras. The authors noted that the low response rate overall raises some concerns about selection bias and suggested that the veterans they initially contacted who were most concerned about stigma may have declined to participate.
National Guard and Reservists are in the unique position in that they may be eligible to use VA services while still serving in the armed forces. Stigma is an often-cited barrier to seeking mental health care by National Guard members, particularly because they are often worried their mental health service utilization will appear on their military records if they are still actively serving (Gorman et al., 2011). 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). The National Guard and Reservists in the studies reviewed sought care at the VA, DoD, and community facilities. The committee is not aware of research that looks at stigma among National Guard and reservists who seek care at the VA specifically.
Pietrzak et al. (2009), however, evaluated how mental health and beliefs about mental health care were related to stigma, barriers, and mental health care use among a sample of 272 OEF/OIF National Guard, Reserve, and active-duty veterans. The authors screened participants for mental health problems using the PTSD Checklist–Military, the Patient Health Questionnaire-9 (for depression), and the CAGE questionnaire (for substance use). Stigma and barriers to care were measured using the Perceived Stigma and Barriers to Care for Psychological Problems, an 11-item instrument that assesses stigma and obstacles that prevent or discourage individuals from seeking mental health care. Not surprisingly, negative beliefs about mental health care, such as “Therapy is not effective for most people” and “Therapy is a sign of weakness,” were significant predictors of stigma and barriers to care. Negative beliefs were also associated with the decreased use of mental health counseling and medication in the previous 6 months. The presence of a disorder was also associated with stigma and barriers to care. The stigma and perceived barriers items that had the strongest association with a positive screen for a psychiatric disorder were embarrassment, being perceived as weak, not knowing where to get help, and having trouble scheduling an appointment. The authors surmised that those with mental health disorders may perceive more barriers because they have a more difficult time navigating the VA system. The results of this study confirm those of an earlier look at the topic (Hoge et al., 2004) 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.
Veterans with mental health conditions often encounter or perceive stigma that may affect their use of mental health services. They also may experience self-stigma, where an individual internalizes stigmatizing beliefs about mental illness which may, in turn, discourage the use of mental health care (Lucksted et al., 2011). A 2012 review of interventions designed to combat self-stigma revealed that such interventions tend to follow one of two approaches (Mittal et al., 2012). Interventions that follow the first approach focus on the beliefs and attitudes of the self-stigmatizing individual. The other common approach focuses on improving coping with self-stigma by improving self-esteem, empowerment, and treatment-seeking behavior. The authors of the review noted that most of the 14 studies included were pilot programs or exploratory investigations with limitations (e.g., small sample sizes, no control group, no randomization). Furthermore, none of the studies controlled for mediating effects such as symptom severity. Most of the study populations were individuals with schizophrenia or depression, and only one study was veteran focused. The authors noted that while the field is emerging, many interventions reviewed were not based on a theoretical framework and lacked clear definitions of self-stigma and clear measurement tools (Mittal et al., 2012).
A more recent review looked at six intervention approaches to reduce self-stigma and found several common elements in emerging self-stigma interventions (Yanos et al., 2015). The review included three self-stigma treatment approaches that were not covered in the Mittal et al. (2012) study discussed above. Psychoeducation was common in all interventions, many of the interventions included cognitive techniques and offered opportunities to practice skills to combat stigmatizing thoughts and beliefs, narration was a key element in many interventions to help individuals make sense of past experiences and empower them to be active agents within their lives, and nearly all the interventions offered tools designed to encourage feelings of hope, empowerment, and motivation to achieve one’s goals. The authors noted that while many of the interventions shared common features, they were all unique in their emphasis and development and were best suited for certain people in different contexts. For example, some interventions were designed to be implemented in a group setting (Ending Self Stigma, Narrative Enhancement, and Cognitive Therapy) while others were designed for a peer-support setting (Coming Out Proud, Anti-Stigma Photovoice). Outcome research of many of the interventions is emerging, and
what has been completed shows positive results. More rigorous evaluation is needed and is under way for several interventions (Yanos et al., 2015).
An adaptation of the Coming Out Proud program called Honest, Open, Proud is currently in use at the VA (VA, 2017c). Master trainers will train peer specialists to use the intervention with veterans they work with. The intervention is designed to reduce self-stigma, thereby reducing that barrier to seeking and continuing treatment. However, a randomized trial of Coming Out Proud found (among a non-veteran sample) that the intervention had no significant effect on self-stigma. It did, however, have a positive effect on disclosure-related stress, on the perceived benefits of disclosure, and on secrecy (Rusch et al., 2014).
One intervention included in the Yanos et al. (2015) review was called Ending Self Stigma, which may have greater application in the VA system (Lucksted et al., 2011). The intervention consists of nine weekly 90-minute sessions that are a combination of lecture, group sharing of experiences, problem solving, and other discussion. Participants are assigned work to complete between sessions. In the evaluation, 34 participants completed the full intervention. Using the Internalized Stigma of Mental Illness (Ritsher et al., 2003) to measure self-stigma pre- and post-intervention, the analysis found that 32 percent of participants scored above 2.5 after the intervention, compared with 47 percent at baseline, indicating a decrease in self-stigma among the participants. The authors noted that a larger study (with a control group) is needed, but the results of this intervention to reduce self-stigma are promising (Lucksted et al., 2011).
Similarly, Stecker et al. (2011) piloted a cognitive behavioral therapy (CBT) intervention designed to reduce mental health stigma among a sample of 27 OEF/OIF National Guard veterans with mental health needs (there was no control group). The intervention was a single one-on-one CBT session that focused on individual beliefs about mental health treatment. The session lasted 45–60 minutes. While beliefs about seeking mental health treatment did not change significantly post-intervention, at a 1-month follow-up, or at a 3-month follow-up, the intention to seek treatment did increase significantly following the intervention. That said, while participants reported that they intended to seek treatment, service use did not actually go up. The authors suggested that a longer follow-up period may be needed to see a change in service use. They also noted that the change in intention to seek behavior may be attributed to a change in symptoms post-intervention, which the authors did not assess. The authors noted that interventions designed to increase treatment initiation are greatly needed, but a larger study with a control group will be necessary to assess the effectiveness of this intervention (Stecker et al., 2011).
This chapter outlined studies from the literature that examined racial and ethnic disparities in mental health diagnosis and treatment provided by the VA and in adherence to care among veterans as well as addressing issues affecting women veterans. It also described access and stigma issues faced by various select population groups and associated findings from this study’s survey and site visits. A summary of the committee’s findings on this topic is outlined below.
- 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.
- The affordability of care was cited in several studies as a common barrier to seeking needed services.
- Women veterans were more likely than men to believe that they are not entitled to or eligible for VA mental health care.
- Compared to non-Hispanic white veterans, a higher percentage of non-Hispanic black veterans indicated that they did not use VA services because they were not aware of VA mental health care benefits and also that they did not know how to apply for VA mental health care benefits.
- 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.
- Minority veterans generally have fewer health care options outside of the VA than white veterans.
- Minority veterans report more difficulty accessing PCMH care, a care model that is being implemented at a higher rate in areas that serve predominantly non-minority veterans.
- The literature documents racial and ethnic differences in mental health diagnosis patterns among veterans. The reasons are not clear, but some researchers posit that the difference in diagnosis patterns may be related to provider characteristics, doctor–patient communication, patient participation, or the lack of cultural sensitivity of diagnostic criteria for mental health conditions.
- The literature shows the existence of disparities in treatment, with studies showing that compared to white veterans, non-white veterans are not as likely to receive pharmacotherapy treatment and are more likely to receive psychotherapy.
- Non-white veterans are less likely to be adherent to treatment.
- Although research is limited, LGB veterans may use VA mental health services at a lower rate than their non-LGB counterparts.
- The limited research on transgendered veterans suggests that they may be more likely to have a mental health diagnosis than their non-transgendered counterparts.
- Following a directive in 2011, the VA provides services to transgendered individuals that most private insurance does not cover.
- Research on homeless veterans shows they are more likely to defer or delay mental health care than housed veterans, but they also have a greater need for services.
- While the evidence base is sparse regarding stigma as a barrier to care among OEF/OIF/OND veterans, the available literature suggests that higher perceived stigma and concern about consequences that may result from seeking care is a barrier to seeking mental health services.
- Veterans with mental health disorders are, not surprisingly, more likely to perceive stigma, and a more severe disorder may predict more perceived stigma.
- Some research suggests that the perception of stigma may not align with the reality—that is, veterans may fear negative judgment from others for seeking care but may not in fact actually experience it.
- While the field is just now emerging, there are some promising interventions in place at the VA, such as “Ending Self Stigma,” to help reduce stigma among veterans.
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