The wars in Afghanistan and Iraq have been among the longest-ever sustained U.S. military operations. Operation Enduring Freedom (OEF)1 is the name for the war in Afghanistan that began on October 7, 2001, and ended on December 31, 2014, and Operation Iraqi Freedom (OIF) is the name of the war in Iraq that began on March 20, 2003. Since September 1, 2010, the continuing operations in Iraq have been referred to as Operation New Dawn (OND).
In contrast with previous wars, the all-volunteer military supporting OEF/OIF/OND has experienced numerous deployments of individual service members and has seen increased deployments of women, parents of young children, and Reserve and National Guard troops (IOM, 2013). In some cases the deployed have been subject to longer deployments and shorter times at home between deployments than in previous wars. Military families sometimes endure adverse consequences of deployments, including health problems, family violence, and economic burdens (IOM, 2013).
Numerous reports in the popular press have made the public aware of issues indicating that military personnel have returned home with posttraumatic stress disorder (PTSD) and other mental health diagnoses, such as major depressive disorder, anxiety, substance use disorder, and suicidal ideation. As early as 2004, it was estimated that over one-fourth of troops returning from OEF and OIF were suffering from mental health disorders (Hoge et al., 2004). Later estimates suggested that one-fifth of the troops reported symptoms of PTSD or depression and about the same fraction experienced a probable traumatic brain injury (TBI) during deployment (Tanielian and Jaycox, 2008). RAND reports note that a full one-third of returning OEF and OIF service members reported symptoms of mental health or cognitive problems (Hosek, 2011; Tanielian and Jaycox, 2008). RAND also reports that 18.5 percent of a representative sample of returning service members met the diagnostic criteria for PTSD or depression, 19.5 percent reported a probable TBI during deployment, and 7 percent met the criteria for both a
1 Operation Enduring Freedom officially refers to several operations around the world that were part of the Global War on Terror; however, in the context of this report, the focus is the operation in Afghanistan.
mental health problem and a probable TBI (Tanielian and Jaycox, 2008). In addition, the prevalence of substance use disorder among OEF/OIF/OND veterans is greater than in the general population (Larson et al., 2012). Details on the prevalence of mental health conditions, including substance use disorder, in OEF/OIF/OND veterans can be found in Chapter 4.
The influx of returning OEF/OIF/OND veterans in need of treatment for mental health conditions has placed increased demands on the Veterans Health Administration (VHA), the sub-cabinet level agency within the Department of Veterans Affairs (VA) that manages the VA’s integrated health care system, and there have been reports of delayed care, inadequate care, and other problems with accessing and obtaining timely and high-quality mental health care for some OEF/OIF/OND veterans. Problems with access to and the quality of VHA mental health care services were identified in several previous investigations. For example, concerns were raised about how long veterans had to wait to receive appointments at VHA health facilities, including mental health appointments (Commission on Care, 2016; GAO, 2012; VA, 2014; VA Office of Inspector General, 2012); about the implementation of the Uniformed Mental Health Services Handbook, which defines minimal mental health clinical requirements for VHA health facilities (VA Office of Inspector General, 2010); about VHA residential mental health care facilities (VA Office of Inspector General, 2009); and about postdischarge follow-up mental health care, especially for veterans at risk of suicide (VA Office of Inspector General, 2013). As the present study was ongoing, investigations by governmental oversight bodies (for example, the VA Office of Inspector General and the Government Accountability Office) and media reports were released that brought to the public’s attention problems with the VHA health care system, in some cases with the agency’s mental health clinical services. In this report, the committee does not react to individual incidents or “scandals”; rather, it has sought to conduct a comprehensive and unbiased review of evidence on the overall performance of the VHA’s mental health care services and to make recommendations for improving those services.
It should be noted that problems in accessing and obtaining high-quality mental health care are not unique to the VHA. Similar problems have been reported in the private health care sector as well (for example, The Commonwealth Fund, 2013; Merritt Hawkins, 2014; O’Hanlon et al., 2017).
Not all veterans are eligible for health care through the VHA. Veterans may be eligible to receive health care through the VHA if (1) they served in the active military service and left the service under any condition other than dishonorable or (2) they served or are currently serving in the Reserves or National Guard and they were called to active duty by a federal order and completed the full period for which they were called or ordered to active duty (VA, 2015). As detailed in Chapter 6, even if veterans meet the broad eligibility requirements noted above, they may not qualify to receive health care through the VHA. In addition, some veterans who qualify for health care through the VHA may choose not to use VHA services; for example, veterans who have health insurance through their employers may seek health care services from private providers. Veterans who served in a combat theater after November 11, 1998, and were discharged from active duty on or after January 28, 2003, are eligible for comprehensive VHA health care services for 5 years following their discharge. Veterans in this group would include veterans serving in combat theaters in support of OEF/OIF/OND (unless they discharged before January 28, 2003). After 5 years, these veterans are assigned to a priority group based on their income and degree of disability due to their service-related condition at that time (IOM, 2014). Combat veterans who did not enroll within the 5-year window of eligibility and were discharged from service between January 1, 2009, and January 1, 2011, were granted 1 additional year of eligibility under the Clay Hunt Suicide Prevention for American Veterans Act.2
2 Public Law 114-2.
In response to concerns about the health care experience of the approximately 4 million U.S. veterans who supported the wars in Iraq and Afghanistan and who may have mental health conditions, Congress passed Section 726 of the National Defense Authorization Act (NDAA) for fiscal year (FY) 2013; Section 726 required that the VA enter into an agreement with the National Academies of Sciences, Engineering, and Medicine (the National Academies) for a study that would assess veterans’ ability to access mental health services at the VHA as well as the quality of mental health services within the VHA and to provide recommendations to address problems with access and quality of services. The National Academies assembled the Committee to Evaluate the Department of Veterans Affairs Mental Health Services and assigned to it the following task:
A National Academies of Sciences, Engineering, and Medicine committee will comprehensively assess the quality, capacity, and access to mental health care services for veterans who served in the Armed Forces in OEF/OIF/OND. The committee will assess the spectrum of mental health services available across the entire VA. The scope of this assessment will include analysis not only of the quality and capacity of mental health care services within the VHA, but also barriers faced by patients in utilizing those services. Types of evidence to be considered by the committee in its assessment include relevant scientific literature and other documents, interviews with VHA mental health professionals, survey data to be provided by the VHA, and results from surveys of veterans to be conducted independently by the committee. Site visits will be conducted to at least one VA medical center in each of 21 Veterans Integrated Service Networks across the country. In addition, the committee will hold an open meeting of experts to discuss the Secretary’s plan for the development and implementation of performance metrics and staffing guidance. The committee will provide a final report with recommendations to the Secretary of the VA regarding overcoming barriers and improving access to mental health care in the VA as well as increasing effectiveness and efficiency.
The National Academies appointed a committee of 18 experts to carry out the study. The committee members have expertise in fields such as epidemiology, biostatistics, survey design and data analysis, health services research, clinical medicine, psychiatry, psychology, nursing, sociology, and social work. Furthermore, several committee members had previously been employed at the VHA as providers of mental health care, one committee member is a former official of the VHA, and several are former active-duty military members.
The VHA is a large, complex, and dynamic health system, which made the committee’s work particularly challenging. To meet the challenge, the committee took a three-part approach to gathering information: reviewing the literature, conducting site visits, and developing and fielding a survey of OEF/OIF/OND veterans. With a focus on OEF/OIF/OND veterans, the literature search included identifying and reviewing data in the peer-reviewed literature; reviewing government reports and testimony before Congress; reviewing recent National Academies reports on PTSD and physiological, psychological, and psychosocial effects of deployment-related stress; and gathering information directly from VA researchers and officials. Consistent with the statement of task, the committee uses the terms “mental health” and “mental health conditions” to encompass diagnoses such as PTSD, major depressive disorder, and substance use disorders. Similarly, the terms “mental health services” and “mental health treatments” include health care addressing this range of conditions. The committee was mindful of the practical consideration that research studies and other documents cited in this report often use the term “behavioral health” to refer specifically to alcohol and drug abuse.
In its attempts to understand the mental health needs of OEF/OIF/OND veterans, veterans’ access to care, and the quality of the VHA programs, the committee conducted extensive searches of the peer-reviewed literature and considered about 3,000 articles. It also relied on the gray literature, including publications produced by government, business, and industry; conference proceedings; and abstracts presented at conferences. Specifically, the committee members reviewed numerous reports of the Government Accountability Office, the inspectors general of VA and the Department of Defense, and the Congressional Research Service.
The committee also sought input on the use of VHA mental health services directly from veterans, veterans’ families and caregivers, providers, and others at each of the 21 Veterans Integrated Service Networks across the United States. To assist with the organization of the site visits, data collection, and data analysis, the committee retained the services of Westat, an independent research corporation. All 21 site visits were conducted between February 2015 and November 2015. In addition to the site visits, the committee held four public sessions in Washington, DC, to gather information from invited speakers and members of the public.
Finally, the committee developed a survey that was administered to OEF/OIF/OND veterans in order to gather information on access to and the quality of VHA mental health services and to determine why some veterans choose not to use VHA mental health services. Westat was subcontracted to assist with this task as well. The methods used to carry out the site visits and the survey are detailed in Chapter 5. The survey of veterans, which includes responses from both eligible individuals who have chosen not to use VHA mental health services and individuals who do use VHA mental health services, is unique both in scope and size and provides new and valuable insights about access. Although Section 726 of the NDAA FY 2013 specifies only that the committee conduct a survey of non-users of VHA mental health services, the committee members decided to also include users of VHA mental health services as a comparison group. Results from the data analyses are presented in Chapters 6 and 8–15.
To accomplish the part of the statement of task that requires discussion of “the Secretary’s plan for the development and implementation of performance metrics and staffing guidance,” the committee held a public meeting on November 22, 2013, in Washington, DC. At that meeting, VHA officials presented information on their work on measures related to capacity, timeliness, evidence-based treatments, and veterans’ satisfaction with VHA mental health services and also on the VHA’s staffing model. The committee engaged in a discussion with the VHA officials in attendance on the information presented during the meeting. That information is not summarized in this report; however, Chapter 15 contains additional information about quality measurement at the VHA.
This report is organized into 16 chapters. Chapter 2 provides an overview of the structure of the VHA; the chapter also discusses how the VHA fits into the U.S. health care landscape. Chapter 3 provides an overview of mental health services provided by the VHA and its research and evaluation programs that support clinical operations. Chapter 4 summarizes how select mental health conditions are clinically managed in the VHA. Chapter 5 details the committee’s methods for data collection, which consisted of a survey, site visits, and a comprehensive literature review, as well as its methods for data analysis. Chapter 6 describes the need for and use of VHA health care services, including mental health care services, by veterans. It includes the analyses of the committee’s survey of veterans who use and do not use the VHA for mental health services; the chapter includes descriptions of problems associated with accessing VHA mental health care services. Chapter 7 provides an introduction to the eight dimensions of health care quality (workforce and infrastructure, timely mental health care, patient-centered
mental health care, effective mental health care, efficient mental health care service delivery, equitable mental health care, health technology for mental health care, and quality improvement) around which the committee’s evaluation is organized. Chapters 8–15 summarize information from the survey, site visits, and literature on these dimensions. Chapter 16 contains the committee’s findings, conclusions, and recommendations. The report has two appendixes. Appendix A contains the survey instrument and other supporting documents related to the survey, and Appendix B contains the site visit questionnaires and NVivo codes.
Commission on Care. 2016. Final report of the Commission on Care. Washington, DC: Commission on Care.
The Commonwealth Fund. 2013. International profiles of health care systems, 2013. New York: The Commonwealth Fund.
GAO (Government Accountability Office). 2012. VA health care: Reliability of reported outpatient medical appointment wait times and scheduling oversight need improvement. Washington, DC: Government Accountability Office.
Hoge, C. W., K. Wright, P. Bliese, A. Adler, and J. Thomas. 2004. Prevalence and screening of mental health problems among U.S. combat soldiers pre- and post-deployment. Silver Spring, MD: Walter Reed Army Institute of Research.
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IOM (Institute of Medicine). 2013. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press.
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Larson, M. J., N. R. Wooten, R. S. Adams, and E. L. Merrick. 2012. Military combat deployments and substance use: Review and future directions. Journal of Social Work Practice in the Addictions 12(1):6–27.
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O’Hanlon, C., C. Huang, E. Sloss, R. Anhang Price, P. Hussey, C. Farmer, and C. Gidengil. 2017. Comparing VA and non-VA quality of care: A systematic review. Journal of General Internal Medicine 32(1):105–121.
Tanielian, T. L., and L. H. Jaycox. 2008. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.
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