Evaluation of
the Department
of Veterans Affairs
Mental Health
Services
Committee to Evaluate the Department of Veterans Affairs
Mental Health Services
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was supported by Contract/Grant No. VA77713A0009 between the National Academy of Sciences and the U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-46657-8
International Standard Book Number-10: 0-309-46657-1
Digital Object Identifier: https://doi.org/10.17226/24915
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24915.
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COMMITTEE TO EVALUATE THE DEPARTMENT OF VETERANS AFFAIRS MENTAL HEALTH SERVICES
ALICIA L. CARRIQUIRY (Chair), Iowa State University
F. JAY BREIDT, Colorado State University
DENNIS M. DONOVAN, University of Washington
SUSAN V. EISEN, Boston University School of Public Health (retired)
CONSTANTINE GATSONIS, Brown University School of Public Health
ROBERT C. GRESEN, Medical College of Wisconsin
STEVEN HEERINGA, University of Michigan
KENNETH W. KIZER, University of California, Davis
JOHN W. KLOCEK, Baylor University (through August 19, 2016)
RICHARD A. KULKA, Consultant, Statistical, Survey and Social Research, Raleigh, NC
BRUCE G. LINK, University of California Riverside
SUSAN M. PADDOCK, RAND Corporation
DEBORAH K. PADGETT, New York University
BETHANY J. PHOENIX, University of California, San Francisco
ROBERT L. SANTOS, The Urban Institute
JEANNETTE E. SOUTH-PAUL, University of Pittsburgh
THANH V. TRAN, Boston College
PETER M. YELLOWLEES, University of California, Davis
Study Staff
LAURA AIUPPA DENNING, Study Co-Director
ABIGAIL MITCHELL, Study Co-Director
MARC MEISNERE, Associate Program Officer
HEATHER L. CHIARELLO, Research Associate (through October 2016)
JOSEPH GOODMAN, Senior Program Assistant
CHRISTIE BELL, Financial Officer
ROBERT POOL, Editor
FREDERICK (RICK) ERDTMANN, Director, Board on the Health of Select Populations (through July 2016)
SHARYL NASS, Director, Board on Health Care Services (from January 2017)
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Margarita Alegría, Harvard Medical School and Massachusetts General Hospital, Disparities Research Unit
Robert A. Barish, University of Illinois at Chicago
Jonaki Bose, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services
John Boyle, ICF International
Babette Brumback, University of Florida
Eric Goplerud, NORC at the University of Chicago
Joel B. Greenhouse, Carnegie Mellon University
Ronald C. Kessler, Harvard Medical School
Richard C. Larson, Massachusetts Institute of Technology
Richard A McCormick, MetroHealth/Case Western Reserve University
Bernadette Mazurek Melnyk, The Ohio State University
Harold A. Pincus, Columbia University
Terri Tanielian, RAND Corporation
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final
draft before its release. The review of this report was overseen by Dan G. Blazer, Duke University School of Medicine, and Bradford H. Gray, The Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
Preface
Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. Shortly after troops started returning from their deployments, some active-duty service members and veterans began experiencing mental health problems. Given the stressors associated with war, it is not surprising that some service members developed such mental health conditions as posttraumatic stress disorder, depression, and substance use disorder. Subsequent epidemiologic studies conducted on military and veteran populations that served in the operations in Afghanistan and Iraq provided scientific evidence that those who fought were in fact being diagnosed with mental illnesses and experiencing mental health–related outcomes—in particular, suicide—at a higher rate than the general population.
Media reports also brought to the nation’s attention problems that veterans were having obtaining timely health care appointments and high-quality care through the Department of Veterans Affairs (VA) health system (that is, the Veterans Health Administration, VHA). Addressing the health needs of the large influx of veterans presented a substantial challenge to the VHA. In the National Defense Authorization Act of 2013, Congress included a mandate for the National Academies of Sciences, Engineering, and Medicine (the National Academies) to conduct a study to assess the VHA’s mental health care services and provide recommendations to assist the VHA with improving its services. The report that follows details the work of the National Academies’ study committee that was appointed to carry out this task.
Gathering the evidence on which the committee developed its findings, conclusions, and recommendations was an enormous task. We on the committee used a multipronged approach to build the evidence base necessary to complete our work by conducting a survey of veterans who served in the operations in Afghanistan and Iraq; visiting 21 areas of the country to talk with veterans and their families, VHA employees, and others who work with the veteran population; conducting multiple literature searches; holding public meetings; and obtaining performance data collected by the VA on its mental health services.
Those of us on the committee could not have accomplished its task without the assistance of the many people who provided valuable information about the VA and the agency’s mental health services. First and foremost, I would like to thank all of the veterans and their families who took time to tell us
their stories and about their experiences getting health care at VHA facilities. Their input was critical to the committee’s understanding of their health-related needs.
I would like to extend my sincere thanks to several individuals at the VA who assisted us by responding to our many requests for information. Stacy Gavin from the Office of Mental Health and Suicide Prevention effectively coordinated our requests with others at the VA to send us the information we needed in a timely manner. Rani Hoff from the Northeast Program Evaluation Center compiled a complex set of data for the committee from several groups within the VA so that we could conduct the survey of veterans. Dawne Vogt from the VA’s National Center for PTSD assisted the committee with developing a brief instrument to measure combat exposure to include in the committee’s survey of veterans.
Over the course of the study, the committee held several public meetings to obtain information from subject-matter experts. We committee members are grateful to have heard from the following people and I thank them for taking time to meet with us:
David Carroll, Office of Mental Health and Suicide Prevention, VA
Carolyn Clancy, Veterans Health Administration, VA
Mike Davies, Access and Clinic Administration Program, VA
Peter Duffy, Colonel, U.S. Army (Ret.), The National Guard Association of the United States
John Fairbank, VISN 6 Mental Illness Research, Education and Clinical Center, VA
Warren Goldstein, The American Legion
Rani Hoff, Northeast Program Evaluation Center, VA
Joy Ilem, Disabled American Veterans
Kenneth Jones, Office of Academic Affiliations, VA
Daniel Kivlahan, Seattle VA Medical Center
Laura Krejci, Office of Patient Centered Care and Cultural Transformation, VA
Harold Kudler, Durham VA Medical Center
David Latini, Office of Academic Affiliations, VA
Thomas Lynch, Veterans Health Administration, VA
Jacqueline Maffucci, Iraq and Afghanistan Veterans of America
Jennifer Patterson, Office of Patient Centered Care and Cultural Transformation, VA
Andrew Pomerantz, Integrated Services, Mental Health Services, VA
Stacy Pommer, Office of Academic Affiliations, VA
Paula Schnurr, National Center for PTSD, VA
Mary Schohn, Office of Mental Health and Suicide Prevention, VA
Howard Somers and Jean Somers, Coronado, CA
Jodie Trafton, Program Evaluation and Resource Center, VA
Janet Vertrees, Office of Patient Centered Care and Cultural Transformation, VA
Kendra Weaver, Mental Health Clinical Operations, VA
The committee worked closely with Westat, an independent research corporation, on the conduct of the survey of veterans and the site visits. We appreciate the hard work put forth by Westat team members to produce the array of technical products necessary to support the committee’s work. I thank the Westat project director, Shelley Perry, along with her team members.
I was honored to chair the committee and lead a group of very knowledgeable and hardworking individuals. Their dedication to this study, which took place over 4 years, is commendable. I would like to thank Thomas Horvath for his committee service during the initial period of the study. I also would like to thank the staff from the National Academies who guided the committee through the study process.
Laura Aiuppa and Abigail Mitchell directed the study and kept us on task. Heather Chiarello and Marc Meisnere assisted the committee with research and with writing the report. Joseph Goodman provided administrative support and handled the logistics for our committee meetings; he made sure that all 16 meetings ran smoothly. Constance Citro, Director of the National Academies’ Committee on National Statistics, and Krisztina Marton provided valuable input on the committee’s survey.
Finally, I thank the VA for providing support for this study. We hope that the committee’s recommendations will help the VHA to improve mental health care for veterans.
Alicia L. Carriquiry, Chair
Committee to Evaluate the Department of Veterans Affairs Mental Health Services
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3 THE VETERANS HEALTH ADMINISTRATION’S MENTAL HEALTH SERVICES
Mental Health–Related Programs and Services
Programs and Centers Supporting Quality of Mental Health Services
4 CLINICAL MANAGEMENT OF MENTAL HEALTH CONDITIONS AT THE VETERANS HEALTH ADMINISTRATION
Screening, Assessment, and Treatment
Eligibility and Priority for Department of Veterans Affairs Health Care Services
Need for and Use of Department of Veterans Affairs Health Care Services
Barriers and Facilitators to Service Use
Factors That May Influence Future Use
7 DIMENSIONS OF QUALITY IN MENTAL HEALTH CARE
Integrated Systems Approach to Quality
System Transformation in the Department of Veterans Affairs
9 TIMELY ACCESS TO MENTAL HEALTH CARE
Wait Times and Scheduling Care at the VA
Programs to Improve Timely Access to VHA Care
Practices to Facilitate Timely Access
10 PATIENT-CENTERED CARE AND THE VETERAN EXPERIENCE
Patient-Centered Care at the Veterans Health Administration
Veteran Experiences with Receiving Mental Health Care at the Veterans Health Administration
11 EFFECTIVE MENTAL HEALTH CARE
Availability of Evidence-Based Practices for Mental Health in the Department of Veterans Affairs
Delivery of Mental Health Care in the Veterans Health Administration
12 EFFICIENT MENTAL HEALTH CARE
Mental Health Workforce Tracking and Efficiency
Care Integration and Collaboration
Findings from the Committee’s Site Visits
13 EQUITABLE MENTAL HEALTH CARE
Access to Mental Health Care Services for Select Populations
The Department of Veterans Affairs Office of Health Equity
14 HEALTH TECHNOLOGY FOR MENTAL HEALTH CARE
Other Health Technology in Use at the Department of Veterans Affairs
Technological Barriers in the Department of Veterans Affairs
Boxes, Figures, and Tables
BOXES
6-1 Department of Veterans Affairs Priority Groups
12-2 Stepped-Care Model for Mental Health at the VHA
FIGURES
5-1 Flowchart of questionnaire modules
5-2 Data collection plan as originally designed
5-4 Number and percentage of interviews and group discussions by venue
5-5 Number and percentage of participants by type
5-6 Number and percentage of veteran participants by service branch
6-3 Veteran population by Veterans Integrated Service Network, FY 2015
9-1 Actual versus VA calculated wait time for mental health appointments
11-1 Average number of veteran mental health visits for fiscal years 2013–2017
12-1 Continuum of VA mental health services
15-1 VHA Mental Health Management System Framework
TABLES
3-3 National Center for Posttraumatic Stress Disorder Focus Areas by Division
4-1 Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for PTSD
4-2 Comparison of DSM-IV-TR Criteria to DSM-5 Criteria for Substance Use Disorders (SUDs)
4-3 Prevalence of Mental Health Conditions and Suicide Rates in Veteran and Non-Veteran Populations
4-4 Example of the Scope of Mental Health Practice for Five Main Types of Health Care Providers
4-5 Mental Health Screening in the VA
5-1 Second-Phase Stratification and Sample Sizes
5-2 Timeline of Actual Data Collection Activities
5-3 Final Survey Status at End of Data Collection
5-4 Final Survey Completes, by User and Need Status
5-6 Site Visit Data Collection Modality and Location by Respondent Type
5-7 Sites and Dates of Site Visits (in Order by VISN Number)
6-3 Percent of U.S. Armed Forces Veterans by Service Era
6-4 Six States with Largest Populations of OEF/OIF/OND Veterans
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Abbreviations and Acronyms
A/PI | Asian/Pacific Islander |
ACA | Patient Protection and Affordable Care Act |
ACT | acceptance and commitment therapy |
AI/AN | American Indian/Alaska Native |
APPN | advanced practice psychiatric nurse |
ATP | asynchronous telepsychiatry |
AUDIT | Alcohol Use Disorder Identification Test |
BHIP | Behavioral Health Interdisciplinary Program |
CAPS | Clinician-Administered PTSD Scale |
CBOC | community-based outpatient center |
CBT | cognitive behavioral therapy |
CCHT | care coordination home telehealth |
CDC | Centers for Disease Control and Prevention |
CIH | complementary and integrative health |
CPG | clinical practice guideline |
CPT | cognitive processing therapy |
CVT | clinical videoconferencing technology |
CWT | compensated work therapy |
CWT-TR | compensated work therapy-transitional residence |
DAST | Drug Abuse Screening Test |
DBT | dialectical behavior therapy |
DCHV | domiciliary care for homeless veterans |
DoD | Department of Defense |
Dom SA | domiciliary substance abuse |
DRRI | Deployment Risk and Resilience Inventory |
DRRTP | Domiciliary Residential Rehabilitation and Treatment Program |
DSM-5 | Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition |
EBP | evidence-based practice |
ECT | electroconvulsive therapy |
ED | emergency department |
EHR | electronic health record |
FDA | Food and Drug Administration |
FRCP | Federal Recovery Coordination Program |
FTE | full-time equivalent |
FY | fiscal year |
GAD | generalized anxiety disorder |
GAO | Government Accountability Office |
GPD | Grant and Per Diem |
HCHV | Health Care for Homeless Veterans |
HCRV | Health Care for Re-entry Veterans |
HUD | Department of Housing and Urban Development |
HUD-VASH | Department of Housing and Urban Development-Department of Veterans Affairs Supportive Housing |
ICD-9 | International Classification of Diseases, Ninth Revision |
IOM | Institute of Medicine |
IOP | intensive outpatient program |
IPT | interpersonal therapy |
IT | information technology |
LCSW | licensed clinical social worker |
LGBT | lesbian, gay, bisexual, transgender |
LPC | licensed professional counselor |
LRC | local recovery coordinator |
MA | matched attention (health education control intervention) |
MAOI | monoamine oxidase inhibitor |
MDD | major depressive disorder |
MFT | marriage and family therapist |
MH RRTP | Mental Health Residential Rehabilitation Treatment Program |
MHEE | mental health education expansion |
MHICM | mental health intensive case management |
MHIS | Mental Health Information System |
MHMS | Mental Health Management System |
MIRECC | Mental Illness Research, Education, and Clinical Center |
MSA | medical support assistant |
MST | military sexual trauma |
NCPTSD | National Center for Posttraumatic Stress Disorder |
NDAA | National Defense Authorization Act |
NIAAA | National Institute on Alcohol Abuse and Alcoholism |
NQF | National Quality Forum |
NSDUH | National Survey on Drug Use and Health |
OAT | opioid-agonist treatment |
OEF | Operation Enduring Freedom |
OHE | Office of Health Equity |
OIF | Operation Iraqi Freedom |
OMHSP | Office of Mental Health and Suicide Prevention |
OND | Operation New Dawn |
OPCC&CT | Office of Patient Centered Care and Cultural Transformation |
OSI | Opioid Safety Initiative |
OTH | other than honorable (discharge) |
OTP | opioid treatment program |
PACT | Patient Aligned Care Team |
PAM | Patient Activation Measure |
PC-PTSD | Primary Care PTSD screen |
PC3 | Patient-Centered Community Care |
PCL(-M) | PTSD checklist (Military) |
PCMH | patient-centered medical home |
PC-MHI | primary care-mental health integration |
PCP | primary care physician |
PCT | present-centered therapy |
PDSI | Psychotropic Drug Safety Initiative |
PE | prolonged exposure (therapy) |
PERC | Program Evaluation and Resource Center |
PET | prolonged exposure therapy |
PHQ | Patient Health Questionnaire |
PII | personally identifiable information |
PRRC | psychosocial rehabilitation and recovery center |
PRRTP | Psychosocial Residential Rehabilitation Treatment Program |
PST | problem-solving therapy |
PTSD | posttraumatic stress disorder |
QI | quality improvement |
QUERI | Quality Enhancement Research Initiative |
RANGE | Rural Access Network for Growth and Enhancement |
RCT | randomized clinical trial |
RRTP | residential rehabilitative treatment program |
SAIL | Strategic Analytics for Improvement and Learning |
SARRTP | Substance Abuse Residential Rehabilitative Treatment Program |
SeRV-MH | Services for Returning Veterans-Mental Health |
SIT | stress inoculation training |
SMI | serious mental illness |
SMITREC | Serious Mental Illness Research and Evaluation Center |
SNRI | serotonin norepinephrine reuptake inhibitor |
SoCRR | Social and Community Reintegration Research |
SPAN | Suicide Prevention Applications Network (of the VA) |
SSN | Social Security number |
SSRI | selective serotonin reuptake inhibitor |
SSVF | Supportive Services for Veteran Families |
STEPS-UP | Stepped Enhancement of PTSD Services Using Primary Care |
SUD | substance use disorder |
TAP | Transition Assistance Program |
TBI | traumatic brain injury |
TCA | tricyclic antidepressant |
TLC | time-limited care (coordination intervention) |
TOP | Telemedicine Outreach for PTSD |
UBHC | Unified Behavioral Health Center |
VA | Department of Veterans Affairs |
VABHS | VA Boston Healthcare System |
VACO | Department of Veterans Affairs Central Office |
VAMC | Department of Veterans Affairs medical center |
VAR | veteran appointment request |
VBA | Veterans Benefits Administration |
VCCE | VA Medical Center Call Center Expansion (project) |
VCL | Veterans Crisis Line |
VCP | Veterans Choice Program |
VHA | Veterans Health Administration |
VISN | Veterans Integrated Service Network |
VSE | VistA Scheduling Enhancements |
WTU | warrior transition unit |