New report evaluates the VA's mental health services, finds substantial unmet need

While the U.S. Department of Veterans Affairs (VA) provides mental health care of comparable or superior quality to care provided in private and non-VA public sectors, accessibility and quality of services vary across the VA health system, leaving a substantial unmet need for mental health services among veterans of the recent wars in Afghanistan and Iraq, says a new congressionally mandated report from the National Academies of Sciences, Engineering, and Medicine. A survey of these veterans developed and fielded by the committee that conducted the study found that approximately half of those who may have a need for mental health care do not use VA or non-VA services, indicating that a large proportion of veterans do not receive any treatment for conditions such as post-traumatic stress disorder, substance use disorder, or depression. In addition, more than half of veterans who screened positive in the survey for having a mental health care need do not perceive a need for mental health services.

Approximately 4 million U.S. service members took part in the wars in Afghanistan and Iraq. In Afghanistan, Operation Enduring Freedom (OEF) began on Oct. 7, 2001, and ended on Dec. 31, 2014. In Iraq, Operation Iraqi Freedom (OIF) began on March 20, 2003, and on Sept. 1, 2010, operations there continued under the name Operation New Dawn (OND). To help carry out its charge, the committee conducted site visits and sought input on the use of VA mental health services directly from veterans of these wars, their families and caregivers, health care providers, and others at each of the Veterans Integrated Service Networks across the U.S.

A lack of awareness about how to connect with the VA for mental health care is pervasive among OEF/OIF/OND veterans, the report says. Among veterans who have a mental health care need and who have not sought VA mental health services, their main reasons for not doing so are that they do not know how to apply for VA mental health care benefits, they are unsure whether they are eligible, or they are unaware that VA offers these benefits.

Other barriers to seeking VA mental health care services, the committee found, include lack of transportation options to and convenience of medical facility locations; concerns about taking time off work and potentially harming their careers; and fears that discrimination could lead to a loss of contact with or custody of their children, or lead to a loss of medical or disability benefits.

Many veterans who are aware of these services say that the process of accessing VA mental health services is burdensome. However, a majority of OEF/OIF/OND veterans who use the VA report positive experiences with its mental health services, including the availability of services, privacy and confidentiality of medical records, the ease of using VA mental health care, and the staff's skill, expertise, and courtesy toward patients.

"As the nation's largest provider of mental health care services, the VA system has a unique and unparalleled opportunity to address the mental health care needs of veterans in a truly integrated and strategic manner," said committee chair Alicia Carriquiry, distinguished professor of liberal arts and sciences in the department of statistics at Iowa State University. "The VA needs to make high-quality mental health care consistently and predictably available at every facility for all veterans."

The VA should set a goal of becoming a reliable provider of high-quality mental health care services throughout its system within three to five years, the report says. It should develop a comprehensive strategic plan that addresses ways to enhance and facilitate timely access to patient-centered care, hire and retain diverse, skilled staff, expand the use of virtual care technologies, and overcome facility and infrastructure barriers to access, such as lack of parking. For example, the VA, along with the U.S. Department of Defense, should re-examine the processes for transitioning services from DOD to VA to enhance the coordination and continuation of health care services. The implementation of the strategic plan should be regularly monitored, reviewed, and updated as needed during that time frame.

While evidence-based mental health care services are available to veterans and are mostly concordant with clinical standards and policy mandates, there are significant gaps in care delivery, the report says. Adequate clinical and office space and staffing are necessary to reduce wait times, lessen clinician burnout that may contribute to high staff turnover, improve the reliability of treatment, and increase adherence to clinical practice guidelines.

The VA should take steps to ensure that its diverse patient population—including racial and ethnic minorities, women, LGBT, rural-dwelling, and homeless veterans—receives readily accessible, high-quality, integrated mental health care services, the report says. Demographic data show that the OEF/OIF/OND veteran population is more racially and ethnically diverse and has more women than other veteran cohorts. Women veterans who served in OEF/OIF have a higher need for mental health care compared with women veterans from previous conflicts, and also are significantly more likely than men veterans who served in the same wars to believe that they are not entitled to or eligible for VA mental health services.

The report also includes recommendations for examining best practices for VA facilities to forge community partnerships, addressing workforce shortages, and developing and implementing standardized performance measures to assess and improve care for veterans with mental health conditions.