Since October 2001, approximately 2.3 million U.S. troops have been deployed to support operations in Iraq and Afghanistan. In that time, we have seen how the strain of a long war can affect the health and well-being of veterans and their families. Although the majority of the nation's veterans return home with few post-deployment problems, a significant percentage face challenges with mental health and/or reintegration to civilian life. Research has consistently demonstrated that at any given time, about 15-20 percent of returning service members meet criteria for a probable diagnosis of post-traumatic stress disorder (PTSD), with similar numbers meeting the criteria for post-deployment major depression.
In response, the federal agencies responsible for caring for veterans have invested billions of dollars to hire more health care providers, implement new screening programs, and educate returning service members and their families about the challenges they may face and how to get care. Yet, despite all of these efforts, only about half of those currently diagnosed with PTSD or major depression seek help for their problems. Worse yet, only about half of those who seek care receive minimally adequate treatment. The number of veterans who receive high quality care is even smaller.
Many barriers deter veterans from seeking help for their mental health problems, including concerns about negative career repercussions, beliefs that treatment won't be effective, and the prospect of long wait times and limited availability of providers. Veterans, even more so than civilians, voice concerns about the potential side effects of the medications that are commonly used to treat these problems.
However, if PTSD and depression aren't properly diagnosed and treated, they can affect work, family, and social functioning in highly detrimental ways, including substance abuse, homelessness, intimate partner violence, and suicide. Thus, early intervention is needed to help stem this cascade of negative consequences.
Our work has identified several gaps in the organizational tools and incentives that support delivery of high-quality mental health care. The VA provides a promising model for quality improvement in mental health care—one that outperforms the private sector in many respects. At this time, too many veterans report difficulty securing appointments, particularly in facilities they believe are primarily resourced to meet the demands of older veterans.
Improving access to mental health services for veterans will require reaching beyond DoD and VA health care systems to ensure quality care in the civilian world as well. Too often, policy decisions have focused on expanding capacity without attention to the quality of service being offered. Yet, we know that high quality care can promote recovery and reduce spending in the long run. Improving access to quality treatment will require:
• More providers who are properly trained and certified to deliver evidence-based care.
Both the DoD and the VA are struggling to recruit and retain appropriately trained mental health professionals to fill existing and new slots. In light of the growing shortage of mental health professionals in the U.S. health care system, this is a critical challenge for our nation.
• Policies and practices that not only enable but also encourage veterans and active duty personnel to seek care.
Many veterans are reluctant to seek services for fear of negative career repercussions. Policies must be changed so that there are no perceived or real adverse career consequences for individuals who seek treatment, except when functional impairment compromises fitness for duty. Although strides have been made with anti-stigma campaigns, studies continue to document concerns and identify low rates of help-seeking by veterans.
• Closing the quality gap for service members and veterans, wherever and whenever they are served.
Treatments for PTSD and major depression vary substantially in their effectiveness. Although effective treatment is being delivered in some sectors, gaps in system-wide implementation remain. Our work has demonstrated that delivery of evidence-based care to all veterans with PTSD or depression would pay for itself—or even save money—within two years by improving productivity and reducing medical and mortality costs.
• Investing in research to fill information gaps and plan effectively for the future.
Continued research is needed to develop more effective treatment options. Greater knowledge is needed to understand who is at risk and who is most vulnerable to relapse. Policymakers must be able to accurately measure the costs and benefits of different treatment options so that fiscally responsible investment decisions can be made.
As the U.S. winds down its involvement in these wars, addressing the post-deployment mental health problems of those who deployed to Afghanistan and Iraq should not be forgotten. This will not be an easy undertaking, especially in an era of budgetary austerity. System-level changes will be needed across the entire U.S. health care system if the nation expects to recruit, prepare, and sustain an effective military force in the future, while honoring the sacrifices—visible and invisible—of those who served.
AcademyHealth welcomes guest blogger Terri Tanielian, who will be moderating the panel "The Future of Health Care for Military and Veterans" at the 2012 National Health Policy Conference. Tanielian is director of the Center for Military Health Policy Research at the RAND Corporation, a nonprofit institution that helps improve policy and decision-making through research and analysis. She was also one of the key contributors to RAND's comprehensive study "The Invisible Wounds of War," a project that earned AcademyHealth's HSR Impact Award in 2011.
Tanielian's panel will focus on the health care system and how it will adapt to the influx of returning veterans from Iraq and Afghanistan. In the post above, she discusses strategies for identifying and closing the gaps in treating returning veterans with post-deployment mental health problems such as post-traumatic stress disorder (PTSD) and depression.
This commentary appeared on AcademyHealth on December 5, 2011