Since October 2001, approximately 2 million U.S. troops have deployed as part of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Although not always counted as official casualties by the U.S. Department of Defense (DoD), mental health disorders and other types of impairments resulting from deployment experiences are beginning to emerge.
DoD, the U.S. Department of Veterans Affairs (VA), and Congress have moved to study the issues, quantify the problems, and formulate policy solutions. They are beginning to implement the hundreds of recommendations that have emerged from various task forces, commissions, and research reports. However, despite widespread policy interest and a firm commitment from the military services to address these injuries, fundamental gaps remain in our knowledge about the needs of veterans returning from Iraq and Afghanistan, the adequacy of the care system available to meet those needs, and the experiences of veterans and service members who use these systems. Since many veterans will seek care in the civilian health care sector, state-based programs that integrate services and provide comprehensive lists of available resources might help service members and their families. But a lack of information about veterans’ state-level needs hampers states in their planning efforts.
We recently examined the problems facing the broad population of OEF/OIF service members and veterans (referred to as the “Invisible Wounds” study; see Burnam et al., 2009; Tanielian and Jaycox, 2008; Tanielian et al., 2008; Post-Deployment Stress: What You Should Know, 2008; Post-Deployment Stress: What Families Should Know, 2008; Meredith et al., 2008; Karney et al., 2008; Tanielian, 2009, 2008; Eibner, 2008; Jaycox, 2008). That project took a broad, societal view of problems facing returning service members and applied a health services perspective to develop policy recommendations. As in the current study of New York veterans, we examined prevalence of problems among returned service members and veterans and the systems of care in place to help them, using both qualitative and quantitative methods. We found that about one in five service members and veterans screened positive for a probable diagnosis of post-traumatic stress disorder (PTSD) or depression and that only about half of those had received any mental health care in the prior year. We identified important gaps both in access to mental health care and in quality of that care at the national level and made recommendations to help close those gaps that were widely disseminated to policymakers, to the media, and to key stakeholders.
Other research teams within the military and the VA health care system have also worked on these issues. We have published two recent reviews of this literature (Ramchand, Schell, Jaycox, and Tanielian, forthcoming; Ramchand, Schell, Karney, et al., 2010). These studies have typically found PTSD rates among previously deployed individuals that vary between 5 and 20 percent, depending on the specific population being sampled. Rates of major depression are typically similar to the rates of PTSD. In addition, studies of veterans actively seeking services in the VA have found somewhat higher rates of PTSD, depression, and physical health problems than have been found in other populations of returned service members.
Although there are now many studies assessing the challenges that individuals face who previously deployed for OEF/OIF, this existing literature is extremely limited for planning at the state and local levels. There are three reasons that these existing studies do not provide useful guidance to policymakers or service providers in these communities. First, the existing studies have systematically excluded a large proportion of community-dwelling veterans. Across all of the studies on OEF/OIF veterans, there are no studies that can estimate the need among veterans who have left the military service but have not sought treatment in the VA health care system. Neither DoD nor VA researchers have studied these individuals. Secondly, studies at the national level are not necessarily representative of the particular types of veterans who reside in particular states or communities, and they might not provide accurate estimates of the problems and needs of local veterans. Finally, research on veterans’ needs has focused almost exclusively on mental health problems. There is considerably less information about their needs across the broader range of services that states and communities might provide, such as other health, occupational, or educational benefits.
The current study is designed to address these shortcomings in the existing literature. It focuses directly on the veterans living in New York state; it includes veterans who currently use VA services as well as those who do not; and it looks at needs across a broad range of domains.
The study took a three-pronged approach to assessing and addressing the needs of veterans in New York state. First, we collected information and advice from a series of qualitative interviews with veterans of OIF/OEF residing in New York, as well as their family members. Second, we conducted a quantitative assessment of the needs of veterans and their spouses from a sample that is broadly representative of OEF/OIF veterans in New York state. Finally, we conducted a review of the services available in New York state for veterans. This information has been compiled in a format that is designed to serve as a guide for veterans.
Qualitative Interviews of Veterans and Their Family Members
We conducted six focus groups across the state of New York. Five of these were with veterans and one with family members. To increase the inclusion of women and family members, we also conducted eight individual phone interviews with female veterans and family members of veterans. Participants were recruited primarily through Iraq and Afghanistan Veterans of America (IAVA), which was funded separately by the New York State Health Foundation to assist with recruiting interviewees. IAVA sent email to its membership within approximately 50 miles of selected focus group locations, and potential participants registered online to attend. Participants received $50 for their participation.
The interviews were designed to (1) document how veterans and their family members think about the challenges they face; (2) gather opinions about the availability, quality, and comprehensiveness of the available programs and services; and (3) elicit innovative ideas for improvement. Across these interviews, several common themes emerged. In particular, veterans and family members reported a range of mental health concerns following veterans’ return from Iraq or Afghanistan, difficulties reconnecting with friends and family, and problems finding jobs commensurate with their skills. There was also a shared perception that it is extremely difficult to navigate the existing system of benefits and services across both VA and non-VA providers, including difficulties determining (1) what services are available, (2) whether the services would be helpful for one’s specific problems, (3) where services are available, (4) who is eligible to receive them, and (5) how to apply. Finally, there was general agreement on several suggestions for improvement, including improving military out-processing and subsequent outreach and educational efforts to increase utilization of existing services; expanding VA services to reduce travel time, waiting times, and delays in scheduling appointments; and expanding programs to help families of veterans.
It should be noted that, while qualitative interviews are extremely useful for gaining insight into how individuals think about specific issues, these research methods have substantial limitations. It is extremely important that the reader keep these limitations in mind while reviewing our results. First, the reader should be careful to avoid treating these opinions and perceptions as if they reflect objective facts in the world. We have abstracted these opinions from the interviews and focus groups but have deliberately not attempted to fact-check their statements. Secondly, participants in our interviews and focus groups were not a representative or random sample of veterans in New York state. In fact, they differed in systematic ways from the large group of veterans who were not interviewed. Finally, it is important to realize that these interviews represent a snapshot of these veterans’ opinions at a given point in time. It is possible that the veterans reintegrating in the future will be facing a different set of challenges from those discussed in these interviews.
Although the opinions expressed in qualitative interviews should not be taken as representative or accurate descriptions of the challenges that veterans face, these interviews do provide important insight into veterans’ beliefs and perceptions. It is important to document that veterans think that the system of care that serves them is difficult to understand, that it is time-consuming to navigate these systems, and that the quality of care is suspect and highly variable. These perceptions are important because they likely inhibit the use of services that would help veterans meet the challenges they face, even if, by objective or comparative measures, the services are promptly delivered and of high quality.
Quantitative Needs Assessment of Veterans and Their Spouses
We conducted a mixed-mode, telephone and web-based survey with 913 veterans and 293 spouses of these veterans. The data used for sampling veterans were obtained from a release of names and addresses (RONA) request to the VA. The RONA mechanism is designed to allow governmental and nonprofit organizations to provide outreach for veterans’ services, and this study provided a targeted needs assessment and service referrals to the participating veterans. The RONA provided names and mailing addresses of all VA-eligible veterans with addresses in New York who became eligible in the prior five years. Because these addresses did not have matched phone numbers and were, in many cases, several years old, we used two commercial databases, LexisNexis and Telematch, to get a land-line telephone number associated with a particular name and address and to identify more-recent addresses if they were available.
Letters were sent to a random sample of veterans explaining the study and providing information to allow them to complete the survey on the web. Individuals who did not complete the survey on the web were called on the phone and given an opportunity to complete the telephone version of the interview. After completing the veteran interview, we asked to interview the spouse of each married veteran participant. Participants and their spouses were each paid $30 for their participation. Interviews were conducted in August–October 2010.
The assessment of veterans identified several areas of diminished health and well-being. A relatively high percentage of veterans (22 percent) were found to have a probable mental health diagnosis based on symptoms over the prior 30 days, with approximately equal numbers screening positive for major depression and for PTSD (16 percent for each). Ten percent of the sample met criteria for both PTSD and depression. This suggests that veterans are at substantially increased risk for mental health problems, particularly PTSD, relative to similar individuals in the general population. In addition to those with a current probable mental health diagnosis, many participants felt that they would benefit from mental health services. Approximately half of the sample had a probable need for treatment defined by either a current probable diagnosis or a self-indicated need for treatment. About a third of those with a need for treatment had sought mental health services in the prior 12 months. Slightly more than half of those who sought help received a minimally adequate dose of treatment in the past 12 months. When asked about barriers to seeking treatment, the most–commonly endorsed barriers were concerns about the side effects of medications and concerns about potential institutional discrimination (e.g., by an employer or the government) against those getting treatment.
In addition to mental health problems, there was evidence that veterans face significant physical health and economic problems. Veterans were found to have significantly worse overall physical functioning scores than similar individuals in the general population. They were also unemployed at a significantly higher rate than the overall New York unemployment rate. In contrast, the level of alcohol abuse in the sample was very similar to that found among similar individuals in the general population, and relatively low rates of illicit drug use were reported.
Veterans were asked about specific benefits that they thought would be helpful to them. A majority of veterans viewed the following benefits as personally helpful: VA health care; education benefits; housing assistance, including home loans; and assistance at a VA vet center.
In contrast to the broad range of needs experienced by the veterans in the study, their spouses were remarkably similar to the general population. Their mental health, alcohol use, physical functioning, and rate of unemployment were all approximately equal to general-population norms. When asked about a range of common life hassles, few spouses reported being greatly bothered by them. However, when asked about problems experienced at the time of the veteran’s return from deployment, 44 percent reported having problems dealing with their veteran spouse’s mood changes, and 42 percent reported being worried about the possibility of future military deployments.
As we look across both the qualitative and quantitative needs assessment, several common themes emerge. First, it is clear from our study that veterans’ health and well-being are the responsibility of more than just the VA. We found both in our focus groups and in our survey that other clinical and social-service delivery systems are critically important for addressing veterans’ needs. The majority of veterans have other sources of health insurance, and much of the care delivered to veterans in New York is through either the civilian health care system or other public-sector providers. When thinking about how to improve the access to high-quality services for veterans, we need to think beyond making changes in the VA and look at factors in the private health care system, such as severe restrictions on the amount of mental health care provided by some insurance; the availability of both counseling and drug therapy; the mental health screening and referral procedures of primary-care physicians; and the level of training in evidence-based treatments for PTSD and depression among civilian providers.
A second theme that emerges across the qualitative and quantitative needs assessments, as well as our review of the available services, is that the health care systems that serve veterans are extremely complicated. Enabling veterans to access the benefits and services that are available to them will require, in many instances, personalized assistance. Focus group participants widely praised the work of the new regional OEF/OIF care coordinators within the VA. However, (1) most veterans do not know about this resource, and (2) these coordinators are focused primarily on helping coordinate VA care and might not know about other resources or benefits available to veterans. Better outreach is needed to connect veterans with care coordinators who can provide personalized assistance across a range of service sectors. Such outreach is extremely difficult in the current system, which is likely to miss the veterans who are most in need of assistance—i.e., those who have not yet enrolled in the VA system. Improving this outreach would be facilitated by more-up-to-date data on the full population of veterans. For instance, this could be accomplished by having the VA get regularly updated addresses from the databases maintained by the Social Security Administration or Internal Revenue Service.
A third theme that emerges across both the focus groups and the survey is that addressing veterans’ mental health needs will require a multipronged approach. It will require reducing barriers to seeking treatment; improving the sustainment of, or adherence to, treatment; and improving the quality of the care being delivered. Given the veterans’ concerns about drug side effects, making sure psychotherapy is widely available might be important. Addressing veterans’ concerns about occupational discrimination against those who get treatment might be more difficult. However, it might be helpful to educate veterans about the laws ensuring confidentiality of medical services (within both the VA and the civilian sectors), as well as recent changes to the security clearance process that reduce the likelihood of such negative outcomes from treatment. In addition to addressing these barriers, it might be critical to improve the overall quality of mental health care being delivered across all service sectors. This might require programs that increase screening in the civilian sector for the specific mental health problems that affect veterans, reduce wait times for counseling, increase the number of providers trained in the provision of evidence-based treatments for PTSD and depression, and provide mental health services at more-convenient locations and times.
Finally, many of the findings presented in this report have focused on mental health issues, which is consistent with the prominent role they played in both the qualitative and quantitative assessments. However, it is important to note that veterans have other serious needs. The current economic environment is extremely difficult for individuals who are making major career transitions. High unemployment is certainly a substantial threat to veterans’ overall psychological and physical well-being. This suggests that job placement, education, and vocational programs might be a welcome and effective means to improve veterans’ well-being. Similarly, there is a small, but important, subset of veterans who are facing substantial physical health limitations. Although there are disability benefits available to these individuals for limitations that can be shown to be service connected, there are a broader range of services that would likely benefit these individuals.
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