Over the past decade, there has been a growing recognition of the challenges faced by U.S. veterans, including mental health problems such as posttraumatic stress disorder (PTSD), substance misuse, depression, and suicide. Most of the research done to understand the size and scope of the mental health issues facing this group has focused on problems at either the national level, within very specific settings—such as the Department of Veterans Affairs (VA)—or within specific local or regional units—such as National Guard units. What have often been lacking are state- or local-level assessments of veterans' mental health issues that provide context on the specific challenges facing particular veteran populations.
In an effort to inform future investments in expanding or coordinating mental health support in the metro Detroit area (Wayne, Oakland, and Macomb counties), RAND was asked to document the types of mental health issues facing veterans living in the region and identify gaps in the provision of services targeted to them. This is a particularly urgent concern in the region, which has only in the past several years begun to make significant progress recovering from a period of serious economic decline; with approximately 225,000 veterans living in the metro Detroit area—and high poverty rates among them—it is unclear whether veterans' needs are being met during this period of revitalization.
To assess the mental health needs and service landscape of metro Detroit area veterans, we used multiple methods that included: a review of the literature describing the veteran population, the mental health sector within the state, and the veteran support community in and around the metro Detroit area; a review of publicly available data from the VA and public information on organizations and service providers that work with veterans; stakeholder interviews focused on service providers and veteran-support government and nongovernmental organizations across the region; and focus groups and interviews with veterans aimed at gathering qualitative data on the types of mental health—related issues and challenges that veterans in the region face.
Understanding Postdeployment and Postmilitary Mental Health Problems
Though not all service members will experience mental health problems, research shows that such issues are common across this population. This research has shown that exposure to combat, for example, is particularly related to PTSD and depression. Females are at increased risk for depression and males are at increased risk for substance use; however, findings are mixed with respect to PTSD and gender. PTSD is also more associated with younger age groups, individuals who are single and those who are not as satisfied in their romantic relationship. The limited number of studies that have examined race and education as risk factors for PTSD, depression, and substance misuse suggests that these may not be strong risk factors among military populations, particularly after accounting for combat experience. Finally, we looked at the evidence for military risk factors, such as service branch and rank, related to PTSD, depression, and substance misuse and found that, while studies indicate that PTSD is more prevalent in the Army and Marine Corps, and among enlisted personnel compared to officers, the failure to control for combat exposure makes the findings inconclusive.
Consequences Associated with Mental Health Problems
RAND's 2008 model of the consequences of postcombat mental health and cognitive conditions provided a useful framework to assess the consequences that veterans may face. The model highlights that consequences may be direct and short term as well as indirect and longer term, and may be affected by individual resources and vulnerabilities. We also looked more closely at the literature on the potential consequences of mental health problems, including comorbidity with other mental health problems and suicide (including substance misuse); physical health and mortality; employment and productivity; homelessness; and marriage, parenting, and child outcomes.
Notwithstanding the serious short- and long-term consequences of mental health problems, evidence-based treatments for PTSD and depression do exist. However, not all veterans who need mental health care will seek it out, nor are all providers trained to deliver such care. Prior research suggests that a significant gap exists between mental health care needs and access. In addition, treatment of co-occurring conditions, particularly mental health problems and substance abuse, continues to present challenges due to differences in treatment philosophies, funding streams, and administrative and regulatory environments. Thus far, efforts to integrate treatment have been limited.
Challenges Facing Veterans in the Metro Detroit Area
Individual interviews and focus groups conducted with metro Detroit area veterans highlighted the major issues they faced, from their separation from the military to the present day. We note that concerns were similar across veterans of different eras and similar to those expressed by veterans in other communities.
Although questioning was not limited to mental health issues, concerns with adjustment to civilian life and mental health problems were among the predominant challenges identified. In particular, many veterans perceived that the support and regimentation of military life were lacking when they returned to civilian life. This transition to civilian life included challenges with reestablishing relationships with family and friends, accessing needed services and benefits, and finding and maintaining meaningful employment. Many of the veterans with whom we spoke noted that the speed with which a service member returns to civilian life can be problematic; while historically a “decompression” period could take weeks, service members may now transition from combat to home in as little as three days.
Many metro Detroit area veterans with whom we spoke noted that services were available to aid them during their transition; however, there was concern that awareness of and access to these services were lacking. Many indicated that they had gone years without taking advantage of available financial and medical benefits; indeed, data from the VA indicate that Michigan veterans are among the least likely in the nation to receive or take advantage of their benefits. Veterans also pointed to difficulties navigating local and federal processes to access services and claim benefits. Furthermore, logistical barriers, such as limited public transportation in the metro Detroit area, were reported to limit care seeking. Notwithstanding the aim of the VA Choice Act of 2014 to expand the network of available service providers, many veterans with whom we spoke expressed discomfort with receiving treatment from civilians, who they felt may not have sufficient familiarity with the experience of being a veteran to provide adequate care.
Beyond the above-noted challenges of transitioning to civilian life, veterans pointed to particular concerns with respect to addressing mental health problems. Among these, they noted that many service members and veterans do not recognize that they suffer from mental health problems and, for those who do, the perceptions surrounding mental health problems can keep them from accessing needed care. Even when they do access care, some veterans felt that their mental health concerns are likely to be dismissed by the VA if they had not served in a combat position. In addition, some veterans expressed concern about treatment modalities commonly used (for example, regarding overmedication). Veterans also reported concern that family members may be unprepared to support them with mental health problems.
Mental Health Support Services and Resources Available to Metro Detroit Region Veterans
Our review of organizations in the metro Detroit area that provide services and support to veterans looked at federal, state, and county government offices as well as nongovernment organizations. We found that access to specific resources may depend on the characteristics of an individual's military service and discharge status, creating a distinction between those services that are available to veterans based on meeting certain eligibility requirements, and those available to all veterans, regardless of status.
For veterans who meet conditions such as minimum active service time and discharge “under conditions other than dishonorable,” we identified the following services and supports.
- Department of Veteran Affairs: In Michigan, the VA, which provides health care services to eligible veterans, has five VA Medical Centers, six outpatient clinics, 18 community-based outpatient clinics, and eight vet centers across the state. Within the metro Detroit area specifically, the John D. Dingell VA Medical Center is the largest provider of mental health care services for veterans, and includes a wide array of programs dedicated to mental health. In addition to the main VA Medical Center, which is located in downtown Detroit, satellite clinics and centers throughout the surrounding counties offer varied mental health care services.
- State-based and state-funded resources: The Michigan Veterans Affairs Agency (MVAA), which is housed within the Michigan Department of Military and Veteran Affairs, works to decrease barriers and increase access to education, employment, health care, and quality of life for eligible veterans residing in Michigan. For veterans with an honorable discharge and at least 180 days of service during a period of war, the MVAA runs a program through the Michigan Veterans Trust Fund that pays for up to five community mental health service provider visits for a veteran who is eligible for federal benefits but not currently registered in the VA health care system.
- County-based services and resources: Each of the three counties comprising the metro Detroit area have county-level veteran affairs departments that facilitate access to federal and state benefits to veterans who are county residents. Wayne County Veterans Affairs focuses on financial hardship issues, while Macomb and Oakland county veteran services mainly assist veterans and their families applying for federal, state, and county benefits. For the most part, veterans with mental health–related needs are referred to local vet centers or the VA Medical Center in Detroit.
- Nongovernmental organization services: The many veteran service organizations in metro Detroit focus primarily on helping connect veterans to each other and sharing information about the available benefits and services that support local veterans. While none of the organizations we identified provides mental health services directly, most offer referrals to relevant service providers. Targeted programs in the region also offer support with employment and career planning, training, and housing services.
Beyond those services restricted to veterans who meet specific eligibility criteria, we identified a number of local organizations that support veterans regardless of discharge status, through mental health service provision and advocacy, as well as housing and wraparound services. Looking specifically at mental health services, we found the metro Detroit area to have a variety of individual service providers, who work through large health systems, in private clinics, or through solo practices. In recent years, several organizations have undertaken efforts to increase awareness of and access to these providers. While community mental health agencies, such as the Detroit Wayne Mental Health Authority, also provide care, their use by veterans is limited.
Despite the variety and number of organizations working to support metro Detroit area veterans, there are concerns that these entities operate independently from one another. Since 2013, MVAA's Veteran Community Action Team has been working to promote community collaboration to deliver service and support to veterans more effectively. Other critical gaps in the service environment that were identified by stakeholders included eligibility requirements and restrictions related to the distribution and use of funding.
Recommendations for Improving Support
To sustainably and effectively meet the needs of metro Detroit area veterans, a comprehensive approach is needed to pursue the following recommendations simultaneously.
- Raising awareness: To strengthen support to veterans, stakeholders should work to increase awareness across diverse organizations—including community-based mental health providers—regarding the challenges faced by veterans, and also to empower veterans to take advantage of the mental health resources and services available to them.
- Creating connections: To better connect veterans in need with available services and to strengthen collaboration across provider communities, resources beyond word-of-mouth connections are needed. Local website directories can complement the existing MVAA website, which primarily features federal- and state-level resources. Other approaches include enhanced one-stop navigation assistance, for example, through a call center (such as the 1-800-MICH-VET) or MVAA and other websites that link veterans with peers or social workers for a full range of referral support. In addition, stronger connections between service providers can increase the efficiency of their outreach efforts, while stronger connections between veterans can support relationship building and promote an opportunity to learn from peers how they have overcome mental health challenges.
- Filling gaps in resources: Stakeholders pointed to a number of specific gaps in support, and noted attention could improve the provision of high-quality services to veterans. These gaps include eligibility restrictions that prevent veterans with a less than honorable discharge status from accessing benefits and services; limitations on the use of state-provided block grants to community mental health agencies which prioritize the VA as a service provider for veterans; and limited capacity at vet centers to accommodate those interested in counseling services.
This study was sponsored by the Wins for Warriors Foundation and the Ethel and James Flinn Foundation and conducted within RAND Health, a division of the RAND Corporation.