High-Quality Mental Health Care for Veterans

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There are approximately 18 million veterans living in the United States. Many served during a wartime era and deployed to a combat zone during their service. Many also experienced some kind of traumatic event. Studies of service members deployed to combat areas have found that traumatic experiences — such as being attacked, viewing human remains, or knowing someone who was seriously injured or killed — are common.

These experiences can cause returning veterans to have disruptive thought patterns, such as difficulty concentrating, reliving traumatic events, or having thoughts of death or suicide. Veterans may experience sadness, hopelessness, worthlessness, guardedness, anxiety, guilt, or anger and avoid situations that remind them of the traumatic experiences or avoid socializing. They may also use drugs, drink too much, or have trouble sleeping.

For many veterans, these thoughts, feelings, and behaviors are normal reactions to difficult experiences and can fade away during the adjustment from military to civilian life. For others, they can be signs of mental health problems, sometimes labeled the "invisible wounds of war." These include posttraumatic stress disorder (PTSD), depression, anxiety, and combinations of these.

Fortunately, there are effective treatments for these problems. Veterans who receive effective treatments are much more likely to improve and recover. This brief distills lessons from RAND Corporation research on high-quality mental health care for veterans — what it is, why it matters, and how it makes a difference.

What Is High-Quality Care?

High-quality care is defined by the Institute of Medicine as care that has been demonstrated to be effective (i.e., is based on scientific evidence that it works), safe, patient-centered, timely, efficient, and equitable.

Why Does Quality of Care Matter?

High-quality mental health care can improve recovery rates and is cost-effective. Poor quality of care is less likely to lead to recovery, and negative experiences with care could discourage veterans from seeking care that they need in the future.

Mental health conditions that persist may have long-term consequences. They can contribute to physical health problems, drug use, and general deterioration of health. They can also contribute to problems with relationships and work. Over the longer term, mental health problems can harm marriages and families, leading to higher divorce rates and emotional and behavioral harms to children. Mental health problems also increase the likelihood of homelessness, suicide, and premature death from other causes. Therefore, ensuring that individuals who experience mental health problems get high-quality mental health care not only promotes the recovery of those individuals but can also help to stem other consequences for their families.

What to Look for in Seeking High-Quality Care

The highest-quality care–evidence-based care that scientific research has shown to be effective — is most likely to be delivered by providers with extensive training in such practices. Because of the standards that the Department of Veterans Affairs (VA) has set for mental health care delivery, mental health providers who work mostly in a VA setting are significantly more likely to have this training than providers who do not.

Private-sector providers are less likely to have this training, and there is more variation in their training and experience with delivering evidence-based mental health care to veterans. Veterans and their families seeking care in private settings should ask about their providers' training as they assess whether that provider is likely to deliver evidence-based care. They should ask explicit questions about the types of treatments offered by the provider and realistic expectations for symptom reduction and recovery. Veterans should talk with their providers often about their preferences for and concerns about mental health treatment to ensure that they receive high-quality care.

Despite the availability of effective treatments for PTSD, depression, and other mental health conditions, veterans underuse mental health services: Studies estimate that up to half of all veterans who need mental health care never receive it. There are multiple reasons for this. There are institutional barriers, which can include shortages of mental health providers in a given area or lack of insurance coverage or eligibility for a given source of care, such as VA or a private-sector program. There are also logistical barriers: Veterans may have difficulty scheduling appointments or finding transportation to take them to office visits.

Overcoming Barriers to Care

There can also be personal barriers related to veterans' attitudes and perceptions about mental health care. A barrier commonly reported in surveys of veterans is concern about treatment — specifically, that medications might have too many side effects. Some veterans also cite concerns that seeking mental health care could harm their careers.

In the past decade, the VA has taken dramatic steps to address these barriers to care. The VA has substantially increased the number of mental health providers it employs. It has also established outreach programs to help veterans overcome logistical obstacles to getting care and educational programs tailored to specific populations, such as veterans with severe mental illness, veterans in rural areas, and Native American populations.

To fill service gaps for those veterans who do not use or are not eligible for VA services, support from the philanthropic community has led to the creation of new organizations, programs, and initiatives. Many of these efforts have focused specifically on meeting veterans' postdeployment mental health needs. For example, funding from private-sector and nonprofit organizations (such as the Welcome Back Veterans Initiative, launched in 2008 by Major League Baseball and the Robert R. McCormick Foundation) has helped create or adapt community-based programs to assist service members, veterans, and their families in connecting with mental health care — with some organizations offering medical services to veterans and their families for free.

How Caregivers Can Help

Many U.S. veterans need help with the activities of daily life and other important tasks, including scheduling and attending visits with their health care providers. This help comes most often from caregivers — spouses, parents, other family members, or friends who provide informal and unpaid care.

Caregivers can play an important role in helping veterans get the most out of their health care. They can join care recipients when meeting with doctors, nurses, and case managers. Caregivers play an essential role in informing and administering treatment plans. This may include administering medical treatments or medicine, which can improve adherence to prescriptions, or ensuring that appointments are kept. Caregivers can also help veterans

• manage pain
• maintain emotional stability
• engage in healthy behaviors.

Doing so requires that caregivers interact regularly with providers, who should acknowledge caregivers' key role and include them when possible in delivering care to veterans. Providers should also recognize that the burden of caregiving can take a toll. For example, military caregivers are at an increased risk for depression and other health-related challenges. Therefore, it is recommended that providers conduct caregiver needs assessments among those who provide this support to veterans to ensure that their mental health needs are met as well.

This research brief was made possible, in part, by the Zwick Impact Fund. Charles Zwick — a researcher at RAND from 1956 to 1965 who later served as both a trustee and an advisory trustee — presented RAND Ventures with $1 million and the charge to take on new and emerging policy challenges and to support top talent in their focus on these issues. Each year, RAND's president and CEO draws on this generous gift to help RAND research and outreach teams extend the impact of completed research.

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Topics

• Mental Health Treatment
• United States Department of Defense