Strategies to Improve Treatment for Post-9/11 Veterans with Co-Occurring Substance Use Disorders

Veterans are at risk for a range of behavioral health problems, including posttraumatic stress disorder (PTSD), depression, and substance use disorders. This risk is particularly acute for those who have served in the U.S. military since September 11, 2001, and often a result of combat experiences or military sexual trauma. These post-9/11 veterans are also more likely than veterans of other eras to be diagnosed with more than one of these disorders (for example, PTSD alongside a substance use disorder). This co-occurrence has important implications for treatment decisions and veterans' behavioral health outcomes, but available treatment options do not always meet these needs of post-9/11 veterans with co-occurring disorders.

Veterans who use substances to alleviate symptoms of PTSD, depression, or another mental health disorder may resist giving up those substances out of a fear of intensified symptoms, particularly if using substances helps them to avoid or alleviate their mental health symptoms in the short term. Not all treatment facilities are equipped to address these co-occurring problems, and mental health treatment facilities often require patients to abstain from substances before they can receive care for a mental health disorder. Conversely, veterans who enter substance use treatment before receiving care for a co-occurring mental health disorder may fail to meet their substance use treatment goals if they have not yet received treatment to address their mental health symptoms. As a result, there is an increased risk that veterans with co-occurring substance use disorders and mental health disorders will drop out of treatment or forgo treatment altogether.

The Wounded Warrior Project (WWP), a nonprofit organization established to support post-9/11 veterans with significant injuries, has a robust program to address the mental health needs of veterans and their families. WWP partnered with the RAND Corporation to help improve access to effective treatment for post-9/11 veterans with substance use disorders and co-occurring PTSD or depression.

A comprehensive review of approaches to treating substance use disorders and co-occurring mental health disorders and data on treatment facilities for veterans, combined with interviews and visits to facilities, informed a series of recommendations to help WWP (and other organizations) expand and enhance treatment opportunities for post-9/11 veterans with co-occurring disorders. The recommendations address the types of treatments provided to veterans, how treatment facilities can better meet their needs, and how providers, insurers, and organizations such as WWP can help support veterans' care transitions to help prevent a recurrence of mental health symptoms or substance use relapse.

Substance abuse is a common barrier to treatment for veterans who also have mental health disorders, such as PTSD or depression, because of the following cycle:

1. Veterans may use substances to cope with PTSD or depression
2. Abstinence is often required for mental health treatment
3. Untreated PTSD or depression could exacerbate substance use
4. As substance use increases, symptoms of PTSD or depression can worsen

Standardized, Evidence-Based, Integrated Treatments Would Improve Veterans' Outcomes

Traditional models of care that separate treatment for substance use and treatment for PTSD or depression can ultimately cause veterans to oscillate between treatment for their mental health disorder and for their substance use disorder, if they agree to treatment at all. In the treatment literature, there are many promising approaches to address single and co-occurring disorders among veterans, but, in many cases, further research is needed to strengthen the evidence base.

Providers should select treatments based on the strength of supportive evidence whenever possible and continually renew their knowledge as new studies identify innovative ways of treating substance use disorders and mental health disorders.

For veterans and nonveterans with co-occurring substance use disorders and mental health disorders, integrated treatments, which address both types of disorders concurrently, had a stronger evidence base than approaches that focused on a single disorder or treated the problems sequentially. Two approaches have shown the greatest efficacy in treating substance use with co-occurring PTSD: integrated cognitive behavioral therapy and Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure (COPE). There is a need for further research on medication-based approaches to treating co-occurring disorders, but naltrexone and antidepressants have shown promising results. Effectively implementing these types of integrated approaches requires a thorough assessment to determine which symptoms a veteran is experiencing and tailoring a treatment plan to address those symptoms concurrently.

However, discussions with providers indicated that evidence-based practices and data-driven decisionmaking were not standardized across facilities, and there was a need for consistent data collection and processes, such as validated self-report and diagnostic measures, for tracking treatment outcomes over time and informing modifications to treatment plans.

Treatment Facilities Could Better Address Barriers to Care

Treatment facilities specializing in either mental health or substance use treatment are often not equipped to address the needs of veterans with co-occurring substance use and mental health disorders. Access to these facilities may also pose a barrier to care, particularly for rural veterans.

The Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services, tracks the availability of licensed mental health and substance use treatment facilities nationwide. RAND's study focused on facilities that offered (1) specialized programs for veterans and (2) specialized programs for veterans with substance use disorders and co-occurring mental health disorders—specifically, PTSD and depression.

Using WWP survey data, RAND researchers were able to calculate the average drive time from where veterans resided to mental health and substance use treatment facilities. U.S. Department of Veterans Affairs (VA) standards for access to care imply that a treatment facility should be within a 60-minute drive time but, ideally, accessible within 30 minutes. This analysis found that the average veteran lived well within a 60-minute drive of the nearest mental health or substance use treatment facility with a specialized treatment program for co-occurring disorders that also served veterans—and within a 30-minute drive of a mental health provider. However, VA medical centers and VA-affiliated facilities were substantially farther away, about a 60-minute drive, on average. Although the results suggest that veterans generally have reasonable geographic access to facilities that meet their needs, they could face other barriers to care, such as transportation limitations or childcare needs. Moreover, although veterans have access to care, the quality of the care or the types of evidence-based treatments available at these facilities could vary.

One advantage to receiving treatment at a VA medical center or VA-affiliated facility is providers' familiarity with military and veteran culture. Studies have shown that veterans prefer a provider who understands the military and the veteran experience. Additional training to improve the military cultural competence of providers in non-VA facilities would help better meet the needs of veterans.

Veterans may also have specific preferences regarding their treatment options; for example, they prefer to participate in group therapy alongside other veterans or with a mix of veterans and nonveterans. Some might prefer a demographic-specific group, such as all women. There was no compelling evidence to conclude that one mix of group therapy participants leads to better outcomes than another. However, given that veterans may have difficulty engaging with care, accommodating these types of preferences may improve treatment outcomes, if resources are available.

Cost is a significant barrier for veterans who do not have access to care through VA or are eligible for Medicaid. To reduce costs, facilities often modify evidence-based protocols or shorten treatment duration; these modifications may weaken their effectiveness. Therefore, payment models that prioritize the delivery of evidence-based treatments with fidelity are essential to ensuring that veterans have an opportunity to achieve recovery, decreasing the overall costs to society, and increasing treatment capacity and quality.

Veterans Need Extra Support During Care Transitions

Prevention and early intervention in primary and specialty care settings—engaging veterans soon after discharge from active duty or soon after symptoms manifest—can prevent heavy alcohol or other substance use from developing into a disorder and improve subsequent treatment initiation and retention.

Transitions following care can be precarious for veterans with co-occurring disorders. After intensive treatment concludes, it is imperative that veterans have access to aftercare programs that provide ongoing support and reinforce the treatment they have received.

WWP and other veterans' organizations offer outreach programs that can help veterans identify behavioral health concerns outside of formal care settings and connect veterans with providers. Such efforts can be particularly useful in reaching women and racial/ethnic minority veterans, who may be less likely to receive substance use and mental health treatment.

Recommendations

The study's findings point to several recommendations to guide providers, treatment facilities, and policymakers, along with directions for future research, to help improve access and quality of care for post-9/11 veterans.

Increase the Adoption of Evidence-Based, Patient-Centered Treatment for Co-Occurring Disorders

Most treatment facilities and providers specialize in either substance use or mental health treatment; these facilities and their providers would better serve veterans with co-occurring disorders by implementing the following changes:

• Screen veterans for co-occurring disorders and offer treatment programs and evidence-based, integrated approaches that address both types of disorders.
• Evaluate both substance use and mental health outcomes regularly over the course of treatment to ensure that both are being addressed adequately.
• Incorporate and accommodate veterans' treatment preferences into treatment decisions and provide care in a way that is sensitive to military and veteran culture.
• Provide patients with a clear aftercare plan focused on relapse prevention.

Expand Treatment Availability and Accessibility

Improving availability and access to treatment for veterans with co-occurring substance use disorders and mental health disorders will require a coordinated effort across the treatment community:

• Consider policies to expand the capacity of VA medical centers and VA-affiliated facilities, and enhance access to facilities offering programs for veterans with co-occurring disorders.
• Decrease barriers to accessing care, and provide incentives for treatment facilities to offer evidence-based treatments.
• To address challenges that veterans may face to receiving in-person care, support further research on the effectiveness of telehealth programs.
• Increase early prevention and intervention, including outreach to veterans outside of treatment settings.

Despite federal and community efforts to improve the quality and availability of care for veterans, veterans remain at high risk of developing both substance use disorders and mental health disorders, and their treatment outcomes are poorer when these disorders co-occur. Additional research on the quality of care available to veterans and their short- and long-term treatment outcomes would further inform efforts to address the complex challenges to treating post-9/11 veterans with co-occurring disorders.

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Topics

• Mental Health and Illness
• Substance Use Disorder Treatment
• Veterans Health Care