Post-9/11 veterans are at particularly high risk for co-occurring substance use disorders (SUDs) and mental health disorders. Integrated care—in which both SUDs and mental health problems are addressed concurrently—is a recommended form of treatment for these veterans. This report provides guidance and recommendations to support the delivery of quality care for veterans with co-occurring SUDs and mental health disorders.

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Improving Substance Use Care

Addressing Barriers to Expanding Integrated Treatment Options for Post-9/11 Veterans

by Eric R. Pedersen, Kathryn E. Bouskill, Stephanie Brooks Holliday, Jonathan H. Cantor, Sierra Smucker, Matthew L. Mizel, Lauren Skrabala, Aaron Kofner, Terri Tanielian

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Research Questions

  1. What treatments targeting SUDs and co-occurring SUDs and mental health disorders has research shown to be effective?
  2. Do most veterans live relatively close to mental health and substance use treatment facilities that offer (1) specialized programs for veterans or (2) specialized programs for veterans with SUDs and co-occurring mental health disorders—specifically, posttraumatic stress disorder and depression?
  3. What insights do providers of mental health and substance use treatment offer on the treatment of post-9/11 veterans?
  4. How can treatment facilities, policymakers, and researchers help increase the adoption of evidence-based, patient-centered approaches to treating co-occurring disorders and expand the availability of such approaches for veterans?

Veterans who have served in the military since September 11, 2001, are at particularly high risk for co-occurring substance use disorders (SUDs) and mental health disorders, such as posttraumatic stress disorder and depression. Many treatment facilities require abstinence from substances prior to admission for mental health care, but the combination of symptoms that these disorders present makes them difficult to treat separately. Thus, integrated care—in which both SUDs and mental health problems are addressed concurrently—is a recommended form of treatment for these veterans.

To help improve access to effective treatment for these veterans, the authors review the literature on efficacious approaches to treating SUDs alone and alongside mental health disorders. They also present findings from an analysis of the availability of treatment centers that offer SUD care for veterans and from a series of interviews and site visits with treatment providers. The authors conclude with guidance and recommendations to support the delivery of quality care for veterans with SUDs and, ultimately, to help expand and enhance treatment opportunities for veterans with co-occurring SUDs and mental health disorders.

Key Findings

Veterans with co-occurring mental health and substance use disorders require evidence-based treatment for both types of disorders

  • Research shows more-consistent evidence for the effectiveness of integrated treatments, in which both SUDs and co-occurring mental health disorders are addressed concurrently, than approaches that focused on a single disorder or treated problems sequentially.
  • Most integrated treatment studies targeted SUDs with co-occurring PTSD specifically, with the most promising being Concurrent Treatment for PTSD and Substance Use Disorder Using Prolonged Exposure; Seeking Safety; and integrated cognitive behavioral therapy.
  • Although most of the integrated treatment literature is psychotherapy-focused, the literature shows promise for certain medications, such as naltrexone and antidepressants.

Most veterans live within an hour's drive of a facility that treats veterans with co-occurring disorders

  • On average, Wounded Warrior Project alumni are well within a 60-minute drive time from 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 time to a mental health provider.
  • U.S. Department of Veterans Affairs (VA) medical centers and VA-affiliated facilities are farther away, but still on average around a 60 minute drive time.

However, most veterans with co-occurring disorders do not receive treatment

  • Veterans with co-occurring mental health disorders and SUDs may not receive needed care because of fear of repercussions or career harm, logistical barriers (e.g., high costs, homelessness, not knowing where to get help), and beliefs that they can handle their problems on their own or that available treatments are not effective.
  • Women veterans may face additional barriers to treatment, such as childcare responsibilities or concerns about harassment at VA facilities.
  • Treatment programs often require abstinence from substances prior to treatment for mental health disorders, which can pose a significant barrier to veterans with SUDs and co-occurring mental health disorders.
  • Specific veteran subpopulations (e.g., women, racial/ethnic minorities, those who have experienced certain types of trauma) often prefer treatment groups that are composed of individuals with similar characteristics.
  • The cost of care is a significant system-level barrier to receiving treatment for veterans who do not have access to care through VA.

Recommendations

  • Screen for co-occurring disorders and offer treatment programs for veterans with SUDs and co-occurring mental health disorders.
  • Offer evidence-based integrated treatments that target both SUDs and co-occurring mental health disorders concurrently.
  • Evaluate both substance use and mental health outcomes regularly throughout the course of treatment to ensure that both are being addressed adequately.
  • Incorporate and accommodate veterans' treatment preferences into treatment decisions.
  • Provide patients with a clear aftercare plan focused on relapse prevention.
  • Consider policies to expand the capacity of VA medical centers and VA-affiliated facilities, and enhance access to facilities offering co-occurring programs for veterans.
  • Implement policies to decrease barriers to accessing care and provide incentives for treatment facilities to offer evidence-based treatments.
  • Support further research on the effectiveness of telehealth programs that address SUDs and co-occurring mental health problems; these are potentially promising approaches for reducing barriers to care for veterans.
  • Increase early prevention efforts by providers, including outreach to engage veterans outside of treatment settings, and address substance use issues early to help veterans avoid developing chronic mental health or substance use problems.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Prevalence of Behavioral Health Problems Among Veterans and Barriers to Care

  • Chapter Three

    Treatments for Veterans with Substance Use Disorders and Co-Occurring Mental Health Disorders

  • Chapter Four

    Availability and Accessibility of Treatment Centers for Veterans with Substance Use Disorders and Co-Occurring Mental Health Disorders

  • Chapter Five

    Perspectives and Experiences of Treating Co-Occurring Disorders

  • Chapter Six

    Conclusions and Recommendations

  • Appendix A

    Overview of Studies Included in the Literature Reviews

  • Appendix B

    Mental Health Treatment Facilities and Substance Use Treatment Facilities Within a 30-Minute Drive Time of 2019 Alumni Survey Respondents

Research conducted by

This study was funded by the Wounded Warrior Project and carried out within the Quality Measurement and Improvement program in RAND Health Care.

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