My late grandfather, Ziggy, was a first-generation American. During World War II, he served in the US Navy in the South Pacific. I will always remember the pride in his voice when he spoke about his experiences. We all have stories like this about at least one person we know who served and sacrificed for our way of life.
Why then, in the modern era, does our country struggle to provide adequate healthcare and services to our Veterans? Why do we speak so highly of their service, and then fail to take care of them in their time of need?
This is especially true when it comes to mental health. Nearly 2 million Veterans receive mental health care and services from the Veterans Administration (VA) every year. VA researchers are actively seeking better ways to treat mood disorders, such as depression and bipolar disorder; psychotic disorders, such as schizophrenia; PTSD and other anxiety conditions; and substance use disorders.
Healthcare improvement is part art, part science. And that’s exactly how 13 Veterans health experts are thinking about the ways to improve Veterans healthcare that are discussed in this post.
- What does the Veterans Health Administration do?
- What kinds of health issues or problems do Veterans face?
- 10 evidence-based ways to improve mental health care and services for Veterans
If you’re ready to explore ways to improve the mental health and well-being of our nation’s Veterans, let’s dive right in.
What does the Veterans Health Administration do?
Let's start with where the majority of Veterans access health care and services.
The Veterans Health Administration, also called the VHA, provides health care and services for Veterans across a network of 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year. It is the largest integrated healthcare system in the nation, spending tens of billions of dollars on essential care and services every year.
Across the country, there are different ways for Veterans to access care from the VHA, including:
- Healthcare System: In many areas of the country, several medical centers and clinics work together to offer services to area Veterans, which is called a Healthcare System. Examples of Healthcare Systems include the VA Pittsburgh Healthcare System which serves the Pittsburgh area of Pennsylvania, and the VA Puget Sound Healthcare System which serves the Seattle and Tacoma areas of Washington state.
- Veterans Integrated Services Network: The U.S. is divided into 18 Veterans Integrated Service Networks, or VISNs – regional systems of care working together to better meet local health care needs and provide greater access to care.
- Other Clinics and Centers: The VHA also utilizes more than 800 Community-Based Outpatient Clinics across the country, which provide the most common outpatient services, as well as more than 100 Community Living Centers, which are skilled nursing facilities and nursing homes. For social and behavioral health needs, the VHA also offers Domiciliaries which provide a variety of care for more intensive medical or behavioral health needs in a safe, homelike environment, and there are Vet Centers in all 50 states for readjustment counseling.
Nine million Veterans are enrolled in the VHA. Of that number, some 6.5 million use VA health care services in any given year. Let’s look at some of the unique health concerns of Veterans.
Most health care systems in the United States care for a broad range of patients, but the VHA cares for some of the oldest, sickest, poorest and medically-complex patients in the nation, according to the Veterans Healthcare Policy Institute.
A 2016 RAND Corporation study found that “VHA providers are likely to be treating a sicker population with more chronic conditions, such as cancer, diabetes, and chronic obstructive pulmonary disease (COPD) than the population expected by civilian providers.”
Common Health Conditions Among Veterans
- Chronic pain: Military training and deployments can lead to chronic musculoskeletal diseases which can cause chronic pain. Veterans of younger ages suffer from more chronic pain than their civilian counterparts.
- Hearing loss and tinnitus: These are the most common ailments that bring Veterans to VHA care. Almost every branch of the military exposes personnel to high levels of noise.
- Toxic exposure-related conditions: These impact Veterans whether they have served in the U.S. or abroad, where service members are exposed to pit smoke, radiation, pesticides, and an array of other chemical hazards - including nerve agents.
- Infectious disease: These include risks like West Nile virus and tuberculosis, and the potentially fatal “black fever.”
- Women’s health: Women make up 16% of the enlisted force and 18% of the officer corps. Women are more likely than men to experience sexual harassment In the armed services, and Military Sexual Trauma (MST).
- Mental and behavioral health problems: Veterans experience a higher risk for suicide and PTSD than civilian populations.
10 evidence-based ways to improve mental health for Veterans
Since the 1920s, the federal government has employed Veterans health researchers focused on improving the well-being of our Veterans. Did you know that their accomplishments have resulted in 3 Nobel prizes?
Given the nature of Veterans’ health conditions, and the scale of the country’s investment in Veterans health services, many Veterans health experts in diverse organizations advocate for evidence-based ways to improve care and services for this vulnerable population.
We reviewed the work of 13 Veterans health experts, looking specifically for concrete ways to improve mental health care and services for Veterans.
Here’s what these experts have been studying, researching, and advocating.
- Screen all Veterans for suicide risk
- Prevent suicide among Veterans
- Recommend effective treatments for PTSD
- Reduce Veteran stress through mindfulness
- Leverage digital apps to help with mental health
- Understand exposure to ACEs among Veterans
- Address racial and ethnic disparities in Veterans health
- Help Veterans deal with race-based stress
- Reduce sexual harassment and gender discrimination in the Armed Services
- Help community healthcare providers better serve Veterans
1. Screen all Veterans for suicide risk
“Nobody really knows why suicide rates continue to climb,” explained Craig Bryan, PsyD, ABPP, the executive director of the National Center for Veterans Studies at the University of Utah, to the American Psychological Association. Which is why the Veterans Administration is developing and piloting interventions, at both individual and community levels, to help respond to this deadly issue.
A key evidence-based recommendation is to to integrate screening for suicide risk into all clinical settings, which is something the VA’s Office of Mental Health and Suicide Prevention is already working to do.
“It’s become one of the largest implementations of a standardized screening and evaluation process in a healthcare system,” explained Lisa Brenner, PhD, ABPP, a rehabilitation psychologist and director of the VA Rocky Mountain Mental Illness Research Education and Clinical Center, who has been involved in the universal screening process.
2. Prevent suicide among Veterans
Sara J. Landes, PhD, is a psychologist and researcher at the Central Arkansas Veterans Healthcare System in Little Rock, AR. Her research interests are in the implementation of evidence-based mental health interventions, with a focus on suicide prevention and larger health care systems such as the VA.
The evidence shows that suicide prevention efforts are usually prioritized in mental health treatment settings. However, about half of those who died by suicide in the USA had no known mental health condition, and similar results have been observed in military populations.
Dr. Landes has evaluated the efficacy of a suicide prevention approach called Caring Contacts, which involves sending patients who are suicidal brief, non-demanding expressions of care and concern at specified intervals over a year or more. She is working to implement this program in a VHA emergency care setting, which will enable the creation of an implementation toolkit to facilitate greater adoption of this innovative approach.
3. Recommend effective treatments for PTSD
Following the experience of a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault, it is normal to have upsetting memories, feel on edge, or have trouble sleeping after this type of event. If symptoms last more than a few months, it may be post-traumatic stress disorder, or PTSD.
The evidence shows that PTSD can be treated. With treatment, trauma survivors can feel safe in the world and live happy and productive lives. Effective treatments for PTSD include different types of psychotherapy (talk therapy) or medication.
According to Dr. Paul Holtzheimer, Deputy Director of Research at the VA’s National Center for PTSD, 53% of people who receive trauma-focused psychotherapy no longer meet the criteria for PTSD, meaning their symptoms have subsided. In addition, 42% of people who take recommended medications no longer meet the criteria for PTSD.
The message is clear: treatment for PTSD works.
4. Reduce Veteran stress through mindfulness
Mindfulness is the basic human practice of being fully present, and it has been shown to be effective for reducing stress, improving resilience, increasing self-awareness, helping with anxiety and depression, and coping more effectively with chronic pain.
“Most of the time we’re caught either in the past or in the future with our thoughts and we’re really missing out on what’s going on in this moment,” said Christiane Wolf, MD, Ph.D., lead consultant for VA CALM, a mindfulness facilitators training program for clinicians. She and clinical psychologist Dr. Greg Serpa, PhD, created the first national mindfulness facilitators training program for VA staff.
“We’re either rehearsing the future and thinking about what we have to do next or rehashing the past,” said Dr. Serpa. “Between all the rehearsing and rehashing, we forget that at this moment right here is when we’re alive.”
Practicing mindfulness can help rewire the brain in as little as eight weeks, making it a tool Veterans can use daily to help improve their life.
5. Leverage digital apps to help with mental health
The VA Mobile Health program aims to improve the health of Veterans by providing technologies that expand clinical care beyond the traditional office visit.
A number of helpful apps have been developed for both Veterans and VA care teams, offering safe and secure mobile access to patient data, and providing more opportunities for Veterans to be active participants in their health care.
“With the proliferation of smart devices, it’s no surprise that Veterans have begun to turn to consumer products and apps to help monitor their own health using their cellphones and other personal devices such as Fitbits, Apple Watches, and more,” wrote Kathleen Frisbee, PhD, the executive VHA’s Executive Director for Connected Health, in HealthTech Magazines.
Apps released to the public have gone through extensive testing and evaluation by Veterans and VA care teams to improve apps before they are available.
6. Understand exposure to ACEs among Veterans
ACEs are “adverse childhood experiences” that harm children's developing brains and lead to changes in how they respond to stress, according to the ACEs Connection network.
Data suggests that ACEs cause much of our burden of chronic disease, most mental illness, and are at the root of most violence.
“The mental health of veterans who have experienced ACEs may be at particular risk because they were often exposed to other types adversity during their military career,” said Keith Aronson, associate director of the Clearinghouse for Military Family Readiness at Penn State.
“Male veterans exposed to one to two ACEs are more vulnerable to mental health symptoms than women similarly exposed,” said Aronson. “For women, the experience of combat appears to make them somewhat more vulnerable to mental health challenges compared to men.”
Both male and female veterans who possessed high rates of resilience reported significantly fewer mental health symptoms, providing a direction for the development of innovative interventions that are informed by ACEs science.
7. Address racial and ethnic disparities in Veterans health
According to the VA, racial and ethnic minority veterans represent about 22% of the total veteran population, and this population will expand to make up 36% of the total veteran population by 2040.
Jasper Craven, a freelance reporter who covers the military, recently reported in The New Republic that, while “black veterans generally enjoy better health and economic outcomes than people of color who never served,” there is ample evidence of “racial disparities across all types of conditions, from cancer to diabetes.”
Fears of racial bias appear to alter encounters between Black veterans receiving mental health services and their health care provider, according to Johanne Eliacin, PhD, who is currently developing a peer-led, patient navigation intervention for VA mental health services.
“Using a person-centered approach to care that involves assessing what matters the most to patients and incorporating shared decision-making processes may be particularly relevant and useful for minority patients, especially when they do not share the same sociocultural backgrounds as their providers,” Eliacin recently told the Healio Race and Medicine page.
8. Help Veterans deal with race-based stress
Dr. Lamise Shawahin is a former psychology trainee at the VA who now teaches at Governor's State University outside Chicago.
"Our book that has all our diagnostic criteria is the DSM-5,” Dr. Shawahin told the American Homefront Project, but “it doesn't recognize racial trauma.”
"Experiencing racism was turning into people being labeled with pathology, when really they were just experiencing racism," Shawahin said.
Shawahin and other VA psychologists were awarded a grant in 2018 to create a program to help veterans identify racism as the source of at least some of their anxiety. The program holds group meetings for veterans of color.
Veterans have said that these groups give them tools to cope with racism, which then helps them also deal with other painful memories and experiences.
9. Reduce sexual harassment and gender discrimination in the Armed Services
With over 560,000 participants, the RAND Military Workplace Study is one of the largest surveys of the rates of sexual assault, sexual harassment, and gender discrimination in the military ever conducted for the Department of Defense.
The survey found that sexual harassment is a common experience in the military, especially among women. An estimated 116,600 active service members are sexually harassed in a given year, with 22% of women and 7% percent of men experiencing harassment.
Veterans who have experienced sexual harassment or military sexual trauma often face numerous barriers to receiving adequate care, according to Tammy Barlet, health policy coordinator for the American Legion.
In testimony to Congress, Barlet advocated for strategies to bring awareness, empower bystanders and lay out instructions for reporting incidents, provide stronger support for victims, change how the military follows through with investigations, and establish more severe consequences in order to change behavior and culture.
10. Help community providers better serve Veterans
In recent years, the VA has tried to make it easier for veterans to get care and services from private-sector providers closer to home, with plans to spend more than $14 billion on outside care per year.
Terri Tanielian, a senior behavioral scientist at RAND, suggests that “there's this belief sometimes that the private sector has all the solutions and that by providing veterans with more choice and greater access to community-based providers, somehow their needs will be met.”
However, in a RAND study, fewer than a third of non-VA, community-based providers knew enough about military culture to talk with veterans on their own terms, most were unfamiliar with deployment-related health stressors, and fewer than one in five even asked their patients if they had ever served.
Researchers like Tanielian suggest that the VA should require more training and testing on veteran care before it signs any community care contract with a private-sector provider, and also work to better monitor the providers it works with, to make sure they meet the same standards it sets for itself.