Evidence-Based Mental Health

It is important to understand that all veterans do not have the same ability to re-integrate into civilian life; some succeed while many slip through the cracks. That is why one cannot generalize/categorize the veteran population and put individuals into boxes; one must take this matter case by case. The veterans who are able to assimilate into civilian life will most likely receive mental health care through the benefits package they receive through their employer-based health plans (Burnam et. al, 2009).

Some veterans prefer to use community-based agencies that will accept TRICARE rather than strictly utilizing VA services. One important point to note here is that not all veterans qualify for TRICARE, perhaps therefore increasing the homeless population. The OEF/OIF is made up of a younger generation of veterans who happen to feel uncomfortable in VHA settings because they think that the VHA facilities cater to older and chronically ill patients (Burnam et. al, 2009). Personally, I have witnessed this on the West Los Angles VA campus.

It seems that the younger veterans (OEF/OIF) veterans seek to attain whatever benefits, treatments, and services they need in order to go home; while the older generation of veterans (Vietnam, Korea, and even some very elderly WWII) are either struggling to attain benefits through the VA system or lingering around the VA campus inhabiting it like a home. The older ones definitely hangout more at the West LA VA. The VHA plans to expand its mental health care services to include PTSD; it is also responding to the popular demand for these services from earlier generations of Vietnam and Gulf War veterans.

To start the conversation about mental health issues related to OEF/OIF veterans, reluctance to seek care and workforce capacity are two challenges that must be met in order to provide services for those who require mental health care. Reluctance to Seek Care Multiple data collection from surveys on focus groups share the same conclusion that the attitudes and beliefs of military members and veterans prevent them from seeking mental health services (Burnam et. al, 2009).

Stigma often hinders a veteran’s decision to seek help, but at the same time, ironically, the veteran is interested in receiving services to improve their quality of life. Another barrier that often hinders a veteran from receiving services is their own self-pride and denying that they even have a problem (Stecker et. al, 2007). Workforce Capacity There are currently about half a million clinically trained mental health professionals in the country. Geographic and regional disparities in the distribution of services, resources, and/or benefits of this workforce are a major, longstanding issue.

Research claims that most professionals seek out urban areas, which leaves rural areas with a deficit of services (Burnam et. al, 2009). Meager availability of mental health care for OEF/OIF veterans and their families is due to the scant availability of mental health professionals. In addition, even in communities where mental health services are obtainable, the cost is too much for the veteran. It has been reported that some mental health care providers will not accept TRICARE patients because of low reimbursement rates (Burnam et. l, 2009).

Community Initiatives After the acknowledgment of access barriers, many states have responded by developing efforts to connect with the surrounding community by networking. Rhode Island formed a Veterans Task Force to address the state’s needs for veterans and their families. Washington State implemented a free PTSD counseling program and also trains teachers and school counselors of the potential needs of children and families of service members.

It has been reported that in some states where there are geographical and regional disparities that the VHA has partnered with other community-based mental health care facilities (this includes both private and public agencies). Other states have taken drastic measures to create special programs for their guard troops in an effort to ensure that there are programs to fill the access gaps left by restricted VHA capacity (Burnam et. al, 2009). The New York State Office of Mental Health is partnering with the VHA to offer mental health screening as part of the New York National Guard Yellow Ribbon Reintegration Program.

There is currently no information on the extent to which the many and diverse state and local initiatives have increased access to mental health services for OEF/OIF veterans. Gaps in Quality of Care Unfortunately while program and policy initiatives address the mental health needs of OEF/OIF veterans increasing access to care by extending eligibility and/or hiring more providers, major quality gaps within the mental health care system is occurring (Burnam et. al, 2009).

Until this issue regarding the gaps gets addressed, we increase the chances of veterans receiving poor quality health care. Evidence-Based Treatments Evidence-based treatments for PTSD and depression include psychotherapy (this usually entails Cognitive Therapy or Cognitive Behavioral Therapy for depression and PTSD; interpersonal therapy for depression; prolonged exposure therapy and eye movement desensitization and reprocessing for PTSD); and medications (most commonly selective serotonin reuptake inhibitors [SSRIs] for major depression and PTSD) (Burnam et. al, 2009).

Choice among treatments, or their combination depends on the patients’ preferences, severity of symptoms, and prior treatment response. For patients who suffer from PTSD it is highly recommended to choose psychotherapy over medication. Luckily, none of these treatments are either complicated or cost prohibitive, making them easily accessible. The challenges to provide evidence-based practices include the national workforce competency concerns, and limited implementation of systems that support improvements in the quality of care.

Workforce Competency/Systems Support for QI There are a wide variety of mental health professionals that provide psychotherapy to their clients, but research claims that not all these theoretical approaches have the same standards of practice. The training of mental health professionals does not significantly emphasize evidence-based treatments or quality improvement (QI) approaches to practice (Burnam et. al, 2009). Training and experience specific to combat-related mental health problems, and understanding the military culture and experience are rare amongst community-based practitioners.

Given this knowledge, one can now empathize with veterans who face challenges in locating providers who use best practices to treat depression and PTSD. Since some practitioners lack the training of evidence-based guidelines and core competencies, the DoD and VHA have begun developing and implementing programs to train in this lack of skill. The extent to which QI programs are being implemented in the community to address priorities for mental health problems faced by OEF/OIF veterans and whether these treatments result in meaningful improvements in care are largely unknown.

The QI system support is most apparent within the VHA, which developed an infrastructure to manage quality using a system- wide performance measurement based on administrative data and patient satisfaction data. The VHA has also undertaken the Mental Health Quality Enhancement Research Initiative (MH-QUERI), which supports ongoing QI programs to improve outcomes for patients and improve the delivery of clinical services for mental health (Burnam et. l, 2009).

Studies of QI efforts have found that patient care in the VHA is better, relative to community-based care. Conclusion and Recommendations Currently underway, there are numerous efforts to identify and treat PTSD and depression among veterans. The funding of the DoD and VHA as well to the inception of the DCoE for Psychological health and TBI are classic examples to why we need to provide service members and veterans with resources/benefits.

Many challenges still remain as some swift changes in improvements on research, staff, training, and programs have occurred. Recent research has suggested that the prevalence of PTSD and depression is high and may continue to rise as current conflicts continue (Burnam et. al, 2009) . If left untreated or undertreated, these problems could increase, thus potentially placing a high economic toll on society. Effective treatments for PTSD and depression exist, yet there are disparities in how these treatments are being geographically/regionally dispersed.

Key challenges already highlighted are: veterans’ perceptions of the negative consequences of seeking care; inadequate availability of mental health professionals; diverse and often competing mental health specialties and training approaches that inadequately prepare many practitioners to deliver evidence-based treatments for combat-related disorders or to understand military experience (Burnam et. al, 2009); and limited dissemination and implementation of QI strategies in mental health care settings . Overcoming these obstacles will require federal, state, and local leadership.