Access to care is essential for any organization that hopes to provide successful prevention, screening, diagnosis, treatment, and rehabilitation for posttraumatic stress disorder (PTSD). Access has been defined as the timely use of health services to achieve the best possible health outcomes (IOM, 1993). In this chapter, three dimensions of access to PTSD care in Department of Defense (DoD) and Department of Veterans Affairs (VA) are considered—availability, accessibility, and acceptability.
- Availability measures the extent to which a health care system has the resources, such as personnel and technology, required to meet the needs of patients. To ensure availability of effective care, a PTSD management system ensures that care is equitable for users and potential users.
- Accessibility refers to activities to overcome such institutional hurdles as a poor referral process and such logistic problems as distance to treatment site and reaching those in underserved areas. It can also refer to accommodating patients’ needs such as extended hours of operation, which may encourage them to seek and remain in treatment.
- Acceptability incorporates patient-centered care and takes a holistic view of the patient, integrating all health issues and social factors that may influence the patient’s priorities and preferences for care, including such individual characteristics as age, sex, and ethnicity and culture of the patient and the provider (Delbanco, 1992; Gerteis et al., 1993; IOM, 2013; Laine and Davidoff, 1996;
Zatzick et al., 2001). Involving patients and their families in care decisions that address patient preferences and establish treatment goals (including the right to refuse or not seek care) can lead to increased patient engagement and better adherence to the plan of care (Batten et al., 2009; Khaylis et al., 2011; MacDermid Wadsworth et al., 2013), which can lead to better health outcomes and lower health care costs (Cosgrove et al., 2013).
A patient’s beliefs about mental health (his or her own and that of others), including what can cause and who is at risk for mental health problems and the value of engaging professional help and expectations about treatment can all influence seeking care. Negative and erroneous assumptions about mental illness (that is, stigma1) are widespread in both civilian and military society and can be held by people who have symptoms of a mental health disorder. Stigma can adversely affect access to, engagement in, and adherence to mental health care (Corrigan, 2004).
Executive Order 13625 (August 31, 2012), “Improving Access to Mental Health Services for Veterans, Service Members, and Military Families,” requires DoD, VA, and other federal departments to take steps to meet current and future demands for mental health and substance use disorder treatment for service members, veterans, and their families. The following sections assess DoD and VA efforts to ensure the availability, accessibility, and acceptability of PTSD care for service members and veterans.
DEPARTMENT OF DEFENSE
There is considerable variability in service members’ access to PTSD treatments in military treatment facilities (MTFs), in mental health clinics, and from TRICARE purchased care providers. Service members reported a number of difficulties in receiving care for their PTSD, such as long waits to see a preferred provider and a lack of confidence in a provider’s capabilities. Access can depend on the acceptability of the care that is offered to a service member. Acceptability is influenced by a service member’s preferences, characteristics, situation, and social supports. Barriers to accessing care and approaches to overcoming those barriers are discussed in this section.
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1 Stigma is often cited as a barrier to seeking mental health care. The committee uses this term to mean negative attitudes about mental health conditions at the societal, institutional, or individual level, including those of the person who has the condition (Burnam et al., 2008, in Tanielian and Jaycox, 2008).
Availability
Given the growing number of service members who have PTSD and are in need of mental health services, ensuring that they are treated promptly and consistently is a concern. The issue of service members’ timely access to mental health care has been the subject of some scrutiny (IOM, 2013; Tanielian and Jaycox, 2008; VA Office of the Inspector General, 2012). DoD policy requires that mental health care providers in primary care complete an initial clinical consultation with a service member within 10 days of receiving a primary care referral (DoD, 2013a), but DoD does not track wait times and time between appointments (Wendy Funk, Kennell and Associates, Inc., personal communication, January 23, 2013).
There has been a substantial increase in the number of DoD health care beneficiaries, including active-duty service members, who are referred to TRICARE contractors for PTSD care. The Government Accountability Office (GAO) recently reported on a congressionally mandated, 4-year access-to-care survey of DoD health care beneficiaries, including reservists (GAO, 2013). The survey showed that only 39% of civilian mental health care providers were willing to accept new TRICARE patients compared with 67% of primary care and 77% of specialty care providers. About 28% of the 24,000 TRICARE beneficiaries in the survey reported problems in accessing mental health care: 45% of the respondents reported that mental health care providers would not take TRICARE payments, 25% reported that providers would not take new TRICARE patients, 24% reported that travel distances to providers willing to see them were too great, and 24% reported that the wait for appointments was too long. The most common reason that providers cited for not accepting new TRICARE patients was a lack of awareness or knowledge about the TRICARE program (GAO, 2013).
Although all the military installations have mental health clinics that can treat for PTSD, few installations have specialized outpatient or residential programs for PTSD. There are only 21 specialized PTSD outpatient programs throughout the service branches (O’Toole, 2012), and no data were available on access to these programs, the number of patients that they serve, or how service members are prioritized for admission.
Accessibility
Accessibility to PTSD care in DoD varies according to location and setting, particularly whether in theater or in garrison. Repeated surveys of service members deployed to Afghanistan and Iraq, such as those conducted by mental health advisory teams (MHATs), indicate that accessing mental health care during deployment to a war zone can be difficult. Enlisted
soldiers who screened positive for any mental health problem were more than twice as likely as those who did not screen positive to perceive that mental health services were not available (27.0% vs 11.2%), that it was difficult to get an appointment (29.4% vs 12.2%), that it was difficult to get time off work to go for treatment (47.8% vs 18.5%), and that it was too difficult to get to a location where mental health services were available (31.7% vs 15.5%) (MHAT-7, 2011). When the same questions were asked of marines in theater, similar differences were reported between those who screened positive for any mental health problem and those who did not. For example, 7.9% versus 7.0%, respectively, reported that mental health services were not available, 11.9% versus 6.6% that it was difficult to get an appointment, 24.5% versus 18.3% that it would be difficult to get time off work to go for treatment, and 14.2% versus 12.5% that it was too difficult to get to a location where mental health services were available (MHAT-7, 2011).
A survey of 1,659 Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members found that 17% of respondents reported receiving mental health care in the past year, either from a specialty mental health or primary care provider. Of those seen by a specialty mental health provider, 79% found that treatment helped “a lot or some” and none thought it was not at all helpful, whereas for those who saw a primary care provider, 51% though treatment had helped “a lot or some” but 15% reported that treatment was not at all helpful (Wong et al., 2013). The authors note that previously deployed active-duty personnel were much more likely to seek care from specialty mental health care providers, where they received more numerous, intensive, and longer treatment sessions than from primary care providers.
Specialized intensive PTSD care, particularly for residential or dual diagnosis care (usually substance use disorders), is not always available in an installation or in local communities, and a service member and family may need to travel a considerable distance from a base to access such care. This in effect precludes their families from participating in their treatment. Some installations do have programs to treat PTSD and comorbidities concurrently, such as the Overcoming Adversity and Stress Injury Support program and the PTSD and traumatic brain injury clinic at Fort Campbell, but they may not be near a service member’s duty station and they often have long wait lists.
The phase 1 report addressed barriers to accessing mental health services and recommended that DoD explore telehealth approaches. One such approach that is being pilot-tested is having mental health care providers conduct psychotherapy and pharmacotherapy sessions via videoconferencing with a provider in an MTF or large clinic and a service member in a remote clinic. This telehealth approach may result in fewer missed ap-
pointments and more effective use of a clinician’s time if the patient has a shorter travel distance and is more likely to keep regular appointments. Telehealth services are located at three medical centers—Walter Reed National Military Medical Center, Maryland; Warrior Resiliency Program, Texas; and Tripler Army Medical Center, Hawaii—and include access for deployed service members (DoD, 2013b). DoD has also established online and telephone resources for mental health issues for service members and their families; for example, Military OneSource is available online and by telephone 24 hours a day, 7 days a week.
Vet Centers have extended services to all military personnel who are or have been on active duty in OEF and OIF, not only those who served in combat. No data are available on the number of active-duty service members who are using Vet Centers, but almost a half-million OEF and OIF veterans had contact with a Vet Center as of 2010 (Fisher, 2014). Although most Vet Centers operate during normal business hours, they may also offer extended hours (evenings and weekends) for counseling on request.
Acceptability
Acceptability of care depends on a service member’s needs and preferences. This section focuses on factors that influence service members’ interest in treating their PTSD, including stigma; how patient characteristics effect treatment; and the role of social support. All those factors are part of a patient-centered approach to PTSD care.
Some service members dislike using evidence-based medications for PTSD because of adverse effects. Diagnosis of and medications used to treat for PTSD can, in some situations, automatically result in a service member’s being non-deployable, relieved of duty or command, or being unable to carry weapons. Such restrictions on duties may make service members reluctant to seek treatment or use medications for PTSD. Having an array of treatment options can help engage patients in care.
Perceptions of Mental Health Care
Personal beliefs may hinder service members from seeking care for their PTSD. Hoge et al. (2004) found that many soldiers and marines have beliefs that can interfere with accessing care, including the belief that getting mental health care would cause them to be seen as weak (65%), to be treated differently by unit leaders (63%), to lose the confidence of their peers (59%), or to be blamed for their problems (50%). A recent survey of marines found that the most common factors that affected decisions to seek mental health care were a desire to solve their own problems (65%), fear of their commanders losing trust in them (50%), being treated differently
(45%), lack of confidentiality (37%), and adverse effects on their career (37%) (Momen et al., 2012). Some surveys have found that beliefs about stigma are strongest among those who screen positive for mental health problems (Hoge et al., 2006; MHAT-7, 2011). The MHAT-7 and MHAT-9 reports concluded that, on the basis of surveys of soldiers and marines deployed to Afghanistan in 2006, 2007, 2010, and 2013, stigma as a barrier to care has declined among marines who are experiencing psychological symptoms but has been unchanged among soldiers. The perception of barriers to care had also decreased in both groups (MHAT-7, 2011; MHAT-9, 2013).
The DoD TRICARE Management Activity found that of 80,000 service members returning from OEF and OIF who used military health services, 20% had received mental health counseling for personal or family problems and of those 87% found the counseling helpful. About 4% of those who did not receive counseling indicated that it was because of such barriers as an inability to get an appointment and concerns about effects on one’s career (TRICARE Management Activity, 2013). Among 577 OIF combat veterans who screened positive for PTSD, depression, or general anxiety disorder, three-quarters recognized they had a problem, but only 40% were interested in receiving help. Negative attitudes about mental health care were associated with lower interest in receiving it (Brown et al., 2011).
DoD has undertaken a number of efforts to address these negative attitudes about mental health care. DoD Instruction 6490.08 (DoD, 2011) states that health care providers do not need to notify a service member’s commander if he or she self-refers or has a medical referral for mental health services, but the impact of this instruction on reducing stigma is unknown. Embedding mental health care providers in units to give service members and mental health staff the opportunity to get to know each other outside the clinic may also reduce stigma. Embedded mental health staff work closely with and can educate unit commanders on the benefits of mental health care for their unit members and are able to provide ad hoc advice and referrals. Integrating mental health care into primary care clinics is yet another effort to decrease stigma by reducing the negative perception of visiting a separate mental health clinic. Public-service announcements and websites, such as After Deployment (http://www.afterdeployment.org), are also being used to reduce negative views of mental health care among service members and the general public.
Service Member Characteristics
The Interagency Task Force on Military and Veterans Mental Health—a collaboration between DoD, VA, and the Department of Health and
Human Services—stated that mental health strategies need to respond to the diversity of veterans, service members, and their families, including diversity in sex, race, ethnicity, sexual orientation, and age, and that mental health educational and outreach efforts be tailored to those factors (DoD et al., 2013).
Most DoD efforts to accommodate minority groups have focused on military women, who make up about 14% of active-duty personnel. Although women have historically been excluded from direct combat roles, they have been exposed to combat and other violence in Afghanistan and Iraq. Sexual assault is the primary causal factor of PTSD in military women, whereas combat experience is the strongest predictor of PTSD in men (Kang et al., 2005; Street et al., 2008). Women and men who have experienced a prior assault (including sexual or violent physical assault) are more likely to develop postdeployment PTSD symptoms after combat exposure than are women and men who had no prior assault (22% vs 10% in women and 12% vs 6% in men) (Smith et al., 2008).
Each service branch has established its own sexual assault prevention and response program and guidance (NAVADMIN 181/13, Marine Corps Order 1752.5A, Army MEDCOM Regulation 40-36, and Air Force Policy Directive 36-60) in compliance with DoD Directive 6495 (April 30, 2013), but these documents do not specify any protocols for treating service members who have sexual-assault-related PTSD. These programs are required to provide care that is gender responsive, culturally competent, and recovery oriented.
Data on PTSD in racial minorities underscore the importance of considering race and ethnicity in patient-centered care in DoD. The prevalence of PTSD in 2012 in white beneficiaries was 8.5% compared with 11.0% in nonwhites (see Table 2-3). No information was found in the published literature or DoD reports on the need for and availability of racial and ethnic-group-specific mental health treatment services in the military. Other than separate therapy groups for men and women who have experienced sexual trauma (but not combat-related PTSD), no programs tailored to specific sexes, races, or cultures were identified. At site visits, most of the mental health providers indicated that there was little or no need for such programs.
Social Support
Many service members seek treatment for their PTSD only when family members insist that they do so. Many service members and providers reported that they would like to have more family involvement in service members’ PTSD treatment, including PTSD education programs, support groups for families, and couple and family therapy. Some specialized PTSD
treatment programs—such as the Warrior Resilience Center at Fort Bliss, Texas—do offer support groups for partners of service members who are in the program, and they are well received. In particular, the National Intrepid Center of Excellence (NICoE) encourages family members to participate in the service member’s treatment plan through its family services program. However, there are barriers to a family’s participation in the service member’s care. One is that many DoD mental health clinics and providers are at capacity for treating service members who have PTSD, and they do not have additional resources to offer education or other support programs to family members or to involve families more closely in service members’ treatment.
Higher levels of posttraumatic stress symptoms have been associated with lower couple functioning in Army couples (Melvin et al. 2012). Khaylis et al. (2011) found a strong positive association between PTSD symptoms and degree of relationship distress. They also reported that service members who had symptoms of PTSD had a distinct preference for family-based interventions over individual treatment. NICoE offers short-term solution-focused therapy sessions for spouses and family members in individual, marital, and group sessions after care hours if appropriate.
Many support services are available to service members and their family members in military installations, such as Military and Family Life Counselors, Family Advocacy Programs, Marine Corps Community Services, and Families OverComing Under Stress. Other support services for service members and their families include installation chaplains, numerous community groups (such as the Yellow Ribbon Program), and peer-support groups. NICoE has informal support groups for spouses through its family services. Many family counseling services are housed in buildings that are often at a distance from the mental health or primary care clinics and do not interact with them regularly. Chaplains may be a service member’s (or veteran’s) first contact regarding a mental health problem because they are associated with reduced stigma, greater confidentiality, and more flexible availability (Besterman-Dahan et al., 2012; Nieuwsma et al., 2013).
TRANSITIONING FROM DOD TO VA
DoD and VA have jointly developed the Integrated Disability Evaluation System (IDES) to shorten the time required for a service member who is being medically separated to receive a disability rating from both departments (see the phase 1 report for more information on IDES). GAO (2012) found that average IDES case-processing times for active-duty personnel and reservists were 394 and 420 days, respectively, far exceeding the stated goals of 295 and 305 days but less than the 540 days typically required for the previous evaluation process. Only 19% of active-duty and 18% of
National Guard or reserve component members completed the process and received benefits within the time goals. The number of IDES cases who have PTSD has not been reported. Shortening the disability process expedites the transition of a service member to veteran status and eligibility for VA care.
There are challenges for service members who have PTSD as they transition between the DoD and the VA health care systems. Transitioning between systems may affect access and quality of care, for example, because of treatment interruption, the need to form new relationships with providers who are not familiar with one’s history or progress, and handoff errors (IOM, 2013). VA established the Office of Seamless Transition to ensure that OEF and OIF veterans have access to any needed services in VA. The responsibilities of that office have moved to the Office of Care Management and Social Work Services and the Office of Interagency Health Affairs. VA liaisons are available to facilitate the transition for ill, wounded, and injured service members (for example, those in Wounded Warrior battalions or being medically separated from the military) as they move from DoD to VA. Such assistance consists of setting up all necessary medical appointments in VA before a service member leaves active duty. If the service member already has a diagnosis of PTSD, the VA liaison helps to coordinate continued PTSD care in VA. However, not all installations have VA liaisons. Military liaisons (service branch representatives stationed in VA medical centers), VA health care liaisons, and VA social workers and nurses who are responsible for patient issues are all coordinated by the Office of Care Management and Social Work Services. DoD and VA staff facilitate continuity of care and services in the VA medical facility closest to a veteran’s residence after his or her military discharge (Office of Interagency Health Affairs, 2013). No information is available on whether this approach to transitioning care from DoD to VA is increasing access to care.
OEF/OIF/OND (Operation New Dawn) care management teams are in every VA facility to assist these veterans in accessing and coordinating care. The teams have lists of service members who are separating from the military in their catchment areas and can actively reach out to them. Case managers in each VA medical center and benefits office coordinate with DoD discharge staff and serve as the VA points of contact for reservists (Office of Interagency Health Affairs, 2013). These case management teams manage more than 50,000 OEF and OIF veterans (VA, 2012b).
The joint DoD and VA inTransition program is specific to service members who are receiving mental health care and who are transitioning within or across the military, from deployment to redeployment, from the military to veteran status, or, for National Guard and reservists, from civilian status to activated status (www.health.mil/inTransition). DoD Health Affairs Policy 10-001 (DoD Office of the Assistant Secretary of Defense, 2010) calls for transition support coaches to work with these service members to
provide patient education, answer technical mental health questions, and connect service members with appropriate providers. There are no published data on the effectiveness of this program or on how many service members have used it.
DEPARTMENT OF VETERANS AFFAIRS
VA serves a highly diverse, although still largely male, population, many of whom receive care from VA for their entire lives after leaving military service. OEF and OIF veterans who have PTSD are accessing mental health care in VA in greater numbers than veterans of previous eras (Elbogen et al., 2013; Shiner et al., 2012). OEF and OIF veterans had significantly more PTSD treatment visits than Vietnam veterans, but Vietnam veterans have more overall medical visits as a result of age-related and comorbid conditions (Harpaz-Rotem and Rosenheck, 2011).
Not all veterans are eligible for care in the VA health care system. VA has established eight priority groups; veterans in priority group 1 are those who have VA-rated service-connected disabilities that are 50% or more disabling and those determined by VA to be unemployable because of service-connected conditions.2 Veterans who served in a theater of combat after November 11, 1998, and who were discharged from active duty on or after January 28, 2003, are eligible for comprehensive VA health benefits for 5 years following their discharge. At the end of the 5 years, those veterans are assigned to the highest priority group for which they qualify at that time. Some veterans who have PTSD may receive care from non-VA providers such as a community clinic or a private provider, and other veterans may have symptoms of PTSD but not seek care from any source (see Figure 3-4). This section examines the availability, accessibility, and acceptability of care for PTSD in VA and efforts to increase access to it, as well as the challenges VA faces in doing so.
Availability
VA provides an array of PTSD interventions, including specialized treatment, in its medical centers, community-based outpatient clinics (CBOCs), and Vet Centers, but not all levels of care or types of care are available in all VA medical facilities. For example, in the specialized intensive PTSD programs (SIPPs), pharmacotherapy and a variety of psychotherapies are offered. Some psychotherapies are available specifically for veterans who have PTSD and substance use disorders. VA is also integrating mental health
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2 The VA priority groups are described at http://www.va.gov/healthbenefits/resources/priority_groups.asp (accessed April 2, 2014).
care providers into primary care clinics for veterans who need less intensive PTSD treatment. As of 2013, mental health care providers were in 89% of the 349 VA primary care clinics in medical centers and large CBOCs (Davison, 2013). CBOCs that have more than 1,500 unique veteran visits per year are required to provide mental health services; smaller CBOCs can refer veterans to contract care providers in the community (VA, 2008). The VA 2012 report of the Office of Mental Health Operations (OMHO) found that 105 (75%) of 140 health care facilities surveyed were providing evidence-based psychotherapies for PTSD (OMHO, 2013a), although it is unclear where the care was offered (for example, in medical centers or CBOCs) or whether there was adequate capacity to provide services for all those who require it.
Timeliness of appointments has been an issue for veterans treated at VA. Wait times for admission to a specialized PTSD outpatient program (SOPP) was highly variable by veterans integrated service networks (VISNs) and medical facility, averaging 47.2 days (range, 7–163 days) (VA, 2012a). The Veterans Health Administration Uniform Mental Health Services in VA Medical Centers and Clinics handbook requires that all VISNs provide timely access to residential services for PTSD (VA, 2008), but wait times for admission to a SIPP averaged 68 days (range, 22–117 days) (VA, 2012a).
The VA handbook also requires that all first-time patients referred to or requesting mental health services receive an initial evaluation within 24 hours and a more comprehensive diagnostic and treatment-planning evaluation within 14 days of the desired date of care (VA, 2008). VA reported a 95% success rate for meeting that 14-day goal; however, the VA inspector general found that the measure that VA was using to track those times was flawed. For example, VA reported how long it took to conduct an evaluation, not how long a veteran waited to receive an evaluation. Better estimation methods indicated that only about 49% of appointments met this 14-day goal (VA Office of Inspector General, 2012).
The VA handbook further requires that PTSD treatment be initiated within 14 days of the time when a provider and a patient wish to begin. VA again reported success rates of 95% for new patients and 98% for established patients receiving treatment within that period, but the inspector general stated that more accurate estimates were 64% and 88%, respectively (VA Office of Inspector General, 2012). As the inspector general noted, “for established patients, medical providers told us they frequently scheduled the return to clinic appointments based on their known availability rather than the patient’s clinical need. For example, providers may not have availability for 2–3 months, so they specify that as the return to clinic time frame.”
In a 2009 survey of 6,190 veterans who had PTSD or one of four other mental health diagnoses, 40–50% they were usually or always able
to receive an appointment for counseling or treatment “right away” or as soon as they wanted it; 15% or less reported never being able to do so (Watkins et al., 2011). A retrospective analysis by Maguen et al. (2012) found that among OEF and OIF veterans the median time from the end of last deployment until initiation of care was about 1.5 years for primary care, about 2 years for mental health outpatient care, and about 4 years for minimally adequate mental health care (defined as eight or more outpatient visits within a 12-month period). About 30% of veterans attending mental health outpatient care at least once received minimally adequate care within 1 year of their first visit. Moreover, the authors found that there was a median lag time of 7.5 years between an initial mental health treatment session and initiation of minimally adequate care.
The OMHO report (2013a) cited the following areas for improvement in the 140 medical facilities: making mental health services available in a timely manner, scheduling of mental health services, and providing required mental health services at CBOCs to ensure services in rural locations. Specifically, OMHO found that 45% of the facilities reported wait times of weeks or months for veterans seeking PTSD care; 22% stated that evidence-based treatments were offered for PTSD but that access to them was limited for a variety of reasons (unspecified); 30% noted that evidence-based treatments could not be offered at the frequency required; 40% noted long wait times for evidence-based treatments; 40% reported inadequate after hours and weekend appointments; and 35% noted gaps in telehealth capacity, primarily lack of staff.
Accessibility
Some VA facilities do not have specialized intensive PTSD services, and patients who require these services must be referred to other VA facilities. That can result in long travel distances, even across the country, and result in separation from family and other social support. VA has found that veterans in the SOPPs travel an average of 30 miles (range of averages among VISNs, 16–54 miles) between their homes and the SOPPs (VA, 2012a). VA has 70 mobile Vet Centers to expand access to counseling for veterans, service members, National Guard members, and reservists in rural areas (Fisher, 2014); they are important because Vet Center use by veterans in rural areas is lower than it is in urban areas (Brooks et al., 2012).
The national VA no-show rate for mental health appointments is 18% (Mike Davies, Executive Director Access and Clinic Administration Program, VA, personal communication, November 23, 2013), although those specifically for PTSD may differ. No-shows can indirectly reduce accessibility of care because when appointments go unfilled, providers or adminis-
trative staff may spend clinical time trying to contact no-shows to ensure their safety.
VA is exploring options to increase accessibility and reduce barriers to PTSD care via new technologies such as telehealth and mobile telephone applications. The VA National Telemental Health Center is promoting the delivery of prolonged exposure (PE) therapy and cognitive processing therapy (CPT) and has hired or reassigned more than 100 staff to focus on the telehealth delivery of these therapies. VA is also piloting three CPT and PE telehealth clinics to augment the local delivery of these therapies and expand their reach to more rural areas (OMHO, 2013b), but results as to its ease of use and effectiveness are not yet available. One study of 85 American Indian veterans who had PTSD and received services through rural telehealth clinics found that their use of general medical and mental health services, and use of psychotropic medications, was increased after receiving telehealth (Shore et al., 2012). A meta-analysis of 13 studies of telehealth treatments found they were associated with significant reductions of PTSD symptoms and resulted in better treatment effects compared with wait lists; however, this analysis also found telehealth outcomes were inferior compared with face-to-face interventions; the studies were not specific to veterans (Sloan et al., 2011). Although telehealth for PTSD may improve some veterans’ access to evidence-based therapies, it may not necessarily alleviate staff shortages, even if in some situations (for example, a veteran in a CBOC and a provider in a VA medical center) it cuts providers’ or veterans’ travel time to appointments. Some facilities appear to be successfully providing telehealth (both psychotherapy and pharmacotherapy) to veterans in CBOCs and have dedicated telehealth clinicians. With this technology, veterans who otherwise might not have access to a mental health care provider in their closest facility can schedule regular, weekly appointments with medical center providers.
In spite of VA’s increased use of technology to improve access to PTSD services, there continue to be institutional barriers (such as Internet restrictions, lack of computer literacy, and lack of dedicated and secure equipment) to its use. For example, requirements of the Health Insurance Portability and Accountability Act restrict technological options for mental health care providers to e-mail their patients or provide appointment reminders via text message without a secure platform (45 C.F.R. Parts 160, 162, and 164). There are also privacy and cybersecurity issues related to the use of telehealth, such as the requirement that veterans who would like to have telehealth psychotherapy in their own homes use computer equipment provided by VA.
Mobile telephone applications (apps) and mental health resource websites can keep veterans engaged in care between appointments and provide educational materials to them and their families. For example, the jointly
developed VA and DoD PTSD Coach app can be downloaded by anyone. It provides general information about PTSD, allows users to track and manage their PTSD symptoms, and links them with support resources (VA, 2013). The Make the Connection website (http://maketheconnection.net) has a variety of tools and information to connect veterans with appropriate services and professionals. The website contains a resource locator, including PTSD programs; screening tools, such as the PTSD Checklist; and general information on PTSD. The National Center for PTSD website contains extensive information for veterans, families, providers, and the general public on PTSD diagnosis, treatment, and research. See Chapter 9 for more information on technological innovations for PTSD management.
Acceptability
As with service members, such societal and personal factors as veterans’ attitudes and beliefs about mental health, sex, and ethnicity influence their use of PTSD care. In a recent survey of 143 OEF and OIF veterans who screened positive for PTSD but did not seek treatment, Stecker et al. (2013) found that the four factors most closely associated with decisions not to seek treatment were concerns about treatment itself, such as not wanting medications (40%); lack of emotional readiness for treatment (35%); stigma (16%); and logistical issues, such as lack of time (8%).
A survey of 6,190 veterans with PTSD or one of four other mental health disorders that assessed patient-centeredness and reasons for seeking care from the VA found 42% of them rated their VA mental health care as “the best counseling or treatment possible,” and 74% reported being helped “a lot” of “somewhat” by the treatment that they received in the past 12 months. Only one-third, however, reported that their symptoms had improved with the counseling or treatment (Watkins et al., 2011).
The VA handbook Uniform Mental Health Services in VA Medical Centers and Clinics and the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress both call for veterans and their providers to collaborate on decisions about particular treatments for a veteran’s mental health conditions (VA, 2008; VA/DoD, 2010). For veterans to make such informed treatment decisions, they need to be educated about what treatment options are available and the risks, benefits, and possible outcomes associated with each option, including no treatment. The VA/DoD clinical practice guideline states that “providers should explain to all patients with PTSD the range of available and effective therapeutic options for PTSD” (VA/DoD, 2010). Psychoeducation that explains the development and symptoms of PTSD and introduces treatment concepts and options can help to engage patients in evidence-based interventions (Chen et al., 2013). Some VA sites have a formal patient education process. For example, the
Edward J. Hines VA Medical Center uses CORE, a two-session education program for all veterans who express an interest in receiving evidence-based treatment for PTSD. The first session provides an overview of what PTSD is and the many possible symptoms, and the second session is a description of treatment options and how they work. Some VA medical centers provide psychoeducational groups for couples, which introduce veterans and chosen family members to basic information about PTSD, co-occurring conditions, and the potential impact of PTSD on a veteran’s family. Patient testimonials can also encourage other patients to seek PTSD treatment (Pruitt et al., 2012).
Veteran Characteristics
VA serves a diverse population of veterans—including veterans of all ages, eras, ethnic groups, and race—and a growing number of women. Care should be individualized on the basis of such factors as a veteran’s background, symptom presentation, characteristics, preferences, living situation, sex, race, socioeconomic status, employment status, legal status, and goals of treatment. In a study of veterans who had PTSD, sex and era of service influenced the veterans’ goals of treatment—veterans from OEF and OIF reported anger and hypervigilance symptoms and nightmares less often than veterans who served in other conflicts. Female veterans were more likely to want help with coping and functioning, self-concept, and sexual trauma, whereas male veterans wanted help with anger and sleep (Rosen et al., 2013).
Treatment plans for PTSD need to factor in treatment for comorbidities as well. For example, a small study of 35 veterans who had both PTSD and substance use disorder found that nearly two-thirds of them preferred to integrate their PTSD and substance use disorder treatments, as opposed to receiving treatment for each condition sequentially; however, only eight veterans reported receiving integrated treatment (Back et al., 2014). Many veterans who have PTSD may also be experiencing psychosocial problems—such as homelessness, unemployment, divorce, or be in an abusive relationship—all of which may influence their interest in seeking treatment and their treatment preferences.
Sex-Specific Care for PTSD
All VA facilities are required to accommodate and support women and men with safety, privacy, dignity, and respect, and all inpatient and residential-care facilities must provide separate and secured sleeping accommodations for women (VA, 2008). Women who have PTSD have been found to have higher rates of VA health service use, including hospitalizations, than
men who have PTSD (Maguen et al., 2012). Goldzweig et al. (2006) found that although predictors for PTSD were similar in male and female veterans (for example, combat and sexual trauma), women experienced higher rates of mental health disorders and medical comorbidities. In a review, Bean-Mayberry et al. (2011) found that OEF and OIF female veterans had higher rates of positive screens for PTSD symptoms than recently deployed men and were disproportionately affected by the symptoms.
VA reports that it is increasing the treatment capabilities in all VA medical centers and clinics to serve its growing population of female veterans better (see Chapter 3). Every VA medical center has a Women Veterans Program Manager who serves as an advocate and coordinator for women veterans to assist them in obtaining needed services. The 2008−2009 VA Survey of Women Veterans Health Programs found that 34% of the 195 reporting VA health care facilities had designated women’s mental health providers in general outpatient mental health clinics and 48% had group therapy for women in these clinics; 24% of women’s primary care clinics provided mental health services (Oishi et al., 2011).
In 2012, 11% of patients in SOPPs were women; 18 of the 127 SOPPs treated no women (7 of these sites treated fewer than 10 men), and fewer than 5% of patients in 26 SOPPs were women. The three women’s stress disorder treatment teams (WSDTTs), a type of SOPP, are located in Dallas, Texas; Loma Linda, California; and Albuquerque, New Mexico. These three SOPPs admitted a total 112 women in 2012—70 in the Dallas program, 5 in Loma Linda, and 37 in Albuquerque (VA, 2012a).
The VA handbook requires that residential rehabilitation and treatment programs, one form of SIPP, be provided to female veterans at a level equivalent to that for male veterans. In 2012, 11 of 40 SIPPs treated no women; in the ones that did treat women, the percentage of female patients varied from 1% to 24%, and most treated 10% or fewer female patients. In three VISNs, the intensive programs treated no women at all, and in another nine VISNs, the intensive programs treated 5% or fewer women (VA, 2012a). There are two small residential SIPPs—women’s trauma recovery programs (WTRPs)—located in Batavia, New York (6 beds), and Palo Alto, California (10 beds), that in 2012 treated a total of 73 women. This unexplained variation in the number of women treated in the SOPPs and SIPPs is of concern, but possible reasons for it include a lack of outreach to women and program exclusion criteria.
VA estimates that about one-fifth of female veterans enrolled in VA screen positively for military sexual trauma (MST). One survey of 166 female veterans discharged from VA inpatient or residential programs for MST found that 96% of them had received a diagnosis of PTSD and nearly all of them had more than one mental health disorder, particularly depression and substance use disorder (VA Office of Inspector General, 2012).
MST services are available in all VA medical centers for both women and men (OMHO, 2013b), and the use of MST services by both female and male veterans is increasing (McCutcheon, 2013). For example, the Bay Pines Health Care System has a Center for Sexual Trauma Services that treats only women and has a residential program, but this program is not identified as a WTRP or WSDTT (VA Office of Inspector General, 2012).
Each VA medical center has a dedicated MST coordinator and is “strongly encouraged” to give veterans who are being treated for MST the option of being assigned a same-sex mental health care provider or an opposite-sex provider if the trauma involved a same-sex perpetrator (VA, 2008). The OMHO site visit report found that 31% of sites specifically mentioned problems in providing adequate staffing for MST, 26% noted the inappropriate use of MST staff, and 31% of sites reported that CBOCs had difficulty in providing MST services because of staffing shortages (OMHO, 2013a).
Racial, Cultural, or Ethnic Group-Specific Care for PTSD
The availability of culturally tailored treatments may enhance engagement by members of racial and ethnic minority groups (Carter et al., 2012; Manson, 1996), but empirical evidence on their reach and effectiveness is lacking (Pole et al., 2009). There is a dearth of literature on approaches for matching patients who have PTSD to specific treatments and what, if any, patient characteristics might improve treatment acceptability and response. Tailoring treatment is important in VA because the population of veterans who receive mental health care from VA is diverse; about 23% of veterans who received PTSD care in SOPPs are black, 10% are Hispanic, and 15% identify themselves as of another nonwhite race or ethnicity (VA, 2012a).
VA acknowledges the importance of integrating racial, cultural, or ethnic group–specific needs of individual veterans into the clinical context by, for example, developing specific programming for American Indian veterans to address both the high proportion of rural residence of this group, which limits their potential access to mental health services, and their high rates of military service (OMHO, 2013b). Clinicians also need to be sensitive to the beliefs and cultural traditions of a veteran’s tribe, and how these may affect treatment, such as including a shaman, using sweat lodges, or using other traditional medicines (OMHO, 2013b). Cultural sensitivity of providers is an important aspect of treatment of any veteran. VA’s National Center for PTSD has developed educational videos (for example, related to PTSD cross-cultural considerations, black veterans, Hispanic veterans, and Asian-Pacific Islander veterans) on the cultural issues of racial and ethnic groups. They are available for both VA and non-VA audiences (OMHO, 2013b).
VA has also tailored programs to address veterans who served in different eras as they may have different treatment needs. For example, Chard et al. (2010) found that Vietnam veterans who had chronic PTSD did not respond as well to CPT as did OEF and OIF veterans. For OEF and OIF veterans, special programs include Serving Returning Veterans—Mental Health teams. The teams collaborate with the postdeployment integrated-care initiative teams, which are in primary care clinics throughout the VA system, to offer rapid, comprehensive assessment of and treatment for mental health, medical, and psychosocial needs of combat veterans. Regularly scheduled calls between the two teams provide opportunities for sharing information on effective practices for treating the OEF and OIF population.
Social Support
Social support can help veterans who have PTSD engage in care. Support systems can include family, friends, colleagues, and others who are interested in the health and well-being of a veteran. Some veterans face substantial challenges, such as unemployment, homelessness, and loss of social contacts, and need wraparound support services.
VA offers a number of social support and rehabilitation programs and services to meet those needs, including the Housing and Urban Development–Veterans Affairs Supportive Housing program, and Compensated Work Therapy, a vocational rehabilitation program. These programs work in collaboration with mental health care providers to ensure that veterans’ medical and social support needs are met. A small randomized controlled trial of veterans who had PTSD and received either individual placement and supported employment or vocational rehabilitation treatment found that individual placement and support with competitive employment was more effective than vocational rehabilitation only (76% vs 28%) in helping veterans obtain and maintain employment (Davis et al., 2012).
The family is a potential source of support for a veteran who has PTSD, although PTSD itself also can be the source of distress and disturbance for family members. Thus, support of the family provides a mechanism for preserving and enhancing long-term social support of a veteran who has PTSD. Some veterans have expressed great interest in partner involvement in their PTSD treatment and stated that they wished that their spouses or partners were able to receive more education and support, including a VA spouse-support group to help them to cope.
VA health care leadership endorses family involvement in veterans’ mental health care and is examining the multifamily group treatment model as a potential mechanism for providing family psychoeducation, communication training, and problem-solving skill building; the group format encourages social support (Sherman et al., 2012). Although VA medical
centers do not provide mental health counseling for family members unless they are seen conjointly with the veteran in family or couples therapy, most SOPPs “plan to work with family”; information on what these interactions consist of was not provided (VA, 2012a). The National Center for PTSD offers a course for providers “Couples and PTSD” that explains methods for including partners and loved ones in the assessment and treatment of veterans who might have PTSD.
VA has recently hired over 800 peer support personnel (VA and Sherrard, 2013). The use of peer counselors and peer support can increase the acceptability of PTSD care for veterans (Barber et al., 2008; Davidson et al., 2006; New Freedom Commission on Mental Health, 2003; SAMHSA, 2011a). Peer counselors are veterans themselves (some of whom may have or have had PTSD) who can provide experiential advice on the need for PTSD treatment and treatment options. Although they are not clinicians and do not provide therapy, they have an understanding and an ability to relate to other veterans because they may have had similar experiences. Peer counselors have been found to improve veterans’ recovery (SAMSHA, 2011b). Peer-to-peer programs facilitate opportunities for veterans to talk with trained peer supporters who can offer educational and social support and provide avenues for additional help if needed (DCoE, 2011). Peer support groups can help to reduce the stigma related to accessing evidence-based treatment for PTSD and lead some veterans to take the initiative to seek trauma-focused treatment (Pruitt et al., 2012; VA and Sherrard, 2013). Peer support groups also provide a long-term resource for veterans after they complete the acute phase of treatment. In 46% of VA OMHO site visits to facilities, it was noted specifically that peer support had or could have a benefit for their staffing and veteran care (OMHO, 2013a).
Vet Centers provide social support to combat veterans and their families. Vet Center counselors, 72% of whom are veterans, offer confidential, culturally competent services and referrals for MST, substance abuse, employment, bereavement, family counseling for military-related issues, and outreach and community education. It is estimated that over a half million OEF and OIF veterans have been in contact with a Vet Center staff member (Fisher, 2014).
SUMMARY
DoD and VA are working to improve the availability, accessibility and acceptability of PTSD care for service members and veterans but much remains to be done. DoD does not track information on wait times or time between mental health appointments. In spite of education efforts to overcome the perception by service members and commanders that seeking treatment is unacceptable, stigma and other perceived barriers to care such
as lack of belief that treatment will be effective or an inability to take time to attend appointments, persist. The availability of some PTSD services such as specialized programs is limited as there are few of them and they treat only a small number of service members annually.
More service members are being referred to TRICARE purchased care providers; the availability of these providers can also be uncertain. No PTSD programs tailored to specific sexes, races, or cultures in DoD were identified, other than separate therapy groups for men and women who have experienced sexual trauma. There is no information on the need for and availability of racial and ethnic group-specific mental health treatment services in the military.
VA serves a highly diverse, although still largely male, veteran population. Most PTSD care in VA is provided in general mental health clinics and other nonspecialized settings. The SOPPs and SIPPs treat only about one-third of veterans who have PTSD and used VA health care in 2012. MST services are available in all VA medical centers for both women and men, and each medical center has a dedicated MST coordinator, although adequate MST services are not always available. VA has only a few mental health programs that integrate the racial, cultural, or ethnic group–specific needs with clinical treatment; for example, specific programming has been developed for American Indian veterans and some programs are tailored to veterans who served in different eras.
Overall, in both the DoD and VA there are few opportunities for families to be involved in service members’ or veterans’ PTSD treatment. Some counseling and support services are available to family members on military installations, but these services are typically not integrated with mental health services. PTSD education programs, support groups for families, and couple and family therapy, such as those offered at NICoE, might be beneficial for both service members and their family members. VA is limited in the support services it can offer to families of veterans who have PTSD. Veterans expressed an interest in having more programs available for their family members to learn about PTSD, and some also stated that they would like family members, usually a spouse or partner, to be more engaged in their treatment. VA is leveraging the use of peer counselors to improve access to and promote the acceptance of PTSD care. Vet Centers have extended their services also, including the availability of peer counselors, to all military personnel who are or have been on active duty in OEF and OIF, not only those who have served in combat and are veterans.
DoD and VA are increasing the accessibility of PTSD care through telehealth, particularly having providers deliver evidence-based treatments via videoconference to patients at distant locations. They have also developed mobile apps and educational websites to reach and engage a greater number of service members and veterans.
DoD and VA are also working to improve the transition process from active-duty status to veteran status through the use of the Integrated Disability Evaluation System. VA liaisons are available to facilitate the transition for ill, wounded, and injured service members as they move from DoD to VA by setting up all necessary medical appointments in VA before a service member leaves active duty.
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