C O R P O R A T I O N

High-Quality Mental Health Care for VeteransWhat It Means and Why It Matters

There are approximately 18 million veterans living in the United States. Many served during a wartime era and deployed to a combat zone during their service. Many also experienced some kind of traumatic event. Studies of service members deployed to combat areas have found that traumatic

experiences—such as being attacked, viewing human remains, or knowing someone who was seriously injured or killed—are common.

These experiences can cause returning veterans to have disruptive thought patterns, such as difficulty concentrating, reliving traumatic events, or having thoughts of death or suicide. Veterans may experience sadness, hopelessness, worthlessness, guardedness, anxiety, guilt, or anger and avoid situations that remind them of the traumatic experiences or avoid socializing. They may also use drugs, drink too much, or have trouble sleeping.

For many veterans, these thoughts, feelings, and behaviors are normal reactions to difficult experiences and can fade away during the adjustment from military to civilian life. For others, they can be signs of mental health problems, sometimes labeled the “invisible wounds of war.” These include posttraumatic stress disorder (PTSD), depression, anxiety, and combinations of these.

Fortunately, there are effective treatments for these problems. Veterans who receive effective treatments are much more likely to improve and recover. This brief distills lessons from RAND Corporation research on high-quality mental health care for

veterans—what it is, why it matters, and how it makes a difference.

RESEARCH BRIEF

What Is High-Quality Care?High-quality care is defined by the Institute of Medicine as care that has been demonstrated to be effective (i.e., is based on scientific evidence that it works), safe, patient-centered, timely, effi-cient, and equitable.

Why Does Quality of Care Matter?High-quality mental health care can improve recovery rates and is cost-effective. Poor quality of care is less likely to lead to recovery, and negative experiences with care could discourage veterans from seeking care that they need in the future.

Mental health conditions that persist may have long-term consequences. They can contribute to physical health problems, drug use, and general deterioration of health. They can also contribute to problems with relationships and work. Over the longer term, mental health problems can harm marriages and families, leading to higher divorce rates and emotional and behavioral harms to chil-dren. Mental health problems also increase the likelihood of homelessness, suicide, and prema-ture death from other causes. Therefore, ensuring that individuals who experience mental health problems get high-quality mental health care not only promotes the recovery of those individuals but can also help to stem other consequences for their families.

Ensuring that individuals who experience mental health problems get high-quality mental health care not only promotes the recovery of those individuals but can also help to stem other consequences for their families.

What to Look for in Seeking High-Quality CareThe highest-quality care—evidence-based care that scientific research has shown to be effective—is most likely to be delivered by providers with extensive training in such practices. Because of the standards that the Department of Veterans Affairs (VA) has set for mental health care delivery, mental health providers who work mostly in a VA setting are significantly more likely to have this training than providers who do not.

Private-sector providers are less likely to have this training, and there is more variation in their training and experience with delivering evidence-based mental health care to veterans. Veterans and their families seeking care in private settings should ask about their providers’ training as they assess whether that provider is likely to deliver evidence-based care. They should ask explicit questions about the types of treatments offered by the provider and realistic expectations for symptom reduction and recovery. Veterans should talk with their providers often about their preferences for and concerns about mental health treatment to ensure that they receive high-quality care.

Overcoming Barriers to CareDespite the availability of effective treatments for PTSD, depression, and other mental health condi-tions, veterans underuse mental health services: Studies estimate that up to half of all veterans who need mental health care never receive it. There are multiple reasons for this. There are institutional barriers, which can include shortages of mental health providers in a given area or lack of insurance coverage or eligibility for a given source of care, such as VA or a private-sector program. There are also logistical barriers: Veterans may have difficulty scheduling appointments or finding transportation to take them to office visits.

There can also be personal barriers related to veter-ans’ attitudes and perceptions about mental health care. A barrier commonly reported in surveys of veterans is concern about treatment—specifically, that medications might have too many side effects.

Some veterans also cite concerns that seeking men-tal health care could harm their careers.

In the past decade, the VA has taken dramatic steps to address these barriers to care. The VA has sub-stantially increased the number of mental health providers it employs. It has also established out-reach programs to help veterans overcome logistical obstacles to getting care and educational programs tailored to specific populations, such as veterans with severe mental illness, veterans in rural areas, and Native American populations.

To fill service gaps for those veterans who do not use or are not eligible for VA services, support from the philanthropic community has led to the creation of new organizations, programs, and initiatives. Many of these efforts have focused specifically on meeting veterans’ postdeployment mental health needs. For example, funding from private-sector and nonprofit organizations (such as the Welcome Back Veterans Initiative, launched in 2008 by Major League Baseball and the Robert R. McCormick Foundation) has helped create or adapt community-based pro-grams to assist service members, veterans, and their families in connecting with mental health care—with some organizations offering medical services to veterans and their families for free.

How Caregivers Can HelpMany U.S. veterans need help with the activities of daily life and other import-ant tasks, including scheduling and attending visits with their health care providers. This help comes most often from caregivers—spouses, parents, other family members, or friends who provide informal and unpaid care.

Caregivers can play an important role in helping veterans get the most out of their health care. They can join care recipients when meeting with doctors, nurses, and case managers. Caregivers play an essential role in informing and administering treatment plans. This may include adminis-tering medical treatments or medicine, which can improve adherence to prescriptions, or ensuring that appointments are kept. Caregivers can also help veterans

• manage pain• maintain emotional stability• engage in healthy behaviors.

Doing so requires that caregivers interact regularly with providers, who should acknowledge caregivers’ key role and include them when possible in delivering care to veterans. Providers should also recognize that the burden of caregiving can take a toll. For example, military caregivers are at an increased risk for depression and other health-related challenges. Therefore, it is recommended that providers conduct caregiver needs assessments among those who provide this support to veterans to ensure that their mental health needs are met as well.

Six features of high-quality health care

1. EffectiveProven by scientific evidence to work

2. SafeAvoids harms to patients

3. TimelyAvoids waits and delays

4. Patient-centeredRespects individual patient preferences, needs, and values

5. EfficientAvoids waste, such as unneeded visits, tests, or treatments

6. EquitableDoes not vary based on personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status

SOURCE: Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001.

RB-10088 (2019)

Abstracts of all RAND Health Care publications and full text of many research documents can be found on the RAND Health Care website at www.rand.org/health. To view this brief online, visit www.rand.org/t/RB10088. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. RA® is a registered trademark. © RAND 2019.

Limited Print and Electronic Distribution Rights: This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of our research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions.

Cover: asiseeit/Getty Images; pg. 2: two men, martinedoucet/Getty Images; pg. 3: patient with doctor, Adobe Stock; pg. 4: girl with elder, adamkaz/Getty Images; pg. 5: female doctor with patient, asiseeit/Getty Images.

THIS BRIEF SUMMARIZES RAND RESEARCH REPORTED IN THE FOLLOWING PUBLICATIONS:

Peter S. Hussey, Jeanne S. Ringel, Sangeeta C. Ahluwalia, Rebecca Anhang Price, Christine Buttorff, Thomas W. Concannon, Susan L. Lovejoy, Grant R. Martsolf, Robert S. Rudin, Dana Schultz, Elizabeth M. Sloss, Katherine E. Watkins, Daniel A. Waxman, Melissa Bauman, Brian Briscombe, James R. Broyles, Rachel M. Burns, Emily K. Chen, Amy Soo Jin DeSantis, Liisa Ecola, Shira H. Fischer, Mark W. Friedberg, Courtney A. Gidengil, Paul B. Ginsburg, Timothy R. Gulden, Carlos Ignacio Gutierrez, Samuel Hirshman, Christina Y. Huang, Ryan Kandrack, Amii M. Kress, Kristin J. Leuschner, Sarah MacCarthy, Ervant J. Maksabedian Hernandez, Sean Mann, Luke J. Matthews, Linnea Warren May, Nishtha Mishra, Lisa Kraus, Ashley N. Muchow, Jason Nelson, Diana Naranjo, Claire E. O’Hanlon, Francesca Pillemer, Zachary Predmore, Rachel Ross, Teague Ruder, Carolyn M. Rutter, Lori Uscher-Pines, Mary E. Vaiana, Joseph Vesely, Susan D. Hosek, and Carrie M. Farmer, Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans, Santa Monica, Calif.: RAND Corporation, RR-1165/2-VA, 2015 (www.rand.org/t/RR1165z2).

Post-Deployment Stress: What Families Should Know, What Families Can Do, Santa Monica, Calif.: RAND Corporation, CP-535 (3/08), 2008 (www.rand.org/t/CP535-2008-03).

Post-Deployment Stress: What You Should Know, What You Can Do, Santa Monica, Calif.: RAND Corporation, CP-534 (3/08), 2008 (www.rand.org/t/CP534-2008-03).

Rajeev Ramchand, Terri Tanielian, Michael P. Fisher, Christine Anne Vaughan, Thomas E. Trail, Caroline Batka, Phoenix Voorhies, Michael Robbins, Eric Robinson, and Bonnie Ghosh-Dastidar, Hidden Heroes: America’s Military Caregivers, Santa Monica, Calif.: RAND Corporation, RR-499-TEDF, 2014 (www.rand.org/t/RR499).

Terri Tanielian, Caroline Batka, and Lisa S. Meredith, Bridging Gaps in Mental Health Care: Lessons Learned from the Welcome Back Veterans Initiative, Santa Monica, Calif.: RAND Corporation, RR-2030-MTF, 2017 (www.rand.org/t/RR2030).

Terri Tanielian, Coreen Farris, Caroline Batka, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael Robbins, and Lisa H. Jaycox, Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families, Santa Monica, Calif.: RAND Corporation, RR-806-UNHF, 2014 (www.rand.org/t/RR806).

Terri Tanielian and Lisa H. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, Santa Monica, Calif.: RAND Corporation, MG-720-CCF, 2008 (www.rand.org/t/MG720).

Veterans with mental health conditions can get better. With the right care, many are able to recover fully. Their best chance of improv-ing is to receive evidence-based mental health treatment. Veterans, their caregivers, and their families have access to a broad range of re-sources to help them find evidence-based care for mental health issues and get the most out of their care experience.

Resources for Veterans

VA Mental Health https://www.mentalhealth.va.gov

Make the Connection https://maketheconnection.net

Resources for Caregivers

VA Caregiver Support https://www.caregiver.va.gov

Hidden Heroes www.hiddenheroes.org

Resources for Veterans and Caregivers

RAND Ventures is a vehicle for investing in policy solutions. Philanthropic contributions support our ability to take the long view, tackle tough and often-controversial topics, and share our findings in innovative and compelling ways. RAND’s research findings and recommendations are based on data and evidence, and therefore do not necessarily reflect the policy preferences or interests of its clients, donors, or supporters.

This research brief was made possible, in part, by the Zwick Impact Fund. Charles Zwick—a researcher at RAND from 1956 to 1965 who later served as both a trustee and an advisory trustee—presented RAND Ventures with $1 million and the charge to take on new and emerging policy challenges and to support top talent in their focus on these issues. Each year, RAND’s president and CEO draws on this generous gift to help RAND research and outreach teams extend the impact of completed research.

Support for this project is also provided, in part, by the income earned on client-funded research.