New Report Urges Funding, Effective Treatment for Veterans with Mental Health Needs

Have you seen this article in Mental Health Weekly (Nov 19, 2012) featuring a new report released by the National Council about the effectiveness of serving veterans’ mental behavioral health needs in the community?

New report urges funding, effective treatments for veterans with mental health needs

A new report examining the cost of veterans’ unmet mental health needs found that every dollar invested in providers to deliver proper outreach evidence-based care for Iraq and Afghanistan veterans could result in $2.50 in savings over two years. The report, released and prepared by the National Council for Behavioral Health calls for a mandate and funding for providers to deliver proper outreach and assessment techniques and evidence-based treatments for veterans.

The report, “Meeting the Behavioral Health Needs of Veterans of Operation Enduring Freedom and Operation Iraqi Freedom,” found that currently 27 percent (657,000) of Iraq and Afghanistan veterans are using community-based care. More veterans are moving from Department of Defense (DOD)-provided services to Veterans Administration (VA)-provided services to community-based care. By 2014, 40 percent (970,000) of veterans will be using community-based care, the report estimates.

According to the report, of the 2.4 million Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF) veterans, 40 percent are still on active duty and 60 percent have been discharged. Of veterans who have been discharged, just more than half are using VA care, while the rest are using private healthcare.

“The sheer numbers of veterans coming back who are going to need behavioral health services is alarming,” Jeannie Campbell, veteran and executive vice president of the National Council, told MHW.

According to the report, which offers a state-by-state analysis of costs and needs, community behavioral health centers (CBHCs) are an important source of support for veterans. The report calls on CBHCs to fill the gap in mental healthcare. “There is a growing recognition that anytime you serve in a war zone, [you may] suffer from PTSD, depression or combat anxiety,” said Campbell.

More than 90 percent of the National Council’s 2,000 members are already serving veterans, Campbell said. Currently, only 50 centers have contracts with the VA to provide behavioral health services to returning veterans, and an additional 400 centers have expressed interest in pursuing VA contracts.

“We’ve got the opportunity in front of us to serve veterans,” said Campbell. “Community providers are willing to do their part. The VA has been slow in moving contracts forward for providers to address unmet mental health and addiction treatment needs, she said.

“We’re working with the VA to work with community behavioral health providers to put these contracts in place,” she said. More of the National Council’s providers are becoming TRICARE-credentialed, said Campbell. TRICARE is a regionally managed healthcare program serving active-duty service members, retirees and their families worldwide.

“Community behavioral health providers have an ongoing, well-documented desire to work with the VA,” Campbell added. “That requires all of us to step up, whether it’s the VA, DOD or providers.”

Executive order

In August 2012, President Obama issued an Executive Order to Improve Access to Mental Health Services for Veterans, Service Members, and Military Families, noted Campbell. The Executive Order called for the VA to hire 800 peer-to-peer counselors and 1,600 mental health professionals, and to establish a small number of pilot projects with community-based providers.

These efforts appear to have been prompted not by careful review of the actual mental health needs of veterans, but rather by the overwhelming number of calls being placed to VA crisis phone lines, the report stated.

The report notes that while the president’s mandate marks progress in meeting the mental health needs of veterans, it also illustrates how underequipped the field has been. “The president’s mandate for the pilot programs is moving very slowly,” said Campbell.

A major concern, said Campbell, is the looming “fiscal cliff” — a newly coined term referring to the effect of a number of laws that, if unchanged, could result in tax increases, spending cuts and a corresponding reduction in the budget deficit beginning in 2013. “The potential cuts to Medicaid and to SAMHSA [Substance Abuse and Mental Health Services Administration] could have a ripple effect in terms of providers’ ability to serve anyone — whether they’re veterans or not,” said Campbell. “That’s a big issue.”

The report noted that since 2001, 2.4 million active-duty and reserve military personnel were deployed to the wars in Iraq and Afghanistan. Of this group, nearly 730,000 (30 percent) men and women will have a mental health condition requiring treatment. Studies have shown that 18.5 percent of all OEF/OIF veterans have PTSD and major depression. Other mental health disorders are estimated to affect 11.6 percent.

Evidence-based care

“Another important goal is to call attention to the evidence-based treatments that have proven effective in the treatment of veterans who have PTSD, depression or a comorbid diagnosis,” said Campbell. “We know that CBT treatments work.”

Prolonged exposure (PE) therapy, which involves talking about the trauma repeatedly until memories are no longer upsetting; and eye movement desensitization and reprocessing (EMDR), involving focusing on sounds or hand movements while talking about the trauma, have also proven effective, she said.

The report noted that less than 50 percent of returning veterans in need receive any mental health treatment for PTSD and major depression. Of those receiving care, only 30 percent get evidence-based care. Instead, the majority are getting what is called “usual care,” the provision of a broad set of services, only a portion of which is evidence-based. The report noted that, not surprisingly, research has proven that evidence-based care is more effective than usual care, but usual care is better than no care.

“Usual care means when physicians were informed of the patient’s psychiatric diagnosis, and were urged to treat it in whatever manner and for whatever duration they deemed appropriate,” said Campbell.

While medication can be helpful in treating some people with PTSD, the evidence is less conclusive than for cognitive behavioral therapies. Selective serotonin reuptake inhibitors (SSRIs) and Prazosin (Vasoflex) have been found to be helpful, but what has been proven is that benzodiazepines and atypical antipsychotics should generally be avoided for PTSD treatment. For major depression, a combination of medication and psychotherapy has proven most helpful to people, the report stated.

Economic issues

Given the current fiscal challenges, it is quite likely that veterans’ increasing use of non-DOD/VA behavioral health services will result in huge costs down the road for public mental health agencies as well as Medicaid and Medicare.

The report noted RAND’s landmark 2008 study, “Invisible Wounds of War,” in which the nonprofit institution that offers research and analysis to the armed forces computed the costs over two years for veterans who had PTSD and/or major depression. They computed healthcare costs and lost wages costs as well as costs associated with suicide. According to the RAND study, if untreated veterans were to receive evidence-based care, it could result in a savings of $3,000 to $12,000 per person depending on the condition.

If all 210,000 untreated veterans with PTSD and/or major depression were to receive evidence-based care, the $481 million investment would result in over $1.2 billion in cost savings, a return on investment of 2.5 to 1, according to an update from the 2008 RAND report.

Combined with the increase in VA staff, additional support for meeting veterans’ behavioral health needs in the CBHCs will save both money and lives, the report stated.

For a copy of the report, “Meeting the Behavioral Health Needs of Veterans of Operation Enduring Freedom and Operation Iraqi Freedom,” visit