Spotlight on Mental Health for Veterans
Veterans Crisis Line
If you or a Veteran you know are in crisis please call 911, go to your nearest Emergency Room, or call the Veterans Crisis Line, which is available 24/7 at 1-800-273-8255. You can also chat live online with a crisis counselor 24/7 by visiting the Veterans Crisis Line website.
The National Institute of Mental Health (NIMH) estimates that in 2016, 44.7 million American adults, or one in every six, were living with a mental illness1. Rates of mental illness among Veterans are disproportionately high, especially for conditions such as posttraumatic stress disorder (PTSD), substance use disorders, depression, and anxiety2. In 2015, nearly 60% of Veterans from the Iraq and Afghanistan wars received a mental health diagnosis3 and an estimated 20 Veterans died by suicide every day4.
While VA has shortened wait times5 for access to care, and formalized plans to expand mental health care to all Veterans6, mental health remains a high priority within VA.
Following is a selection of studies designed to improve the quality and delivery of mental health care in VA.
Veteran College Students’ Mental Health and Academic Achievement
Veteran college students report high rates of mental health issues and suicidal thoughts, even higher than Veterans returning from OEF/OIF conflicts. One main goal of this study was to measure mental health symptoms, problematic alcohol use, and wellness among Veteran college students. Another was to look at how getting mental health treatment can affect school performance, and the difficulties Veteran college students can have in seeking treatment. Lastly, this study looked at experiences working and going to college at the same time.
The information came from surveys filled out by college students and administrators, plus college performance and VA healthcare information for Veteran college students who gave permission to access their records. Over 5,000 students were involved in the study. They filled out surveys at the start, and once a year for two years.
They found that:
- Veteran students, compared to non-Veteran students, were more likely to report mental health symptoms, risky alcohol use, and a lower quality of life, but not more thoughts of suicide.
- Barriers to mental health treatment reported by Veterans included privacy, dealing with it alone, and support from friends and family.
- There was no real difference in school performance between Veteran and non-Veteran students with or without mental health symptoms.
- Veterans were less likely than non-Veterans to be working and attending school at the same time. Those who were not working rated their performance lower than non-Veterans.
Implications: This study is the first assessment of the link between Veteran student mental health and academic performance. It will help VA and colleges decide how to best help Veteran college students to succeed. It will show how alcohol use affects performance in school, where there is the most need for VA help, and where that help will make the biggest impact.
Principal Investigator: Paul N. Pfeiffer, MD, MS. VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI.
Veterans with diabetes often have depression as well, affecting their quality of life. Veterans with diabetes and depression who live in rural areas have limited access to programs that address these conditions together. The Healthy Outcomes through Patient Empowerment (HOPE) study was created to see if coaching patients by telephone could help with both diabetes management and depression symptoms.
All Veterans enrolled in the program received “enhanced usual care” which was education, test results, and follow-up appointments. The test group Veterans were teamed with coaches to work on behavioral skills and action plans to control diabetes and depression symptoms by telephone. Researchers collected blood samples and survey responses at the beginning, after 6 months, and after one year.
Researchers found that:
- The study intervention had greater impact on participants’ depression symptoms than their diabetes management.
- Test group participants had significantly more improvement in depression symptoms, including distress over diabetes, than patients who received enhanced usual care.
- Test group participants also had improved diabetes control, but not significantly more than those who received usual care for diabetes and depression.
Implications: The HOPE Project improved depression symptoms and diabetes-related quality of life for Veterans compared to enhanced usual care. The project used an approach that improved access to care beyond traditional face to face visits. These findings offer a safe and effective method for improving access and care to rural living Veterans.
This study resulted in the following publication(s):
Miles SR, Khambaty T, Petersen NJ, Naik AD, Cully JA. The Role of Affect and Coping in Diabetes Self-Management in Rural Adults with Uncontrolled Diabetes and Depressive Symptoms. Journal of Clinical Psychology in Medical Settings. March 1, 2018; 25(1):55-65.
Martin CE, Renn BN, Winderman KE, Hundt N, Petersen NJ, Naik AD, Cully JA. Classifying diabetes-burden: A factor analysis of the Problem Areas in Diabetes Scale. Journal of Health Psychology. November 1, 2016; 1359105316678667.
Naik AD, Lawrence B, Kiefer L, Ramos K, Utech A, Masozera N, Rao R, Petersen NJ, Kunik ME, Cully JA. Building a primary care/research partnership: lessons learned from a telehealth intervention for diabetes and depression. Family Practice. April 1, 2015; 32(2):216-23.
Cully JA, Breland JY, Robertson S, Utech AE, Hundt N, Kunik ME, Petersen NJ, Masozera N, Rao R, Naik AD. Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial. BMC Health Services Research. April 28, 2014; 14:191.
Naik AD, White CD, Robertson SM, Armento ME, Lawrence B, Stelljes LA, Cully JA. Behavioral health coaching for rural-living older adults with diabetes and depression: an open pilot of the HOPE Study. BMC Geriatrics. Jul 24, 2012; 12(1):37.
Tinetti ME, Naik AD, Dodson JA. Moving From Disease-Centered to Patient Goals-Directed Care for Patients With Multiple Chronic Conditions: Patient Value-Based Care. JAMA Cardiology. Apr 1, 2016; 1(1):9-10.
Principal Investigators: Aanand Naik, MD, and Jeffrey Cully, PhD, HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQuESt); Houston, TX.
Stopping Opioid Therapy after a Long Time is Associated with Risk of Suicidal Thoughts and Actions
The main goal of this study was to find ways to recognize when a Veteran may be thinking of committing suicide or planning to try, after ending an opioid prescription they’ve had for a long time. Researchers reviewed electronic health records of over 500 Veterans who had been prescribed opioids for a long time to treat pain, and whose doctors had stopped their opioid prescriptions. About half of them had been diagnosed with substance use disorder and half had not.
The study found that:
- A large proportion of Veterans with substance use disorder had thoughts of suicide or made suicide attempts.
- Half of patients who made attempts tried to overdose using anxiety medications.
- Higher proportions of patients with PTSD and psychotic disorders had suicidal thoughts and attempts.
- The reason for stopping opioid prescriptions for 75% of the study participants was unsafe behavior such as misusing opioids or other substances.
Implications: Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, especially patients with PTSD or psychotic disorders.
This study resulted in the following publication(s):
Demidenko MI, Dobscha SK, Morasco BJ, Meath TH, Ilgen MA, and Lovejoy TI. Suicidal Ideation and Suicidal Self-Directed Violence following Clinician-Initiated Prescription Opioid Discontinuation among Long-Term Opioid Users. General Hospital Psychiatry. 2017;47:29-35.
Lovejoy TI, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Dobscha SK. Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders. Pain. 2017;158:526-534.
Nugent SM, Dobscha SK, Morasco BJ, Demidenko MI, Meath THA, Frank JW, Lovejoy TI. Substance use disorder treatment following clinician-initiated discontinuation of long-term opioid therapy resulting from an aberrant urine drug test. Journal of General Internal Medicine. 2017;32:1076-1082.
Principal Investigator: Travis I. Lovejoy, PhD, MPH. HSR&D's Center to Improve Veterans Involvement in Care (CIVIC), VA Portland Health Care System, Portland OR.
Reaching Out to Smokers in VA Mental Health
(Photo ©iStock/Antonio Guillem)
Smoking and other tobacco use is the biggest preventable cause of death in the United States. Treating diseases caused by tobacco use makes up almost one quarter of VA healthcare costs. Veterans who use VA healthcare, especially those with mental illness, smoke more than the general population. So it’s important to try to convince Veterans with mental illnesses such as schizophrenia, bipolar disorder, PTSD, and depression to quit using tobacco.
Most doctors and nurses suggest quitting, but they don’t have the time to work with VA patients to help them quit. Psychologists and social workers need to help with bigger problems and usually don’t address smoking and other tobacco use.
This study found VA patients who smoke and were getting VA mental health help, and reached out to them over the telephone. They received medication and counseling to develop a quit-plan just for them.
Compared to the usual treatment:
- Nearly 15% more Veterans in the study reported not smoking for six months or more.
- At the 6 month follow-up, 5% more patients reported not smoking for at least a week.
- Participants were more likely to use counseling, medication, or both, to quit tobacco.
- Reaching out to Veterans with mental illness worked better than the usual treatment.
Implications: This study supports reaching out to smokers receiving VA mental health care. Future research should identify the best counseling for mental health patients, and ways to increase participation.
This study resulted in the following publication(s):
Rogers ES, Fu SS, Krebs P, et al. Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial. BMC Public Health. December 17, 2014;14:1294.
Erin S. Rogers, Steven S. Fu, Paul Krebs, Siamak Noorbaloochi, Sean M. Nugent, Amy Gravely, Scott E. Sherman, Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics. American Journal of Preventive Medicine, March 15, 2018
Principal Investigator: Scott E. Sherman MD, MPH. Manhattan Campus of the VA NY Harbor Healthcare System, New York, NY
- National Institute of Mental Health. Statistics. National Institutes of Health; 2017. Available from: https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
- Removing Barriers to Mental Health Services for Veterans. American Public Health Association; November 18, 2014. Available from: https://www.dav.org/wp-content/uploads/MentalHealth.pdf
- Suicide Among Veterans and Other Americans 2001–2014. U.S. Department of Veterans Affairs Office of Suicide Prevention. August 3, 2016. Available from: https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf
- VHA Vitals Top 15. February 2, 2018. Available from: https://www.vapulse.net/community/commsite/content?filterID=contentstatus%5Bpublished%5D~category%5Bvha-fact-sheets%5D
- S. Department of Veterans Affairs. VAntage Point. June 27, 2017. Available from: https://www.blogs.va.gov/VAntage/39092/va-secretary-formalizes-expansion-emergency-mental-health-care-former-service-members-honorable-discharges/