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Using Shared Decision-Making to Individualize Mental Health Services for Post-9/11 Veterans

Key Points

  • Research shows that there are critical gaps in engaging Veterans in the needed, and sometimes lifesaving, mental healthcare (MH) offered by skilled VA providers. Many women Veterans report MH care stigma and barriers, yet only a quarter use VA services.

  • A team of researchers from the Iowa City, Central Arkansas, and VA Greater Los Angeles Healthcare Systems is exploring the use of eHealth and shared decision-making (SDM) in addressing these gaps.

  • Onsite interviews at five VA healthcare centers found that SDM training and decision aids are needed, feasible, and welcomed; such aids may be especially helpful to women Veterans.

Every day, thousands of VA clinicians across the nation report to work to provide care to approximately nine million Veterans. Those treated include post-9/11 Veterans, an emerging population with complex care needs who are distinctly different from those who served in previous eras. Three quarters of these 2.8 million post-9/11 Veterans have deployed at least once, with women and Reserve and National Guard members (RNG) among the fastest growing segments of VA-eligible Veterans. Notably, post-9/11 Veterans are twice as likely as those serving in earlier eras to have served in a combat zone and more likely to have experienced emotional trauma, although only a third indicate they have sought mental health (MH) services. Almost half of post-9/11 women Veterans report that it is difficult to adjust to civilian life, similar to their male peers.1 RNG Veterans may be actively serving and potentially have care fragmented between the Department of Defense, VA, and/or community providers; and both women and RNG Veterans experience unique deployment and readjustment stressors, as well as suicide risk.

Research is unequivocal that PTSD, depression, and substance use are highly prevalent post-deployment MH conditions. However, many women Veterans report MH care stigma and barriers, and only a quarter use VA services. These findings are of great concern as most suicides occur among Veterans who have not recently received VA services. Even among those enrolled in VA care, engagement in MH care is not a given. A large, national study examined post-9/11 Veterans with newly diagnosed PTSD and identified that less than a quarter had initiated evidence-based psychotherapy, and only nine percent of these had completed treatment.2 The disparity in impacts (economic, childcare, gender-based violence) of the COVID-19 pandemic on women sheds an important light on women Veterans’ MH care needs and barriers. In sum, there are critical gaps in engaging Veterans in the needed, and sometimes lifesaving, MH care offered by skilled VA providers. Consequently, our team’s research seeks to address these gaps by using eHealth and shared decision-making (SDM) platforms.

SDM is an active process that occurs when a patient and a provider work together to reach healthcare decisions that are best for the patient, with an emphasis on the patient’s priorities, preferences, and values. SDM exemplifies VA core values because it emphasizes patient-centeredness and relies on a strong evidence base. SDM includes:

  • Deciding what MH or readjustment condition the Veteran and provider believe is the priority;
  • Reviewing information about available treatment options for the condition; and
  • Using the provider’s knowledge and expe-rience and the Veteran’s values and prefer-ences to reach healthcare decisions together

It is the ethical right of every patient to make decisions about their health and treatment. These decisions should be informed by current gender-specific research evidence in collaboration with the patient’s provider. Despite differences in communication styles found between male and female providers, research indicates that SDM is equally effective between clinician/patient gender dyads.3 As males comprise two-thirds of VA medical providers, SDM may be important in delivering equitable care for women Veterans by offering a framework to support clinical discussions about MH treatment options.

SDM is especially relevant for women Veterans who are acculturated during their military service to follow orders; or who may fear a loss of control or be disengaged because of their MH symptoms or perceptions of institutional betrayal following gender-based violence. But are VA providers using SDM already? Prior research indicates that there are many myths about SDM that delay widespread adoption, such as providers believing a) they are doing SDM when they really are not; b) using SDM takes more time; and c) that their patients do not really wish to be involved in decision-making.

In this article, our research team describes foundational work leading to, and preliminary findings for, our team’s HSR&D-funded study: Online and Shared Decision-Making Interventions to Engage Service Men and Women in Post-Deployment Mental Health Care (IIR 16-096). This work evaluates processes needed to integrate a web-based interface into current VA systems and to support Veterans’ and providers’ use of SDM regarding MH treatment options. This research aligns with key challenges and priorities identified by VA Secretary Denis McDonough in 2021, including prioritizing women who have served or are still serving in the military, reducing suicide rates, and helping Veterans transition into civilian society.4

Data from this team’s prior studies among women have demonstrated that our web-based interface (WEB-ED): 1) screens or common post-deployment MH and readjustment concerns; 2) provides tailored education about positive screens; 3) facilitates connections to VA resources; and 4) can be successfully implemented in VA. Further, over half of high-risk RNG women Veterans with multiple positive MH screens indicated that this online information reduced their discomfort about MH care and activated them to seek this care. Women Veterans also reported high satisfaction with our telephone-implemented SDM approach to PTSD treatment decisions. However, Veterans reported reluctance to initiate conversations with providers about their WEB-ED screening results and treatment preferences, and questioned whether their VA providers knew about SDM.

In response to those findings, the first phase of our present study sought to understand provider and stakeholder guidance on how to successfully integrate online and SDM interfaces into providers’ daily practice and Veterans’ care. We also sought feedback on SDM training materials.

Provider perspectives. Two research team members conducted 40 semi-structured interviews with administrators and transition patient advocates (N=15); and primary care/MH providers (N=25) at five VA healthcare centers in the VA Women’s Health Practice-Based Research Network (Seattle, Washington; Minneapolis, Minnesota; Albany, New York; Temple, Texas; and Miami, Florida). Key findings included:

  • Providers expressed concern that high-risk post-9/11 Veterans have complex care needs but encounter a system that fails to address each individual Veteran’s goals for MH care.
  •  Providers agreed that SDM can be used to individualize services to the needs/preferences of each Veteran.
  • Providers reported concerns that SDM would take too much time or that they are doing it already, and many confused SDM with motivational interviewing.
  • Primary care providers are accustomed to utilizing decision aids for medical diagnoses. However, both primary care and MH providers said they do not have such aids readily available for MH conditions, indicating they need brief decision aids that can be integrated into their busy clinics.
  • Providers acknowledged a preference for brief training videos for educating both providers and Veterans about SDM, and offered detailed feedback on our SDM videos.
  • Nearly all providers said they welcome informed patients who have reviewed decision aids prior to appointments.

Veteran perspectives. We also sought Veteran input by presenting our products and research goals to men and women Veterans in a VA consumer group (N=9). These Veterans reported:

  • A desire to be liked and respected by their providers.
  • A reluctance to “tell my doctor what to do,” despite positively endorsing the idea of being an empowered care partner with their provider.
  • A common preference to avoid MH care and associated stigma.
  • Awareness of Veteran peers who need MH care and who find VA difficult to access.
  • Interest in SDM training and knowing that their VA provider would be trained.
  • Emphatic preferences for animated SDM training videos, not lectures.

Collectively, these findings reconfirmed the need to support Veterans’ VA access through existing virtual platforms; and that SDM training and decision aids are needed, feasible, and welcomed. These findings guided development of processes and materials for our current implementation study phase. Specifically, we have:

  1. Developed one-page decision aids for PTSD, depression, and alcohol use disorder.
  2. Modified our WEB-ED interface to include questions and tailored educational modules responsive to current Veteran needs, e.g., suicide prevention, social determinants of health, and social isolation.
  3. Increased our effort to assist Veterans with online VA enrollment and support Veterans to share their MH screening results with their providers.
  4. Shortened our SDM training videos and made them available online for those in the intervention group.
  5. Added a provider training video demonstrating a clinical encounter with and without the use of SDM for a complex and acutely symptomatic woman Veteran.

We are following the subsequent care, experiences, and satisfaction of both Veterans and providers in the intervention group who have received these materials and support, as well as those in the comparison group who have received WEB-ED alone. We anticipate that our products can be readily implemented, are cost-effective and, with partner collaboration, can be successfully integrated into VA systems.

Anecdotally, the COVID-19 pandemic interrupted this research for several months. Both Veterans and providers have acknowledged overload and other negative impacts on their willingness to participate. However, many Veterans have expressed gratitude for research that addresses the MH needs of returning war Veterans and VA care linkage. Further, rapid and widespread adoption of telemedicine by VA leadership has demonstrated the benefit of virtual care and has normalized this health services delivery option.

Research Team: Anne G. Sadler, PhD, RN, James C. Torner, PhD, Michelle A. Mengeling, PhD, and Brian L Cook, DO, all with the Iowa City VA Healthcare System; Jeffrey Smith, Central Arkansas Veterans Healthcare System; Alison B. Hamilton, PhD, MPH, VA Greater Los Angeles Healthcare System

  1. “The American Veteran Experience and the Post-9/11 Generation,” Pew Research Center, Washington, DC (September 10, 2019).
  2. Maguen S, et al. “Factors Associated with Completing Evidence-based Psychotherapy for PTSD Among Veterans in a National Healthcare System,” Psychiatry Research 2019. 04; 274:112-28. 
  3. Wyatt, KD, et al. “Genders of Patients and Clinicians and their Effect on Shared Decision Making: a Participant-level Meta-analysis,” BMC Medical Informatics and Decision Making 2014 Sep 2;14:81.
  4. Korb L, Toofan K. “The Challenges Facing the Department of Veterans Affairs in 2021,” American Progress (2021).

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