VA Mental Health
Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access Gao ID: GAO-12-12 October 14, 2011In fiscal year 2010, the Department of Veterans Affairs (VA) provided health care to about 5.2 million veterans. Recent legislation has increased many Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans' priority for accessing VA's health care, and concerns have been raised about the extent to which VA is providing mental health care to eligible veterans of all eras. There also are concerns that barriers may hinder some veterans from accessing needed mental health care. GAO was asked to provide information on veterans who receive mental health care from VA. In this report, GAO provides information on (1) how many veterans received mental health care from VA from fiscal years 2006 through 2010, (2) key barriers that may hinder veterans from accessing mental health care from VA, and (3) VA efforts to increase veterans' access to VA mental health care. GAO obtained data from VA's Northeast Program Evaluation Center (NEPEC) on the number of veterans who received mental health care from VA. The number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. GAO also reviewed literature published from 2006 to 2011, reviewed VA documents, and interviewed officials from VA and veterans service organizations (VSO).
Over the 5-year period from fiscal years 2006 through 2010, about 2.1 million unique veterans received mental health care from VA. Each year the number of veterans receiving mental health care increased, from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year 2010. OEF/OIF veterans accounted for an increasing proportion of veterans receiving care during this period. The key barriers identified from the literature that may hinder veterans from accessing mental health care from VA, which were corroborated through interviews, are stigma, lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about VA's care, such as concerns that VA's services are primarily for older veterans. Many of these barriers are not necessarily unique to veterans accessing mental health care from VA, but may affect anyone accessing mental health care from any provider. Veterans may be affected by barriers differently based on demographic factors, such as age and gender. For example, younger OEF/OIF veterans and female veterans may perceive that VA's services are primarily for someone else, such as older veterans or male veterans. VA has implemented several efforts to increase veterans' access to mental health care, including integrating mental health care into primary care. VA also has implemented efforts to educate veterans, their families, health care providers, and other community stakeholders about mental health conditions and VA's mental health care. According to VA officials, these efforts help get veterans into care by reducing, and in some cases eliminating, the barriers that may hinder them from accessing care. GAO provided a draft of this report to VA for comment. In its response, VA provided technical comments, which were incorporated as appropriate.
GAO-12-12, VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access
This is the accessible text file for GAO report number GAO-12-12
entitled 'VA Mental Health: Number of Veterans Receiving Care,
Barriers Faced, and Efforts to Increase Access' which was released on
October 14, 2011.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as
part of a longer term project to improve GAO products' accessibility.
Every attempt has been made to maintain the structural and data
integrity of the original printed product. Accessibility features,
such as text descriptions of tables, consecutively numbered footnotes
placed at the end of the file, and the text of agency comment letters,
are provided but may not exactly duplicate the presentation or format
of the printed version. The portable document format (PDF) file is an
exact electronic replica of the printed version. We welcome your
feedback. Please E-mail your comments regarding the contents or
accessibility features of this document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
United States Government Accountability Office:
GAO:
Report to the Ranking Member, Committee on Veterans' Affairs, House of
Representatives:
October 2011:
VA Mental Health:
Number of Veterans Receiving Care, Barriers Faced, and Efforts to
Increase Access:
GAO-12-12:
GAO Highlights:
Highlights of GAO-12-12, a report to the Ranking Member, Committee on
Veterans‘ Affairs, House of Representatives.
Why GAO Did This Study:
In fiscal year 2010, the Department of Veterans Affairs (VA) provided
health care to about 5.2 million veterans. Recent legislation has
increased many Operations Enduring Freedom (OEF) and Iraqi Freedom
(OIF) veterans‘ priority for accessing VA‘s health care, and concerns
have been raised about the extent to which VA is providing mental
health care to eligible veterans of all eras. There also are concerns
that barriers may hinder some veterans from accessing needed mental
health care.
GAO was asked to provide information on veterans who receive mental
health care from VA. In this report, GAO provides information on (1)
how many veterans received mental health care from VA from fiscal
years 2006 through 2010, (2) key barriers that may hinder veterans
from accessing mental health care from VA, and (3) VA efforts to
increase veterans‘ access to VA mental health care. GAO obtained data
from VA‘s Northeast Program Evaluation Center (NEPEC) on the number of
veterans who received mental health care from VA. The number of
veterans represents a unique count of veterans; veterans were counted
only once, even if they received care multiple times during a fiscal
year or across the 5-year period. GAO also reviewed literature
published from 2006 to 2011, reviewed VA documents, and interviewed
officials from VA and veterans service organizations (VSO).
What GAO Found:
Over the 5-year period from fiscal years 2006 through 2010, about 2.1
million unique veterans received mental health care from VA. (See
figure.) Each year the number of veterans receiving mental health care
increased, from about 900,000 in fiscal year 2006 to about 1.2 million
in fiscal year 2010. OEF/OIF veterans accounted for an increasing
proportion of veterans receiving care during this period.
Figure: Number of Veterans Who Received Mental Health Care from VA,
Fiscal Years 2006 through 2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2006;
OEF/OIF: 34,559;
All other veterans: 862,570;
Total: 897,129.
Year: 2007;
OEF/OIF: 55,343;
All other veterans: 897,319;
Total: 952,662.
Year: 2008;
OEF/OIF: 83,947;
All other veterans: 944,045;
Total: 1,027,992.
Year: 2009;
OEF/OIF: 113,277;
All other veterans: 1,005,370;
Total: 1,118,646.
Year: 2010;
OEF/OIF: 139,167;
All other veterans: 1,064,360;
Total: 1,203,530.
Number of unique veterans, fiscal years 2006 through 2010:
OEF/OIF: 213,781;
All other veterans: 1,846,430;
Total: 2,060,211.
Source: GAO analysis of NEPEC data.
[End of figure]
The key barriers identified from the literature that may hinder
veterans from accessing mental health care from VA, which were
corroborated through interviews, are stigma, lack of understanding or
awareness of mental health care, logistical challenges to accessing
mental health care, and concerns about VA‘s care, such as concerns
that VA‘s services are primarily for older veterans. Many of these
barriers are not necessarily unique to veterans accessing mental
health care from VA, but may affect anyone accessing mental health
care from any provider. Veterans may be affected by barriers
differently based on demographic factors, such as age and gender. For
example, younger OEF/OIF veterans and female veterans may perceive
that VA‘s services are primarily for someone else, such as older
veterans or male veterans.
VA has implemented several efforts to increase veterans‘ access to
mental health care, including integrating mental health care into
primary care. VA also has implemented efforts to educate veterans,
their families, health care providers, and other community
stakeholders about mental health conditions and VA‘s mental health
care. According to VA officials, these efforts help get veterans into
care by reducing, and in some cases eliminating, the barriers that may
hinder them from accessing care.
GAO provided a draft of this report to VA for comment. In its
response, VA provided technical comments, which were incorporated as
appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-12-12] or key
components. For more information, contact Debra A. Draper at (202) 512-
7114 or draperd@gao.gov.
[End of section]
Contents:
Letter:
Background:
More Than 2 Million Unique Veterans Received Mental Health Care from
VA over the 5-Year Period from Fiscal Years 2006 through 2010:
Stigma, Lack of Understanding of Mental Health, Logistical Challenges,
and Concerns about VA May Hinder Veterans from Accessing Care:
VA Has Implemented Several Efforts to Increase Veterans' Access to
Mental Health Care:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Number of Veterans Receiving Mental Health Care from VA
by Setting and Era, Fiscal Years 2006 through 2010:
Appendix III: Number of Veterans Receiving Care from VA by Gender and
Era, Fiscal Years 2006 through 2010:
Appendix IV: Comments from the Department of Veterans Affairs:
Appendix V: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Veteran Eras of Military Service:
Table 2: Five Most Common Diagnostic Categories for Veterans Receiving
Mental Health Care from VA, Fiscal Year 2010:
Table 3: Key Barriers That May Hinder Veterans from Accessing Mental
Health Care from VA:
Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans
about VA Mental Health Care:
Figures:
Figure 1: Number of Veterans Who Received Mental Health Care from VA,
Fiscal Years 2006 through 2010:
Figure 2: Percentage of Veterans Receiving Mental Health Care from VA
as a Percentage of the Total Number of Veterans Receiving Any Health
Care from VA over the 5-Year Period from Fiscal Years 2006 through
2010:
Abbreviations:
NEPEC: Northeast Program Evaluation Center:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
PTSD: post-traumatic stress disorder:
VA: Department of Veterans Affairs:
VHA: Veterans Health Administration:
VSO: veterans service organization:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
October 14, 2011:
The Honorable Bob Filner:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Filner:
In fiscal year 2010, the Department of Veterans Affairs (VA), which
operates one of the largest health care delivery systems in the
nation, provided health care to about 5.2 million veterans. VA
provides care to eligible veterans from all eras of service,[Footnote
1] including World War II, Korea, Vietnam, Gulf War, and most
recently, military operations in Afghanistan and Iraq--Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),
respectively.[Footnote 2] Recent legislation has increased many
OEF/OIF veterans' priority for accessing VA's health care.[Footnote 3]
Given the increased focus on OEF/OIF veterans, concerns have been
raised by some, including veterans service organizations (VSO), about
the extent to which VA is providing mental health care to eligible
veterans of all eras. We have previously reported that VA has
experienced an increased demand for its mental health care--including
care for conditions such as post-traumatic stress disorder (PTSD),
depression, and substance abuse.[Footnote 4] Additionally, there are
concerns that barriers--such as distance from a VA treatment facility
or stigma associated with mental health care--may hinder some veterans
from accessing needed mental health care. When veterans do not receive
the mental health care they need, wide-ranging and negative
implications for their physical, work, family, and social functioning
can result. For example, mental health conditions can lead to
increased risks of unemployment, homelessness, and suicide.
You expressed interest in obtaining information on veterans who
receive mental health care from VA. In this report, we provide
information on (1) how many veterans received mental health care from
VA from fiscal years 2006 through 2010, (2) key barriers that may
hinder veterans from accessing mental health care from VA, and (3)
efforts VA has implemented to increase veterans' access to VA mental
health care.
To perform our work, we obtained data from VA's Northeast Program
Evaluation Center (NEPEC)[Footnote 5] on the number of veterans who
received mental health care from VA from fiscal years 2006 through
2010. For the purposes of this report, we defined mental health care
as the care provided to veterans with mental health conditions. A
veteran was counted as having a mental health condition if, at any
point in the fiscal year, his or her medical record indicated at least
two outpatient encounters with any mental health diagnosis (with at
least one encounter having a primary mental health diagnosis) or an
inpatient stay in which the veteran had any mental health diagnosis.
[Footnote 6] Additionally, the number of veterans represents a unique
count of veterans; veterans were counted only once, even if they
received care multiple times during a fiscal year or across the 5-year
period. To assess the reliability of the data NEPEC provided us, we
discussed with NEPEC officials their methodology and data collection
techniques for obtaining and using the data, the data checks that
NEPEC performed, as well as any limitations officials identified in
the data. In addition, we did our own review of NEPEC's programming
and methodological approaches using data file documentation, code book
and file dictionaries, and programming logs NEPEC officials provided.
We determined that the data were sufficiently reliable for our
purposes.
To identify the key barriers that may hinder veterans from accessing
mental health care from VA, we searched research databases, such as
MEDLINE and PsycINFO, that included peer-reviewed journals to capture
relevant literature published on or between January 1, 2006, and March
3, 2011. We also reviewed relevant literature that was cited in
articles from our original search or recommended to us during the
course of our research. To corroborate the barriers we identified in
the literature, we interviewed officials from (1) several VA offices--
the Office of Mental Health Services, the Office of Mental Health
Operations, the Office of Rural Health, the Office of Research and
Development, and Readjustment Counseling Services; (2) several mental
health-focused VA research centers--the Mental Illness Research,
Education and Clinical Center, the Serious Mental Illness Treatment
Resource and Evaluation Center, the Center for Chronic Disease
Outcomes Research, and the National Center for PTSD; (3) several VA
mental health and primary care providers;[Footnote 7] and (4) a
judgmental sample of VSOs.[Footnote 8] We defined "key barriers" as
those that the majority of VA and VSO officials we interviewed said
could have the greatest impact on veterans. As a result, we do not
report an exhaustive list of all potential barriers that veterans may
face.
Finally, to identify the efforts VA has implemented to increase
veterans' access to VA mental health care, we reviewed documentation
and interviewed officials from the same VA offices and mental health-
focused VA research centers that we interviewed to corroborate the
barriers for veterans. We compiled a list of efforts based on those
that had been implemented and were national in scope. As a result, we
do not report an exhaustive list of all VA efforts. In addition, we
did not assess the extent to which VA has fully implemented these
efforts or their effectiveness, including the extent to which the
efforts eliminate or diminish barriers that may hinder veterans from
accessing mental health care.
We conducted our work from November 2010 to October 2011 in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence
to meet our stated objectives and to discuss any limitations in our
work. We believe that the information and data obtained, and the
analysis conducted, provide a reasonable basis for any findings and
conclusions. See appendix I for a complete description of our scope
and methodology.
Background:
VA manages access to services in relation to available resources
through a priority system established by law.[Footnote 9] The order of
priorities is generally based on service-connected disability, income,
or other special status, such as having been a prisoner of
war.[Footnote 10] Additionally, Congress has stipulated that certain
combat veterans discharged from active duty on or after January 2003
are eligible for priority enrollment.
VA Mental Health Care:
VA provides mental health care--for conditions such as PTSD,
depression, and substance abuse disorders--in a variety of facilities,
including medical centers, community-based outpatient clinics, and
rehabilitation treatment programs. These facilities may include both
specialty mental health care settings and other settings. Specialty
mental health settings, including mental health clinics, primarily
provide mental health services. Other settings may provide mental
health services but focus primarily on other types of care, such as
primary care.
VA also provides counseling services that focus on mental health
issues through its Vet Centers, a nationwide system of community-based
centers that VA established separately from other facilities. The
counseling services provided by Vet Centers differ from the mental
health services provided by other VA facilities in that they focus on
counseling to assist combat veterans in readjusting from wartime
military service to civilian life but do not diagnose veterans' mental
health conditions. Veterans needing more acute care--for example,
veterans with multiple mental health conditions, such as severe PTSD
and depression, or those who pose a risk of harm to themselves or
others--are often referred to VA medical centers for diagnosis and
treatment.
Veteran Eras of Military Service:
VA groups veterans by dates--or era--of their military service based
on provisions in federal law.[Footnote 11] (See table 1.)
Table 1: Veteran Eras of Military Service:
Era of military service: World War II;
Years: Dec. 7, 1941 - Dec. 31, 1946;
Estimated number of living veterans, as of September 30, 2011[A]: 1.7
million.
Era of military service: Korea;
Years: June 27, 1950 - Jan. 31, 1955;
Estimated number of living veterans, as of September 30, 2011[A]: 2.3
million.
Era of military service: Vietnam;
Years: Feb. 28, 1961 - May 7, 1975;
Estimated number of living veterans, as of September 30, 2011[A]: 7.4
million.
Era of military service: Persian Gulf War[B];
Years: Aug. 2, 1990 - present;
Estimated number of living veterans, as of September 30, 2011[A]: 3.3
million.
Era of military service: OEF/OIF[B];
Years: October 2001 - present;
Estimated number of living veterans, as of September 30, 2011[A]: 2.6
million.
Era of military service: Peacetime;
Years: Any dates outside of specified eras of service;
Estimated number of living veterans, as of September 30, 2011[A]: 5.7
million.
Source: GAO analysis of 38 U.S.C. § 101 and VA VetPop2007 data.
[A] Estimates are from VetPop2007, a VA model for estimating the
number of living veterans using U.S. Census Bureau and Department of
Defense data. There were an estimated 22.2 million total living
veterans as of September 30, 2011. This total is less than the sum of
the number of living veterans from the individual eras of military
service because some veterans served in multiple eras.
[B] OEF/OIF is a set of military operations that is considered part of
the Persian Gulf War. Although most veterans who have served since
2001 served in OEF/OIF, there are some veterans who served in the
Persian Gulf War after 2001 who did not serve in OEF/OIF. For the
purposes of this report, we consider OEF/OIF to be an era of military
service, and we use the time frame corresponding to the beginning of
OEF, the operation with the earliest start date. In addition, we
include veterans of Operation New Dawn--the name given to combat in
Afghanistan after September 2010--in the OEF/OIF era of military
service. Finally, for the estimated number of living veterans,
veterans who served in both the Persian Gulf War era and the OEF/OIF
era are counted in the OEF/OIF era.
[End of table]
VA estimates that as of September 30, 2011, there were approximately
22.2 million living veterans. OEF/OIF veterans represented
approximately 12 percent (2.6 million) of that total.
More Than 2 Million Unique Veterans Received Mental Health Care from
VA over the 5-Year Period from Fiscal Years 2006 through 2010:
Over the 5-year period from fiscal years 2006 through 2010, about 2.1
million unique veterans received mental health care from VA.[Footnote
12] Each year the number of veterans receiving care increased--from
about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year
2010. (See figure 1.) VA provided this mental health care to veterans
in both specialty mental health care and other settings, such as
primary care clinics staffed with mental health providers.[Footnote
13] (See appendix II for information on the number of veterans
receiving mental health care in specialty mental health care and other
settings.)
Figure 1: Number of Veterans Who Received Mental Health Care from VA,
Fiscal Years 2006 through 2010:
[Refer to PDF for image: stacked vertical bar graph]
Year: 2006;
OEF/OIF: 34,559 (4%);
All other veterans: 862,570 (96%);
Total: 897,129.
Year: 2007;
OEF/OIF: 55,343 (6%);
All other veterans: 897,319 (94%);
Total: 952,662.
Year: 2008;
OEF/OIF: 83,947 (8%);
All other veterans: 944,045 (92%);
Total: 1,027,992.
Year: 2009;
OEF/OIF: 113,277 (10%);
All other veterans: 1,005,370 (90%);
Total: 1,118,646.
Year: 2010;
OEF/OIF: 139,167 (12%);
All other veterans: 1,064,360 (88%);
Total: 1,203,530.
Number of unique veterans, fiscal years 2006 through 2010:
OEF/OIF: 213,781 (10%);
All other veterans: 1,846,430 (90%);
Total: 2,060,211.
Source: GAO analysis of NEPEC data.
Notes: The number of veterans represents a unique count of veterans;
veterans were counted only once, even if they received care multiple
times during a fiscal year or across the 5-year period.
We defined mental health care as the care provided to veterans with
mental health conditions. A veteran was counted as having a mental
health condition if, at any point in the fiscal year, his or her
medical record indicated at least two outpatient encounters with any
mental health diagnosis (with at least one encounter having a primary
mental health diagnosis) or an inpatient stay in which the veteran had
any mental health diagnosis.
[End of figure]
Although the number of veterans receiving mental health care from VA
increased for both OEF/OIF veterans and veterans of other eras of
service, as shown in figure 1, OEF/OIF veterans accounted for an
increasing proportion of the veterans receiving care. Specifically,
the proportion of OEF/OIF veterans receiving mental health care from
VA out of the total number of veterans receiving mental health care
increased from 4 percent in fiscal year 2006 to 12 percent in fiscal
year 2010. Nonetheless, veterans from earlier eras, such as Vietnam,
accounted for approximately 90 percent of the 2.1 million veterans
receiving care at VA over the 5-year period from fiscal years 2006
through 2010, although the proportion decreased from 96 percent in
fiscal year 2006 to 88 percent in fiscal year 2010. VA officials
indicated that the increasing proportion of OEF/OIF veterans receiving
mental health care is not unexpected because of the nature of OEF/OIF
veterans' military service--veterans of this era typically had intense
and frequent deployments. In addition, according to VA officials, VA
has made changes in its mental health screening protocols that may
have resulted in more mental health conditions being diagnosed among
veterans entering the VA system. For example, VA requires veterans
treated in primary care settings to be screened for mental health
conditions such as PTSD, depression, substance abuse disorders, as
well as a history of military sexual trauma.
Additionally, the 2.1 million veterans receiving mental health care
from VA accounted for almost a third of the 7.2 million total unique
veterans receiving any type of health care from VA over the 5-year
period from fiscal years 2006 through 2010.[Footnote 14] Specifically,
38 percent of all OEF/OIF veterans and 28 percent of all other
veterans receiving any health care during this time period received
mental health care. (See figure 2.)
Figure 2: Percentage of Veterans Receiving Mental Health Care from VA
as a Percentage of the Total Number of Veterans Receiving Any Health
Care from VA over the 5-Year Period from Fiscal Years 2006 through
2010:
[Refer to PDF for image: pie-chart and subcharts]
29% of all veterans who received care from VA received mental health
care:
* 2,060,211 veterans received mental health care.
38% of all OEF/OIF veterans who received care from VA received mental
health care:
* 213,781 OEF/OIF veterans received mental health care;
* 346,555 OEF/OIF veterans did not receive mental health care.
28% of all other veterans who received care from VA received mental
health care:
* 1,846,430 other veterans received mental health care;
* 4,746,552 other veterans did not receive mental health care.
Source: GAO analysis of NEPEC data.
Notes: The number of veterans represents a unique count of veterans;
veterans were counted only once, even if they received care multiple
times across the 5-year period.
We defined mental health care as the care provided to veterans with
mental health conditions. A veteran was counted as having a mental
health condition if, at any point in the fiscal year, his or her
medical record indicated at least two outpatient encounters with any
mental health diagnosis (with at least one encounter having a primary
mental health diagnosis) or an inpatient stay in which the veteran had
any mental health diagnosis.
[End of figure]
The five most common diagnostic categories for veterans receiving
mental health care from VA in fiscal year 2010 were adjustment
reaction, depressive disorder, episodic mood disorder, neurotic
disorder, and substance abuse disorder. (See table 2.) Within each
diagnostic category, there are specific mental health diagnoses; for
example, PTSD is one of the diagnoses within the adjustment reaction
category. Although veterans of all eras had similar diagnoses, the
likelihood of experiencing diagnoses in any one category varied by
era. Specifically, almost twice as many OEF/OIF veterans had diagnoses
within the adjustment reaction category compared to the next most
common diagnostic category--depressive disorder. In comparison, for
veterans of all other eras, depressive disorder was the most common
diagnostic category, but it was closely followed by adjustment
reaction. According to VA officials, the higher relative incidence of
adjustment reaction (including PTSD) among OEF/OIF veterans may be due
to many factors, including the length and frequency of their
deployments and a better understanding of how to identify and diagnose
PTSD among mental health care providers.
Table 2: Five Most Common Diagnostic Categories for Veterans Receiving
Mental Health Care from VA, Fiscal Year 2010:
Diagnostic category[A]: Adjustment reaction;
Description: A group of mental health diagnoses, including PTSD,
characterized by an emotional and behavioral reaction that develops
within 3 months of a life stress, and which is stronger or greater
than what would be expected for the type of event that occurred;
Number of OEF/OIF veterans: 109,850 (includes 96,916 with PTSD
diagnosis);
Number of all other veterans: 465,448 (includes 383,832 with PTSD
diagnosis);
Total number of veterans: 575,298 (includes 480,748 with PTSD
diagnosis).
Diagnostic category[A]: Depressive disorder;
Description: A group of mental health diagnoses that reflect a sad or
irritable mood exceeding normal sadness or grief;
Number of OEF/OIF veterans: 57,639;
Number of all other veterans: 477,029;
Total number of veterans: 534,668.
Diagnostic category[A]: Episodic mood disorder;
Description: A group of mental health diagnoses best recognized by
depression or mania that can have potentially severe health
consequences;
Number of OEF/OIF veterans: 38,715;
Number of all other veterans: 352,651;
Total number of veterans: 391,366.
Diagnostic category[A]: Neurotic disorder;
Description: A group of mental health diagnoses characterized by
symptoms such as phobias, obsessive thoughts, and compulsive actions,
or by losses of specific bodily functions;
Number of OEF/OIF veterans: 45,252;
Number of all other veterans: 343,562;
Total number of veterans: 388,814.
Diagnostic category[A]: Substance abuse disorder;
Description: A group of mental health diagnoses arising from the abuse
of alcohol or drugs;
Number of OEF/OIF veterans: 36,797;
Number of all other veterans: 326,417;
Total number of veterans: 363,214.
Source: GAO analysis of NEPEC data.
Notes: Veterans could have more than one diagnosis; therefore the
numbers do not add to the 1.2 million veterans receiving mental health
care from VA in fiscal year 2010.
We defined mental health care as the care provided to veterans with
mental health conditions. A veteran was counted as having a mental
health condition if, at any point in the fiscal year, his or her
medical record indicated at least two outpatient encounters with any
mental health diagnosis (with at least one encounter having a primary
mental health diagnosis) or an inpatient stay in which the veteran had
any mental health diagnosis.
[A] Diagnostic categories are based on International Classification of
Diseases, Ninth Revision, codes.
[End of table]
Stigma, Lack of Understanding of Mental Health, Logistical Challenges,
and Concerns about VA May Hinder Veterans from Accessing Care:
The key barriers we identified from the literature that may hinder
veterans from accessing mental health care from VA, which were
corroborated through interviews with VA and VSO officials, are stigma,
lack of understanding or awareness of mental health care, logistical
challenges to accessing mental health care, and concerns about VA's
care. (See table 3 for a description of each of these key barriers.)
For example, stigma--negative personal or societal beliefs about
mental health conditions or mental health care--may discourage
veterans from accessing care. According to VA and VSO officials we
spoke with, some veterans may have concerns that if colleagues or
employers find out they are receiving mental health care, their
careers will be negatively affected.
Table 3: Key Barriers That May Hinder Veterans from Accessing Mental
Health Care from VA:
Key barrier: Stigma and beliefs about mental health care;
Description: Veterans may have:
* Perceptions that as a result of accessing mental health care they
will be viewed negatively by others, such as peers or employers. For
example, veterans may feel that by accessing mental health care they
will be perceived as weak or having lost control;
* Confidentiality and privacy concerns. For example, veterans may fear
that accessing mental health care would harm their current or future
careers;
* Values and priorities--such as family, work, or school commitments--
that conflict with accessing treatment;
* Perceptions that treatment may bring up painful or trauma-related
feelings and memories they wish to avoid;
* Perceptions that social networks--such as families or military
communities--have values and priorities that conflict with accessing
treatment.
Key barrier: Lack of understanding or awareness of mental health care;
Description: Veterans may have:
* Lack of knowledge about VA's mental health services;
* Lack of awareness or understanding of their mental health
conditions. For example, veterans may have difficulty distinguishing
their mental health symptoms from the symptoms they are experiencing
as a result of physical injuries;
* Perception that mental health treatment is only for people with
extreme mental health conditions. Veterans may feel that their mental
health conditions are not severe enough to warrant treatment or that
resources should go to those most in need;
* Perception that mental health treatment is unnecessary or unhelpful.
Key barrier: Logistical challenges to accessing mental health care;
Description: Veterans may have:
* Difficulty scheduling appointments. For example, veterans may have
challenges coordinating multiple appointments or perceptions that
there is limited availability of appointments;
* Distance and transportation challenges. For example, veterans who
live in rural areas may have to travel long distances to obtain
treatment;
* Family challenges, such as arranging child care or spousal support;
* Other logistical challenges, such as time constraints or physical or
mental impairments that may limit the opportunity to obtain treatment.
Key barrier: Concerns about VA's health care;
Description: Veterans may have:
* Perceptions that VA's programs and service options are not adequate
to meet their needs, such as not having enough providers or not having
enough time during appointments to discuss both health and mental
health care needs;
* Perceptions that VA's services are not uniform across all provider
locations (e.g., certain programs are not available at all VA medical
centers);
* Perceptions that VA's services are primarily or only for someone
else, such as older veterans, war veterans, male veterans, or veterans
with severe disabilities;
* Perceptions that VA does not provide quality care to veterans, does
not treat veterans well, or is not welcoming to particular groups of
veterans (e.g., women);
* Reluctance to talk with a VA mental health provider. For example,
veterans may distrust mental health providers or fear that providers
will not understand or believe them;
* Negative perceptions about the government or VA.
Source: GAO's review of relevant literature published on or between
January 1, 2006, and March 3, 2011, and corroborated by interviews
with VA and VSO officials.
[End of table]
Many of these barriers are not necessarily unique to veterans
accessing mental health care from VA, but may affect anyone accessing
mental health care from any provider. According to the Substance Abuse
and Mental Health Services Administration's 2008 National Survey on
Drug Use and Health, approximately 5 million adults who reported an
unmet need for mental health care reported similar barriers.[Footnote
15] In particular, survey participants cited the following as
barriers: a belief that the problem could be handled without care, not
knowing where to go for care, and not having the time to go for care.
Additionally, according to the literature we reviewed and VA and VSO
officials we interviewed, some of these key barriers may affect
veterans from different demographic groups differently. For example,
veterans may be affected by barriers differently based on age, gender,
Reservist or National Guard status, or rural location.
* Age: OEF/OIF veterans, who are generally younger than other
veterans, may have concerns about VA's health care system because they
perceive that primarily older veterans, such as those who served in
Vietnam, go to VA for care.[Footnote 16] Additionally, some younger
veterans may have multiple personal priorities--such as family,
school, or work commitments--that make accessing care a lower
priority. Older veterans may have different reasons for not accessing
mental health care. For example, stigma and beliefs about mental
health care may hinder veterans who served in World War II and Korea
from accessing care because they grew up during a time when mental
health conditions generally were not recognized and accepted.
According to a national survey of veterans, as of March 2010, more
than 60 percent of all veterans were 55 years of age or older.
[Footnote 17]
* Gender: Female veterans may perceive some barriers to accessing
mental health care differently than male veterans.[Footnote 18] For
example, some female veterans may not identify themselves as veterans
if they did not serve in combat and, as a result, may not access care
from VA. In addition, female veterans may have concerns about VA's
health care system because they perceive that the care is male
oriented, and therefore, VA is not a place where they feel comfortable
receiving mental health care. Female veterans are a growing
demographic in the veteran population--from fiscal year 2010 to fiscal
year 2020, the percentage of female veterans in the total veteran
population is projected to increase from approximately 8 percent to
approximately 10 percent, according to VA's National Center for
Veterans Analysis and Statistics.[Footnote 19] (See appendix III for
data on the gender of veterans receiving care from VA.)
* Reservist or National Guard status: Reservists and National Guard
members may be particularly hindered by privacy and confidentiality
concerns because they worry that accessing mental health care might
have a negative impact on their military or civilian careers.[Footnote
20] For example, Reservists and National Guard members may not access
mental health care because of concerns about military leaders
obtaining access to their VA health records and these leaders treating
them differently or limiting their career development because they
accessed mental health care. As of November 2010, Reservists and
National Guard members made up nearly 50 percent of the OEF/OIF
veteran population, according to VA data.
* Rural location: Veterans who live in rural locations may be
particularly hindered by access challenges because of the distance
they may have to travel to obtain mental health care.[Footnote 21]
According to the Office of Rural Health, veterans in rural areas are
less likely to access mental health services than veterans in urban
areas in part because they must travel greater distances to receive
care and have more limited public transportation options. According to
VA's Office of Rural Health, as of fiscal year 2010, veterans living
in rural areas made up 41 percent of the veterans enrolled in VA's
health care system.
VA Has Implemented Several Efforts to Increase Veterans' Access to
Mental Health Care:
VA has expanded options to increase veterans' access to mental health
care and implemented education efforts to help connect veterans with
care, according to VA officials.
VA Has Expanded Options to Increase Veterans' Access to Mental Health
Care:
VA has begun integrating mental health care into its primary care
settings. Specifically, VA now requires its primary care clinics to
conduct mental health screenings and has placed mental health care
providers in primary care settings. For example, VA requires veterans
treated in primary care settings to be screened for PTSD, depression,
substance abuse disorders, and history of military sexual trauma.
[Footnote 22] Further, in 2008, VA began requiring primary care
clinics that serve more than 1,500 veterans annually to have mental
health providers available on-site, able to serve veterans.[Footnote
23] Historically, veterans were more limited in the ways they could
access VA's mental health services. For example, some veterans could
receive mental health care only if they went to specialty VA mental
health facilities, such as mental health clinics. According to VA,
from fiscal years 2008 through 2010, the number of unique patients
receiving mental health care in a primary care setting doubled.
Several VA officials who work in primary care clinics that have
integrated primary and mental health care told us that this
integration is critical for lowering the stigma of receiving mental
health care and for creating an environment of collaboration among
providers for discussing veterans' needs and treatment options.
VA also has continued to increase the number of its Vet Centers, which
provide confidential and free counseling services to address mental
health issues. From fiscal year 2008 to August 2011, VA increased the
number of Vet Centers from 232 to 292 and, according to VA, plans to
open another 8 before the end of 2011. VA also has expanded the
availability of Vet Center services through the use of approximately
70 Mobile Vet Centers--specially equipped vehicles that help bring Vet
Center counseling services to more veterans, particularly those in
rural areas. Vet Centers are often the first point of contact within
VA for veterans and, according to VA and VSO officials, can help
veterans overcome barriers to accessing mental health care. For
example, many Vet Center counselors have firsthand combat experience,
which, according to VA, helps them relate to veterans and reduce the
stigma of mental health care that veterans may experience.
Additionally, VA has expanded its use of call centers to help connect
veterans with counseling services. VA call centers are telephone-based
systems through which veterans can access free, confidential
counseling services. VA officials said that the call centers are an
effective way to reach veterans because discussions with call center
staff, many of whom are also veterans, may help callers assess whether
they could benefit from mental health care. One call center VA
operates, the Veterans Crisis Line, allows veterans and their families
to call to receive multiple services, including suicide prevention
services, 24 hours a day, 7 days a week.[Footnote 24] According to VA
officials, since the Veterans Crisis Line became operational in 2007,
it has received more than 400,000 calls and referred approximately
55,000 veterans to local VA suicide prevention coordinators for same-
day or next-day services. In addition to the Veterans Crisis Line, VA
officials told us that VA has call centers focused on specific
populations, such as combat veterans, homeless veterans, and family
members of veterans.
Moreover, VA has increased its mental health staff from about 14,000
in fiscal year 2006 to more than 21,000 in fiscal year 2011, according
to VA.[Footnote 25] VA also has expanded the availability of
telemental health services, which allow veterans to access mental
health care providers remotely through VA medical centers, community-
based outpatient clinics, and Mobile Vet Centers. Without telemental
health, according to VA, some veterans in rural areas would have to
drive as much as 5 hours to the nearest mental health provider,
potentially decreasing their access to mental health care. To increase
the availability of mental health appointments, as of 2007, VA
required its mental health clinics to begin providing "after hours"
treatment times, such as early morning, evening, or Saturday morning
treatment times, to better accommodate veterans' schedules, including
weekday school or work schedules. Additionally, as of 2007, VA has
required that all veterans with mental health referrals be contacted
within 24 hours to assess their needs; for nonemergency situations, VA
requires that veterans receive follow-up care within 14 days of their
referral.[Footnote 26]
VA Has Implemented Education Efforts to Help Connect Veterans with
Mental Health Care:
To help connect veterans with mental health care, VA has implemented
various efforts to educate veterans, veterans' families, health care
providers, and other community stakeholders about mental health
conditions and care. VA's efforts to help connect veterans with mental
health care include collaborations with the Department of Defense,
redesigned websites, and other technology-based education tools. VA
has collaborated with the Department of Defense to educate veterans
and active duty servicemembers returning home from deployments about
VA benefits, including mental health care, through activities such as
Yellow Ribbon Program events and postdeployment health reassessments.
[Footnote 27] According to VA officials, VA has redesigned some of its
key mental health websites--including its websites for the Office of
Mental Health Services and the National Center for PTSD--to raise
awareness of and provide convenient access to some of VA's mental
health services, such as its call centers and resources for locating
mental health providers. VA also has developed interactive technology-
based tools to help educate veterans about how to recognize the
symptoms of mental health conditions and connect with VA mental health
care, including web-based self-help applications, mobile phone
applications, and social media sites, such as Twitter and Facebook. In
addition, VA has developed tailored efforts to educate specific groups
of veterans, such as Native American veterans and veterans with
serious mental illness. (See table 4 for examples of VA efforts to
educate specific groups of veterans.)
Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans
about VA Mental Health Care:
Specific group of veterans: Native American veterans;
Description of VA efforts: Face-to-face outreach activities, including
visits with tribal councils. Trainings for VA staff about how to
conduct outreach that is culturally sensitive and focused specifically
on the needs of Native American veterans.
Specific group of veterans: Veterans with serious mental illness;
Description of VA efforts: Program to identify and reengage veterans
with serious mental illness, such as schizophrenia, who have
discontinued VA treatment.
Specific group of veterans: Homeless veterans;
Description of VA efforts: Educational outreach and interventions in
community locations, such as shelters and bus stations, to help
eligible homeless veterans access VA benefits and care. Regional Stand
Down events that provide information and services to homeless
veterans, including health screenings that help identify potential
mental health conditions and referrals to VA mental health care.
Specific group of veterans: Reservists and National Guard members;
Description of VA efforts: VA staff presentations about eligibility
for VA benefits, including mental health care, to Reservists and
National Guard members at military bases.
Specific group of veterans: Women veterans;
Description of VA efforts: Outreach to women using websites and
brochures describing VA's specialized mental health care for women,
such as women-only support groups to help women veterans who have
experienced military sexual trauma.[A]
Specific group of veterans: Student veterans;
Description of VA efforts: Outreach about VA's mental health services
on college and university campuses to veterans enrolled as students.
Source: GAO analysis of VA data.
[A] Military sexual trauma includes both sexual harassment and sexual
assault occurring during a servicemember's military career.
[End of table]
VA also has efforts to educate veterans' families about what veterans
may be experiencing and how to recognize the possible need for mental
health care, according to VA officials. For example, VA has a guide
for family members posted on its websites that describes common
reactions to being in war, warning signs that a veteran or
servicemember might need outside help, and where to go for help.
According to VA and VSO officials, veterans' families are often the
first to notice that the veteran is having mental health problems and
may be more successful in encouraging the veteran to seek care.
Additionally, VA has trainings to teach its primary care physicians
how to screen veterans for mental health conditions and have
discussions with veterans about what to expect during mental health
care. VA also has trainings for its providers covering topics such as
the assessment and treatment of PTSD or military sexual trauma.
According to VA, these types of trainings are important because
primary care physicians are often a first point of contact for
veterans who might benefit from VA mental health care. Additionally,
the trainings help educate mental health care providers about evidence-
based mental health practices, including issues regarding gender
differences and cultural competencies. For example, according to VA,
its National Center for PTSD offers web-based training intended to
enhance VA staff sensitivity to, and knowledge of, specific health
care needs affecting women veterans.[Footnote 28]
VA also has developed efforts to educate other community stakeholders,
including law enforcement personnel, chaplains, and employers, about
veterans' mental health conditions and VA mental health care. For
example, VA has a program that helps law enforcement personnel
identify veterans with mental health conditions and connect these
veterans to appropriate mental health treatment options. The
literature shows that some veterans' mental health conditions have
been found to increase their likelihood of entering or reentering the
criminal justice system.[Footnote 29] VA also has developed a series
of training conferences for chaplains and clergy to educate them to
recognize the symptoms of PTSD and other service-related mental health
conditions and to refer veterans to VA for care. According to VA,
training chaplains and clergy to recognize the symptoms of mental
health conditions is important because they are often a first point of
contact for veterans in need of assistance. To support employers who
may interact with veterans who have mental health conditions, VA has
developed a set of online resources, including information on
postdeployment mental health issues and information on mental health
care available through VA.
Agency Comments:
We provided a draft of this report to VA for comment. In its response,
which is reprinted in appendix IV, VA provided technical comments,
which we have incorporated as appropriate.
We are sending a copy of this report to the appropriate congressional
committees and the Secretary of Veterans Affairs. In addition, the
report is available at no charge on the GAO website at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-7114 or draperd@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made key contributions
to this report are listed in appendix V.
Sincerely yours,
Signed by:
Debra A. Draper:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To determine how many veterans received mental health care from the
Department of Veterans Affairs (VA) from fiscal years 2006 through
2010, we obtained data from VA's Northeast Program Evaluation Center
(NEPEC).[Footnote 30] NEPEC used VA's administrative data files, which
include inpatient and outpatient files, to generate counts of the
number of veterans who received mental health care. For the purposes
of this report, we defined mental health care as the care provided to
veterans with mental health conditions. A veteran was counted as
having a mental health condition if, at any point in the fiscal year,
his or her medical record indicated at least two outpatient encounters
with any mental health diagnosis (with at least one encounter having a
primary mental health diagnosis) or an inpatient stay in which the
veteran had any mental health diagnosis.[Footnote 31] Additionally,
the number of veterans represents a unique count of veterans; veterans
were counted only once, even if they received care multiple times
during a fiscal year or across the 5-year period. NEPEC also used VA
administrative data files to provide us with data on the total number
of veterans receiving any health care at VA--not just veterans
receiving mental health care. The number of veterans includes former
active duty servicemembers, including Reservists and National Guard
members.[Footnote 32]
NEPEC's data on the number of veterans receiving mental health care
included breakouts by specific demographic groups, such as era of
service; by the type of setting where care was provided; and by the
mental health diagnostic category. For the era of service data, NEPEC
identified two groups of veterans: (1) veterans serving in the
Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) era and (2)
veterans from all other eras--including peacetime. Because OEF/OIF
veterans are not tracked separately from Persian Gulf War veterans in
VA's administrative data files, NEPEC used Department of Defense data
to identify OEF/OIF veterans from the total population of veterans in
the VA data. The non-OEF/OIF veterans in the VA data comprised the
veterans from all other eras. Veterans who served in more than one era
of service were assigned based on their most recent era of service.
NEPEC also provided data on the settings where care was provided--that
is, specialty mental health care settings that primarily provided
mental health services or other settings that may have provided some
mental health services but focus primarily on other types of care,
such as primary care. Furthermore, NEPEC provided data on the top five
mental health diagnostic categories.[Footnote 33] The most common
diagnostic categories were determined based on the number of veterans
with diagnoses included in the diagnostic category, not the number of
visits associated with the diagnoses. To assess the reliability of the
data NEPEC provided us, we discussed with NEPEC officials their
methodology and data collection techniques used for obtaining and
using the data, the data checks that NEPEC performed, as well as any
limitations officials identified in the data. In addition, we did our
own review of NEPEC's programming and methodological approaches using
data file documentation, code book and file dictionaries, and
programming logs NEPEC officials provided. We determined that the data
were sufficiently reliable for our purposes. The data on veterans
receiving care from VA are not necessarily representative of the
entire veteran population because some veterans receive care outside
of VA.
To identify the key barriers that may hinder veterans from accessing
mental health care from VA, we searched research databases, such as
MEDLINE and PsycINFO, that included peer-reviewed journals to capture
relevant literature published on or between January 1, 2006, and March
3, 2011. We searched these databases for articles with key words in
their titles or subject terms related to veterans, mental health, and
barriers. In addition, we also reviewed relevant literature that was
cited in articles from our original search or recommended to us during
the course of our research. To corroborate the barriers identified in
the literature, we interviewed officials from (1) several VA offices--
the Office of Mental Health Services, the Office of Mental Health
Operations, the Office of Rural Health, the Office of Research and
Development, and Readjustment Counseling Services; (2) several mental
health-focused VA research centers--the Mental Illness Research,
Education and Clinical Center, the Serious Mental Illness Treatment
Resource and Evaluation Center, the Center for Chronic Disease
Outcomes Research, and the National Center for PTSD; (3) several VA
mental health and primary care providers;[Footnote 34] and (4) a
judgmental sample of veterans service organizations (VSO).[Footnote
35] We defined "key barriers" as those that the majority of VA and VSO
officials we interviewed said could have the greatest impact on
veterans. As a result, we do not report an exhaustive list of all
possible barriers that veterans may face.
To identify the efforts VA has implemented to increase veterans'
access to VA mental health care, we interviewed officials from the
same VA offices and mental health-focused VA research centers that we
interviewed to corroborate the barriers for veterans. We also reviewed
supporting VA documentation, such as program descriptions, policy
directives, and congressional budget justifications. We compiled a
list of efforts by focusing on the efforts that had been implemented
and were national in scope. As a result, the list of efforts we report
is not an exhaustive list of all VA efforts. In addition, we did not
assess the extent to which VA has fully implemented these efforts or
their effectiveness, including the extent to which the efforts
eliminate or diminish barriers that may hinder veterans from accessing
mental health care.
We conducted our work from November 2010 to October 2011 in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence
to meet our stated objectives and to discuss any limitations in our
work. We believe that the information and data obtained, and the
analysis conducted, provide a reasonable basis for any findings and
conclusions.
[End of section]
Appendix II: Number of Veterans Receiving Mental Health Care from VA
by Setting and Era, Fiscal Years 2006 through 2010:
Era of military service: OEF/OIF;
2006:
Specialty mental health care setting: 32,235;
Other settings: 33,123;
2007:
Specialty mental health care setting: 52,037;
Other settings: 53,164;
2008:
Specialty mental health care setting: 78,693;
Other settings: 81,339;
2009:
Specialty mental health care setting: 105,628;
Other settings: 109,865;
2010:
Specialty mental health care setting: 129,399;
Other settings: 134,970.
Era of military service: All other eras of service;
2006:
Specialty mental health care setting: 701,988;
Other settings: 845,067;
2007:
Specialty mental health care setting: 733,129;
Other settings: 881,287;
2008:
Specialty mental health care setting: 777,718;
Other settings: 928,956;
2009:
Specialty mental health care setting: 829,792;
Other settings: 991,306;
2010:
Specialty mental health care setting: 885,230;
Other settings: 1,049,819.
Era of military service: Total;
2006:
Specialty mental health care setting: 734,223;
Other settings: 878,190;
2007:
Specialty mental health care setting: 785,166;
Other settings: 934,451;
2008:
Specialty mental health care setting: 856,411;
Other settings: 1,010,295;
2009:
Specialty mental health care setting: 935,420;
Other settings: 1,101,171;
2010:
Specialty mental health care setting: 1,014,629;
Other settings: 1,184,789.
Source: NEPEC.
Notes: Specialty mental health settings, including mental health
clinics, primarily provide mental health services. Other settings may
provide some mental health services but focus primarily on other types
of care, such as primary care. The numbers do not add to the total
number of veterans receiving mental health care because veterans may
have received care in both types of settings. Additionally, the number
of veterans represents a unique count of veterans; veterans were
counted only once, even if they received care multiple times during a
fiscal year or multiple times in each type of setting.
[End of table]
[End of section]
Appendix III: Number of Veterans Receiving Care from VA by Gender and
Era, Fiscal Years 2006 through 2010:
Veterans receiving mental health care from VA:
Era of military service: OEF/OIF;
2006:
Male: 29,842;
Female: 4,717;
2007:
Male: 48,379;
Female: 6,964;
2008:
Male: 73,776;
Female: 10,171;
2009:
Male: 99,904;
Female: 13,373;
2010:
Male: 122,428;
Female: 16,739.
Era of military service: All other eras of service;
2006:
Male: 800,334;
Female: 62,236;
2007:
Male: 830,415;
Female: 66,904;
2008:
Male: 871,230;
Female: 72,815;
2009:
Male: 924,566;
Female: 80,803;
2010:
Male: 975,983;
Female: 88,380.
Era of military service: Total;
2006:
Male: 830,176;
Female: 66,953;
2007:
Male: 878,794;
Female: 73,868;
2008:
Male: 945,006;
Female: 82,986;
2009:
Male: 1,024,470;
Female: 94,176;
2010:
Male: 1,098,411;
Female: 105,119.
All veterans receiving any health care from VA:
Era of military service: OEF/OIF;
2006:
Male: 127,821;
Female: 19,239;
2007:
Male: 174,644;
Female: 25,313;
2008:
Male: 223,975;
Female: 32,266;
2009:
Male: 280,643;
Female: 39,190;
2010:
Male: 338,737;
Female: 47,789.
Era of military service: All other eras of service;
2006:
Male: 4,424,742;
Female: 217,539;
2007:
Male: 4,406,149;
Female: 224,458;
2008:
Male: 4,395,448;
Female: 232,561;
2009:
Male: 4,465,169;
Female: 245,299;
2010:
Male: 4,589,963;
Female: 260,006.
Era of military service: Total;
2006:
Male: 4,552,563;
Female: 236,778;
2007:
Male: 4,580,793;
Female: 249,771;
2008:
Male: 4,619,423;
Female: 264,827;
2009:
Male: 4,745,812;
Female: 284,489;
2010:
Male: 4,928,700;
Female: 307,795.
Source: NEPEC.
Note: The number of veterans represents a unique count of veterans;
veterans were counted only once, even if they received care multiple
times during a fiscal year.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington, DC 20420:
September 26, 2011:
Ms. Debra Draper:
Director, Health Care:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Draper:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Mental Health: Number
of Veterans Receiving Care, Barriers Faced, and Efforts to Increase
Access" (GAO-12-12) and is providing technical comments in the
enclosure.
VA appreciates the opportunity to comment on your draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Debra A. Draper, (202) 512-7114 or draperd@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Janina Austin, Assistant
Director; Jennie F. Apter; Eleanor M. Cambridge; Kathleen Diamond;
Lisa Motley; Monica Perez-Nelson; Karin Wallestad; and Suzanne Worth
made key contributions to this report.
[End of section]
Footnotes:
[1] Veterans who served in active military and who were discharged or
released under conditions other than dishonorable are generally
eligible for VA health care. Reservists and National Guard members may
also be eligible for VA health care if they were called to active duty
by a federal order and completed the full period for which they were
called. Veterans can also receive health care funded by sources other
than VA, including private insurance, Medicare, and Medicaid. In
general, veterans must enroll in VA health care to receive VA's
medical benefits package--a set of services that includes a full range
of hospital and outpatient services, prescription drugs, and
noninstitutional long-term care services.
[2] Military operations in Afghanistan occurring after September 2010
are referred to as Operation New Dawn. For the purposes of this
report, we refer to all veterans participating in military operations
in Afghanistan as OEF veterans.
[3] See 38 U.S.C. § 1710(a), 38 C.F.R. §§ 17.36, 17.38 (2009). Any
veteran who has served in a combat theater after November 11, 1998,
including OEF/OIF veterans, and who was discharged or released from
active service on or after January 28, 2003, has up to 5 years from
the date of the veteran's most recent discharge or release from active
duty service to enroll in VA's health care system and receive VA
health care services. See 38 U.S.C. § 1710(e)(1)(D), (e)(3).
[4] See GAO, VA Health Care: Reporting of Spending and Workload for
Mental Health Services Could Be Improved, [hyperlink,
http://www.gao.gov/products/GAO-10-570] (Washington, D.C.: May 28,
2010).
[5] NEPEC is one of VA's national evaluation centers, and it evaluates
and monitors the mental health care delivered by VA nationally.
[6] Because providers may document a mental health diagnosis while
providing care for a non-mental health condition, a portion of this
care may be unrelated to a mental health condition.
[7] The mental health and primary care providers we spoke with were
identified by VA officials as having specific knowledge of either
barriers to veterans accessing mental health care or efforts VA has
implemented to increase veterans' access to VA mental health care.
[8] We spoke with officials from eight VSOs: American Legion, American
Veterans, Disabled American Veterans, Paralyzed Veterans of America,
Veterans of Modern Warfare, Vietnam Veterans of America, Women
Veterans of America, and Wounded Warrior Project.
[9] The Veterans' Health Care Eligibility Reform Act of 1996, Pub. L.
No. 104-262, 110 Stat. 3177, 3182, § 104 (Oct. 9, 1996), codified at
38 U.S.C. § 1705, directed VA to establish a patient enrollment system
to manage the provision of care and services by establishing priority
groups and directing VA to enroll veterans in accordance with the
priorities.
[10] For example, in fiscal year 2010 approximately 790,000 veterans
were identified as having service-connected mental health disorder
disabilities.
[11] See 38 U.S.C. § 101.
[12] The number of veterans receiving care from VA includes eligible
former active duty servicemembers, including Reservists and National
Guard members. In some cases, VA also provides care to nonveterans,
such as active duty servicemembers or veterans' dependents; however,
nonveterans were not included in our analysis. Veterans who received
care were counted only once, even if they received care multiple times
during a fiscal year or across the 5-year period.
[13] In fiscal year 2010, about 1 million veterans received mental
health care in specialty mental health care settings and about 1.2
million veterans received mental health care in other settings. These
numbers do not add to the total number of veterans receiving mental
health care in fiscal year 2010 because veterans may have received
care in both types of settings.
[14] Among the general U.S. population, an estimated 26 percent of
adults experience a mental health condition in a given year. See R.C.
Kessler, W.T. Chiu, O. Demler, K.R. Merikangas, and E.E. Walters,
"Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in
the National Comorbidity Survey Replication," Archives of General
Psychiatry, vol. 62, no. 6 (2005).
[15] Substance Abuse and Mental Health Services Administration, Office
of Applied Studies, Results from the 2008 National Survey on Drug Use
and Health, NSDUH Series H-36, HHS Publication No. SMA 09-4434
(Rockville, Md.: September 2009).
[16] See for example, M. A. Burnam et al., "Mental Health Care for
Iraq and Afghanistan War Veterans," Health Affairs, vol. 28, no. 3
(2009).
[17] Westat, The National Survey of Veterans, Active Duty Service
Members, Demobilized National Guard and Reserve Members, Family
Members and Surviving Spouses, prepared for the Department of Veterans
Affairs (Rockville, Md.: Oct. 18, 2010).
[18] See for example, A. E. Street, D. Vogt, and L. Dutra, "A New
Generation of Women Veterans: Stressors Faced by Women Deployed to
Iraq and Afghanistan," Clinical Psychology Review, vol. 29, no. 8
(2009).
[19] Department of Veterans Affairs, National Center for Veterans
Analysis and Statistics, Veteran Population Projections: FY2000 to
FY2036 (December 2010).
[20] See, for example, C.S. Milliken, J.L. Auchterlonie, and C.W.
Hoge, "Longitudinal Assessment of Mental Health Problems Among Active
and Reserve Component Soldiers Returning From the Iraq War," JAMA,
vol. 298, no. 18 (2007).
[21] See, for example, A. West and W.B. Weeks, "Physical and Mental
Health and Access to Care Among Nonmetropolitan Veterans Health
Administration Patients Younger than 65 Years," Journal of Rural
Health, vol. 22, no. 1 (2006).
[22] Military sexual trauma includes both sexual harassment and sexual
assault occurring during a servicemember's military career. VA is
required to operate a program to provide counseling and treatment for
veterans suffering from sexual trauma under 38 U.S.C. § 1720D.
[23] Primary care clinics in facilities that serve fewer than 1,500
veterans can provide access to mental health professionals who may not
be on-site, through options such as telemental health services.
[24] The Veterans Crisis Line (1-800-273-TALK) was established as a
partnership between VA, the Substance Abuse and Mental Health Services
Administration, and the National Suicide Prevention Lifeline. Callers
to this call center talk to trained counselors about their concerns
and can be referred to VA mental health service providers in their
area, or receive emergency interventions if necessary. This service is
also available to veterans who visit the program's website [hyperlink,
http://www.veteranscrisisline.net/] through online chat services. The
Veterans Crisis Line is part of VA's Suicide Prevention Program. In
addition to the Veterans Crisis Line, VA's Suicide Prevention Program
also includes national outreach campaigns to educate the public about
suicide prevention and local suicide prevention coordinators who
provide information to veterans in their communities.
[25] According to VA officials, these mental health staff include
mental health providers, such as psychiatrists, psychologists, and
social workers, as well as additional staff, such as occupational
therapists and pharmacists.
[26] Also in 2007, VA required its emergency rooms to have mental
health staff available for consultation 24 hours a day, 7 days a week,
and for its urgent care centers to have mental health providers
available during their hours of operation.
[27] The Yellow Ribbon Program is a Department of Defense effort to
help Reservists and National Guard members and their families connect
with local resources, including information on VA mental health care,
especially during the reintegration phase that occurs months after
servicemembers return home. Postdeployment health reassessments are a
Department of Defense program for assessing the physical and mental
health condition of servicemembers from 90 to 180 days after
deployment. During these events, VA officials are present to help with
enrollment in VA health care and to provide referrals, as necessary,
for mental health care.
[28] The National Center for PTSD is one of VA's Centers of
Excellence, or communities of researchers and educational
professionals focused on certain mental health issues. According to VA
officials, this center identifies best practices through research,
participates in the development of clinical practice guidelines
describing best practices, and works to disseminate them through
educational programs for VA mental health providers to use, among
other activities.
[29] For example, see H. Balshem, V. Christensen, A. Tuepker, and D.
Kansagara, A Critical Review of the Literature Regarding Homelessness
among Veterans, VA-ESP Project #05-225 (2011).
[30] NEPEC is one of VA's national evaluation centers, and it
evaluates and monitors the mental health care delivered by VA
nationally.
[31] Because providers may document a mental health diagnosis while
providing care for a non-mental health condition, a portion of this
care may be unrelated to a mental health condition.
[32] The number of veterans does not include veterans who only
received medications, or contract, or fee-based care. Contract and fee-
based care represent inpatient and outpatient care, respectively, that
VA may authorize veterans to receive at non-VA health care facilities.
VA also provides care to nonveterans such as active duty
servicemembers and veterans' dependents; however, nonveterans were not
included in our analysis.
[33] NEPEC uses standardized diagnostic categories that include
specific International Classification of Diseases, Ninth Revision,
codes for mental health diagnoses.
[34] The mental health and primary care providers we spoke with were
identified by VA officials as having specific knowledge of either
barriers to veterans accessing mental health care or efforts VA has
implemented to increase veterans' access to VA mental health care.
[35] We spoke with officials from eight VSOs: American Legion,
American Veterans, Disabled American Veterans, Paralyzed Veterans of
America, Veterans of Modern Warfare, Vietnam Veterans of America,
Women Veterans of America, and Wounded Warrior Project.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO‘s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO‘s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
