Journal of General Internal Medicine

, Volume 26, Issue 10, pp 1160–1167 | Cite as

Reducing Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic

  • Karen H. Seal
  • Greg Cohen
  • Daniel Bertenthal
  • Beth E. Cohen
  • Shira Maguen
  • Aaron Daley
Original Research

ABSTRACT

BACKGROUND

Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized.

OBJECTIVE

To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed.

DESIGN

Retrospective cohort study using VA administrative data.

POPULATION

Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009.

MAIN MEASURES

Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes.

KEY RESULTS

After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics.

CONCLUSIONS

Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.

KEY WORDS

veterans mental health health services utilization primary care 

REFERENCES

  1. 1.
    Department of Defense. Defense Manpower Data Center: Contingency Tracking System Deployment File. Data current as of Dec. 2009.Google Scholar
  2. 2.
    Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA. 2007;298:2141–2148.PubMedCrossRefGoogle Scholar
  3. 3.
    Seal KH, Metzler TJ, Gima KS, Bertenthal D, Maguen S, Marmar CR. Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. Am J Publ Health. 2009;99:1651–1658.CrossRefGoogle Scholar
  4. 4.
    Tanielian TL, Jaycox LH, eds. Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation; 2008.Google Scholar
  5. 5.
    Andersen J, Wade M, Possemato K, Ouimette P. Association between posttraumatic stress disorder and primary care provider-diagnosed disease among iraq and afghanistan veterans. Psychosom Med. 2010;72:498–504.PubMedCrossRefGoogle Scholar
  6. 6.
    Frayne SM, Chiu VY, Iqbal S, et al. Medical Care Needs of Returning Veterans with PTSD: Their Other Burden. J Gen Intern Med. 2010;26:33–39.PubMedCrossRefGoogle Scholar
  7. 7.
    Cohen BE, Marmar C, Ren L, Bertenthal D, Seal KH. Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care. JAMA. 2009;302:489–492.PubMedCrossRefGoogle Scholar
  8. 8.
    Schnurr PP, Green BL, Kaltman S. Trauma exposure and physical health. In: Friedman MJ, Keane TM, Resick PA, eds. Handbook of PTSD. New York, NY: The Guilford Press; 2007.Google Scholar
  9. 9.
    Schnurr PP, Lunney CA, Bovin MJ, Marx BP. Posttraumatic stress disorder and quality of life: extension of findings to veterans of the wars in Iraq and Afghanistan. Clin Psychol Rev. 2009;29:727–735.PubMedCrossRefGoogle Scholar
  10. 10.
    Pietrzak RH, Goldstein MB, Malley JC, Rivers AJ, Johnson DC, Southwick SM. Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord. 2010;123:102–107.PubMedCrossRefGoogle Scholar
  11. 11.
    Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. J Trauma Stress. 2009;22:303–306.PubMedCrossRefGoogle Scholar
  12. 12.
    Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Murdoch M. Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatr Serv. 2010;61:589–597.PubMedCrossRefGoogle Scholar
  13. 13.
    Seal KH, Bertenthal D, Maguen S, Gima K, Chu A, Marmar CR. Getting beyond “Don’t ask; don’t tell”: an evaluation of US Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. Am J Publ Health. 2008;98:714–720.CrossRefGoogle Scholar
  14. 14.
    Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13–22.PubMedCrossRefGoogle Scholar
  15. 15.
    Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295:1023–1032.PubMedCrossRefGoogle Scholar
  16. 16.
    Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr Serv. 2009;60:1118–1122.PubMedCrossRefGoogle Scholar
  17. 17.
    Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge CW. Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Serv. 2010;61:582–588.PubMedCrossRefGoogle Scholar
  18. 18.
    Cohen BE, Gima K, Bertenthal D, Kim S, Marmar CR, Seal KH. Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25:18–24.PubMedCrossRefGoogle Scholar
  19. 19.
    Hoge C, Terhakopian A, Castro C, Messer S, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatr. 2007;164:150–153.PubMedCrossRefGoogle Scholar
  20. 20.
    Department of Veterans Affairs. Uniform Mental Health Services in VA Medical Centers and Clinics: Veterans Health Administration; 2008.Google Scholar
  21. 21.
    Maguen S, Cohen G, Cohen B, Lawhon GD, Marmar C, Seal KH. The role of psychologists in the care of Iraq and Afghanistan Veterans in primary care settings. Prof Psychol Res Pract. 2010;41:135–142.CrossRefGoogle Scholar
  22. 22.
    Prins A, Ouimette P, Kimmerling R, Camerond RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatr. 2004;9:9–14.CrossRefGoogle Scholar
  23. 23.
    Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284–1292.PubMedCrossRefGoogle Scholar
  24. 24.
    Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158:1789–1795.PubMedCrossRefGoogle Scholar
  25. 25.
    Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med. 2003;163:821–829.PubMedCrossRefGoogle Scholar
  26. 26.
    Schwab KA, Ivins B, Cramer G, et al. Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: initial investigation of the usefulness of a short screening tool for traumatic brain injury. J Head Trauma Rehabil. 2007;22:377–389.PubMedCrossRefGoogle Scholar
  27. 27.
    OEF/OIF ROSTER. Department of Veterans Affairs; 2009.Google Scholar
  28. 28.
    Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–706.PubMedCrossRefGoogle Scholar
  29. 29.
    Stata Statistical Software: Release 11. [computer program]. College Station, TX: StataCorp LP; 2009.Google Scholar
  30. 30.
    Stecker T, Fortney J, Hamilton F, Ajzen I. An assessment of beliefs about mental health care among veterans who served in Iraq. Psychiatr Serv. 2007;58:1358–1361.PubMedCrossRefGoogle Scholar
  31. 31.
    Batten S, Pollack S. Integrative outpatient treatment for returning service members. J Clin Psychol. 2008;64:928–939.PubMedCrossRefGoogle Scholar
  32. 32.
    Mittenberg W, DiGiulio DV, Perrin S, Bass AE. Symptoms following mild head injury: expectation as aetiology. J Neurol Neurosurg Psychiatry. 1992;55:200–204.PubMedCrossRefGoogle Scholar
  33. 33.
    Hunt SC, Richardson RD, Engel CC Jr, Atkins DC, McFall M. Gulf War Veterans’ illnesses: a pilot study of the relationship of illness beliefs to symptom severity and functional health status. J Occup Environ Med. 2004;46:818–827.PubMedCrossRefGoogle Scholar
  34. 34.
    VA Consensus Conference. Practice recommendations for treatment of veterans with comorbid TBI, pain, and PTSD. 2008.Google Scholar
  35. 35.
    Killgore WD, Cotting DI, Thomas JL, et al. Post-combat invincibility: Violent combat experiences are associated with increased risk-taking propensity following deployment. J Psychiatr Res. 2008;42:1112–1121.PubMedCrossRefGoogle Scholar
  36. 36.
    Kuhn E, Drescher K, Ruzek J, Rosen C. Aggressive and unsafe driving in male veterans receiving residential treatment for PTSD. J Trauma Stress. 2010;23:399–402.PubMedGoogle Scholar
  37. 37.
    Kang HK, Bullman TA. Risk of suicide among US veterans after returning from the Iraq or Afghanistan war zones. JAMA. 2008;300:652–653.PubMedCrossRefGoogle Scholar
  38. 38.
    National Institute on Alcohol Abuse and Alcoholism. Helping patients with alcohol problems: a clinician’s guide. NIH Pub No. 05–3769. Bethesda, MD: The National Institute of Health; 2005.Google Scholar
  39. 39.
    Andrews B, Brewin CR, Philpott R, Stewart L. Delayed-onset posttraumatic stress disorder: a systematic review of the evidence. Am J Psychiatry. 2007;164:1319–1326.PubMedCrossRefGoogle Scholar
  40. 40.
    Vogt D, Bergeron A, Salgado D, Daley J, Ouimette P, Wolfe J. Barriers to Veterans Health Administration care in a nationally representative sample of women veterans. J Gen Intern Med. 2006;21(Suppl 3):S19–25.PubMedCrossRefGoogle Scholar
  41. 41.
    Street AE, Vogt D, Dutra L. A new generation of women veterans: stressors faced by women deployed to Iraq and Afghanistan. Clin Psychol Rev. 2009;29:685–694.PubMedCrossRefGoogle Scholar
  42. 42.
    Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled in veterans affairs health care. Am J Publ Health. 2010;100:2450–2456.CrossRefGoogle Scholar
  43. 43.
    VA Health Services Research and Development Service. Collaborative care for depression in the primary care setting. A Primer on VA’s Translating Initiatives for Depression into Effective Solutions (TIDES) Project. Washington, DC: Department of Veterans Affairs; 2008.Google Scholar
  44. 44.
    Felker BL, Chaney E, Rubenstein LV, et al. Developing effective collaboration between primary care and mental health providers. Prim Care Companion J Clin Psychiatry. 2006;8:12–16.PubMedCrossRefGoogle Scholar
  45. 45.
    Rubenstein LV, Chaney EF, Ober S, et al. Using evidence-based quality improvement methods for translating depression collaborative care research into practice. Fam Syst Health. 2010;28:91–113.PubMedCrossRefGoogle Scholar
  46. 46.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273:1026–1031.PubMedCrossRefGoogle Scholar
  47. 47.
    Katon W, Russo J, Von Korff M, et al. Long-term effects of a collaborative care intervention in persistently depressed primary care patients. J Gen Intern Med. 2002;17:741–748.PubMedCrossRefGoogle Scholar
  48. 48.
    Wells K, Sherbourne C, Schoenbaum M, et al. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry. 2004;61:378–386.PubMedCrossRefGoogle Scholar
  49. 49.
    Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314–2321.PubMedCrossRefGoogle Scholar
  50. 50.
    Roy-Byrne P, Craske MG, Sullivan G, et al. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial. JAMA. 2010;303:1921–1928.PubMedCrossRefGoogle Scholar
  51. 51.
    Oxman TE, Dietrich AJ, Williams JW Jr, Kroenke K. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics. 2002;43:441–450.PubMedCrossRefGoogle Scholar
  52. 52.
    van Schaik DJ, Klijn AF, van Hout HP, et al. Patients’ preferences in the treatment of depressive disorder in primary care. Gen Hosp Psychiatry. 2004;26:184–189.PubMedCrossRefGoogle Scholar
  53. 53.
    Engel CC, Oxman T, Yamamoto C, et al. RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care. Mil Med. 2008;173:935–940.PubMedGoogle Scholar
  54. 54.
    Zoellner LA, Feeny NC, Bittinger JN. What you believe is what you want: modeling PTSD-related treatment preferences for sertraline or prolonged exposure. J Behav Ther Exp Psychiatry. 2009;40:455–467.PubMedCrossRefGoogle Scholar
  55. 55.
    Seal KH, Maguen S, Cohen B, et al. VA mental health services utilization in Iraq and Afghanistan veterans in the first year of receiving new mental health diagnoses. J Trauma Stress. Feb;23:5–16.Google Scholar
  56. 56.
    Zatzick D, Roy-Byrne P, Russo J, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004;61:498–506.PubMedCrossRefGoogle Scholar
  57. 57.
    Wessely S, Bryant RA, Greenberg N, Earnshaw M, Sharpley J, Hughes JH. Does psychoeducation help prevent post traumatic psychological distress? Psychiatry. 2008;71:287–302.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Karen H. Seal
    • 1
    • 2
  • Greg Cohen
    • 1
  • Daniel Bertenthal
    • 1
  • Beth E. Cohen
    • 1
    • 2
  • Shira Maguen
    • 1
    • 2
  • Aaron Daley
    • 1
  1. 1.San Francisco VA Medical CenterSan FranciscoUSA
  2. 2.University of California, San FranciscoSan FranciscoUSA

Personalised recommendations