November 10, 2011
Veterans' Mental Health Care Emphasizes Recovery and Return to Full and Meaningful Lives
Six questions for VA’s chief consultant of Mental Health Services
Veterans Day on Nov. 11 offers an opportunity to illuminate how the science of psychology is helping service members adjust to life at home after the trauma of war. Psychologist and APA member Antonette M. Zeiss, PhD, is chief consultant, Office of Mental Health Services, U.S. Department of Veterans Affairs. Dr. Zeiss is responsible for policy and program guidance development for all VA mental health services. That includes a special focus on the VA Uniform Mental Health Services Handbook, which describes the continuum of mental health care mandated to be delivered in the VA.
Dr. Zeiss has been with the VA since 1982. She was previously director of Interdisciplinary Team Training and Development, and then director of Psychology Training and assistant chief of psychology at the VA Palo Alto Health Care System. She came to the VA Central Office in 2005 as the deputy chief consultant for the Office of Mental Health Services. She has served on the editorial boards of nine professional journals and has published extensively on mental health policy, heath care service delivery and depression treatment and risk factors.
The APA recently posed the following questions to Dr. Zeiss:
APA: How has veterans mental health care changed over the past 25 years and what do you consider the most significant change?
Dr. Zeiss: The primary change is the enormous expansion of mental health services delivered in the Department of Veterans Affairs health care system. VA’s full spectrum of health care now integrates mental health at every level of care.
Mental health services integrated into the primary care system are typically in Patient Aligned Care Teams (PACT) and also in teams that deliver care directly for home-bound veterans with physical or mental illness. We also have mental health staff in long-term care settings; in units serving those with multiple physical disabilities and accompanying psychological problems; in rehabilitation programs for spinal cord injury or blindness; in end-of-life care such as hospice; in interdisciplinary pain clinics; and in many other medical specialty clinics, such as oncology and endocrinology.
Every VA facility has a general mental health outpatient clinic along with specialty mental health outpatient clinics, such as PTSD specialty teams. Specialty substance use disorder clinics are available at every facility, increasingly including intensive outpatient clinics. Secure inpatient units for veterans at danger to self or others due to acute mental illness also are available throughout the system.
VA’s extensive mental health residential rehabilitation treatment program (RRTP) offers treatment up to several months in a less restrictive inpatient environment. These RRTPs grew out of the domiciliaries, sometimes referred to as “old soldier’s homes,” that were the very first programs offered by VA. They have changed profoundly over the past decade to support active, intensive rehabilitation to help veterans return to and be fully involved their communities.VA still supports the needs of homeless veterans, the original purpose of domiciliaries, but now has a full array of supportive services for housing and health care needs.
Additionally, VA now addresses veterans’ needs related to experiences with the justice system when it comes to law enforcement, with programs that include civilian police training for responding to mentally ill individuals.VA mental health staff also work with veterans courts to promote diversion and treatment rather than incarceration and with incarcerated veterans to support re-entry into the community.
VA’s model of care today emphasizes psychosocial rehabilitation that follows the Substance Abuse and Mental Health Services Administration (SAMHSA) definition of recovery, which states: “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.”
VA has greatly expanded its mental health staff, especially over the last six years. In 2005, VA had a staff of about 13,500 full-time individuals to deliver mental health care and other services. By 2011, that number had increased to over 21,000. Psychologists increased from just over 1,200 in 2005 to more than 2,500 in July 2011.
Finally, VA is now a full treatment environment for both male and female veterans. Although women veterans have always been eligible for VA care, few have accessed it in the past. VA has dramatically expanded services for both the physical and mental health care of women veterans, and much more is under way.
APA: What differences do you see in the level of post-traumatic stress disorder incidence or severity in veterans of today’s wars in Iraq and Afghanistan compared to PTSD among veterans from previous wars, such as Vietnam or Korea? What are the most recognizable symptoms of PTSD?
Dr. Zeiss: Overall incidence of PTSD does not appear to have changed across the wars we have fought in the late 20th and early 21st centuries, nor has the severity of symptoms. This is an extrapolation from a variety of data sources and clinical experiences, since diagnosis of PTSD was not in the mental health nomenclature during past wars, such as World War II, Korea and Vietnam. We believe the disorder we now call PTSD has existed since wars have been fought, although identified by other names. As a result, data on prevalence of war-related stress disorders in prior conflicts is not as accurate as that developed since the Vietnam War.
The most recognizable symptoms of PTSD are emotional re-experiencing of the traumatic event, avoidance of stimuli associated with the trauma, emotional numbing, and increased arousal. Symptoms of re-experiencing include vivid memories, nightmares and flashbacks. Avoidance symptoms include lack of interest in significant activities – even an inability to drive on busy roads or be in places with other people, personal estrangement and lack of emotional involvement with others. Increased arousal includes irritability and outbursts of anger, an exaggerated response when startled and the inability to fall sleep or stay asleep.
Applying these criteria retrospectively to try to understand PTSD in earlier wars, further studies of WWII era veterans suggest a rate of mental disorders of 20 percent, with higher rates for those seeking mental health services. Among former prisoners of war, Institute of Medicine studies suggest likely rates of PTSD, by current criteria, of 40 percent for World War II Pacific theater and Korean War POWs and 23 percent for World War II European theater POWs. The 1989 National Vietnam Veterans Readjustment Study (NVVRS) reported 15 percent of male Vietnam veterans surveyed met the criteria for PTSD and another 15 percent had met criteria for PTSD at some point since their war experience. Incidence of PTSD from the Persian Gulf War was in the 9 percent to 10 percent range.
Current data from veterans after serving in Iraq or Afghanistan indicate that of the 1,353,627 who left the military from October 2002 through July 2011, 53 percent (711,986) have used VA health care. Of these, 26.7 percent (197,074) have at least a provisional diagnosis of PTSD. However, these figures cannot be extrapolated to all veterans of wars in Iraq or Afghanistan because they are a treatment-seeking population.
It is important to note the different time frames when various surveys were conducted. The NVVRS assessed PTSD among Vietnam veterans 15 to 20 years after their deployments ended. In contrast, much of the research during the Iraq and Afghanistan wars has been carried out very soon after or between deployments. So the best comparisons with earlier wars will not be available until 15 to 20 years have elapsed after war-zone exposure.
APA: How can friends, families and communities best help veterans who suffer from mental health issues?
Dr. Zeiss: Friends, families and communities play a major role in helping to prevent veterans’ mental health problems and to promote resilience. Vietnam veterans still speak with pain of the negative reception they experienced on returning to the United States. Currently returning veterans speak positively of the welcomes they have received on their immediate return, but they still face many challenges as they reintegrate into their families and society. Some research suggests that the likelihood of a veteran developing a mental health problem after return to the United States is related to the level of community support.
For those who do show evidence of mental health issues, we urge their families and friends to encourage the veteran to seek VA care. All veterans currently returning from combat are eligible. Veterans not deployed or who served in other eras can find out if they meet eligibility criteria for VA care on the Department of Veterans Affairs website. The VA’s National Center for PTSD website has a wealth of information about PTSD, including specific guidance for families. This includes “Returning from the War Zone” guides on how to address issues following demobilization and during the reintegration phase.
If there is a crisis, such as signs that a person may be suicidal, encourage the veteran to call the VA Crisis Line at 1-800-273-TALK (1-800-273-8255) and press ”1” when prompted. This will connect the veteran with a professional trained to deal with mental health crises. Friends and family members can also call the Crisis Line for support and information.
Finally, there are many community organizations that support veterans and their families. SAMHSA and federal Health Resources and Services Administration programs – community mental health centers and health centers – serve many veterans, and they can provide direct support for family members that VA is not legally authorized to provide. Another national resource is the “Give an Hour” program, developed by psychologist Barbara Van Dahlen, PhD. This program provides free mental health services for veterans of Iraq and Afghanistan wars and for their family members.
APA: What should family members, friends or colleagues do when they think a veteran they know is suffering from a mental illness but refuses to seek treatment?
Dr. Zeiss: The “Coaching Into Care” call center is a resource for veterans’ family members and friends who are encouraging a veteran with a mental health issue to seek care. The call center is available from 8 a.m. to 8 p.m. ET at (888) 823-7458, and is staffed by trained responders. The free telephone-based service is for anyone close to a veteran having difficulties related to mental health or post-deployment readjustment issues.
Veterans’ peers who have had similar experiences and successful treatment can often provide the greatest influence. Helping a reluctant veteran to meet with a peer can be done through VA’s community-based veteran centers that offer readjustment counseling for combat veterans; through peer support staff at the local VA medical center; or through veterans’ service organizations.
Friends and family members can encourage the veteran to discuss the problem with his or her primary care team. Family members also can accompany the veteran to appointments, with the veteran’s permission, and contribute to discussions of issues the health care system will address.
New media applications are often more acceptable to many current veterans who otherwise would not seek face-to-face mental health care. A mobile phone application called the PTSD Coach, developed jointly by VA and the Department of Defense, can be downloaded free from iTunes. It provides information on assessing PTSD symptoms, self-management strategies, and guidance for professional help. Another resource is an online chat service linked to the VA Crisis Line. Veterans can have anonymous chats with the same mental health professionals who answer phone calls.
APA: What is the VA doing to help eliminate the stigma of mental health care for veterans?
Dr. Zeiss: VA is transforming its mental health services to reflect the concepts of recovery with the ability to live a full and meaningful life and to be a key participant in developing one’s own recovery treatment plan. To achieve this, VA has a national network of local recovery coordinators who educate VA staff, veterans and family members about mental health issues and recovery.VA also supports the hiring of peer support staff in mental health programs to provide role models for veterans with mental health problems.
Another major effort toward destigmatization is VA’s program for integrating mental health services in primary care. This helps avoid the stigma often associated with being referred to a specialty site for mental health care. Of course, specialty mental health services will still be essential to the system, but referrals typically go more smoothly when made by mental health providers in primary care.
Finally, VA’s Make the Connection is a new national public awareness campaign to connect veterans and their families with mental health resources. The campaign aims to reduce the stigma associated with seeking mental health services; educate about the signs and symptoms of mental health issues; increase awareness of and trust in VA mental health services; and promote help-seeking behavior for those who need care. At the heart of Make the Connection are personal testimonials, which illustrate true stories of veterans who faced life events, physical injuries or psychological symptoms, reached out for support and found ways to overcome their challenges.
APA: How do suicide risk factors for veterans compare to those of the civilian population?
Dr. Zeiss: Veterans are at higher risk for suicide than the general population. Most of our data are for veterans who seek VA health care. However, among the 16 states that report history of military service on death certificates, some also provide data on review of death by suicide. Because of the higher suicide risk for this population, VA has established extensive suicide prevention efforts, such as the increase in VA mental health services and the VA Crisis Line and its associated online chat service.VA has placed mental health staff as suicide prevention coordinators in every VA facility and large community-based clinics. The most recent data show that young male veterans who seek VA health care have a lower suicide rate than those who do not come to VA for care.
Veterans are men and women of all ages, culturally and ethnically diverse, with different spiritual and educational backgrounds. In general, they have all the same risk factors as well as protective factors that the general population has. Veterans also carry experiences related to their military service and the subsequent effects. We know that exposure to trauma may be a risk factor for the general population. For veterans who served in a combat zone, those experiences can have an impact, and we know that PTSD is associated with increased suicide risk. Veterans who have a traumatic brain injury also are at increased risk.
For veterans who have been deployed, there are readjustment issues. While these are normal, for some veterans they are overwhelming. As veterans age they deal with the same life-changing events that affect everyone, such as retirement, loss of spouse and friends, economic changes, cognitive changes and increased physical difficulties. These life changes may trigger previous issues concerning their military experiences. It’s important to be aware of these transitional periods and the increased risks associated with them.
The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists. APA's membership includes more than 154,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.