OEF/OIF veterans have a high prevalence of mental health problems, yet significant barriers to accessing mental health treatment prevent adequate treatment of these disorders4,14,16,30
. Prior reports have suggested that OEF/OIF veterans may prefer to receive mental health services within a primary care setting21,31
. Thus, clinicians at the SFVAMC developed the OEF/OIF Integrated Care Clinic to offer new OEF/OIF veteran patients, even those with negative mental health screens, the option of a same-day brief mental health and social services assessment in primary care21
We found that patients seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations than UC patients. Because many VA-enrolled veterans screen positive for mental health disorders and/or TBI on the sensitive, but not highly specific universal VA screens, there are several potential benefits to facilitating access to psychosocial services13
. Same-day psychoeducation and appropriate risk communication in primary care about the meaning of positive screen results may prevent iatrogenesis and promote recovery expectations32–34
. Importantly, given the increased incidence of suicide and other high-risk behaviors among OEF/OIF veterans35–37
, a same-day mental health evaluation provides the opportunity to further assess veterans with positive screens or symptoms using more specific instruments, as well as assess for personal safety. In addition, mental health clinicians may conduct a one-time brief intervention (e.g. for high-risk drinking)38
, and schedule a referral, if indicated.
Improved access to psychosocial services might also benefit those with negative screens. It is well-established that the onset of PTSD and other mental health and psychosocial problems may be delayed after returning from war2,39
. Learning about VA and non-VA mental health and social services resources and benefits during an initial primary care appointment may prove useful should symptoms develop in the future. Finally, while not a direct patient benefit, improved communication within the IC primary care, mental health and social service provider team may improve coordination of care across services.
Our results suggest that the co-located integrated care model may be of particular benefit in certain subgroups of OEF/OIF veterans. For instance, women were far more likely to have received mental health and social services (most often on the same day) if they presented to the IC rather than UC clinic. This is important given women veterans’ perceived barriers to care40
, unique readjustment issues, and potentially greater mental health needs relative to male counterparts41,42
. Moreover, despite VA expectations to conduct evaluations of all veterans with positive PTSD or depression screens20
, our results revealed that veterans with positive screens were more likely to be evaluated if seen in the IC versus UC clinic. In addition, veterans who screened positive for TBI, endorsing symptoms such as poor memory and concentration, were also more likely to receive psychological and social services if seen in the IC clinic. This may be due to a lack of available mental health staff for same-day evaluations for UC patients or other barriers such as a lack of transportation, stigma, avoidance, or difficulties remembering a future appointment.
Unfortunately, while IC increased initial mental health evaluations, there was no significant increase in retention in specialty mental health services among veterans who screened positive for mental health problems. Collaborative Care models for the treatment of depression in primary care, such as the Translating Initiatives for Depression into Effective Solutions (TIDES) model43–45
, have demonstrated significant improvements in depression treatment completion rates in numerous randomized controlled trials46–50
. Central to TIDES is the “Care Manager,” typically a nurse supervised by a psychiatrist, who provides ongoing support for anti-depressant medication adherence in primary care and conducts clinical outcomes assessments to guide PCPs’ decision-making regarding mental health treatment43,51
Despite the efficacy of TIDES for older veterans with depression, collaborative care models may need to be modified to be most effective in OEF/OIF veterans. For example, younger and minority combat veterans with anxiety disorders may be reluctant to accept medication and may instead prefer psychotherapy50,52–54
. Evidence-based psychotherapy for PTSD and other anxiety disorders is typically delivered in specialty mental health settings, but a recent study of OEF/OIF veterans with new PTSD diagnoses in VA healthcare showed that veterans’ failed to attend an adequate number of specialty mental health visits required for evidence-based PTSD treatment55
. The addition of a Care Manager to the IC Clinic to make reminder phone calls for specialty mental health visits could improve retention, yet funding this position through primary care has been challenging.
Because most individuals with post-traumatic stress, including OEF/OIF veterans, pursue medical treatment in primary care, models that integrate primary and mental health care may improve both engagement and retention of patients in mental health treatment18,19
. To date however, there have been only two randomized controlled trials of collaborative care for anxiety disorders that resulted in improved clinical outcomes compared to usual care50,56
. Both were conducted in non-veteran populations and only one of them, which included a relatively small number of PTSD patients, was conducted in a primary care setting50
. Only one study has demonstrated the acceptability and feasibility among OEF/OIF personnel of providing pharmacotherapy and/or psychotherapy for PTSD in a primary care setting using collaborative care (RESPECT-Mil)53
, but to date, there has been no randomized controlled trial of this program. Building on the IC model evaluated in this study and prior research on collaborative care, a next logical step to improve mental health treatment engagement in veterans with mental health symptoms would be to offer a brief psychotherapeutic intervention for post-traumatic stress in primary care following the initial IC visit. This brief intervention may be sufficient, or patients requiring further care could “step up” to specialty mental health treatment.
This study has some important limitations. Our results are based on administrative data from one urban VA medical center and thus, do not generalize to all VA and non-VA healthcare facilities serving OEF/OIF veterans. Further, because our data source was limited to VA, we were not able to capture mental health and social services received outside VA. In addition, study results may have been biased because veterans assigned to the IC clinic may have perceived the 3-part visit to be compulsory, not optional, although they were apprised of the option to decline. Because we were limited to retrospective data, we were also not able to prospectively assess other potential positive and negative clinical outcomes of the IC clinic. For instance, requiring a 3-hour intake visit may add to patient burden and pre-scheduling a mental health and social services visit for all veterans entering primary care could convey the unintended message that something must be wrong with veterans returning from war57
In summary, an IC visit increased the likelihood that OEF/OIF veterans received an initial mental health and social services evaluation. This was especially true for female and relatively younger veterans, and those who screened positive for mental health disorders and TBI, potentially groups with greater barriers to care14
. These results appear robust, even when we consider background increases in mental health services utilization that occurred in usual primary care after April 2007. Despite the increase in initial evaluations among IC patients, however, engagement in follow-up mental health treatment was poor, even among veterans who screened positive for mental health disorders. Future prospective studies of OEF/OIF veterans may shed more light on the clinical effectiveness of an initial IC visit. In addition, including brief mental health treatment interventions for PTSD spectrum disorders in primary care itself may further overcome barriers to mental health treatment and improve retention and clinical outcomes.