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Health and Healthcare Disparities Among Veterans with Serious Mental Illness

Posted: November 08, 2017

The National Veteran Health Equity Report details patterns and provides comparative rates of health conditions for vulnerable Veteran groups. Specifically, this report is designed to provide basic comparative information on the sociodemographics, utilization patterns and rates of diagnosed health conditions among the groups over which the VHA Office of Health Equity (OHE) has responsibility with respect to monitoring, evaluating and acting on identified disparities in access, use, care, quality and outcomes. The report allows the VA, Veterans, and stakeholders to monitor the care vulnerable Veterans receive and set goals for improving their care. Chapter 7 of the Report focuses on Health and Healthcare Disparities Among Veterans with Serious Mental Illness (SMI).

Compared to the general population, individuals with SMI have between 14-30 years shorter life expectancy, depending on the study. Individuals with SMI who are treated in VA are on the lower end of this mortality gap with between 14-18 years shorter life expectancy compared to the general US population.  SMI as a category has been variably defined across studies. For the purposes of this chapter, and in line with the most typical definitions of SMI, the SMI group included schizophrenia, schizoaffective disorder, bipolar disorders, major depression with psychosis, and psychotic disorders not otherwise specified. Schizophrenia is considered the hallmark disorder of SMI.

As a group, mental and substance use disorders have been the leading cause of non-fatal global disease burden and fifth in overall disease burden, which includes impact from both mortality and morbidity as measured in disability-adjusted life years (DALYs).  Although depressive and anxiety disorders are more prevalent and carry higher global burden, SMI accounts for the highest disability weights.  Despite the low prevalence of SMI (approximately 4% of the U.S. population),  they account for the majority of patients treated at outpatient public mental health clinics, including VA.

Some of the implications for veterans spelled out in the chapter include:

  • Not only is the rate of mental illness diagnoses, and SMI in particular, higher in VA compared to the general adult population, the VA numbers here only include those Veterans with the diagnosis who are also in care in a particular fiscal year. This means the numbers in this chapter are an underestimate of the diagnoses in the Veteran population at large and indicates a higher burden of mental health disorders in Veterans.
  • There is considerable burden in this population with SMI of several comorbid mental health diagnoses with at least a quarter also having PTSD or a substance use disorder. There is expertise to be shared across clinicians regarding treatment of Veterans with SMI, substance use disorders, and PTSD. These illnesses are often treated in clinics that are siloed from one another (e.g., specialized PTSD clinic, dual diagnosis clinic) and formal Standards of Practice (SOPs) for consultation across experts of specific mental health diagnoses could improve outcomes and treatment compliance.
  • The gender representation of women in the SMI, mood/anxiety, and other mental health groups compared to the overall VA population in care in FY13 highlights the need for VA healthcare services that are gender sensitive within the mental health services care line.  It also indicates a need for training in the care of SMI for staff and clinicians in the VA women’s clinics.
  • African American Veterans, compared to White Veterans, are more likely to depend on VA to provide at least some of their healthcare and these groups were overrepresented in the population of Veterans with Serious Mental Illness-Patient-Aligned Care Teams (SMI-PACT), or substance abuse. Since African Americans have been shown to have poorer clinical outcomes in hypertension, cardiovascular care, and diabetes care and these physical illnesses are higher in those individuals on second-generation antipsychotics, there is particular concern that gaps in care for these illnesses may exist for the Veteran population with SMI. 
  • Urban locales allow for easier access to in-person VA care, including both physical and mental health services, but those with SMI often live in parts of the city populated by those with limited income. For this reason, VA research should continue to examine the effects of social determinants of health and health behavior.
  • With between a quarter and a third of all Veterans, including those with mental illness, living in rural locales, there needs to be continued support of tele-mental health services.

In order to reduce mortality and disability in SMI, efforts should address provider attitudes towards SMI, quality of care, access to preventative medical care, and help managing chronic comorbid medical conditions. Clinicians, outside of specialty mental health, often have limited experience, discomfort, and a lack of familiarity with evidence-based practices for this population. At the organizational level, systems may lack protocols for care management, shared treatment arrangements, and effective partnerships between primary care and mental health staff. The core difficulty with treating comorbid medical and mental health is the mismatch between the patient, in whom medical and mental conditions and their treatments are interrelated, and a healthcare system with separate services for each disorder; though in VA, primary care-mental health integration is designed to address part of this concern. However, even in VA, a large, quasi-integrated system, the experience of the patient with SMI and their providers is often that of a fragmented healthcare system.

Read more from the National Veterans Health Equity Report.



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