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Treating the Invisible Wounds of War

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Combat-related concussions, depression, and combat stress once were referred to as shell shock or the thousand-yard stare. During World War I, warfighters were reluctant to discuss the psychiatric fallout from battlefield operations for fear they would be considered weak, or worse. Fortunately, today we are much more likely to talk about the mental health issues service members face, such PTSD, alcohol and substance abuse—they are recognized medical conditions with effective treatments available.

Since September 11, 2001, more than 2.69 million troops have returned from deployments to Iraq or Afghanistan. A 2012 study showed that about 40 percent of those who left military service and sought help from the Veterans Affairs Department have been diagnosed with mental health, alcohol, and/or substance use disorders, as a result of their service. This has forced agencies to rethink their approach to treating veterans.

Setting Goals

The Government Accountability Office in 2012 documented a sharp year over year increase in veterans seeking mental health care from VA, with about 900,000 seeking care in fiscal year 2006, to about 1.2 million seeking services in 2010.

A decade after the attacks on the World Trade Center and the Pentagon, according to the National Alliance on Mental Illness: “roughly 18 to 22 Veterans died from suicide each day. These alarming numbers pressed President Obama to step in and take action” in 2012, issuing an executive order detailing specific actions to enhance access to mental health services, to include suicide prevention efforts for veterans, service members, and their families.

The 2012 presidential order led to the creation of the Interagency Task Force on Military and Veterans Mental Health, which is co-chaired by senior leaders from Defense, Veterans Affairs, and Health and Human Services, with a joint program management staff. The task force developed goals and metrics to monitor progress on the implementation of the order and in early 2014, the Obama administration announced that reducing barriers to seeking mental health services by service members, veterans and their families would be one of the 15 cross-agency priority (CAP) goals. The task force’s leadership has become the defacto coordinating and oversight body for this goal.

In late 2014, the scope of the task force grew when it was assigned responsibility to implement a set of 19 specific “executive actions,” such as expanding mental health awareness campaigns and providing opportunities for to return unwanted medications (oftentimes powerful opioids) for destruction. Progress on these executive actions were tied to the CAP Goal.

The task force’s responsibilities were again expanded to help implement a new law supporting suicide prevention efforts among Veterans (The Clay Hunt Act) and the CAP Goal was revised to include additional activities that addressed emerging priorities, such as same day access to care.

Establishing Priorities

The Service Members and Veterans Mental Health CAP Goal is a subset of a broader national agenda to prevent suicides and address the mental health needs of veterans and their families. It is focused on the following:

  • Reducing barriers to mental health treatment. Actions have included developing public awareness campaigns, hosting mental health summits to identify unmet needs, and developing community-based programs and services.
  • Improving access to quality care. Actions include identifying effective VA and Defense programs, integrating mental health and substance abuse programs into primary care, supporting an open source directory of vetted resources for community-based providers and improving VA and Defense medical record data sharing.
  • Developing more effective diagnostic and treatment methodologies. Actions include following through on an agreed-upon National Research Action Plan, developing new metrics for substance abuse disorders, and evaluating the impact of research to improve diagnosis and treatment.
  • Improving patient safety. Actions include implementing drug take-back services for VA and Defense medical facilities, developing and disseminating firearm safety training and toolkits.

While some of these initiatives predated the creation of the CAP goal, participation in the CAP process helped to refine measurable targets, hasten implementation, and provide greater visibility to senior governmental officials about the progress being made.   

Creating Visibility

This CAP Goal received high-level attention, with one of the four co-leads being a White House deputy chief of staff. This visibility ensured active engagement by affected agencies, who provided staff support for the interagency task force. There was also support from the National Security Council and the Domestic Policy Council.

The interagency task force has been responsible for establishing policies, benchmarks, and measures of progress. In addition, it provides concrete coordination and program management services such as professional facilitation of meetings.  

There are dozens of specific actions underway and a set of activity metrics such as monitoring traffic to the MakeTheConnection web resource (372,732 visits in 2016). Another initiative changes the “In Transition” program, which establishes an explicit handoff between Defense and VA mental health providers for individuals with mental health issues as they transition from military to civilian life, from an “opt in” to an “opt out” process. As a result, participation in the program increased four-fold.

GAO has assessed progress on specific activities as well. For example, its 2016 review of the VA’s suicide hotline found calls were not being answered in a timely manner, and were rolling over to a backup number. In response, VA built a new call center in Atlanta, nearly doubling its capacity. Another GAO report examined wait times for access to mental health evaluations and found internally conflicting policies regarding acceptable wait times. According to the latest CAP progress report, VA has implemented standard operating procedures for same-day initial screenings in 100 percent of all of its facilities.

A November 2016 status report declares many of the task force’s original recommendations have largely been completed, but additional efforts will continue, even beyond the targeted Sept. 30, 2017, completion date of the CAP goal. In the report, the task force said in coming years, it “will continue its governance function, with the co-chairs shaping the design and execution of the [task force's] recommendations to proactively identify and address emerging issues in American mental health.”

Note:  This is the 13th in a series about the progress of the 15 Cross-Agency Priority Goals announced in 2014.

John M. Kamensky is a Senior Research Fellow for the IBM Center for the Business of Government. He previously served as deputy director of Vice President Gore's National Partnership for Reinventing Government, a special assistant at the Office of Management and Budget, and as an assistant director at the Government Accountability Office. He is a fellow of the National Academy of Public Administration and received a Masters in Public Affairs from the Lyndon B. Johnson School of Public Affairs at the University of Texas at Austin.

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