The Challenges and Privileges of Caring for Veterans as a VA Psychiatrist
Psychiatrists in the Department of Veterans Affairs (VA) have the distinct honor of serving America’s veterans and the privilege of practicing in a functional federal healthcare system. While rewarding, the job is simultaneously an experience of perpetual demand to ensure time is most efficiently spent treating a panel of patients within a population-based care model.
Veterans have unique risk factors compared to other Americans because of their military service. They experience trauma, homelessness, pain and substance use at elevated rates than the general public. Veterans also have increased risk for suicide and the veterans treated in VA carry additional risk for suicide within the larger veteran population. VA psychiatrists prioritize care for those most in need or at risk, and VA eligibility criteria prioritize veterans with service-connected disability or low financial means.
The 2022 National Veteran Suicide Prevention Annual Report published by VA noted the 2020 suicide rate for Veterans, adjusted for population age and sex differences, was 57.3% greater compared to non-Veteran U.S. adults. Suicide has long accounted for a majority of firearm deaths in the U.S., yet the rate of firearms use in suicide deaths among veterans is 20% higher. There is however reason to be hopeful with VA’s public health approach to suicide. From 2018 to 2020 the veteran suicide rate has been decreasing and has outpaced the decrease seen in the general population 9.7% to 5.5%.
While the veteran population is at increased risk for suicide, veterans eligible for VA healthcare have a significant advantage. In the U.S. healthcare system where access to mental health treatment is inequitably distributed and half of mental health providers are fee-for-service, veterans enrolled in VA healthcare have access to a continuum of mental health benefits mandated by policy or statute that are carefully budgeted and monitored for quality. Prior research has demonstrated that VA outperforms commercial and Medicare HMOs for common outpatient quality measures. A recent study published in the APA journal Psychiatric Services demonstrated that VA provides a more comprehensive set of specialized mental health services than non-VA facilities.
The services encountered more frequently in VA align with strengths and priorities identified within VA mental health care. First, there are services that promote recovery from mental illness and ensure it is accompanied by functional improvements in quality of life — vocational rehabilitation, supported employment, legal advocacy, family therapy, and specialized services for posttraumatic stress, traumatic brain injury, dementia, as well as lesbian, gay bisexual, and transgender patients. Second and consistent with previous findings, there are services that maintain access and quality through efficiency and optimized service delivery — integrated mental health in primary care, telemedicine, evidence-based psychotherapies, and psychiatric emergency services. Lastly, there are the services that the VA, the largest employer of psychiatrists in the U.S., offers to veterans that can be difficult to access due to their cost or intensity and are associated with treatment resistance and serious mental illness — psychotropic medication, assertive community treatment (ACT), chronic illness management, and electroconvulsive therapy (ECT).
VA psychiatrists have played key roles in the treatment and recovery of veterans throughout VA. Coordinated national efforts have ensured veterans have access to medications proven to save lives during the opioid epidemic — naloxone, naltrexone, and buprenorphine. VA psychiatrists have coordinated access and rapidly disseminated services for treatment-resistant depression including ketamine, repetitive transcranial magnetic stimulation (rTMS), and ECT. In addition to leadership with such treatments, in the context of an episodic psychotherapy model, VA psychiatrists commonly find them-selves the continuity-of-care providers for the veterans in their care. VA psychiatrists and their mental health teammates are dedicated to the mission of caring for those “who have borne the battle” for their families, caregivers, and survivors.
This Veterans Day we are grateful for our veterans and the opportunity to serve those who have served.
Harold M. Ginzburg, M.D., J.D., M.P.H.
Co-chair, APA Caucus of VA Psychiatrists
John Korpics, M.D.
Co-chair, APA Caucus of VA Psychiatrists
The statements made in this blog are the personal views of the authors and do not represent the views of the Department of Veterans Affairs.
Video Discussion: Shedding a Light on Veteran Mental Health, with Sean Wilkes, M.D. Erin Fletcher, Psy.D., and Ricard Dorr, veteran. Discussion covering stigma, barriers to care, and resources available to veterans struggling with mental health issues.