Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: outcomes of an integrated primary care clinic

Abstract

Background: Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized.

Objective: To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed.

Design: Retrospective cohort study using VA administrative data.

Population: Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009.

Main measures: Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes.

Key results: After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics.

Conclusions: Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.

Figures

Figure 1

Same-day and within 30-day mental health and social work evaluation by clinic.

Figure 2

Comparison of time to first mental health evaluation by clinic type and time period.

Figure 3

Within 30-day mental health and social work evaluation by gender.

Figure 4

Mental health evaluation within 30 days by mental health screen result *Abbreviations: ALC (+) = Screened positive for high-risk drinking; DEP (+) = Screened positive for depression; PTSD (+) = Screened positive for posttraumatic stress disorder †Screen results are mutually exclusive. For example, ALC (+) denotes veterans who screen positive for high-risk drinking only, whereas ALC (+)/PTSD (+) represents veterans who screen positive for high-risk drinking and posttraumatic stress disorder.