VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access
Published: 2011-10-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In fiscal year 2010, the Department of Veterans Affairs (VA) provided health care to about 5.2 million veterans. Recent legislation has increased many Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans' priority for accessing VA's health care, and concerns have been raised about the extent to which VA is providing mental health care to eligible veterans of all eras. There also are concerns that barriers may hinder some veterans from accessing needed mental health care. GAO was asked to provide information on veterans who receive mental health care from VA. In this report, GAO provides information on (1) how many veterans received mental health care from VA from fiscal years 2006 through 2010, (2) key barriers that may hinder veterans from accessing mental health care from VA, and (3) VA efforts to increase veterans' access to VA mental health care. GAO obtained data from VA's Northeast Program Evaluation Center (NEPEC) on the number of veterans who received mental health care from VA. The number of veterans represents a unique count of veterans; veterans were counted only once, even if they received care multiple times during a fiscal year or across the 5-year period. GAO also reviewed literature published from 2006 to 2011, reviewed VA documents, and interviewed officials from VA and veterans service organizations (VSO).
section_title: What GAO Found
paragraphs: Over the 5-year period from fiscal years 2006 through 2010, about 2.1 million unique veterans received mental health care from VA. Each year the number of veterans receiving mental health care increased, from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year 2010. OEF/OIF veterans accounted for an increasing proportion of veterans receiving care during this period. The key barriers identified from the literature that may hinder veterans from accessing mental health care from VA, which were corroborated through interviews, are stigma, lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about VA's care, such as concerns that VA's services are primarily for older veterans. Many of these barriers are not necessarily unique to veterans accessing mental health care from VA, but may affect anyone accessing mental health care from any provider. Veterans may be affected by barriers differently based on demographic factors, such as age and gender. For example, younger OEF/OIF veterans and female veterans may perceive that VA's services are primarily for someone else, such as older veterans or male veterans. VA has implemented several efforts to increase veterans' access to mental health care, including integrating mental health care into primary care. VA also has implemented efforts to educate veterans, their families, health care providers, and other community stakeholders about mental health conditions and VA's mental health care. According to VA officials, these efforts help get veterans into care by reducing, and in some cases eliminating, the barriers that may hinder them from accessing care. GAO provided a draft of this report to VA for comment. In its response, VA provided technical comments, which were incorporated as appropriate.

section_title: Letter
paragraphs: In fiscal year 2010, the Department of Veterans Affairs (VA), which  operates one of the largest health care delivery systems in the nation,  provided health care to about 5.2 million veterans. VA provides care to  eligible veterans from all eras of service, including World War II, Korea,  Vietnam, Gulf War, and most recently, military operations in Afghanistan  and Iraq—Operation Enduring Freedom (OEF) and Operation Iraqi  Freedom (OIF), respectively. Recent legislation has increased many  OEF/OIF veterans’ priority for accessing VA’s health care.
Given the increased focus on OEF/OIF veterans, concerns have been  raised by some, including veterans service organizations (VSO), about  the extent to which VA is providing mental health care to eligible veterans  of all eras. We have previously reported that VA has experienced an  increased demand for its mental health care—including care for  conditions such as post-traumatic stress disorder (PTSD), depression,  and substance abuse. Additionally, there are concerns that barriers— such as distance from a VA treatment facility or stigma associated with  mental health care—may hinder some veterans from accessing needed  mental health care. When veterans do not receive the mental health care  they need, wide-ranging and negative implications for their physical, work,  family, and social functioning can result. For example, mental health  conditions can lead to increased risks of unemployment, homelessness,  and suicide.
You expressed interest in obtaining information on veterans who receive  mental health care from VA. In this report, we provide information on   (1) how many veterans received mental health care from VA from fiscal  years 2006 through 2010, (2) key barriers that may hinder veterans from  accessing mental health care from VA, and (3) efforts VA has  implemented to increase veterans’ access to VA mental health care.
To perform our work, we obtained data from VA’s Northeast Program  Evaluation Center (NEPEC) on the number of veterans who received  mental health care from VA from fiscal years 2006 through 2010. For the  purposes of this report, we defined mental health care as the care  provided to veterans with mental health conditions. A veteran was  counted as having a mental health condition if, at any point in the fiscal  year, his or her medical record indicated at least two outpatient  encounters with any mental health diagnosis (with at least one encounter  having a primary mental health diagnosis) or an inpatient stay in which  the veteran had any mental health diagnosis. Additionally, the number of  veterans represents a unique count of veterans; veterans were counted  only once, even if they received care multiple times during a fiscal year or  across the 5-year period. To assess the reliability of the data NEPEC  provided us, we discussed with NEPEC officials their methodology and  data collection techniques for obtaining and using the data, the data  checks that NEPEC performed, as well as any limitations officials  identified in the data. In addition, we did our own review of NEPEC’s  programming and methodological approaches using data file  documentation, code book and file dictionaries, and programming logs  NEPEC officials provided. We determined that the data were sufficiently  reliable for our purposes.
To identify the key barriers that may hinder veterans from accessing  mental health care from VA, we searched research databases, such as  MEDLINE and PsycINFO, that included peer-reviewed journals to capture  relevant literature published on or between January 1, 2006, and   March 3, 2011. We also reviewed relevant literature that was cited in  articles from our original search or recommended to us during the course  of our research. To corroborate the barriers we identified in the literature,  we interviewed officials from (1) several VA offices—the Office of Mental  Health Services, the Office of Mental Health Operations, the Office of  Rural Health, the Office of Research and Development, and  Readjustment Counseling Services; (2) several mental health–focused  VA research centers—the Mental Illness Research, Education and  Clinical Center, the Serious Mental Illness Treatment Resource and  Evaluation Center, the Center for Chronic Disease Outcomes Research,  and the National Center for PTSD; (3) several VA mental health and  primary care providers; and (4) a judgmental sample of VSOs. We  defined “key barriers” as those that the majority of VA and VSO officials  we interviewed said could have the greatest impact on veterans. As a  result, we do not report an exhaustive list of all potential barriers that  veterans may face.
Finally, to identify the efforts VA has implemented to increase veterans’  access to VA mental health care, we reviewed documentation and  interviewed officials from the same VA offices and mental health–focused  VA research centers that we interviewed to corroborate the barriers for  veterans. We compiled a list of efforts based on those that had been  implemented and were national in scope. As a result, we do not report an  exhaustive list of all VA efforts. In addition, we did not assess the extent  to which VA has fully implemented these efforts or their effectiveness,  including the extent to which the efforts eliminate or diminish barriers that  may hinder veterans from accessing mental health care.
We conducted our work from November 2010 to October 2011 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.  See appendix I for a complete description of our scope and methodology.
subsections: section_title: Background
paragraphs: VA manages access to services in relation to available resources through  a priority system established by law. The order of priorities is generally  based on service-connected disability, income, or other special status,  such as having been a prisoner of war. Additionally, Congress has  stipulated that certain combat veterans discharged from active duty on or  after January 2003 are eligible for priority enrollment.
subsections: section_title: VA Mental Health Care
paragraphs: VA provides mental health care—for conditions such as PTSD,  depression, and substance abuse disorders—in a variety of facilities,  including medical centers, community-based outpatient clinics, and  rehabilitation treatment programs. These facilities may include both  specialty mental health care settings and other settings. Specialty mental  health settings, including mental health clinics, primarily provide mental  health services. Other settings may provide mental health services but  focus primarily on other types of care, such as primary care.
VA also provides counseling services that focus on mental health issues  through its Vet Centers, a nationwide system of community-based centers  that VA established separately from other facilities. The counseling  services provided by Vet Centers differ from the mental health services  provided by other VA facilities in that they focus on counseling to assist  combat veterans in readjusting from wartime military service to civilian life  but do not diagnose veterans’ mental health conditions. Veterans needing  more acute care—for example, veterans with multiple mental health  conditions, such as severe PTSD and depression, or those who pose a  risk of harm to themselves or others—are often referred to VA medical  centers for diagnosis and treatment.
section_title: Veteran Eras of Military Service
paragraphs: VA groups veterans by dates—or era—of their military service based on  provisions in federal law. (See table 1.)
VA estimates that as of September 30, 2011, there were approximately  22.2 million living veterans. OEF/OIF veterans represented approximately  12 percent (2.6 million) of that total.
section_title: More Than 2 Million Unique Veterans Received Mental Health Care from VA over the 5-Year Period from Fiscal Years 2006 through 2010
paragraphs: Over the 5-year period from fiscal years 2006 through 2010, about   2.1 million unique veterans received mental health care from VA. Each  year the number of veterans receiving care increased—from about  900,000 in fiscal year 2006 to about 1.2 million in fiscal year 2010. (See  fig. 1.) VA provided this mental health care to veterans in both specialty  mental health care and other settings, such as primary care clinics staffed  with mental health providers. (See app. II for information on the number  of veterans receiving mental health care in specialty mental health care  and other settings.)
Although the number of veterans receiving mental health care from VA  increased for both OEF/OIF veterans and veterans of other eras of  service, as shown in figure 1, OEF/OIF veterans accounted for an  increasing proportion of the veterans receiving care. Specifically, the  proportion of OEF/OIF veterans receiving mental health care from VA out  of the total number of veterans receiving mental health care increased  from 4 percent in fiscal year 2006 to 12 percent in fiscal year 2010.  Nonetheless, veterans from earlier eras, such as Vietnam, accounted for  approximately 90 percent of the 2.1 million veterans receiving care at VA  over the 5-year period from fiscal years 2006 through 2010, although the  proportion decreased from 96 percent in fiscal year 2006 to 88 percent in  fiscal year 2010. VA officials indicated that the increasing proportion of  OEF/OIF veterans receiving mental health care is not unexpected  because of the nature of OEF/OIF veterans’ military service—veterans of  this era typically had intense and frequent deployments. In addition,  according to VA officials, VA has made changes in its mental health  screening protocols that may have resulted in more mental health  conditions being diagnosed among veterans entering the VA system. For  example, VA requires veterans treated in primary care settings to be  screened for mental health conditions such as PTSD, depression,  substance abuse disorders, as well as a history of military sexual trauma.
Additionally, the 2.1 million veterans receiving mental health care from VA  accounted for almost a third of the 7.2 million total unique veterans  receiving any type of health care from VA over the 5-year period from  fiscal years 2006 through 2010. Specifically, 38 percent of all OEF/OIF  veterans and 28 percent of all other veterans receiving any health care  during this time period received mental health care. (See fig. 2.)
The five most common diagnostic categories for veterans receiving  mental health care from VA in fiscal year 2010 were adjustment reaction,  depressive disorder, episodic mood disorder, neurotic disorder, and  substance abuse disorder. (See table 2.) Within each diagnostic category,  there are specific mental health diagnoses; for example, PTSD is one of  the diagnoses within the adjustment reaction category. Although veterans  of all eras had similar diagnoses, the likelihood of experiencing diagnoses  in any one category varied by era. Specifically, almost twice as many  OEF/OIF veterans had diagnoses within the adjustment reaction category  compared to the next most common diagnostic category—depressive  disorder. In comparison, for veterans of all other eras, depressive  disorder was the most common diagnostic category, but it was closely  followed by adjustment reaction. According to VA officials, the higher  relative incidence of adjustment reaction (including PTSD) among  OEF/OIF veterans may be due to many factors, including the length and  frequency of their deployments and a better understanding of how to  identify and diagnose PTSD among mental health care providers.
section_title: Stigma, Lack of Understanding of Mental Health, Logistical Challenges, and Concerns about VA May Hinder Veterans from Accessing Care
paragraphs: The key barriers we identified from the literature that may hinder veterans  from accessing mental health care from VA, which were corroborated  through interviews with VA and VSO officials, are stigma, lack of  understanding or awareness of mental health care, logistical challenges  to accessing mental health care, and concerns about VA’s care. (See  table 3 for a description of each of these key barriers.) For example,  stigma—negative personal or societal beliefs about mental health  conditions or mental health care—may discourage veterans from  accessing care. According to VA and VSO officials we spoke with, some  veterans may have concerns that if colleagues or employers find out they  are receiving mental health care, their careers will be negatively affected.
Many of these barriers are not necessarily unique to veterans accessing  mental health care from VA, but may affect anyone accessing mental  health care from any provider. According to the Substance Abuse and  Mental Health Services Administration’s 2008 National Survey on Drug  Use and Health, approximately 5 million adults who reported an unmet  need for mental health care reported similar barriers. In particular,  survey participants cited the following as barriers: a belief that the  problem could be handled without care, not knowing where to go for care,  and not having the time to go for care.
Additionally, according to the literature we reviewed and VA and VSO  officials we interviewed, some of these key barriers may affect veterans  from different demographic groups differently. For example, veterans may  be affected by barriers differently based on age, gender, Reservist or  National Guard status, or rural location.    Age: OEF/OIF veterans, who are generally younger than other  veterans, may have concerns about VA’s health care system because  they perceive that primarily older veterans, such as those who served  in Vietnam, go to VA for care. Additionally, some younger veterans  may have multiple personal priorities—such as family, school, or work  commitments—that make accessing care a lower priority. Older  veterans may have different reasons for not accessing mental health  care. For example, stigma and beliefs about mental health care may  hinder veterans who served in World War II and Korea from accessing  care because they grew up during a time when mental health  conditions generally were not recognized and accepted. According to  a national survey of veterans, as of March 2010, more than   60 percent of all veterans were 55 years of age or older.    Gender: Female veterans may perceive some barriers to accessing  mental health care differently than male veterans. For example,  some female veterans may not identify themselves as veterans if they  did not serve in combat and, as a result, may not access care from  VA. In addition, female veterans may have concerns about VA’s  health care system because they perceive that the care is male  oriented, and therefore, VA is not a place where they feel comfortable  receiving mental health care. Female veterans are a growing  demographic in the veteran population—from fiscal year 2010 to fiscal  year 2020, the percentage of female veterans in the total veteran  population is projected to increase from approximately 8 percent to  approximately 10 percent, according to VA’s National Center for  Veterans Analysis and Statistics. (See app. III for data on the  gender of veterans receiving care from VA.)    Reservist or National Guard status: Reservists and National Guard  members may be particularly hindered by privacy and confidentiality  concerns because they worry that accessing mental health care might  have a negative impact on their military or civilian careers. For  example, Reservists and National Guard members may not access  mental health care because of concerns about military leaders  obtaining access to their VA health records and these leaders treating  them differently or limiting their career development because they  accessed mental health care. As of November 2010, Reservists and  National Guard members made up nearly 50 percent of the OEF/OIF  veteran population, according to VA data.    Rural location: Veterans who live in rural locations may be  particularly hindered by access challenges because of the distance  they may have to travel to obtain mental health care. According to  the Office of Rural Health, veterans in rural areas are less likely to  access mental health services than veterans in urban areas in part  because they must travel greater distances to receive care and have  more limited public transportation options. According to VA’s Office of  Rural Health, as of fiscal year 2010, veterans living in rural areas  made up 41 percent of the veterans enrolled in VA’s health care  system.
section_title: VA Has Implemented Several Efforts to Increase Veterans’ Access to Mental Health Care
paragraphs: VA has expanded options to increase veterans’ access to mental health  care and implemented education efforts to help connect veterans with  care, according to VA officials.
subsections: section_title: VA Has Expanded Options to Increase Veterans’ Access to Mental Health Care
paragraphs: VA has begun integrating mental health care into its primary care  settings. Specifically, VA now requires its primary care clinics to conduct  mental health screenings and has placed mental health care providers in  primary care settings. For example, VA requires veterans treated in  primary care settings to be screened for PTSD, depression, substance  abuse disorders, and history of military sexual trauma. Further, in 2008,  VA began requiring primary care clinics that serve more than 1,500  veterans annually to have mental health providers available on-site, able  to serve veterans. Historically, veterans were more limited in the ways  they could access VA’s mental health services. For example, some  veterans could receive mental health care only if they went to specialty  VA mental health facilities, such as mental health clinics. According to  VA, from fiscal years 2008 through 2010, the number of unique patients  receiving mental health care in a primary care setting doubled. Several  VA officials who work in primary care clinics that have integrated primary  and mental health care told us that this integration is critical for lowering  the stigma of receiving mental health care and for creating an  environment of collaboration among providers for discussing veterans’  needs and treatment options.
VA also has continued to increase the number of its Vet Centers, which  provide confidential and free counseling services to address mental  health issues. From fiscal year 2008 to August 2011, VA increased the  number of Vet Centers from 232 to 292 and, according to VA, plans to  open another 8 before the end of 2011. VA also has expanded the  availability of Vet Center services through the use of approximately   70 Mobile Vet Centers—specially equipped vehicles that help bring Vet  Center counseling services to more veterans, particularly those in rural  areas. Vet Centers are often the first point of contact within VA for  veterans and, according to VA and VSO officials, can help veterans  overcome barriers to accessing mental health care. For example, many  Vet Center counselors have firsthand combat experience, which,  according to VA, helps them relate to veterans and reduce the stigma of  mental health care that veterans may experience.
Additionally, VA has expanded its use of call centers to help connect  veterans with counseling services. VA call centers are telephone-based  systems through which veterans can access free, confidential counseling  services. VA officials said that the call centers are an effective way to  reach veterans because discussions with call center staff, many of whom  are also veterans, may help callers assess whether they could benefit  from mental health care. One call center VA operates, the Veterans Crisis  Line, allows veterans and their families to call to receive multiple services,  including suicide prevention services, 24 hours a day, 7 days a week.  According to VA officials, since the Veterans Crisis Line became  operational in 2007, it has received more than 400,000 calls and referred  approximately 55,000 veterans to local VA suicide prevention  coordinators for same-day or next-day services. In addition to the  Veterans Crisis Line, VA officials told us that VA has call centers focused  on specific populations, such as combat veterans, homeless veterans,  and family members of veterans.
Moreover, VA has increased its mental health staff from about 14,000 in  fiscal year 2006 to more than 21,000 in fiscal year 2011, according to  VA. VA also has expanded the availability of telemental health services,  which allow veterans to access mental health care providers remotely  through VA medical centers, community-based outpatient clinics, and  Mobile Vet Centers. Without telemental health, according to VA, some  veterans in rural areas would have to drive as much as 5 hours to the  nearest mental health provider, potentially decreasing their access to  mental health care. To increase the availability of mental health  appointments, as of 2007, VA required its mental health clinics to begin  providing “after hours” treatment times, such as early morning, evening,  or Saturday morning treatment times, to better accommodate veterans’  schedules, including weekday school or work schedules. Additionally, as  of 2007, VA has required that all veterans with mental health referrals be  contacted within 24 hours to assess their needs; for nonemergency  situations, VA requires that veterans receive follow-up care within 14 days  of their referral.
section_title: VA Has Implemented Education Efforts to Help Connect Veterans with Mental Health Care
paragraphs: To help connect veterans with mental health care, VA has implemented  various efforts to educate veterans, veterans’ families, health care  providers, and other community stakeholders about mental health  conditions and care. VA’s efforts to help connect veterans with mental  health care include collaborations with the Department of Defense,  redesigned websites, and other technology-based education tools. VA  has collaborated with the Department of Defense to educate veterans and  active duty servicemembers returning home from deployments about VA  benefits, including mental health care, through activities such as Yellow  Ribbon Program events and postdeployment health reassessments.
According to VA officials, VA has redesigned some of its key mental  health websites—including its websites for the Office of Mental Health  Services and the National Center for PTSD—to raise awareness of and  provide convenient access to some of VA’s mental health services, such  as its call centers and resources for locating mental health providers. VA  also has developed interactive technology-based tools to help educate  veterans about how to recognize the symptoms of mental health  conditions and connect with VA mental health care, including web-based  self-help applications, mobile phone applications, and social media sites,  such as Twitter and Facebook. In addition, VA has developed tailored  efforts to educate specific groups of veterans, such as Native American  veterans and veterans with serious mental illness. (See table 4 for  examples of VA efforts to educate specific groups of veterans.)
VA also has efforts to educate veterans’ families about what veterans  may be experiencing and how to recognize the possible need for mental  health care, according to VA officials. For example, VA has a guide for  family members posted on its websites that describes common reactions  to being in war, warning signs that a veteran or servicemember might  need outside help, and where to go for help. According to VA and VSO  officials, veterans’ families are often the first to notice that the veteran is  having mental health problems and may be more successful in  encouraging the veteran to seek care.
Additionally, VA has trainings to teach its primary care physicians how to  screen veterans for mental health conditions and have discussions with  veterans about what to expect during mental health care. VA also has  trainings for its providers covering topics such as the assessment and  treatment of PTSD or military sexual trauma. According to VA, these  types of trainings are important because primary care physicians are  often a first point of contact for veterans who might benefit from VA  mental health care. Additionally, the trainings help educate mental health  care providers about evidence-based mental health practices, including  issues regarding gender differences and cultural competencies. For  example, according to VA, its National Center for PTSD offers web-based  training intended to enhance VA staff sensitivity to, and knowledge of,  specific health care needs affecting women veterans.
VA also has developed efforts to educate other community stakeholders,  including law enforcement personnel, chaplains, and employers, about  veterans’ mental health conditions and VA mental health care. For  example, VA has a program that helps law enforcement personnel  identify veterans with mental health conditions and connect these  veterans to appropriate mental health treatment options. The literature  shows that some veterans’ mental health conditions have been found to  increase their likelihood of entering or reentering the criminal justice  system. VA also has developed a series of training conferences for  chaplains and clergy to educate them to recognize the symptoms of  PTSD and other service-related mental health conditions and to refer  veterans to VA for care. According to VA, training chaplains and clergy to  recognize the symptoms of mental health conditions is important because  they are often a first point of contact for veterans in need of assistance.
To support employers who may interact with veterans who have mental  health conditions, VA has developed a set of online resources, including  information on postdeployment mental health issues and information on  mental health care available through VA.
section_title: Agency Comments
paragraphs: We provided a draft of this report to VA for comment. In its response,  which is reprinted in appendix IV, VA provided technical comments, which  we have incorporated as appropriate.
We are sending a copy of this report to the appropriate congressional  committees and the Secretary of Veterans Affairs. In addition, the report  is available at no charge on the GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine how many veterans received mental health care from the  Department of Veterans Affairs (VA) from fiscal years 2006 through 2010,  we obtained data from VA’s Northeast Program Evaluation Center  (NEPEC). NEPEC used VA’s administrative data files, which include  inpatient and outpatient files, to generate counts of the number of  veterans who received mental health care. For the purposes of this  report, we defined mental health care as the care provided to veterans  with mental health conditions. A veteran was counted as having a mental  health condition if, at any point in the fiscal year, his or her medical record  indicated at least two outpatient encounters with any mental health  diagnosis (with at least one encounter having a primary mental health  diagnosis) or an inpatient stay in which the veteran had any mental health  diagnosis. Additionally, the number of veterans represents a unique  count of veterans; veterans were counted only once, even if they received  care multiple times during a fiscal year or across the 5-year period.  NEPEC also used VA administrative data files to provide us with data on  the total number of veterans receiving any health care at VA—not just  veterans receiving mental health care. The number of veterans includes  former active duty servicemembers, including Reservists and National  Guard members.
NEPEC’s data on the number of veterans receiving mental health care  included breakouts by specific demographic groups, such as era of  service; by the type of setting where care was provided; and by the  mental health diagnostic category. For the era of service data, NEPEC  identified two groups of veterans: (1) veterans serving in the Operations  Enduring Freedom (OEF) and Iraqi Freedom (OIF) era and (2) veterans  from all other eras—including peacetime. Because OEF/OIF veterans are  not tracked separately from Persian Gulf War veterans in VA’s  administrative data files, NEPEC used Department of Defense data to  identify OEF/OIF veterans from the total population of veterans in the VA  data. The non-OEF/OIF veterans in the VA data comprised the veterans  from all other eras. Veterans who served in more than one era of service  were assigned based on their most recent era of service. NEPEC also  provided data on the settings where care was provided—that is, specialty  mental health care settings that primarily provided mental health services  or other settings that may have provided some mental health services but  focus primarily on other types of care, such as primary care. Furthermore,  NEPEC provided data on the top five mental health diagnostic  categories. The most common diagnostic categories were determined  based on the number of veterans with diagnoses included in the  diagnostic category, not the number of visits associated with the  diagnoses. To assess the reliability of the data NEPEC provided us, we  discussed with NEPEC officials their methodology and data collection  techniques used for obtaining and using the data, the data checks that  NEPEC performed, as well as any limitations officials identified in the  data. In addition, we did our own review of NEPEC’s programming and  methodological approaches using data file documentation, code book and  file dictionaries, and programming logs NEPEC officials provided. We  determined that the data were sufficiently reliable for our purposes. The  data on veterans receiving care from VA are not necessarily  representative of the entire veteran population because some veterans  receive care outside of VA.
To identify the key barriers that may hinder veterans from accessing  mental health care from VA, we searched research databases, such as  MEDLINE and PsycINFO, that included peer-reviewed journals to capture  relevant literature published on or between January 1, 2006, and   March 3, 2011. We searched these databases for articles with key words  in their titles or subject terms related to veterans, mental health, and  barriers. In addition, we also reviewed relevant literature that was cited in  articles from our original search or recommended to us during the course  of our research. To corroborate the barriers identified in the literature, we  interviewed officials from (1) several VA offices—the Office of Mental  Health Services, the Office of Mental Health Operations, the Office of  Rural Health, the Office of Research and Development, and  Readjustment Counseling Services; (2) several mental health–focused  VA research centers—the Mental Illness Research, Education and  Clinical Center, the Serious Mental Illness Treatment Resource and  Evaluation Center, the Center for Chronic Disease Outcomes Research,  and the National Center for PTSD; (3) several VA mental health and  primary care providers; and (4) a judgmental sample of veterans service  organizations (VSO). We defined “key barriers” as those that the majority  of VA and VSO officials we interviewed said could have the greatest  impact on veterans. As a result, we do not report an exhaustive list of all  possible barriers that veterans may face.
To identify the efforts VA has implemented to increase veterans’ access  to VA mental health care, we interviewed officials from the same VA  offices and mental health–focused VA research centers that we  interviewed to corroborate the barriers for veterans. We also reviewed  supporting VA documentation, such as program descriptions, policy  directives, and congressional budget justifications. We compiled a list of  efforts by focusing on the efforts that had been implemented and were  national in scope. As a result, the list of efforts we report is not an  exhaustive list of all VA efforts. In addition, we did not assess the extent  to which VA has fully implemented these efforts or their effectiveness,  including the extent to which the efforts eliminate or diminish barriers that  may hinder veterans from accessing mental health care.
We conducted our work from November 2010 to October 2011 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.
section_title: Appendix II: Number of Veterans Receiving Mental Health Care from VA by Setting and Era, Fiscal Years 2006 through 2010
subsections: section_title: Era of military service OEF/OIF
section_title: Appendix III: Number of Veterans Receiving Care from VA by Gender and Era, Fiscal Years 2006 through 2010
subsections: section_title: All other eras of service Total All veterans receiving any health care from VA
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Jennie F. Apter; Eleanor M. Cambridge; Kathleen Diamond; Lisa Motley;  Monica Perez-Nelson; Karin Wallestad; and Suzanne Worth made key  contributions to this report.