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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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). 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.