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.