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United States Government Accountability Office: 
GAO: 

Report to the Ranking Member, Committee on Veterans' Affairs, House of 
Representatives: 

October 2011: 

VA Mental Health: 

Number of Veterans Receiving Care, Barriers Faced, and Efforts to 
Increase Access: 

GAO-12-12: 

GAO Highlights: 

Highlights of GAO-12-12, a report to the Ranking Member, Committee on 
Veterans’ Affairs, House of Representatives. 

Why GAO Did This Study: 

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). 

What GAO Found: 

Over the 5-year period from fiscal years 2006 through 2010, about 2.1 
million unique veterans received mental health care from VA. (See 
figure.) 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. 

Figure: Number of Veterans Who Received Mental Health Care from VA, 
Fiscal Years 2006 through 2010: 

[Refer to PDF for image: stacked vertical bar graph] 

Year: 2006; 
OEF/OIF: 34,559; 
All other veterans: 862,570; 
Total: 897,129. 

Year: 2007; 
OEF/OIF: 55,343; 
All other veterans: 897,319; 
Total: 952,662. 

Year: 2008; 
OEF/OIF: 83,947; 
All other veterans: 944,045; 
Total: 1,027,992. 

Year: 2009; 
OEF/OIF: 113,277; 
All other veterans: 1,005,370; 
Total: 1,118,646. 

Year: 2010; 
OEF/OIF: 139,167; 
All other veterans: 1,064,360; 
Total: 1,203,530. 

Number of unique veterans, fiscal years 2006 through 2010: 
OEF/OIF: 213,781; 
All other veterans: 1,846,430; 
Total: 2,060,211. 

Source: GAO analysis of NEPEC data. 

[End of figure] 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-12-12] or key 
components. For more information, contact Debra A. Draper at (202) 512-
7114 or draperd@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

More Than 2 Million Unique Veterans Received Mental Health Care from 
VA over the 5-Year Period from Fiscal Years 2006 through 2010: 

Stigma, Lack of Understanding of Mental Health, Logistical Challenges, 
and Concerns about VA May Hinder Veterans from Accessing Care: 

VA Has Implemented Several Efforts to Increase Veterans' Access to 
Mental Health Care: 

Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Number of Veterans Receiving Mental Health Care from VA 
by Setting and Era, Fiscal Years 2006 through 2010: 

Appendix III: Number of Veterans Receiving Care from VA by Gender and 
Era, Fiscal Years 2006 through 2010: 

Appendix IV: Comments from the Department of Veterans Affairs: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Veteran Eras of Military Service: 

Table 2: Five Most Common Diagnostic Categories for Veterans Receiving 
Mental Health Care from VA, Fiscal Year 2010: 

Table 3: Key Barriers That May Hinder Veterans from Accessing Mental 
Health Care from VA: 

Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans 
about VA Mental Health Care: 

Figures: 

Figure 1: Number of Veterans Who Received Mental Health Care from VA, 
Fiscal Years 2006 through 2010: 

Figure 2: Percentage of Veterans Receiving Mental Health Care from VA 
as a Percentage of the Total Number of Veterans Receiving Any Health 
Care from VA over the 5-Year Period from Fiscal Years 2006 through 
2010: 

Abbreviations: 

NEPEC: Northeast Program Evaluation Center: 

OEF: Operation Enduring Freedom: 

OIF: Operation Iraqi Freedom: 

PTSD: post-traumatic stress disorder: 

VA: Department of Veterans Affairs: 

VHA: Veterans Health Administration: 

VSO: veterans service organization: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

October 14, 2011: 

The Honorable Bob Filner: 
Ranking Member: 
Committee on Veterans' Affairs: 
House of Representatives: 

Dear Mr. Filner: 

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,[Footnote 
1] 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.[Footnote 2] Recent legislation has increased many 
OEF/OIF veterans' priority for accessing VA's health care.[Footnote 3] 

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.[Footnote 4] 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)[Footnote 5] 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. 
[Footnote 6] 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;[Footnote 7] and (4) a 
judgmental sample of VSOs.[Footnote 8] 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. 

Background: 

VA manages access to services in relation to available resources 
through a priority system established by law.[Footnote 9] The order of 
priorities is generally based on service-connected disability, income, 
or other special status, such as having been a prisoner of 
war.[Footnote 10] Additionally, Congress has stipulated that certain 
combat veterans discharged from active duty on or after January 2003 
are eligible for priority enrollment. 

VA Mental Health Care: 

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. 

Veteran Eras of Military Service: 

VA groups veterans by dates--or era--of their military service based 
on provisions in federal law.[Footnote 11] (See table 1.) 

Table 1: Veteran Eras of Military Service: 

Era of military service: World War II; 
Years: Dec. 7, 1941 - Dec. 31, 1946; 
Estimated number of living veterans, as of September 30, 2011[A]: 1.7 
million. 

Era of military service: Korea; 
Years: June 27, 1950 - Jan. 31, 1955; 
Estimated number of living veterans, as of September 30, 2011[A]: 2.3 
million. 

Era of military service: Vietnam; 
Years: Feb. 28, 1961 - May 7, 1975; 
Estimated number of living veterans, as of September 30, 2011[A]: 7.4 
million. 

Era of military service: Persian Gulf War[B]; 
Years: Aug. 2, 1990 - present; 
Estimated number of living veterans, as of September 30, 2011[A]: 3.3 
million. 

Era of military service: OEF/OIF[B]; 
Years: October 2001 - present; 
Estimated number of living veterans, as of September 30, 2011[A]: 2.6 
million. 

Era of military service: Peacetime; 
Years: Any dates outside of specified eras of service; 
Estimated number of living veterans, as of September 30, 2011[A]: 5.7 
million. 

Source: GAO analysis of 38 U.S.C. § 101 and VA VetPop2007 data. 

[A] Estimates are from VetPop2007, a VA model for estimating the 
number of living veterans using U.S. Census Bureau and Department of 
Defense data. There were an estimated 22.2 million total living 
veterans as of September 30, 2011. This total is less than the sum of 
the number of living veterans from the individual eras of military 
service because some veterans served in multiple eras. 

[B] OEF/OIF is a set of military operations that is considered part of 
the Persian Gulf War. Although most veterans who have served since 
2001 served in OEF/OIF, there are some veterans who served in the 
Persian Gulf War after 2001 who did not serve in OEF/OIF. For the 
purposes of this report, we consider OEF/OIF to be an era of military 
service, and we use the time frame corresponding to the beginning of 
OEF, the operation with the earliest start date. In addition, we 
include veterans of Operation New Dawn--the name given to combat in 
Afghanistan after September 2010--in the OEF/OIF era of military 
service. Finally, for the estimated number of living veterans, 
veterans who served in both the Persian Gulf War era and the OEF/OIF 
era are counted in the OEF/OIF era. 

[End of table] 

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. 

More Than 2 Million Unique Veterans Received Mental Health Care from 
VA over the 5-Year Period from Fiscal Years 2006 through 2010: 

Over the 5-year period from fiscal years 2006 through 2010, about 2.1 
million unique veterans received mental health care from VA.[Footnote 
12] 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 figure 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.[Footnote 
13] (See appendix II for information on the number of veterans 
receiving mental health care in specialty mental health care and other 
settings.) 

Figure 1: Number of Veterans Who Received Mental Health Care from VA, 
Fiscal Years 2006 through 2010: 

[Refer to PDF for image: stacked vertical bar graph] 

Year: 2006; 
OEF/OIF: 34,559 (4%); 
All other veterans: 862,570 (96%); 
Total: 897,129. 

Year: 2007; 
OEF/OIF: 55,343 (6%); 
All other veterans: 897,319 (94%); 
Total: 952,662. 

Year: 2008; 
OEF/OIF: 83,947 (8%); 
All other veterans: 944,045 (92%); 
Total: 1,027,992. 

Year: 2009; 
OEF/OIF: 113,277 (10%); 
All other veterans: 1,005,370 (90%); 
Total: 1,118,646. 

Year: 2010; 
OEF/OIF: 139,167 (12%); 
All other veterans: 1,064,360 (88%); 
Total: 1,203,530. 

Number of unique veterans, fiscal years 2006 through 2010: 
OEF/OIF: 213,781 (10%); 
All other veterans: 1,846,430 (90%); 
Total: 2,060,211. 

Source: GAO analysis of NEPEC data. 

Notes: 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. 

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. 

[End of figure] 

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.[Footnote 14] 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 figure 2.) 

Figure 2: Percentage of Veterans Receiving Mental Health Care from VA 
as a Percentage of the Total Number of Veterans Receiving Any Health 
Care from VA over the 5-Year Period from Fiscal Years 2006 through 
2010: 

[Refer to PDF for image: pie-chart and subcharts] 

29% of all veterans who received care from VA received mental health 
care: 
* 2,060,211 veterans received mental health care. 

38% of all OEF/OIF veterans who received care from VA received mental 
health care: 
* 213,781 OEF/OIF veterans received mental health care; 
* 346,555 OEF/OIF veterans did not receive mental health care. 

28% of all other veterans who received care from VA received mental 
health care: 
* 1,846,430 other veterans received mental health care; 
* 4,746,552 other veterans did not receive mental health care. 

Source: GAO analysis of NEPEC data. 

Notes: The number of veterans represents a unique count of veterans; 
veterans were counted only once, even if they received care multiple 
times across the 5-year period. 

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. 

[End of figure] 

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. 

Table 2: Five Most Common Diagnostic Categories for Veterans Receiving 
Mental Health Care from VA, Fiscal Year 2010: 

Diagnostic category[A]: Adjustment reaction; 
Description: A group of mental health diagnoses, including PTSD, 
characterized by an emotional and behavioral reaction that develops 
within 3 months of a life stress, and which is stronger or greater 
than what would be expected for the type of event that occurred; 
Number of OEF/OIF veterans: 109,850 (includes 96,916 with PTSD 
diagnosis); 
Number of all other veterans: 465,448 (includes 383,832 with PTSD 
diagnosis); 
Total number of veterans: 575,298 (includes 480,748 with PTSD 
diagnosis). 

Diagnostic category[A]: Depressive disorder; 
Description: A group of mental health diagnoses that reflect a sad or 
irritable mood exceeding normal sadness or grief; 
Number of OEF/OIF veterans: 57,639; 
Number of all other veterans: 477,029; 
Total number of veterans: 534,668. 

Diagnostic category[A]: Episodic mood disorder; 
Description: A group of mental health diagnoses best recognized by 
depression or mania that can have potentially severe health 
consequences; 
Number of OEF/OIF veterans: 38,715; 
Number of all other veterans: 352,651; 
Total number of veterans: 391,366. 

Diagnostic category[A]: Neurotic disorder; 
Description: A group of mental health diagnoses characterized by 
symptoms such as phobias, obsessive thoughts, and compulsive actions, 
or by losses of specific bodily functions; 
Number of OEF/OIF veterans: 45,252; 
Number of all other veterans: 343,562; 
Total number of veterans: 388,814. 

Diagnostic category[A]: Substance abuse disorder; 
Description: A group of mental health diagnoses arising from the abuse 
of alcohol or drugs; 
Number of OEF/OIF veterans: 36,797; 
Number of all other veterans: 326,417; 
Total number of veterans: 363,214. 

Source: GAO analysis of NEPEC data. 

Notes: Veterans could have more than one diagnosis; therefore the 
numbers do not add to the 1.2 million veterans receiving mental health 
care from VA in fiscal year 2010. 

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. 

[A] Diagnostic categories are based on International Classification of 
Diseases, Ninth Revision, codes. 

[End of table] 

Stigma, Lack of Understanding of Mental Health, Logistical Challenges, 
and Concerns about VA May Hinder Veterans from Accessing Care: 

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. 

Table 3: Key Barriers That May Hinder Veterans from Accessing Mental 
Health Care from VA: 

Key barrier: Stigma and beliefs about mental health care; 
Description: Veterans may have: 
* Perceptions that as a result of accessing mental health care they 
will be viewed negatively by others, such as peers or employers. For 
example, veterans may feel that by accessing mental health care they 
will be perceived as weak or having lost control; 
* Confidentiality and privacy concerns. For example, veterans may fear 
that accessing mental health care would harm their current or future 
careers; 
* Values and priorities--such as family, work, or school commitments--
that conflict with accessing treatment; 
* Perceptions that treatment may bring up painful or trauma-related 
feelings and memories they wish to avoid; 
* Perceptions that social networks--such as families or military 
communities--have values and priorities that conflict with accessing 
treatment. 

Key barrier: Lack of understanding or awareness of mental health care; 
Description: Veterans may have: 
* Lack of knowledge about VA's mental health services; 
* Lack of awareness or understanding of their mental health 
conditions. For example, veterans may have difficulty distinguishing 
their mental health symptoms from the symptoms they are experiencing 
as a result of physical injuries; 
* Perception that mental health treatment is only for people with 
extreme mental health conditions. Veterans may feel that their mental 
health conditions are not severe enough to warrant treatment or that 
resources should go to those most in need; 
* Perception that mental health treatment is unnecessary or unhelpful. 

Key barrier: Logistical challenges to accessing mental health care; 
Description: Veterans may have: 
* Difficulty scheduling appointments. For example, veterans may have 
challenges coordinating multiple appointments or perceptions that 
there is limited availability of appointments; 
* Distance and transportation challenges. For example, veterans who 
live in rural areas may have to travel long distances to obtain 
treatment; 
* Family challenges, such as arranging child care or spousal support; 
* Other logistical challenges, such as time constraints or physical or 
mental impairments that may limit the opportunity to obtain treatment. 

Key barrier: Concerns about VA's health care; 
Description: Veterans may have: 
* Perceptions that VA's programs and service options are not adequate 
to meet their needs, such as not having enough providers or not having 
enough time during appointments to discuss both health and mental 
health care needs; 
* Perceptions that VA's services are not uniform across all provider 
locations (e.g., certain programs are not available at all VA medical 
centers); 
* Perceptions that VA's services are primarily or only for someone 
else, such as older veterans, war veterans, male veterans, or veterans 
with severe disabilities; 
* Perceptions that VA does not provide quality care to veterans, does 
not treat veterans well, or is not welcoming to particular groups of 
veterans (e.g., women); 
* Reluctance to talk with a VA mental health provider. For example, 
veterans may distrust mental health providers or fear that providers 
will not understand or believe them; 
* Negative perceptions about the government or VA. 

Source: GAO's review of relevant literature published on or between 
January 1, 2006, and March 3, 2011, and corroborated by interviews 
with VA and VSO officials. 

[End of table] 

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.[Footnote 
15] 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.[Footnote 16] 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. 
[Footnote 17] 

* Gender: Female veterans may perceive some barriers to accessing 
mental health care differently than male veterans.[Footnote 18] 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.[Footnote 19] (See appendix 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.[Footnote 
20] 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.[Footnote 21] 
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 Implemented Several Efforts to Increase Veterans' Access to 
Mental Health Care: 

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 Expanded Options to Increase Veterans' Access to Mental Health 
Care: 

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. 
[Footnote 22] 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.[Footnote 
23] 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.[Footnote 24] 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.[Footnote 25] 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.[Footnote 26] 

VA Has Implemented Education Efforts to Help Connect Veterans with 
Mental Health Care: 

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. 
[Footnote 27] 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.) 

Table 4: Examples of VA Efforts to Educate Specific Groups of Veterans 
about VA Mental Health Care: 

Specific group of veterans: Native American veterans; 
Description of VA efforts: Face-to-face outreach activities, including 
visits with tribal councils. Trainings for VA staff about how to 
conduct outreach that is culturally sensitive and focused specifically 
on the needs of Native American veterans. 

Specific group of veterans: Veterans with serious mental illness; 
Description of VA efforts: Program to identify and reengage veterans 
with serious mental illness, such as schizophrenia, who have 
discontinued VA treatment. 

Specific group of veterans: Homeless veterans; 
Description of VA efforts: Educational outreach and interventions in 
community locations, such as shelters and bus stations, to help 
eligible homeless veterans access VA benefits and care. Regional Stand 
Down events that provide information and services to homeless 
veterans, including health screenings that help identify potential 
mental health conditions and referrals to VA mental health care. 

Specific group of veterans: Reservists and National Guard members; 
Description of VA efforts: VA staff presentations about eligibility 
for VA benefits, including mental health care, to Reservists and 
National Guard members at military bases. 

Specific group of veterans: Women veterans; 
Description of VA efforts: Outreach to women using websites and 
brochures describing VA's specialized mental health care for women, 
such as women-only support groups to help women veterans who have 
experienced military sexual trauma.[A] 

Specific group of veterans: Student veterans; 
Description of VA efforts: Outreach about VA's mental health services 
on college and university campuses to veterans enrolled as students. 

Source: GAO analysis of VA data. 

[A] Military sexual trauma includes both sexual harassment and sexual 
assault occurring during a servicemember's military career. 

[End of table] 

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.[Footnote 28] 

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.[Footnote 29] 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. 

Agency Comments: 

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 [hyperlink, 
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. 

Sincerely yours, 

Signed by: 

Debra A. Draper: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

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).[Footnote 30] 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.[Footnote 31] 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.[Footnote 32] 

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.[Footnote 33] 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;[Footnote 34] and (4) a 
judgmental sample of veterans service organizations (VSO).[Footnote 
35] 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. 

[End of section] 

Appendix II: Number of Veterans Receiving Mental Health Care from VA 
by Setting and Era, Fiscal Years 2006 through 2010: 

Era of military service: OEF/OIF; 
2006: 
Specialty mental health care setting: 32,235; 
Other settings: 33,123; 
2007: 
Specialty mental health care setting: 52,037; 
Other settings: 53,164; 
2008: 
Specialty mental health care setting: 78,693; 
Other settings: 81,339; 
2009: 
Specialty mental health care setting: 105,628; 
Other settings: 109,865; 
2010: 
Specialty mental health care setting: 129,399; 
Other settings: 134,970. 

Era of military service: All other eras of service; 
2006: 
Specialty mental health care setting: 701,988; 
Other settings: 845,067; 
2007: 
Specialty mental health care setting: 733,129; 
Other settings: 881,287; 
2008: 
Specialty mental health care setting: 777,718; 
Other settings: 928,956; 
2009: 
Specialty mental health care setting: 829,792; 
Other settings: 991,306; 
2010: 
Specialty mental health care setting: 885,230; 
Other settings: 1,049,819. 

Era of military service: Total; 
2006: 
Specialty mental health care setting: 734,223; 
Other settings: 878,190; 
2007: 
Specialty mental health care setting: 785,166; 
Other settings: 934,451; 
2008: 
Specialty mental health care setting: 856,411; 
Other settings: 1,010,295; 
2009: 
Specialty mental health care setting: 935,420; 
Other settings: 1,101,171; 
2010: 
Specialty mental health care setting: 1,014,629; 
Other settings: 1,184,789. 

Source: NEPEC. 

Notes: Specialty mental health settings, including mental health 
clinics, primarily provide mental health services. Other settings may 
provide some mental health services but focus primarily on other types 
of care, such as primary care. The numbers do not add to the total 
number of veterans receiving mental health care because veterans may 
have received care in both types of settings. 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 multiple times in each type of setting. 

[End of table] 

[End of section] 

Appendix III: Number of Veterans Receiving Care from VA by Gender and 
Era, Fiscal Years 2006 through 2010: 

Veterans receiving mental health care from VA: 

Era of military service: OEF/OIF; 
2006: 
Male: 29,842; 
Female: 4,717; 
2007: 
Male: 48,379; 
Female: 6,964; 
2008: 
Male: 73,776; 
Female: 10,171; 
2009: 
Male: 99,904; 
Female: 13,373; 
2010: 
Male: 122,428; 
Female: 16,739. 

Era of military service: All other eras of service; 
2006: 
Male: 800,334; 
Female: 62,236; 
2007: 
Male: 830,415; 
Female: 66,904; 
2008: 
Male: 871,230; 
Female: 72,815; 
2009: 
Male: 924,566; 
Female: 80,803; 
2010: 
Male: 975,983; 
Female: 88,380. 

Era of military service: Total; 
2006: 
Male: 830,176; 
Female: 66,953; 
2007: 
Male: 878,794; 
Female: 73,868; 
2008: 
Male: 945,006; 
Female: 82,986; 
2009: 
Male: 1,024,470; 
Female: 94,176; 
2010: 
Male: 1,098,411; 
Female: 105,119. 

All veterans receiving any health care from VA: 

Era of military service: OEF/OIF; 
2006: 
Male: 127,821; 
Female: 19,239; 
2007: 
Male: 174,644; 
Female: 25,313; 
2008: 
Male: 223,975; 
Female: 32,266; 
2009: 
Male: 280,643; 
Female: 39,190; 
2010: 
Male: 338,737; 
Female: 47,789. 

Era of military service: All other eras of service; 
2006: 
Male: 4,424,742; 
Female: 217,539; 
2007: 
Male: 4,406,149; 
Female: 224,458; 
2008: 
Male: 4,395,448; 
Female: 232,561; 
2009: 
Male: 4,465,169; 
Female: 245,299; 
2010: 
Male: 4,589,963; 
Female: 260,006. 

Era of military service: Total; 
2006: 
Male: 4,552,563; 
Female: 236,778; 
2007: 
Male: 4,580,793; 
Female: 249,771; 
2008: 
Male: 4,619,423; 
Female: 264,827; 
2009: 
Male: 4,745,812; 
Female: 284,489; 
2010: 
Male: 4,928,700; 
Female: 307,795. 

Source: NEPEC. 

Note: 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. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Department of Veterans Affairs: 

Department Of Veterans Affairs: 
Washington, DC 20420: 

September 26, 2011: 

Ms. Debra Draper: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Draper: 

The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, "VA Mental Health: Number 
of Veterans Receiving Care, Barriers Faced, and Efforts to Increase 
Access" (GAO-12-12) and is providing technical comments in the 
enclosure. 

VA appreciates the opportunity to comment on your draft report. 

Sincerely, 

Signed by: 

John R. Gingrich: 
Chief of Staff: 

Enclosure: 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Debra A. Draper, (202) 512-7114 or draperd@gao.gov: 

Staff Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] Veterans who served in active military and who were discharged or 
released under conditions other than dishonorable are generally 
eligible for VA health care. Reservists and National Guard members may 
also be eligible for VA health care if they were called to active duty 
by a federal order and completed the full period for which they were 
called. Veterans can also receive health care funded by sources other 
than VA, including private insurance, Medicare, and Medicaid. In 
general, veterans must enroll in VA health care to receive VA's 
medical benefits package--a set of services that includes a full range 
of hospital and outpatient services, prescription drugs, and 
noninstitutional long-term care services. 

[2] Military operations in Afghanistan occurring after September 2010 
are referred to as Operation New Dawn. For the purposes of this 
report, we refer to all veterans participating in military operations 
in Afghanistan as OEF veterans. 

[3] See 38 U.S.C. § 1710(a), 38 C.F.R. §§ 17.36, 17.38 (2009). Any 
veteran who has served in a combat theater after November 11, 1998, 
including OEF/OIF veterans, and who was discharged or released from 
active service on or after January 28, 2003, has up to 5 years from 
the date of the veteran's most recent discharge or release from active 
duty service to enroll in VA's health care system and receive VA 
health care services. See 38 U.S.C. § 1710(e)(1)(D), (e)(3). 

[4] See GAO, VA Health Care: Reporting of Spending and Workload for 
Mental Health Services Could Be Improved, [hyperlink, 
http://www.gao.gov/products/GAO-10-570] (Washington, D.C.: May 28, 
2010). 

[5] NEPEC is one of VA's national evaluation centers, and it evaluates 
and monitors the mental health care delivered by VA nationally. 

[6] Because providers may document a mental health diagnosis while 
providing care for a non-mental health condition, a portion of this 
care may be unrelated to a mental health condition. 

[7] The mental health and primary care providers we spoke with were 
identified by VA officials as having specific knowledge of either 
barriers to veterans accessing mental health care or efforts VA has 
implemented to increase veterans' access to VA mental health care. 

[8] We spoke with officials from eight VSOs: American Legion, American 
Veterans, Disabled American Veterans, Paralyzed Veterans of America, 
Veterans of Modern Warfare, Vietnam Veterans of America, Women 
Veterans of America, and Wounded Warrior Project. 

[9] The Veterans' Health Care Eligibility Reform Act of 1996, Pub. L. 
No. 104-262, 110 Stat. 3177, 3182, § 104 (Oct. 9, 1996), codified at 
38 U.S.C. § 1705, directed VA to establish a patient enrollment system 
to manage the provision of care and services by establishing priority 
groups and directing VA to enroll veterans in accordance with the 
priorities. 

[10] For example, in fiscal year 2010 approximately 790,000 veterans 
were identified as having service-connected mental health disorder 
disabilities. 

[11] See 38 U.S.C. § 101. 

[12] The number of veterans receiving care from VA includes eligible 
former active duty servicemembers, including Reservists and National 
Guard members. In some cases, VA also provides care to nonveterans, 
such as active duty servicemembers or veterans' dependents; however, 
nonveterans were not included in our analysis. Veterans who received 
care were counted only once, even if they received care multiple times 
during a fiscal year or across the 5-year period. 

[13] In fiscal year 2010, about 1 million veterans received mental 
health care in specialty mental health care settings and about 1.2 
million veterans received mental health care in other settings. These 
numbers do not add to the total number of veterans receiving mental 
health care in fiscal year 2010 because veterans may have received 
care in both types of settings. 

[14] Among the general U.S. population, an estimated 26 percent of 
adults experience a mental health condition in a given year. See R.C. 
Kessler, W.T. Chiu, O. Demler, K.R. Merikangas, and E.E. Walters, 
"Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in 
the National Comorbidity Survey Replication," Archives of General 
Psychiatry, vol. 62, no. 6 (2005). 

[15] Substance Abuse and Mental Health Services Administration, Office 
of Applied Studies, Results from the 2008 National Survey on Drug Use 
and Health, NSDUH Series H-36, HHS Publication No. SMA 09-4434 
(Rockville, Md.: September 2009). 

[16] See for example, M. A. Burnam et al., "Mental Health Care for 
Iraq and Afghanistan War Veterans," Health Affairs, vol. 28, no. 3 
(2009). 

[17] Westat, The National Survey of Veterans, Active Duty Service 
Members, Demobilized National Guard and Reserve Members, Family 
Members and Surviving Spouses, prepared for the Department of Veterans 
Affairs (Rockville, Md.: Oct. 18, 2010). 

[18] See for example, A. E. Street, D. Vogt, and L. Dutra, "A New 
Generation of Women Veterans: Stressors Faced by Women Deployed to 
Iraq and Afghanistan," Clinical Psychology Review, vol. 29, no. 8 
(2009). 

[19] Department of Veterans Affairs, National Center for Veterans 
Analysis and Statistics, Veteran Population Projections: FY2000 to 
FY2036 (December 2010). 

[20] See, for example, C.S. Milliken, J.L. Auchterlonie, and C.W. 
Hoge, "Longitudinal Assessment of Mental Health Problems Among Active 
and Reserve Component Soldiers Returning From the Iraq War," JAMA, 
vol. 298, no. 18 (2007). 

[21] See, for example, A. West and W.B. Weeks, "Physical and Mental 
Health and Access to Care Among Nonmetropolitan Veterans Health 
Administration Patients Younger than 65 Years," Journal of Rural 
Health, vol. 22, no. 1 (2006). 

[22] Military sexual trauma includes both sexual harassment and sexual 
assault occurring during a servicemember's military career. VA is 
required to operate a program to provide counseling and treatment for 
veterans suffering from sexual trauma under 38 U.S.C. § 1720D. 

[23] Primary care clinics in facilities that serve fewer than 1,500 
veterans can provide access to mental health professionals who may not 
be on-site, through options such as telemental health services. 

[24] The Veterans Crisis Line (1-800-273-TALK) was established as a 
partnership between VA, the Substance Abuse and Mental Health Services 
Administration, and the National Suicide Prevention Lifeline. Callers 
to this call center talk to trained counselors about their concerns 
and can be referred to VA mental health service providers in their 
area, or receive emergency interventions if necessary. This service is 
also available to veterans who visit the program's website [hyperlink, 
http://www.veteranscrisisline.net/] through online chat services. The 
Veterans Crisis Line is part of VA's Suicide Prevention Program. In 
addition to the Veterans Crisis Line, VA's Suicide Prevention Program 
also includes national outreach campaigns to educate the public about 
suicide prevention and local suicide prevention coordinators who 
provide information to veterans in their communities. 

[25] According to VA officials, these mental health staff include 
mental health providers, such as psychiatrists, psychologists, and 
social workers, as well as additional staff, such as occupational 
therapists and pharmacists. 

[26] Also in 2007, VA required its emergency rooms to have mental 
health staff available for consultation 24 hours a day, 7 days a week, 
and for its urgent care centers to have mental health providers 
available during their hours of operation. 

[27] The Yellow Ribbon Program is a Department of Defense effort to 
help Reservists and National Guard members and their families connect 
with local resources, including information on VA mental health care, 
especially during the reintegration phase that occurs months after 
servicemembers return home. Postdeployment health reassessments are a 
Department of Defense program for assessing the physical and mental 
health condition of servicemembers from 90 to 180 days after 
deployment. During these events, VA officials are present to help with 
enrollment in VA health care and to provide referrals, as necessary, 
for mental health care. 

[28] The National Center for PTSD is one of VA's Centers of 
Excellence, or communities of researchers and educational 
professionals focused on certain mental health issues. According to VA 
officials, this center identifies best practices through research, 
participates in the development of clinical practice guidelines 
describing best practices, and works to disseminate them through 
educational programs for VA mental health providers to use, among 
other activities. 

[29] For example, see H. Balshem, V. Christensen, A. Tuepker, and D. 
Kansagara, A Critical Review of the Literature Regarding Homelessness 
among Veterans, VA-ESP Project #05-225 (2011). 

[30] NEPEC is one of VA's national evaluation centers, and it 
evaluates and monitors the mental health care delivered by VA 
nationally. 

[31] Because providers may document a mental health diagnosis while 
providing care for a non-mental health condition, a portion of this 
care may be unrelated to a mental health condition. 

[32] The number of veterans does not include veterans who only 
received medications, or contract, or fee-based care. Contract and fee-
based care represent inpatient and outpatient care, respectively, that 
VA may authorize veterans to receive at non-VA health care facilities. 
VA also provides care to nonveterans such as active duty 
servicemembers and veterans' dependents; however, nonveterans were not 
included in our analysis. 

[33] NEPEC uses standardized diagnostic categories that include 
specific International Classification of Diseases, Ninth Revision, 
codes for mental health diagnoses. 

[34] The mental health and primary care providers we spoke with were 
identified by VA officials as having specific knowledge of either 
barriers to veterans accessing mental health care or efforts VA has 
implemented to increase veterans' access to VA mental health care. 

[35] We spoke with officials from eight VSOs: American Legion, 
American Veterans, Disabled American Veterans, Paralyzed Veterans of 
America, Veterans of Modern Warfare, Vietnam Veterans of America, 
Women Veterans of America, and Wounded Warrior Project. 

[End of section] 

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