Save on registration for APHA 2024! Join us in Minneapolis ×

Removing Barriers to Mental Health Services for Veterans

  • Date: Nov 18 2014
  • Policy Number: 201411

Key Words: Armed Forces, Military, Mental Behavioral Health, Warfare

Rates of trauma and mental illness are disproportionately high among American veterans, especially those of the recent wars in Iraq and Afghanistan. Barriers to care after civilian reentry further disadvantage this already vulnerable population. The United States Congress and the Department of Veterans Affairs must take steps to improve access to mental health care for these veterans.

Relationship to Existing APHA Policy Statements
APHA policy resolutions support improved access to mental health care, particularly for vulnerable populations. Although APHA has issued a few policy statements on mental health, many are quite dated, and therefore APHA has called for new policy proposals to fill this gap. No existing APHA policies specifically address mental health services for veterans.

APHA policies related to mental health for general populations include the following:
•    APHA Policy Statement 7524(PP): Suicide Prevention
•    APHA Policy Statement 7501: Mental health is an Essential Part of Comprehensive Health Care Programs
•    APHA Policy Statement 9604: Accountability in the Provision of Health and Welfare Services to Persons with Mental Illness
•    APHA Policy Statement 9701: For Nondiscriminatory Coverage of All Mental Health Treatment

In addition, APHA Policy Statement 20095 (The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War) states that “[p]ractitioners, educators, and other workers in public health can play powerful roles in…mitigating the public health consequences of war.” Expanding access to high-quality mental health services among veterans is consistent with this APHA policy.[1]

Problem Statement and Evidence-Based Strategies
The wars in Iraq and Afghanistan have been the longest sustained US military operations since the Vietnam era, sending more than 2.2 million troops into battle and resulting in more than 6,600 deaths and 48,000 injuries.[2] The Army has now provided more than 1.5 million troop-years to these wars, while the Navy, Air Force, and Marines have collectively contributed another million troop-years. Between December 2008 and December 2011, the deployment time for the average soldier increased by 28%.[3]

For a variety of reasons, however, including mental health challenges, veterans are at risk of family instability, elevated rates of homelessness, and joblessness. More than a half million veterans in the United States are homeless at some time, and on any given night more than 300,000 are living on the streets or in shelters. Veterans are twice as likely as other Americans to become chronically homeless. Conversely, while veterans represent one in 10 adult civilians, they account for one in four homeless people. Although lack of education and limited transferable skills from military to civilian life are significant causes of these problems, physical and mental health problems (and lack of care for those problems) are also factors.[4]

Veterans have disproportionate rates of mental illness, particularly posttraumatic stress disorder (PTSD), substance abuse disorders, depression, anxiety, and military sexual trauma.[5] Nearly 50% of combat veterans from Iraq report that they have suffered from PTSD,[6] and close to 40% of these same veterans report “problem alcohol use”; in addition, according to estimates from 2010, approximately 22 veterans died as a result of suicide each day in that calendar year.[2,7] Studies indicate that 56% to 87% of service members experiencing psychological distress after deployment report that they did not receive psychological help.[8] Veterans face three primary problems as they attempt to access care (including care for mental health conditions):
1.    The requirement that they have either an honorable or general discharge to receive Department of Veterans Affairs (VA) benefits.
2.    The long waitlist for care, which is related to a shortage of health care providers, poor scheduling practices, and problems related to seamlessly transitioning from active-duty military care systems to the veterans’ care system.
3.    Social barriers to care-seeking behavior related to military culture.

The Veterans Health Administration operates the nation’s largest integrated health care delivery system, providing care to nearly 6 million veteran patients, and employs more than 270,000 full-time equivalent workers.[9]

To be eligible for VA medical benefits, a veteran must have been honorably discharged or released. Also, the veteran must have served in the active military, naval, or air service or must have served as a reservist or National Guard member called to active duty and completed his or her full call-up period. The rules for minimum service to be eligible for care changed after 1980. Since then, veterans must have served at least 24 continuous months, or the full period for which they were called to active duty, to be eligible. These minimum duty requirements may not apply to veterans discharged for reasons of hardship, discharged early, or discharged owing to a disability incurred or aggravated in the line of duty.  

The VA has a series of eight eligibility priority tiers to ration care because of limited budgets and capacity. Three of the eight tiers include an income eligibility requirement. Top priority goes to veterans with 50% or more disability or those who are unemployable as a result of their disability. The second tier includes those with 30% to 40% disability. Former prisoners of war and medal winners are grouped in the third tier. Veterans in lower priority tiers may not be able to access care or may face copays for many types of care services. Until 2014, VA-paid medical care was intended to be provided by a VA medical provider at a VA medical facility.[10] After a scandal involving waitlists for long-delayed care for eligible veterans, the secretary of veterans affairs was replaced in the summer of 2014,[11] and a new infusion of resources was authorized in an attempt to hire more staff as well as purchase care outside of the VA system when necessary.[12]

Once enrolled in the VA medical system, a veteran can obtain care at any VA medical facility, although not all facilities provide every type of care. The VA provides medical care to veterans through a system of medical facilities that includes 151 medical centers, 300 veterans centers, and 820 community-based outpatient clinics.[13]

If the facility where a veteran normally receives care cannot provide the care needed, referrals can be made to another VA medical facility. If the veteran requires care that no nearby VA facility can provide, the VA may cover the expense of the veteran traveling to a VA facility that can provide the necessary care, or it may make special arrangements to have the veteran treated outside the system. The tiered system is evidence of a shortage of capacity to treat all eligible veterans.[10]

There are five possible categories of military discharge: general, honorable, other than honorable (OTH), bad conduct, and dishonorable. The latter two categories are punitive and highly stigmatized, and they can be assigned only after a court martial. Veterans with these discharge characterizations are not eligible for any benefits, including health care. General, honorable, and OTH discharges are assigned by the veteran’s commanding officer. A general discharge is assigned to those who, for a variety of reasons, have not honorably completed their service. While a general discharge disqualifies veterans from GI Bill educational benefits, it is not usually a barrier to accessing health care through the VA. An OTH discharge, however, restricts access to all veterans’ benefits, including health care.[14] Discharge status is key to a veteran’s ability to access health care services and disability benefits through the VA.[15–17]

Commanding officers have considerable discretion in characterizing discharges.[18] No precise military standards guide the determination of what sorts of offenses result in a less than honorable discharge. Troops may be punished in one battalion for the same misconduct that garners a counseling statement or corrective training in a different battalion on the same installation. Furthermore, the possibility of bias or discrimination in the exercise of discretion is always cause for concern.[19]

OTH discharges can be issued for drug use, absence without leave, and/or other misconduct. Those with combat-related PTSD and other psychiatric disorders are at an elevated risk of misconduct.[20] From 2008 to 2012, the Army and Marine Corp discharged 20,000 men and women with OTH status.[16] A recent surge in less than honorable discharge characterizations has raised concern that discharge practices are becoming more punitive as the Army attempts to downsize. Army-wide, the annual number of misconduct discharges has increased by more than 25% since 2009.[21] On a positive note, however, Defense Secretary Chuck Hagel announced in fall 2014 that boards for correction of military records or naval records should “fully and carefully consider every petition based on PTSD brought by each veteran.”[22]

Veterans have two ways to appeal discharge characterizations. First, they can petition the discharge review board for their branch of service. These boards review nonpunitive discharges of former soldiers as long as the period since the discharge is less than 15 years. The discharge review board can determine whether the discharge was granted in accordance with regulatory procedures in effect at the time and can judge whether the discharge characterization was equitable. Second, veterans can appeal to their service branch’s board for correction of military records, the highest level of administrative review; the mission of these boards is to correct errors in or remove injustices from military records.[23] Unfortunately, filing these appeals can be costly and complicated, and finding qualified attorneys at reasonable prices is difficult.[24]

Many returning veterans of the recent wars exhibit behaviors that earn them OTH discharges, thus limiting their access to care that could help them modify those behaviors.[16,25] The current system is punitive in nature and precludes many mentally ill soldiers from receiving VA care.[17] By issuing OTH discharges for disorderly conduct, the military is adding to a population of mentally ill individuals who are at risk of harming the public and themselves because of their inability to access treatment.[26] To address this problem, five Vietnam combat veterans and three veterans’ organizations filed a federal class action lawsuit in 2014 seeking relief for tens of thousands of Vietnam veterans who developed PTSD during their military service and subsequently received an OTH discharge. The lawsuit challenges the Pentagon’s refusal to recognize that PTSD led to “bad paper” discharges.[27]

An additional concern for veterans exposed to high levels of violence and their aftermath is an emerging problem labeled “moral injury.” Despite strong battlefield ethics training in the rules of engagement, service members may often find it difficult to decide on the most prudent way to react to noncombatants or ambiguous actors. When enlisted personnel take (or witness the taking of) the lives of civilians, by mistake or otherwise, they often endure lasting psychological, biological, spiritual, behavioral, and social consequences. These moral injuries can result in problems that mimic PTSD but are not necessarily treatable in the same way. They can also result in behaviors leading to discharge characterizations that limit access to care.[28]

The United States Congress could remove discharge status as a prerequisite to mental health service eligibility. Furthermore, the VA could adopt a simpler mechanism for retroactive PTSD and other mental health diagnoses to reverse misconduct-related OTH discharges. In the absence of removing discharge status as a requirement for health benefits from the VA, appeals could be simpler, and advocates could be provided to support veterans in the appeal process. In addition, the problem of moral injury needs additional research to determine its role in mental health.

In a series of stories written for The Bay Citizen (Berkeley, CA) in 2012, reporter Aaron Glantz exposed massive delays within the VA in relation to the processing of disability claims, reporting that the number of veterans waiting on benefits claims had doubled to 870,000 in recent years.[29] After the Glantz series, reporters around the country exposed similar stories, culminating in a series of congressional hearings in 2014[30] and the resignation of the secretary of veterans affairs.

Reasons for excessive wait times include (1) a shortage of health care providers, (2) poor scheduling practices, and (3) problems related to seamlessly transitioning from active-duty military care systems to the veterans’ care system.[31]

The largest single barrier to timely access to care, according to a VA audit, is the lack of provider appointment slots.[31] An acute shortage of doctors in the VA, particularly in primary care, combined with a burgeoning patient population swelled by both aging veterans from the Vietnam war and younger ones who served in Iraq and Afghanistan, has led to long wait times for care. According to the VA, it is trying to fill 400 vacancies to add to its roster of primary care doctors, which numbered 5,100 in 2013.[32] According to the Pentagon’s Task Force on Mental Health, the military’s “current complement of mental health professionals is woefully inadequate.” Only about one in three soldiers and marines who screen positive for PTSD once they come home report having received mental health care in theatre.[33]

A VA audit of its scheduling practices showed that its system was “overly complicated,” resulting in “confusion among scheduling clerks and front-line supervisors.”[31] In addition, “Of the 216 site audit reports, many were flagged for further review because of concerns identified by the site audit team about questionable scheduling practices, signaling a systemic lack of integrity within some Veterans Health Administration facilities.”[31] An internal review of VA services in Phoenix revealed particularly troubling issues related to access to care. The review identified 1,700 individuals waiting for care who were not on proper waitlists, raising concerns about a “secret waitlist.” It was also reported that these veterans were “at risk of being lost or forgotten in Phoenix Health Care Systems’ convoluted scheduling practices.”[34]

When service members leave the military to become civilians again, it is important that they reestablish family connections, housing, and employment. Income replacement for new veterans who are disabled is an important step in their transition. As income is directly related to health status, this is not a peripheral issue. Disability benefits are designed to fill the gaps in loss of earning potential and quality of life that result from injuries sustained in military service. According to VA estimates, nearly 300,000 claims are in backlog status, representing more than 70% of all claims.[35,36] Without disability benefits, veterans are compelled to borrow money, go into debt, or rely on friends and family to provide financial support. The VA has stated that nearly 14% of issued disability claims are inaccurate and that these claims can take 2 years to reevaluate.[35,36] The VA’s disability backlog is a result of insufficient staffing, poor staff training, a lack of funding, and poor recordkeeping.[35]

Before a disability is approved, moreover, a veteran’s status in the VA tier system for rationing care is reduced. Ironically, a veteran can be receiving care for PTSD in the VA system, and yet his or her claim for disability related to PTSD may remain pending for a long period of time.

Another barrier to seamless reentry to civilian status is that medical records generated during active duty are not readily available to the VA health care system because the records systems of the Department of Defense and the Department of Veterans Affairs are not integrated.

VA auditors have recommended a series of strategies for reducing waiting times for care, including filling open health care provider positions, reducing turnover, improving morale, clarifying and improving policies and procedures, updating and improving scheduling software and telephone technology, and providing customer service training.[31]

As in any health system, there are two ways to resolve the shortage of VA psychiatric care personnel. One is to attract new professionals, and the other is to retain the professionals currently in employment. The federal government has demonstrated its ability to both attract and retain providers elsewhere through financial incentives and subsidies to providers. Financial-based incentive programs have shown success in placing physicians in underserved areas. The incentives offered through these initiatives include scholarships and education loans with service requirements, loan repayment programs, and direct financial incentives.[37]

The National Health Service Corps has been a successful model to induce physicians to work in rural and other underserved areas. However, that organization does not include veterans’ hospitals as allowable service sites.[38]

An evidence-based practice for improving VA health personnel retention is to reduce compassion fatigue and burnout among providers caring for vulnerable populations. Secondary trauma and compassion fatigue are significant concerns for VA staff.[39] While many VA staff members report high work satisfaction, those working with Iraq and Afghanistan veterans or individuals with traumatic brain injury and PTSD report much lower satisfaction and high levels of burnout.[40,41] Specific strategies to prevent burnout and fatigue among psychiatric care providers include conducting assessments of staff needs; providing behavioral readjustment training, psychosocial interventions to improve coping skills and attitudes, and leadership training; and identifying skills that can help providers cope with individual stressors.[42]

The VA is moving to design and implement a new medical appointment scheduling system to replace its dysfunctional patient scheduling module within the Veterans Integrated System Technology Architecture (VistA). The VA has admitted that its VistA scheduling module plays a much more fundamental role in the larger cycle of patient care and VA operations than previously disclosed. VistA not only schedules veterans’ appointments but also generates data critical to the long-term management of VA’s medical practices and finances. It is important that the new scheduling system be designed and implemented well.[43]

To reduce the disability claims backlog, the VA should streamline its systems and/or hire more claims personnel. Congress should fund the VA a full year in advance so that it can plan on a steady stream of revenue, and the veterans’ benefits office should modify its adversarial culture by integrating customer service and delivery best practices. Continued pressure and oversight from Congress will help, along with ongoing technological innovations.[35,44] Within the VA’s current structure, proposed evidence-based strategies include increasing training for regional office personnel and staff attorneys and using employee incentive programs to increase motivation and productivity.[45]

In 2009, the VA announced a system to build a single electronic records platform to integrate veteran records from the Department of Defense, the VA, and the private sector.[46] When this record system is operational, it should serve to reduce the gaps in care that occur for newly separated service members between active status and veteran status.

Military culture promotes inner strength, self-reliance, and the ability to shake off injury, contributing heavily to stigma surrounding mental health issues.[47] Commanders are under enormous pressure to deploy their units at full strength. If soldiers are unprepared to deploy, units deploy to the field with insufficient resources. Thus, commanders face incentives to push personnel to deploy, even in the absence of full mental or physical health. These incentive structures contribute to maintenance of the military culture status quo.[48]

Stigma creates a reluctance to seek help and a fear of negative social consequences, and these barriers to care have been characterized as more important than institutional barriers in the VA system.[33,49–51] No more than 40% of soldiers with mental health problems use mental health services, and as few as half of those who seek care follow through on clinical referrals.[52] This could in large part be attributable to stigma. Nearly one in four veterans who have screened positive for mental illness state that they did not seek care because their leaders discouraged the use of mental health services.[33]

The most often cited reason for why people do not seek counseling and other mental health services is the stigma associated with mental illness and seeking treatment.[53] Stigma can decrease the likelihood that an individual will seek services even when the potential consequences of not doing so (e.g., increased suffering) are severe. In fact, in April 2002, during the launching of the New Freedom Commission on Mental Health, President George W. Bush declared that the stigma that surrounds mental illness is the major obstacle to Americans getting the quality mental health care they deserve. This is consistent with the 1999 surgeon general’s report on mental health.[54] According to that report, fear of stigmatization deters individuals from acknowledging their illness, seeking help, and remaining in treatment, thus creating unnecessary suffering. The New Freedom Commission and the surgeon general’s report stress the importance of better understanding the role of stigma in seeking care so that efforts to reduce stigma can be implemented. Self-stigma predicts less positive attitudes toward seeking treatment and mediates the relationship between public stigma and care-seeking attitudes.[49]

The VA has adopted the term military sexual trauma (MST) to refer to severe or threatening forms of sexual harassment and sexual assault sustained in military service, usually at the hands of fellow service members. Because of widespread exposures to MST, the VA now screens for these exposures. According to one study, approximately 22% of screened veteran women reported MST during 2002–2003, representing 29,418 patients,[55] and in another study nearly a third of female veterans reported having been sexually assaulted or raped while in the military, a significant indicator of high cultural tolerance for this crime.[56]

To decrease self-perceptions of stigma, experts recommend motivational interviewing and altering individual attitudes toward seeking help.[57] A 2012 randomized controlled trial involving Iraq and Afghanistan veterans showed that, at 8 weeks, veterans randomized to receive telephone-based motivational interviewing were more likely to report significantly decreased self-stigma regarding mental health treatment and increased intentions to engage in treatment.[58] Internet-based counseling has also been shown to decrease self-stigma, increase intentions to engage in mental health treatment, and reduce PTSD, depression, and anxiety symptoms among Iraq and Afghanistan veterans.[59] Education, outreach, and awareness campaigns are evidence-based strategies that reduce public stigma. Although most evidence about the efficacy of education and awareness campaigns in reducing stigma is derived from nonmilitary population studies, models proposed for these populations may be applicable to military members as well.[49] Local and national mental health campaigns have historically been effective in educating the public and bringing about cultural shifts.[60,61]

One evidence-based strategy to reduce stigma within military populations is conceptualizing mental health care as an extension of military training. Research suggests that standardizing mental health care as a component of military training may reduce the stigma associated with seeking treatment. Increased military unit support, which can help decrease stigma and barriers to mental health care, is another way to improve the mental health of active-duty personnel. Unit support is an important component of soldiers’ psychological well-being, and strong unit support has been associated with low levels of PTSD among Iraq veterans. Increasing mental health education among unit leaders is also suggested to decrease stigma.[62,63]

Attending to the mental health of veterans through an integrated primary health care model can reduce stigma as well. Trials of models in which mental health care is incorporated into primary care have demonstrated effectiveness. Such models also contribute to stigma reduction because veterans do not experience fear of being singled out as needing mental health treatment. For similar reasons, providing veterans with the option of receiving mental health care outside of the VA can reduce self-stigma and lead to an increased willingness to seek treatment.[64,65]

Alternative Strategies
APHA recommends programmatic and evidence-based strategies to improve access to health care among veterans. Some alternatives to the strategies proposed here include the following.
1.    Service members’ exposure to combat and traumatic violence could be reduced through significant decreases in militarism and entry into international conflict situations. Preventing war would be an effective strategy for protecting service members and veterans from war-related disability.[66] While APHA has endorsed this approach, we recognize that its implementation will take some time.[1] Moreover, even if we successfully prevent the next war, there are still many veterans who remain in need of care.
2.    Imposing a military draft could create a larger pool of eligible service members for military conflict engagements, thus limiting the reliance on fewer people whose own exposures are therefore prolonged. A draft would create more equitable social and racial representation in the armed forces, increase public scrutiny of US international commitments, augment mobilized active forces, and lower costs.[67] APHA has not taken a position on this controversial topic.
3.    Some partisans have called for privatizing VA services, allowing veterans to seek care in their communities for all service-related and non-service-related health problems.[68,69] APHA does not endorse this strategy, as there is insufficient evidence that it would improve care for veterans; in addition, it would create inefficiencies and reduce access to important epidemiological data.[70]
4.    California’s Department of Veteran Affairs reached an agreement with the VA in 2013 to hire state-employed limited-term claims personnel to work in regional offices with the VA to process backlogged claims.[71] At least one former high-ranking VA official believes that the VA does not have the capability to eliminate the backlog on its own and therefore recommends state intervention as a viable alternative.[72] APHA will monitor evidence of the efficacy of state involvement in improving claims processing within a federal agency.

Opposing Arguments
Opposing arguments fall under four areas: (1) general cost concerns, (2) issues related to discharge characterizations, (3) the long waitlist for care and transitions from active-duty veteran care systems, and (4) social barriers to care seeking related to military culture.

The costs of providing a full complement of physical and mental health care services to veterans returning from America’s longest wars are high.[73] Furthermore, the science of mental health diagnostics and treatment is not as evolved as that for physical health, resulting in a great deal of ambiguity about the distinctions among behavioral choices, personality, and mental health status. An argument could be made that, in the context of this murky territory, demand for mental health services could constitute a “bottomless pit,” committing taxpayers to unending costs for unending treatment.[74]

APHA counters that American law requires employers and state workers’ compensation systems in the civilian sector to be responsible for on-the-job injuries, regardless of the cost.[75] Service members who were promised care if they risked their lives and health in dangerous military engagements deserve no less.

Defenders of providing full medical benefits only to veterans with an honorable discharge or higher argue that this ensures resources are reserved for veterans of good standing. In addition, they argue that providing services to veterans whose behaviors resulted in their less than honorable discharge status encourages misconduct and is disrespectful of veterans who served honorably. Furthermore, an argument can be made that military commanders need the power to determine a service member’s discharge characterization as a motivation to encourage good order in the military.

APHA counters that American law requires employers in the civilian sector to be responsible for on-the-job injuries, regardless of whether the employee’s service was characterized as deserving.[75] Service members who have been exposed to significant violence, trauma, and stress often manifest behaviors that result in less than honorable discharge characterizations; these behaviors are frequently caused by their exposures. Punishing veterans for behaviors resulting from their wartime exposures constitutes a double injury.

During a time of health workforce shortages associated with the US Patient Protection and Affordable Care Act, it could be argued that attracting health personnel away from the general pool of health workers to work in the VA system would undermine the larger health system. Moreover, the cost of hiring additional health workers would place a higher burden on taxpayers.

There is wide consensus that the disability claims backlog is failing to provide veterans with the benefits they have been promised and have earned through their service. While there is little dispute that the disability backlog is a primary concern, some argue that the VA does not have the ability to oversee and manage any significant decrease in the backlog, and therefore Congress should not increase funding to a broken system.[72]

APHA counters that as we work our way toward a more rational and efficient single-payer health system in America, it is important to maintain strong health care delivery systems that can serve as models for providing care to large populations. Furthermore, it is unconscionable to deny veterans the benefits they deserve.

Without the current military culture, many argue, America’s commitment to winning wars and defending US interests abroad is threatened. Providing additional levels of cognitive care for veterans suffering from mental health problems (e.g., motivational interviewing), while efficacious, is very expensive. Reliance on pharmaceuticals is within acceptable standards of care, some argue, and they go on to claim that it is both cheaper and a reasonable alternative to hiring a larger mental health workforce.

APHA counters that military culture seems to generate stigma toward seeking mental health care among service members and veterans. Individuals who need care but fail to seek it are endangering their health and the well-being of the communities in which they live. Veterans have earned the right to high-quality mental health care.

Action Steps
Given its concern about the health of millions of veterans, APHA recommends the following actions in each of three designated problem areas.

Discharge characterizations:
•    The Department of Veterans Affairs should discontinue using discharge status as a criterion for determining mental health care coverage.

Wait times for care:
•    The US Congress should fully fund the needs of veterans in Department of Veterans Affairs programs.
•    The Department of Veterans Affairs should improve retention and recruitment of health personnel in the VA health system and consider including veteran care facilities in the National Health Service Corps.
•    In cases in which VA services are not able to meet demands for care, services should be made available through licensed mental health providers external to the agency, which may require upgrading reimbursements for services.
•    The US Congress should fund and the Department of Veterans Affairs should process the veteran disability claims backlog; one strategy would be to recognize that if the VA health system is treating a veteran for a health problem, this is an indicator that the problem exists and represents evidence of disability for the disability claims program.
•    State and local jurisdictions should sponsor programs to support veterans; for example, King County in Washington has a property tax levy that generates funding to assist veterans.[76].
•    The Department of Veterans Affairs should improve the appointment scheduling process in the VA health system.
•    The Department of Veterans Affairs should integrate its information system with the Department of Defense system to ensure continuity of care for service members; in addition, it should employ electronic medical records.

Military cultural climate in relation to mental health:
•    All military jurisdictions should increase the involvement of rank-and-file veterans and military personnel in formulating veteran health care policies.
•    All branches of the military and the Department of Veterans Affairs should reduce mental health stigma, starting with basic training.
•    The Department of Veterans Affairs and the Department of Defense should incorporate mental health care and mental health awareness as a component of training for all ranks of the military.
•    The Department of Veterans Affairs should integrate provision of mental health services into the primary care system and provide more cognitive care as a supplement to psychiatric pharmaceuticals.
•    The Department of Veterans Affairs should finance academic research on stigma, military sexual trauma, moral injury, and military culture.
•    Branches of the military should limit the types, duration, and frequency of deployment assignments for service members, especially those at most risk of mental health sequelae.
•    Executive Order 13625, “Improving Access to Mental Health Services for Veterans, Service Members, and Military Families,” should be fully implemented.

1. American Public Health Association. Policy Statement 20095. Available at: Accessed January 20, 2015.
2. Institute of Medicine. Returning Home from Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: National Academies Press; 2013.
3. Baiocchi D. Measuring Army Deployments to Iraq and Afghanistan. Santa Monica, CA: Rand Corporation; 2013.
4. National Coalition for Homeless Veterans. Research briefs. Available at: Accessed January 20, 2015.
5. Spelman JF, Hunt SC, Seal, KH, Burgo-Black AL. Post deployment care for returning combat veterans. J Gen Intern Med. 2012; 27:1200–1209.
6. Pew Research Center. The military-civilian gap: war and sacrifice in the post-9/11 era. Available at: Accessed January 20, 2015.
7. Kemp J, Bossarte R. Suicide data report, 2012. Available at: Accessed January 20, 2015.
8. Blais RK, Renshaw KD. Stigma and demographic correlates of help-seeking intentions in returning service members. J Trauma Stress. 2013;26:77–85.
9. Panangala SV, Bagalman E. Health care for veterans: answers to frequently asked questions. Available at: Accessed January 20, 2015.
10. Matthews JL. VA medical benefits. Available at: Accessed January 20, 2015.
11. Shear MD, Oppel RA. VA chief resigns in face of furor on delayed care. Available at: Accessed January 20, 2015.
12. Senate unanimously approves McDonald to lead the VA. Available at: Accessed January 20, 2015.
13. Griffin RJ. Statement of the acting inspector general of the Department of Veterans Affairs before the Committee on Veterans Affairs hearing on “The State of VA Health Care.” Available at: Accessed January 20, 2015.
14. Newman L. Types of military discharge. Available at: Accessed January 20, 2015.
15. Dao J. Vietnam veterans, claiming PTSD, sue for better discharges. Available at: Accessed January 20, 2015.
16. Bernton H. Troubled veterans left without health-care benefits. Available at: Accessed January 20, 2015.
17. Seamone E. Reclaiming the rehabilitative ethic in military justice: the suspended punitive discharge as a method to treat military offenders with PTSD and TBI and reduce recidivism. Mil Law Rev. 2011;208:1959–1981.
18. The commander’s role in the military justice system. Available at: Accessed January 20, 2015.
19. Brooker J, Seamone E, Rogall L. Understanding VA’s evaluation of a former servicemember’s benefit eligibility following involuntary or punitive discharge from the armed forces. Available at: Accessed January 20, 2015.
20. Highfill-McRoy RM, Larson G, Booth-Kewley S, Garland C. Psychiatric diagnoses and punishment for misconduct: the effects of PTSD in combat-deployed marines. BMC Psychiatry. 2010;10:88.
21. Philipps D. Surge in discharges includes wounded soldiers. Available at: Accessed January 20, 2015.
22. Philpott T. Discharge upgrades may be possible for vets with PTSD. Available at: Accessed January 20, 2015.
23. Army Review Boards Agency. Army Discharge Review Board homepage. Available at: Accessed January 20, 2015.
24. Veterans for America. American veterans and servicemembers survival guide. Available at: Accessed January 20, 2015.
25. Chapman TM. Leave no soldier behind: ensuring access to health care for PTSD-afflicted veterans. Mil Law Rev. 2010;204:1–50.
26. Markowitz FE. Mental illness, crime, and violence: risk, context, and social control. Aggression Viol Behav. 2011;16:36–44.
27. Yale Law School Legal Services Clinic. YLS clinic files nationwide class action lawsuit on behalf of Vietnam veterans with PTSD. Available at: Accessed January 20, 2015.
28. Litz BT, Stein N, Delaney E. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29:695–706.
29. Glantz A. Returning home to battle. Available at: Accessed January 20, 2015.
30. House Committee on Veterans’ Affairs. A continued assessment of delays in VA medical care and preventable veteran deaths. Available at: Accessed January 20, 2015.
31. Access Audit System—Wide Review of Access: Results of Access Audit Conducted May 12, 2014, Through June 3, 2014. Washington, DC: US Department of Veterans Affairs; 2014.
32. Oppel R, Goodnough A. Doctor shortage is cited in delays at VA hospitals. Available at: Accessed January 20, 2015.
33. Williamson V, Mulhall E. Invisible wounds: psychological and neurological injuries confront a new generation of veterans. Available at: Accessed January 20, 2015.
34. Veterans Health Administration. Review of patient wait times, scheduling practices, and alleged patient deaths at the Phoenix VA Health Care System. Available at: Accessed January 20, 2015.
35. 2013 Policy Agenda: The New Greatest Generation. Washington, DC: Iraq and Afghanistan Veterans of America; 2013.
36. US Department of Veterans Affairs. Monday morning workload reports. Available at: Accessed January 20, 2015.
37. Bärnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: a systematic review. BMC Health Serv Res. 2009; 9:86.
38. Saxton JF, Johns MME. Grow the US National Health Service Corps. JAMA. 2009;301:1925–1926.
39. Salyers MP, Rollins L, Kelly YF, Lysaker PH, Williams JR. Job satisfaction and burnout among VA and community mental health workers. Adm Policy Ment Health. 2013;40:69–75.
40. Beder J, Postiglione P, Strolin-Goltzman J. Social work in the Veterans Administration hospital system: impact of the work. Soc Work Health Care. 2012;51:661–679.
41. Morse G, Salyers MP, Rollins AL, Monroe-DeVita M, Pfahler C. Burnout in mental health services: a review of the problem and its remediation. Adm Policy Ment Health. 2012;39:341–352.
42. Finn S, Jones T, Morton BC. VA’s duty to assist in the context of PTSD stressor verification: what must VA do to fulfill the Veterans Claims Assistance Act of 2000? Available at: Accessed January 20, 2015.
43. Verton D. VA poised to kick-off contract for new scheduling system. Available at: Accessed January 20, 2015.
44. Carter P. upholding the promise: supporting veterans and military personnel in the next four years. Available at: Accessed January 20, 2015.
45. Terry J. Report of the chairman: Board of Veterans’ Appeals, 2006. Available at: Accessed January 20, 2015.
46. Office of the Under Secretary of Defense. Virtual lifetime electronic record. Available at: Accessed January 20, 2015.
47. Burnam MA, Meredith LS, Tanjelian, Jaycox LH. Mental health care for Iraq and Afghanistan war veterans. Health Aff (Millwood). 2009;28:771–782.
48. Iraq Veterans Against the War. Operation Recovery: the Fort Hood testimony report, 2011–2013. Available at: Accessed January 20, 2015.
49. Held P, Owens GP. Stigmas and attitudes toward seeking mental health treatment in a sample of veterans and active duty service members. Traumatology. 2013;19:136–143.
50. Hoge C. Interventions for war-related posttraumatic stress disorder. JAMA. 2013;306:549–551.
51. Lineberry TW, O’Connor SS. Suicide in the US Army. Mayo Clin Proc. 2012;87:871–878.
52. Quartana PJ, Wilk JE, Thomas JL, et al. Trends in mental health services utilization and stigma in US soldiers from 2002 to 2011. Am J Public Health. 2014;104:1671–1679.
53. Corrigan P. How stigma interferes with mental health care. Am Psychol. 2004;59:614–625.
54. Satcher D. Mental health: a report of the surgeon general. Available at: Accessed January 20, 2015.
55. Kimerling R, Gima K, Smith MW, Street A, Frayne S. The Veterans Health Administration and military sexual trauma. Am J Public Health. 2007;97:2160–2166.
56. Natelson R. A case for federal oversight of military sexual harassment. J Poverty Law Policy. 2009;43:277.
57. Van Voorhees BW, Gollan J, Fogel J. Pilot study of Internet-based early intervention for combat-related mental distress. J Rehabil Res Dev. 2012;49:1175–1190.
58. Seal KH, Abadjia L, McCamish N, et al. A randomized controlled trial of telephone motivational interviewing to enhance mental health treatment engagement in Iraq and Afghanistan veterans. Gen Hosp Psychiatry. 2012;34:450–459.
59. Zinzow HM. Connecting active duty and returning veterans to mental health treatment: interventions and treatment adaptations that may reduce barriers to care. Clin Psychol Rev. 2012;32:741–753.
60. Kotler P. Social marketing: an approach to planned social change. J Marketing. 1971;35:3–12.
61. Ad Council. Public service advertising that changed a nation. Available at: Accessed January 20, 2015.
62. Blount TH, Cigrang JA, Foa EB, Ford HL, Peterson AL. Intensive outpatient prolonged exposure for combat-related PTSD: a case study. Cogn Behav Pract. 2014;21:89–96.
63. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr Serv. 2009;60:1118–1122.
64. Shim R, Rust G. Primary care, behavioral health, and public health: partners in reducing mental health stigma. Am Journal Public Health. 2013;103:774–776.
65. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan: mental health problems and barriers to care. US Army Med Dep J. July–September 2008:7–17.
66. Levy BS, Sidel VW. War and Public Health. New York, NY: Oxford University Press; 2008.
67. Military Draft: Potential Impacts and Other Issues. Washington, DC: US Government Accountability Office; 1988.
68. Morrissey E. McCain: time to privatize ordinary health care at the VA. Available at: Accessed January 20, 2015.
69. Volsky I. Boehner suggests privatizing the VA: “I still like the idea, and especially now.” Available at: Accessed January 20, 2015.
70. Himmelstein DU, Woolhandler S. Privatization in a publicly funded health care system: the U.S. experience. Int J Health Serv. 2008;38:407–419.
71. California Department of Veteran Affairs. CalVet hiring veterans claims representatives to help ease VA claims backlog. Available at: 2013. Accessed January 20, 2015.
72. Lucas F. A former top VA executive offers his perspective on what went wrong. Available at: Accessed January 20, 2015.
73. Stiglitz J, Blimes L. The Three Trillion Dollar War: The True Cost of the Iraq Conflict. New York, NY: WW Norton; 2008.
74. Miller JE. In harm’s way: the imminent financial threat to mental health care services in Medicaid programs. Available at: Accessed January 20, 2015.
75. Occupational Safety and Health Administration. Employer responsibilities. Available at: https:// Accessed January 20, 2015.
76. King County Community and Human Services. King County veterans and human services levy. Available at: Accessed January 20, 2015.