Patient Care

Health Care Utilization of Veterans With Serious Mental Illness

Outreach regarding veteran-specific factors can help determine which targeted interventions reduce the need for chronic mental illness inpatient hospitalization.

Fed Pract. 2017 March;34(suppl 2):14S-19S

Author(s):

Supria K. Gill, PhD

Gopin Saini, MBBS

Rona Margaret Relova, MD

Tina Lee, MD

Sarah Yasmin, MD

Lauren Drag, PhD, ABPP

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References

1. Substance Abuse and Mental Health Services Administration. Results From the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS publication SMA 13-4805. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

2. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164(1):150-153.

3. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482.

4. Lee SE, Fonseca VP, Wolters CL, et al. Health care utilization behavior of veterans who deployed to Afghanistan and Iraq. Mil Med. 2015;180(4):374-379.

5. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023-1032.

6. Kramarow EA, Pastor PN. The health of male veterans and nonveterans aged 25-64: United States, 2007-2010. NCHS Data Brief. 2012;(101):1-8.

7. Elbogen EB, Wagner HR, Johnson SC, et al. Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv. 2013;64(2):134-141.

8. Bermudes RA, Keck PE Jr, Welge JA. The prevalence of the metabolic syndrome in psychiatric inpatients with primary psychotic and mood disorders. Psychosomatics. 2006;47(6):491-497.

9. Newcomer JW. Metabolic syndrome and mental illness. Am J Manag Care. 2007;13(7 suppl):S170-S177.

10. Toalson P, Ahmed S, Hardy T, Kabinoff G. The metabolic syndrome in patients with severe mental illnesses. Prim Care Companion J Clin Psychiatry. 2004;6(4):152-158.

11. Khatana SA, Kane J, Taveira TH, Bauer MS, Wu WC. Monitoring and prevalence rates of metabolic syndrome in military veterans with serious mental illness. PLoS One. 2011;6(4):e19298.

12. De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10(1):52-77.

13. Lambert TJ, Velakoulis D, Pantelis C. Medical comorbidity in schizophrenia. Med J Aust. 2003;178(suppl):S67-S70.

14. Osborn DP, Nazareth I, King MB. Physical activity, dietary habits, and coronary heart disease risk factor knowledge amongst people with severe mental illness: a cross sectional comparative study in primary care. Soc Psychiatry Psychiatr Epidemiol. 2007;42(10):787-793.

15. Newcomer JW. Medical risk in patients with bipolar disorder and schizophrenia. J Clin Psychiatry. 2007;67(suppl 9):25-30, discussion 36-42.

16. Chwastiak LA, Rosenheck RA, Kazis LE. Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans. Psychosomatics. 2011;52(3):230-236.

17. Cohen BE, Gima K, Bertenthal D, Kim S, Marmar CR, Seal KH. Mental health diagnoses and utilization of VA non-mental health medical services among returning Iraq and Afghanistan veterans. J Gen Intern Med. 2010;25(1):18-24.

18. Chwastiak LA, Rosenheck RA, Kazis LE. Utilization of primary care of veterans with psychiatric illness in the national Department of Veterans Affairs Health Care System. J Gen Intern Med. 2008;23(11):1835-1840.

19. VA Office of Research and Development, Health Services Research and Development Service, Quality Enhancement Research Initiative. Mental health. QUERI fact sheet. http://www.hsrd.research.va.gov/publications/internal/mh_factsheet.pdf. Published December 2008. Accessed January 13, 2017.

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24. Rosenheck R, Massari L. Wartime military service and utilization of VA health care services. Mil Med. 1993;158(4):223-228.

25. Elhai JD, Grubaugh AL, Richardson JD, Egede LE, Creamer M. Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans. J Psychiatr Res. 2008;42(10):858-867.

26. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482.

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About 10 million U.S. adults live with serious mental illness (SMI). ¹ Among military veterans, the number of mental health (MH) diagnoses is increasing with the return of troops from deployment in Iraq and Afghanistan. ^2-4 This increase has considerable implications for service use at the VA. An estimated 35% of army and marine veterans sought MH services within 1 year of returning from Iraq and Afghanistan. ⁵ Furthermore, there is an association of MH disorders, physical illnesses, and mortality rates among veterans. ^2,6 Rising MH needs will increase the need for services; not unexpectedly, the VA is one of the largest providers of integrated health care in the U.S. ⁷

Many patients with SMI have additional health issues, secondary to medication adverse effects, medical comorbidities, and other factors. ^8-12 Furthermore, their rates of preventable risk factors (eg, smoking, alcohol abuse, and poor exercise and diet ^13,14) are higher. Comorbid medical illnesses can sideline the treatment of mental illness and lead to negative health outcomes. ^15,16 These medical conditions coupled with SMI may increase overall rates of health care utilization in terms of outpatient visits, procedures, and inpatient hospitalizations. However, the literature on factors associated with health care utilization in veterans with SMI is scant and generally inconclusive.

Findings on utilization of non-MH medical services for veterans with comorbid MH diagnoses are mixed. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans with MH diagnoses have been found to use significantly more non-MH medical services than do OEF and OIF veterans without these diagnoses. ¹⁷ However, other studies have found that veterans with SMI seem to be less likely to use medical services. ^18,19 For example, in a study of the rate of medical visits for veterans with psychiatric diagnoses, veterans with SMI were found to have fewer outpatient medical visits than do other veterans without SMI. ²⁰ Given the high rates of medical comorbidities in veterans with SMI, this finding of reduced rates of medical care is both informative and concerning. However, more information on utilization rates for other types of health care system services is needed.

In addition to MH diagnoses, multiple factors influence the use of health care services. Lower income predicts overall use of mental and medical services for female but not male veterans. ²¹ A large proportion of VA patients are male, and that disparity may affect female veterans’ perceptions and use of VA health care, underscoring the importance of examining the effects of sex in health care utilization. ²² Unmarried status, unemployment, and combat experience are other factors associated with higher health care utilization. ^23,24 Sociodemographic factors, including income and possession of private health insurance, are associated with veterans’ use of VA health care services. ²⁵ It is important to understand the effects of these factors on service utilization by veterans with SMI in order to provide them with optimal, targeted health care.

The authors conducted this study to examine factors affecting MH service utilization and health outcomes in veterans with SMI at the VA Palo Alto Health Care System (VAPAHCS). A retrospective data analysis of medical records was performed. More specifically, this study aimed to identify veteran-specific variables (eg, demographics, psychiatric diagnosis, comorbid medical conditions, combat status) associated with health care utilization and outcomes in veterans with SMI. Dependent variables of interest included service utilization, such as rate and length of inpatient hospitalization and frequency of outpatient encounters. Examining predictors of inpatient medical and psychiatric hospitalization (demographic, clinical, or treatment-related factors) can provide insight into which veterans can benefit from targeted, intensive interventions. A better understanding of the factors affecting comprehensive health care service use for veterans with SMI can clarify targeted interventions and follow-up care for an expanding population.