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. Author manuscript; available in PMC: 2022 Dec 23.
Published in final edited form as: Public Policy Aging Rep. 2019 Dec 27;30(1):19–23. doi: 10.1093/ppar/prz027

Mental Health and Aging Veterans: How the Veterans Health Administration Meets the Needs of Aging Veterans

Kelly A O’Malley 1,2,3,*, Latrice Vinson 4,5,6, Anica Pless Kaiser 3,7, Zachary Sager 1,2,8, Kate Hinrichs 2,9
PMCID: PMC9780779  NIHMSID: NIHMS1853993  PMID: 36570679

The Veterans Health Administration (VHA) is charged with fulfilling President Lincoln’s promise, “to care for him who shall have borne the battle, and for his widow, and his orphan,” by serving, honoring, and providing health care to America’s veterans. This mission makes the VHA unique among health-care organizations in the United States. The VHA is committed to providing care for veterans with complex medical and mental health needs. Establishing programs and methods to meet these needs while considering shifting geographic and demographic variables among veterans and medical centers has, at times, been challenging. But these challenges have provided opportunities for innovation and the exploration of ways to address and overcome barriers. This article provides an overview of the veteran population and the complexity of medical and mental health issues faced by older adults and older veterans. It examines two VHA programs that meet the complex mental health needs of aging veterans, and highlights ways that VHA policy has supported innovations that address the mental health of aging veterans.

Veteran Demographics

Recent estimates place the current living veteran population at around 19 million (Holder, 2016), consisting of approximately 389,000 World War II, 1.2 million Koreanera, 6.3 million Vietnam-era, 7.6 million Gulf War–era, and 3.5 million Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, with over 9 million veterans served by the VHA annually (Gaudet & Kligler, 2019; National Center for Veterans Analysis and Statistics, 2017). Each cohort is unique in their deployment cycles, service-related exposures (i.e., combat exposure, exposure to the wounded and dying, physical injury, environmental hazards exposures; Taylor, Ureña, & Kail, 2016), and homecoming experiences, which can influence the aging process, physical health, and mental health care needs.

Although the veteran population overall has been decreasing and is projected to continue to decrease in the coming years, the population is increasing in age. Fortyseven percent of the current veteran population is 65 years of age or older, and this number is expected to increase to 52% by 2024 (Amaral, Pollard, Mendelsohn, & Cefalu, 2018; National Center for Veterans Analysis and Statistics, 2017). This increasing age will result in a population of veterans with more complex medical and mental healthcare needs.

Aging and Mental and Physical Health

Physical and mental health have a strong bidirectional relationship, and a lack of care in one domain may result in a worsening of the other. Poor mental health is common among individuals with multiple or chronic illnesses, and chronic illness may make it difficult for older adults to manage their mental health conditions (Bergeron & Smith, 2018). Although the incidence of mental health issues is lower in older adults, 20% can experience clinically significant depression, anxiety, and stress (American Psychological Association, 2019; Karel, Gatz, & Smyer, 2012). Specific stressors associated with aging (e.g., illness, death of loved ones, sensory loss, loss of independence, ageism, financial concerns, frailty, cognitive impairment) may exacerbate or cause mental health issues (Jeon & Dunkle, 2009). In addition, diseases commonly associated with older age (e.g., cataracts, heart disease, high blood pressure, stroke) affect not only physical functioning, but can also lead to depression, anxiety, and stress (Elsawy & Higgins, 2011).

Aging Veterans

Aging veterans face similar challenges as the aging nonveteran population; however, the veteran population typically presents with greater clinical complexity (Kramarow & Pastor, 2012). The average older veteran has more diagnoses than younger veterans and non-veteran older adults. Older veterans receiving care in the VHA typically present with co-occurring medical, mental health, and substance use disorders, which can be further complicated by both symptom presentations that differ from those of younger veterans and by the presence of cognitive impairments. These complex cases are the most difficult to treat, which can lead to misdiagnosis, inefficient and ineffective treatment plans and care, worsening health, increased system costs, and low patient satisfaction (Vinson, Goodman, Hutton, & Kuykendall, 2017).

Veteran Mental Health

Large-scale studies of the prevalence of mental health issues among Vietnam veterans found that Vietnam veterans experienced similar rates of mental health issues as younger veterans (Dohrenwend et al., 2006; Jordan et al., 1991); however, rates of post-traumatic stress disorder (PTSD) vary according to the period of service. Lifetime rates of PTSD vary from 10–31%, with Vietnam-era veterans experiencing the greatest lifetime prevalence (Gradus, 2019). Despite higher rates of PTSD, older veterans are less likely to seek specialty mental health services, due to stigma, less knowledge/access to resources, and a tendency to address mental health needs in primary care (Conner et al., 2010; Pepin, Segal, & Coolidge, 2009).

Prior to 2001, trends in VHA mental health utilization remained relatively constant across cohorts of veterans (Elhai, Grubaugh, Richardson, Egede, & Creamer, 2008); however, utilization among those under the age of 40 increased dramatically (up 94%) from 2003–2011 (Quartana et al., 2014). Reasons cited for this dramatic increase were the reduced stigma about seeking help for mental health concerns, Department of Defense initiatives to promote mental health access and utilization while on active duty, VHA initiatives to increase access, greater discussion of PTSD and combat stress, and greater media attention on mental health issues in veterans (Quartana et al., 2014; Seal et al., 2010). Thus, OEF/OIF veterans are more likely to seek mental health services than Vietnam-era veterans. This willingness to seek services will likely continue as this cohort ages, and will require a system designed to support the increased care needs of the aging veteran population.

Innovative Programs to Address Clinically Complex Care in Veterans Health Administration

Access to an integrated clinical network facilitates effective referrals to mental health services and care coordination among providers. This integration improves well-being and reduces the deleterious effects of medical and mental health disorders on functioning (Bergeron & Smith, 2018). Because veterans typically present with complex medical and mental health needs (Kramarow & Pastor, 2012), the VHA identified the need to integrate mental health services into primary care and other clinics (U.S. Department of Veterans Affairs, 2008). This integration has resulted in an emphasis on team-based care, increased access to mental health services, increased patient engagement, provider satisfaction, and lower costs (Gallo et al., 2004; Torrence et al., 2014). The following section will illustrate how gaps in mental health-care services for older veterans were identified and addressed through the development and implementation of two innovative programs.

As awareness of the complex care needs of older veterans increased, a program was developed to address the systemic challenges that have historically made it difficult to adequately respond to these veterans’ needs. The Care for Patients with Complex Problems ([CP]2) Program focuses on the needs of veterans with overlapping medical, mental health, and neurocognitive and behavioral issues. The (CP)2 Program began a process of meeting these needs by identifying, disseminating, and training interdisciplinary care teams on promising practices models for managing these complex patients. The program also provides technical assistance with the implementation of best practices to meet these complex needs. The first practice model disseminated through the program was the Behavioral Recovery Outreach (BRO) Team, an interdisciplinary team that assists with transitions from VHA inpatient to community care settings. The BRO team offers behavioral planning and ongoing consultation with community sites upon discharge. Although still in the early stages, preliminary evidence suggests the BRO dissemination efforts have effectively helped to reduce costs, shorten lengths of inpatient stays, improve patient and provider satisfaction, and reduce behavioral readmission (Matthews, Vinson, DeWitt, McGuire, & Karel, 2019).

Focusing specifically on the complexity of care needs in veterans with PTSD, the VHA committed to improving care through six priorities: (1) research on biomarkers of PTSD; (2) treatment (focusing on efficiency, effectiveness, and engagement); (3) care delivery; (4) implementation; (5) updates to the conceptual understanding of PTSD; and (6) the connection between PTSD and suicide. Within these priorities, older veterans are frequently marginalized in research and treatment studies (Cook & Simiola, 2018; Dinnen, Simiola, & Cook, 2015). Similarly, there is limited empirical evidence examining the effectiveness of treatments for PTSD in older veterans. As a result, several interdisciplinary groups have been established to address the needs of older veterans affected by psychological trauma. The Stress, Health, and Aging Research Program (SHARP) consists of researchers and clinicians studying the effects of earlier life stress and trauma on mental and physical health in older veterans. The Stress & PTSD, Aging, & Resiliency Clinical Collaborative (SPARCC) is a collaboration among investigators and clinicians in the National Center for PTSD and the New England Geriatric Research Education and Clinical Center. This group focuses on the clinical care of older veterans with PTSD and improving the integration of PTSD research findings and clinical tools into care settings.

One innovative model that grew from these collaborations is Later-Adulthood Trauma Re-engagement (LATR; Davison et al., 2016). LATR describes a process of a re-emergence or exacerbation of thoughts, memories, and reminiscences of past combat or other military experiences, along with the normal challenges of aging. LATR is viewed as a process involving meaning-making, life review, and building coherence. A psychoeducational (i.e., education about PTSD, PTSD in later life, therapeutic skill building) discussion group was developed to promote the successful processing of LATR and facilitate understanding, meaning-making, and growth through psychoeducation, mindfulness, and improving coping skills (Pless Kaiser, Bower, & Moye, 2017). Still in the preliminary stages of implementation at a local level, this program shows promise in reducing emotional distress, depression, and PTSD symptoms; increasing coping, positive appraisals, and social connection; and preparing veterans to engage in evidence-based treatment for PTSD (O’Malley, Bamonti, & Pless-Kaiser, 2018).

Lastly, it should be noted that 40% of veterans live outside a 50-mile radius of VHA medical centers and that a majority of Vietnam-era veterans (i.e., the cohort with the highest lifetime rates of PTSD) live in rural areas. In order to increase access and meet needs, the VHA has begun utilizing telehealth services through the Office of Connected Care, which is also home to the Innovation Program, the VA Mobile app services, and My HealtheVet, which is a personal health record tool for veterans. The VHA leads the way in delivering mental health care using technology (i.e., telemental health; Lemle, 2018). Telemental health care has been shown to decrease psychiatric hospitalizations by 31%; be as effective for assessing, diagnosing, and treating mental health concerns as face-to-face encounters; increase access to and referrals for care; reduce PTSD symptoms; save travel time and reduce travel burdens; and be satisfying to veterans (Hilty et al., 2013; Morland et al., 2014; O’Reilly et al., 2007; Ruskin et al., 2004; U.S. Department of Veterans Affairs, 2018). Given telemental health’s efficacy and ability to increase access to care, this method of care delivery needs to be scaled up and capitalized on to meet the growing needs of older, rural veterans.

Policy Implications

Programs designed to meet the complex care needs of veterans are being developed and implemented nationwide across the VHA system. As is seen in most health-care settings, the wide dissemination of innovative, evidence-based treatments, or other mental health-care programs, does not necessarily guarantee the widespread adoption (i.e., implementation) of such programs. Every program has unique implementation and dissemination challenges (Taylor et al., 2019) that must be addressed to improve care nationwide. Active dissemination (i.e., getting materials, training, and practice into clinical settings), funding, partnerships, and ongoing support (e.g., through program champions) of the uptake and implementation of any approach or program is required to ensure active and continued use (Burgio et al., 2001), and this is particularly challenging in a large, geographically dispersed healthcare system caring for patients with complex care needs.

One approach used by the VHA to overcome these challenges is the VHA Innovators Network. The Network was designed to create a funding stream and network of program champions and VHA employees to support the implementation and dissemination of successful programs (Veterans Health Administration Organizational Excellence, 2018). In another initiative, the VHA developed a “research-operations” partnership to evaluate the dissemination and implementation of the Whole Health program (i.e., a holistic health-care approach focused on improving overall well-being; Taylor et al., 2019, p. S53). The results of this evaluation revealed several common facilitators and challenges to disseminating and implementing the initiative (for the full analysis and re-commendations, see Taylor et al., 2019), which helped inform best practices for the large-scale program implementation.

Conclusion

The VHA has a responsibility to care for the medical and mental health-care needs of veterans across service eras and a broad geographical expanse. This includes older veterans who, on average, are more clinically complex than non-veterans. Innovative programs, like those highlighted in this article, are among the few that have been developed to meet these needs, and efforts have been made to overcome barriers in the widespread implementation of these programs. Continued investment in employees, training programs, research, clinical services, technology, and infrastructure is crucial to the continued maintenance and development of programs to meet the complex care needs of aging veterans. The 2018 National Academies of Sciences, Engineering, and Medicine report of VHA mental health care concluded that the quality of care at the VHA meets or exceeds the quality of care available in the community, while caring for a complex patient population (National Academies of Sciences, Engineering, and Medicine, 2018). Despite the predictable challenges to the widespread implementation of new and innovative care programs, the VHA system remains well suited to meet the care needs of aging veterans through a culture of innovation and a commitment to providing quality care to veterans across service eras.

Acknowledgements

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System. This work was partially supported by the VA RR&D CDA-2 award (1 IK2 RX001832-01A2, Pless Kaiser, PI). The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. The authors have no financial disclosures or conflicts of interest to report.

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