If you were a veteran of the U.S. Civil War, you might have returned home injured, unable to work, and traumatized by what you had seen. As noted in your text, you would have survived a mor

GUEST EDITORIAL

The Emerging Needs of Veterans: A Call to Action for the Social Work Profession

Elizabeth Franklin

The needs of the nation's veterans are chang- ing, and as such, the profession of social work will need to adapt to the increasing

demand for our services. The U.S. Department of Veterans Affairs (VA) is the largest employer of masters-level social workers in the nation. Social workers have been serving veterans since 1926, when the first social work program in the Veterans Bureau was established. According to Manske (2008), the VA originally hired 36 hospital social workers, with the number increasing to 97 by 1930, and they treated patients with psychiatric illness and tuberculosis. Manske (2008) further stated that "in 1989, Congress elevated the VA to Cabinet status, creating the Department ofVeterans Affairs. At that time, more than 3,000 social workers were provid- ing psychosocial and mental health services at 175 VA hospitals" (p. 255).

Today, social workers offer a variety of services to veterans and their families, including resource navigation, crisis intervention, advocacy, benefit assistance, and mental health therapy for conditions such as depression, posttraumatic stress disorder (PTSD), and drug and alcohol addiction. Social workers in the VA also ensure continuity of care through admission, evaluation, treatment, and follow-up processes, and they provide assessment, crisis intervention, high-risk screening, discharge planning, case management, advocacy, and education to veterans and their families.

THE CHANGING FACE OF WAR The United States has been engaged in Operation Enduring Freedom (OEF) in Afghanistan since 2001 and in Operation Iraqi Freedom (OIF) in Iraq since 2003, with 1.64 million troops serving in these wars Oaycox & Tanielian, 2008). As of May 2008, more than 4,100 American troops had died in Iraq and Afghanistan, and 31,850 troops had been physically

wounded in the two wars (Give an Hour, 2009). In past conflicts, such as World War II, people who experienced serious physical and mental trauma often did not survive long enough to deal with the repercussions of the event. With advances in medical technology and body armor, more service members are surviving experiences that would have led to death in prior wars (Jaycox &Tanielian,2008). Nearly all U.S. soldiers wear 16-pound Interceptor body armor, and as a result, 15 out of 16 seriously wounded service members survive injuries that would have been fatal in previous wars. During the Vietnam era, only five out of eight injured soldiers survived (StigUtz & Bilmes, 2008). New casualties are emerging in the form of veterans with mental health conditions and cognitive health impairments.

Another issue of deep concern is the length of deployments and numerous redeployments facing soldiers who may already be dealing with a mental health disorder. Deployments have become longer, redeployment to combat is common, and breaks between deployments are infrequent (Jaycox & Tanielian, 2008). Williamson and Mulhall (2009) stated that

since September 11,2001, troops have regularly had their tours extended and as of June 2008, more than 638,000 troops have been deployed more than once. U.S. soldiers serving in Iraq have essentially spent their entire deployment engaged in round the clock combat operations.

According to the Army's Mental Health Advisory Team, soldiers deployed to Iraq for more than six months, or deployed more than once, are much more likely to be diagnosed with psychological injuries (Mental Health Advisory Team V, 2008). In surveys of troops redeploying to Iraq, 20 percent to 40 percent "still had symptoms of past concussions.

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including headaches, sleep problems, depression, and memory difficulties. Even after getting home, those who had deployed for longer periods are still at higher risk for PTSD" (Williamson & Mulhall, 2009).

THE EMERGING NEEDS OF VETERANS Because of the often traumatic experience of serving in combat, our nation's veterans have unique mental health needs related to PTSD, traumatic brain injury (TBI), depression, and anxiety, among other issues. By March 2008, the VA reported that more than 130,000 Iraq and Afghanistan war veterans had been diagnosed with a mental disorder by their mental health services.WiUiamson and Mulhall (2009) stated that"no one comes home from the war unchanged. But with early screening and adequate access to counseling, the psychological and neurological ef- fects of combat are treatable."

According to a RAND Corporation report re- leased in April 2008, over 18 percent of the troops who have served in Iraq and Afghanistan—nearly 300,000 service members—have symptoms of post- traumatic stress or major depression (Jaycox & Tanielian, 2008). In addition, about 19 percent of service members reported that they experienced a possible TBI. One-third of those previously de- ployed suffer from depression, PTSD, or TBI, and about 5 percent suffer symptoms of all three. Jaycox and Tanielian also reported that only 53 percent of service members with PTSD or depression had sought help over the past year.

Individuals suffering from these mental health and cognitive conditions are more likely to have other psychiatric diagnoses, are at increased risk for committing suicide, have higher rates of unhealthy behaviors (for example, smoking, overeating, engag- ing in unsafe sex), and higher rates of physical health problems (Jaycox & Tanielian, 2008). Finally, mental and brain disorders from the war could cost the U.S. economy more than $6 billion over the next two years, and RAND predicts tVt $2 billion of that could be saved if treatment is provided to the U.S. troops (Jaycox & Tanielian, 2008).

Overall, veterans make up approximately 11 percent of the general population, yet they ac- count for 26 percent of the homeless population. Women veterans are two to four times more likely than nonveteran women to be homeless (Gamache, Rosenheck, & Tessler, 2003). According to Fair- weather (2006),

approximately 600 Iraq veterans have sought homeless healthcare services from the Depart- ment of Veterans Affairs. . . . Knowing that veterans, particularly recent veterans are loath to seek help, we can safely assume that the number of Iraq veterans with unstable housing is much higher, (p. 1)

An important factor to note is that among Iraq and Afghanistan—era veterans of the active-duty military, the unemployment rate was over 8 percent in 2007, about 2 percent higher than that for their civilian peers (Williamson & Mulhall, 2009).

Those who serve in the military are also commit- ting suicide at an alarming rate. In August 2007, the Army Suicide Event Report showed that suicides were at their highest point in 26 years. Rates of suicides in the Army have increased every year since 2004, and Army suicides in 2008 were on track to surpass the prior year's record rate (Williamson & Mulhall, 2009). A CBS News investigation (Keteyian, 2007) found that veterans were twice as likely to commit suicide than nonveterans and that 120 veterans of all wars kill themselves every week—over 5,000 per year.Veterans account for 20 percent of the nation's suicides (Williamson & Mulhall, 2009).

CHALLENGES OF WOMEN VETERANS Officially, women have been serving in the U.S. military since 1901—since the Civil War as nurses— although for most of that time their service was limited to ancillary roles and was constrained by law and policy. In 1973, the Selective Service Act ended the draft, resulting in a slow but steady growth of women serving in the military, from about 2 percent to about 15 percent at the start of 2002 (Costello, Stone, & Wight, 2003).

Female veterans make up 10 percent of the sol- diers who have served in Iraq and Afghanistan. More than 160,000 female soldiers have been deployed in these two wars,compared with the 7,500 who served in Vietnam and the 41,000 who were dispatched to the Gulf War in the early 1990s (Corbett, 2007). Female veterans have a much different demographic profile than that of male veterans. They tend to be younger and have a higher education level, and a greater percentage of them are minorities (Man- ning, 2008).

Women who serve in the military must also deal with the possibility of sexual harassment, sexual as- sault, and rape. Between November 2003 and April

164 Health & Social Work VOLUME 34, NUMBER 3 AUGUST 2009

2004,83 female U.S. soldiers were raped in Iraq and Kuwait (Hackworth,2004).The U.S.Department of Defense (2008) reported 2,085 unrestricted reports of sexual assaults involving military service members in fiscal year 2007. The Service Women's Action Network (2007) stated that "thousands of service women are harassed or sexually assaulted each year. Many don't report incidents for fear that they will be ignored, exposed or punished." A unique fac- tor in the psychological trauma suffered by female troops is the threat of sexual harassment. A report published in VA Research Currents indicated that military sexual trauma leads to a 59 percent higher risk for mental health problems (VA Screenings Yield Data on Military Sexual Trauma, 2008).

As noted, women veterans are not only dealing with the repercussions of combat trauma, but many also endure the trauma associated with sexual harass- ment and abuse. More than one-third ofthe 23,635 women veterans who served in Afghanistan or Iraq and were evaluated at VA health facilities between 2002 and 2006 had a preliminary diagnosis of a mental disorder (Service Women's Action Network, 2007). Women account for 14 percent of, or a total of 27,000, recent veterans treated for PTSD (Give an Hour, 2009).

Women veterans face a host of unique challenges. Women often carry the double burden of serving in the armed forces—a stressful duty in and of itself—while simultaneously balancing marriages, motherhood, and caregiving responsibilities in their home lives. For female service members in particular, divorce rates are very high; female sol- diers face an 8.8 percent annual divorce rate, more than 2.5 times the national average (Williamson & Mulhall, 2009). Women are making extraordinary strides in the military and, while creating a more inclusive armed forces, are also changing the ways in which we must address many challenges facing our service members.

SOCIAL WORK RESPONSE Social workers employed by the VA are competent and passionate. They bring positive, sustainable change to the lives of veterans across the country. But as Meyeroif (2009) said, "Inevitably, . . . when servicemen become disabled, their first question is how soon they can get back to their unit. After a doctor has explained why they cannot return to active duty, the social worker picks up the pieces." Social workers are essential in helping veterans deal

with emotions, challenges, and navigation of new circumstances.

Social workers offer a particular skill set and knowledge base that is beneficial, if not indispensible, to veterans who may return from war with a host of challenges.Veterans are well served by social work- ers' person-in-environment perspective and their ability to solve multi-factor problems. For instance, in the VA, social work coordinates the Community Residential Care program, the oldest and most cost- effective ofthe VA's extended care programs (http:// www.socialwork.va.gov/). Another example is the seamless transition program designed to facilitate the continuous care of injured active-duty military members moving into VA hospitals. In 2006, Manske described the difficulty veterans typically have in navigating the system:"There had to be a better way, and theVA Office of Social Work Service knew that social workers could play a key role" (p. 235).The seamless transitions program includes identification of "case managers . . ., [many] of whom are social workers, to assure the health, mental health, and psychosocial needs of. .. OIF [and] OEF veterans are addressed" (Manske, 2008, p. 256). As Manske (2006) described,

the director of social work suggested assigning a full-time VA social worker to Walter Reed to serve as a liaison in helping Army social work- ers and case managers transfer severely injured or ill OIF/OEF soldiers to VA medical centers. This effort was so successful that within weeks the workload had increased to the point that a second VA social worker was needed to assist." (p. 236)

As a result of this extraordinary program,

nearly 23,000 OIF/OEF service members and veterans have received information about VA benefits, and more than 5,900 have received help with VA benefits applications. VA social workers have provided assistance to more than 15,000 OIF/OEF patients in MTFs, arrang- ing transfers for 5,399 to VA medical centers." (Manske, 2006, p. 236)

However, the current social work workforce, in almost all areas of practice, including work with veterans, cannot keep pace with demand. Our engagement in OIF and OEF has created, and will

FRANKLIN / The Emerging Needs of Veterans: A Call to Artion for the Social Work Profession 165

continue to create, a need for a more robust work- force that is ready and able to tackle new challenges. This translates into a need to recruit and retain social workers with a desire to work with veterans, much as we must recruit and retain social workers to work with our aging population, in child welfare, and in other fields. "The Department of Veterans Affairs is affiliated with over 100 Graduate Schools of Social Work, and operates the largest and most comprehensive clinical training program for social work students—training 600 to 700 students per year" (VA, 2009) .To continue our tradition of caring for veterans while keeping pace with the increasing demand for our services, this pipehne of educated and trained social workers must remain in place and continue to grow. Active-duty mihtary, veterans, and their family members deserve to have access to needed information, services, resources, and equality of opportunity.

For social workers who are not employed within the VA or in a direct practice setting providing ser- vices to veterans, another key piece to this puzzle is advocacy. NASW is increasing its leadership on this complex and changing population in terms of diversity, challenges, and changing face of war and, as such, increasing organizational advocacy on behalf of those who have served our nation in a military capacity. These activities include supporting federal legislation such as the Post-Deployment Health As- sessment Act of 2009, which would require mental health screenings for members of the armed forces who are deployed in connection with a contingency operation, and the Mihtary Domestic and Sexual Violence Response Act, which is aimed at reducing sexual assault and domestic violence involving mem- bers of the armed forces and their family members and partners. On the state and federal levels, we can advocate for job training, employment, education, and housing for our nation s veterans. Social work- ers are natural advocates, whether working with an individual client or on a legislative and policy level—and both approaches are critical.

If the social work profession is the social safety net, veterans should be the last group that we let fall through the cracks. Everyone deserves an equal opportunity to live a healthy, productive life, but because of the extraordinary commitment of our service men and women, social workers have an additional responsibility to this group in particular. It is unacceptable for our country to fail to provide every resource and service promised to those who

voluntarily sign up to protect our nation, and social workers must lead the charge with expertise and innovation to ensure that our veterans' needs are being met. GECZl

REFERENCES Army Suicide Event Report (ASER): CalendarYear

2006. (2007,August).Tacoma,WA.- Suicide Ri.sk Management and Surveillance Office, Army Behavioral Health Technology Office, Madigan Army Medical Center.

Corbett, S. (2007, March 18).The women's war. NewYork Times. Retrieved February 25, 2009, from http:// www.nytimes.com/2007/03/18/magazine/18cover. html?pagewanted= 1 &_r= 1

Costello, C. B., Stone, A. J., & Wight,V. R. (Eds.). (2003). The American woman 2003—2004: Daughters of a revolution—Young women today. NewYork: Palgrave MacmiUan.

Fairweather,A. (2006, December 7). Risk and protec- tive/actors for Iwmelessness among OIF/OEF veter- ans. Retrieved May 11,2009, from http://www. nchv.org/docs/Microsort%20Word%20-%20 Risk%20and%20Protective%20Factors%20for'Xi20 Homelessness%20among%20OIF%20Veteran.s.pdf

Gamache, G., Rosenheck, R., & Tessler, J. (2003). Over- representation of women veterans among homeless women. American Public Health, 93, 1132-1136.

Give an Hour. (2009). Press kit retrieved February 25, 2009, from http://www.giveanhour.org/

Hackworth, D. (2004). Other priorities. Retrieved February 25, 2009, from http://www.military.coni/Resources/ ResourceFileView?file=Hackworth_092404.htm

Jaycox, L. H., &Tanielian,T. (2008,April). Invisible wounds of war: Psychological and cognitive injuries, their conse- quences, and services to assist recovery. Santa Monica, CA: RAND Corporation.

Keteyian, A. (2007, November 13). Suicide epidemic among vet- erans. Retrieved February 25,2009, from http://www. cbsnews.com/blogs/2007/ll/15/primarysource/ entry3507361.shtml?source=search_story

Manning, L. (2008). Women in the military (6th ed.). Washington, DC: Women's Research and Education Institute.

Manske, J. E. (2006). Social work in the Department of Veterans Affairs: Lessons learned [National Health Line]. Health & Social Work, 31, 233-237.

Manske,J. E. (2008).Veteran services. InT. Mizrahi & L. E. Davis (Eds.-in-Chief), Encyclopedia of social work (20th ed.,Vol. 4, pp. 255-257).Washington, DC, and New York: NASW Press and Oxford University Press.

Mental Health Advisory Team V. (2008, February 14). Complete OIF and OEF overview. Retrieved Feljruary 25, 2009, from http://www.armymedicine.arniy.niil/ reports/mhat/nihat_v/MHAT_V_OIFandOEF- Redacted.pdf

MeyerofF,W.J. (2009). Social workers link veterans to a range of services. Retrieved May 7, 2009, from http:// www.mili tary.com/Careers/Content l?file= careersArticlesVeteransServices.htm&area= Reference

Service Women's Action Network. (2007). Wliat every girl needs to know about the U.S. military. Retrieved February 25,2009, from http://servicewomen.org/ projects.shtml

Stiglitz,J., & Bilmes, L. (2008). Vie three trillion dollar war. New York: W.W. Norton.

U.S. Department of Defense. (2008, March). Department of Defense FY07 report on sexual assault in the military. Washington, DC: Author.

166 Health & Social Work VOLUME 34, NUMBER 3 AUGUST 2009

u . s. Department of Veterans Affairs. (2009). VA social work home. Retrieved May 7,2009, from http://www. socialwork.va.gov/index.asp

VA screenings yield data on military sexual trauma. (2008, November/December). VA Research Currents, 1,5-6.

Williamson,V, & Mulhall, E. (2009). Invisible wounds: Psychological and neurological injuries confront a new generation of veterans. Retrieved May 11,2009, from http://iava.org/files/IAVA_invisible_wounds_0.pdf

Elizabeth Franklin, MSVi^ is project manager and lobbyist

for the Social Work Reinvestment Initiative and military and

veterans issues. National Association of Social Workers, 750 First

Street NE, Suite 700, Washington, DC 20002-4241; e-mail:

[email protected]

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The NASW Press expects authors to ad- here to ethical standards for scholarship

as articulated in the NASW Code of Ethics and Writing for the NASW Press: Information for Authors. These standards include actions such as

• taking responsibility and credit only for work they have actually performed

• honestly acknowledging the work of others

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• fully documenting their own and others' related work.

If possible breaches of ethical standards have been identified at the review or publication process, the NASW Press may notify the au- thor and bring the ethics issue to the attention ofthe appropriate professional body or other authority. Peer review confidentiality will not apply where there is evidence of plagiarism.

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Approved by NASW Board of Directors, September 1997

FRANKLIN / The Emerging Needs of Veterans: A Call to Action for the Social Work Profession 167

Reducing Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic

Karen H. Seal, MD, MPH1,2, Greg Cohen, MSW1, Daniel Bertenthal, MPH1, Beth E. Cohen, MD MAS1,2, Shira Maguen, PhD1,2, and Aaron Daley, MA1

1San Francisco VA Medical Center, San Francisco, CA, USA; 2University of California, San Francisco, San Francisco, CA, USA.

BACKGROUND: Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized. OBJECTIVE: To evaluate whether a Department of Veter- ans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psycho- social services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed. DESIGN: Retrospective cohort study using VA adminis- trative data. POPULATION: Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009. MAIN MEASURES: Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes. KEY RESULTS: After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92%versus 59%, p<0.001) and social services evaluation [77% (IC) versus 56% (UC), p<0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for≥1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics. CONCLUSIONS: Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.

KEY WORDS: veterans; mental health; health services utilization;

primary care.

J Gen Intern Med 26(10):1160–7

DOI: 10.1007/s11606-011-1746-1

© Society of General Internal Medicine 2011

INTRODUCTION

Approximately 2 million American men and women have served in the conflicts in Afghanistan (Operation Enduring Freedom, OEF) and Iraq (Operation Iraqi Freedom, OIF)1. The prevalence of mental health disorders has steadily increased: between 18.5% and 42% of OEF/OIF veterans are estimated to suffer from deployment-related mental health problems2–4. Further, mental health diagnoses in this population are typically comorbid with other mental and physical disorders5–8, resulting in a significant public health burden9–12.

Despite population-based mental health screening by the military and VA13, most OEF/OIF veterans with mental health problems, including posttraumatic stress disorder (PTSD), do not access or receive an adequate course of mental health treatment3,4,14,15. OEF/OIF veterans continue to report numerous barriers to mental health care, most notably stigma4,14,16,17. Nevertheless, OEF/OIF veterans with mental health disorders have significantly higher rates of primary care utilization than those without mental health disorders18,19.

In response, priorities were identified for VA primary care nationally20, some of which were operationalized at the San Francisco VA Medical Center (SFVAMC) in April 2007. These included: (1) monitoring rates of VA post-deployment mental health screening, (2) same-day mental health evaluations of veterans screening positive for PTSD and depression, and (3) limits on wait times for initial mental health appointments. In addition, on April 1, 2007, the SFVAMC OEF/OIF Integrated Care (IC) Clinic was established which offered integrated, co- located primary care, mental health and social services as described elsewhere and below21.

Since the establishment of the SFVAMC IC clinic in April 2007, most new OEF/OIF veteran patients initiating primary care have been scheduled for an initial IC visit, consisting of three optional 50-minute sessions with a team of primary care, mental health, and social services providers. IC providers have received training in post-deployment health, including an initial

Received January 10, 2011 Revised April 5, 2011 Accepted May 2, 2011 Published online June 7, 2011

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in-service, bi-monthly seminars on related topics (e.g. PTSD), and ongoing patient case-conferences. Due to scheduling con- straints however (i.e.: limited number of 3-hour appointment blocks with trained providers), many new OEF/OIF veteran patients have been scheduled for “usual care” (UC), consisting of a standard 1-hour intake visit with a primary care provider (PCP) who has not received specialized post-deployment training, with referrals to mental health and social services as needed.

The main aim of this study was to evaluate whether an initial IC visit (compared to a UC visit) improved mental health and social services utilization in OEF/OIF veterans entering primary care at a VA medical center. First we compared UC primary care before and after April 1, 2007 to assess whether the introduction of the aforementioned national VA priorities led to background improvements in mental health services utilization that should be considered in evaluating any additional impact of the IC clinic. We hypothesized that over and beyond background changes, OEF/ OIF veterans who had an initial IC versus UC primary care visit after April 2007 would be more likely to have received an initial mental health and social services evaluation, to have completed it in less time, and to have had a greater number of follow-upmental health visits within one year of initiating primary care.

METHODS

Setting/Intervention

This is a retrospective study based on data from the SFVAMC primary care clinics. In both the IC and UC primary care clinics, nurses conduct population-based VA post-deployment mental health and TBI screening using standard brief screens for PTSD (PC-PTSD)22, depression (PHQ-2)23, high-risk drink- ing (AUDIT-C)24,25, and TBI26. Then, in contrast to the UC clinic, where PCPs conduct a standard medical history and physical (H & P) exam, PCPs in the IC clinic conduct an H & P focused on deployment- and post-deployment-related medical and psychosocial problems. Following the PCP visit, patients in the IC clinic meet with a mental health provider, the “Post- Deployment Stress Specialist,” and social worker, the “Combat Case Manager.” Patients are informed that they may decline these additional visits.

The mental health portion of the IC visit typically consists of: (1) psychoeducation; (2) assessment of positive mental health screens and potential life-threatening problems (e.g. suicide); (3) brief intervention, if appropriate; and (4) referral for mental health treatment, if indicated. The social work visit consists of counseling about psychosocial concerns and veterans’ bene- fits. In contrast, unless a patient screens positive for PTSD or depression or makes a specific request, patients in the UC clinic are not routinely evaluated by a psychologist or social worker on the same day as their first primary care visit.

Study Population

The study population consisted of male and female OEF/OIF veterans presenting to the SFVAMC for their first primary care visit between April 1, 2005 and April 31, 2009. Because the IC clinic was established April 1, 2007, OEF/OIF veteran patients

who presented for primary care prior to April 2007 were seen in the UC clinic. Of 605 OEF/OIF veterans, we excluded 79 veterans who had already received VA mental health treatment in the 60 days prior to their first SFVAMC primary care visit. This yielded a final study population of 526 OEF/OIF veterans whose health services utilization was followed through April 31, 2010. The study was approved by the Institutional Review Boards of the University of California, San Francisco, the San Francisco VA Medical Center, and the United States Depart- ment of Defense.

Source of Data

Data for this study, including identification of the study population, sociodemographics, mental health and TBI screen results, type of primary care received (IC vs. UC) and mental health and social services utilization, were extracted from the SFVAMC Computerized Patient Record System (CPRS), and the Veterans Health Information Systems and Technology Archi- tecture (VistA). We also used the nation