American veterans are estimated to die by suicide at a rate 57% higher than their civilian counterparts.
The specific lived experiences of veterans and their families come with peculiar stressors. And while the data on veteran behavioral health is mixed, the elevated prevalence of suicide among veterans is undeniable. Several behavioral health organizations have or plan on creating specific services for veterans to meet an apparent need.
“Understanding the unique needs of veterans is the case in point,” Meridith Johnson, associate vice president of military affairs for Acadia Healthcare Co. Inc. (Nasdaq: ACHC), told BHB.
Franklin, Tennessee-based Acadia Healthcare is the largest behavioral health provider in the the U.S. Johnson’s duties include oversight of the Acadia military families support team, which exclusively provides and coordinates care for veterans, active-duty services members and their families.
Data from the Substance Abuse and Mental Health Services Administration shows that veterans self-report having comparable or lower rates of behavioral health issues to their non-veteran peers. These data show no major differences in rates of binge drinking, substance use disorders (SUDs), suicidal ideation or planning. They also self-report lower rates of any mental illness (AMI) in comparison to their civilian peers.
Rates of post-traumatic stress disorder (PTSD) are elevated among the veteran population, especially among those who served in the most recent Iraq and Afghanistan theaters of combat. Generally, about 7% of veterans will experience PTSD, compared to about 6% of civilians. Together, veterans of the Iraqi and Afghan conflicts have a pooled estimated PTSD rate of 10.4% and specific rates of 12.9% and 7.1%, respectively.
The specific experiences of the 18 million or so American veterans may vary widely based on their tour of duty. Still, several common experiences can lead to behavioral health issues, not all of which are directly related to combat. Veterans report a higher rate of adverse childhood experiences, for example. Moral injury, deployment stress, traumatic brain injury, abuse (including sexual assault) and the transition to civilian life also complicate the picture.
However, none of these issues can be addressed with specificity or with the proper subtlety if providers don’t ask basic questions, including about prior military service.
“The vast majority of health providers in America don’t ask their patients if they have or if someone close to them has served in the military,” Dr. Harold Kudler, a member of the American Psychiatric Association’s Veterans Affairs Caucus, told BHB. “We’ve found out that doctors don’t like questions they don’t know the answers to. They weren’t trained about this in medical school in general … Because community doctors don’t ask the question, because they’re not trained to what the resources are or what’s available, they’re not in a good position to serve veterans.”
What drives access to private providers
Increasing access to care has been a continuous and ever-evolving issue for the U.S. Department of Veterans Affairs. Much of what sends veterans to the private sector is driven by reforms contained in the Veterans Access, Choice, and Accountability Act of 2014 (Choice Act), the VA MISSION Act of 2018 and the Veterans Comprehensive Prevention, Access to Care, and Treatment (COMPACT) Act of 2020. Both are meant to expand veterans’ access to private health care providers through the Veterans Community Care Program (VCCP).
This effectively opens the door for providers to serve this population. The VCCP has historically been the exception rather than the norm. The cost of the VCCP in the federal fiscal year 2023 was $28.5 billion, nearly twice as high as in fiscal 2018, according to a working group report organized by the Veterans Health Administration. About 5%, or $1.43 billion, was spent on mental health.
“A lot of veterans don’t know where to start when it comes to getting help,” Johnson said.
Veterans may also be driven to private care sources by stigma. While in active duty, some fear that their progress through promotion or overall treatment by superiors will be different if they are known to receive care for a behavioral health issue, according to Felicia Pressley, a counselor and founder of Pressley Counseling and Wellness. She works with veterans and active duty service members.
“When a client builds rapport with you and they’re comfortable with you, they stay with you,” Pressley said.
That stigma may continue post-discharge from the service.
What private providers should do
Behavioral health insiders say organizations should bone up on their military cultural competency and build connections with local VA facilities and related veterans organizations. On the training side, several sources — including Meredith and Kudler — pointed to PsychArmor, a nonprofit organization that provides training and conducts other awareness efforts on behalf of the military community.
“Providers can understand some of the issues that veterans present and how veterans feel talking to non-military or non-VA doctors — they don’t feel understood,” Kudler said. “The best advice I can give a clinician, which I’ve taken myself, is the creative use of ignorance. You don’t have to [know everything about military history]. You can just ask a veteran, ‘Could you tell me a little bit about experience? You just need to have an open mind and not get defensive about not knowing something.”
Providers should also be prepared to handle severe issues, including crisis care and suicide response, or have the right partnerships in place to refer patients. The COMPACT Act allows veterans to seek crisis care at no cost to them in either VA or non-VA settings.
It’s possible for non-veterans to deliver quality care to veterans, Johnson said. Specialization in care and continuous training allow for the unique needs of veterans to be met. Still, where possible, it’s often preferable for veterans to treat veterans. At Acadia Healthcare, some facilities have dedicated units that are staffed by veterans.
Companies featured in this article:
Acadia Healthcare, American Psychiatric Association, Pressley Counseling and Wellness
