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9 Access to Care
Pages 339-362

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From page 339...
... The chapter first provides an overview of the types of barriers to high-quality PTSD care followed by a historical overview of research on barriers to and facilitators of PTSD treatment and related comorbid conditions for veterans in previous wars, beginning with Vietnam. The chapter then reviews the empirical literature on barriers to and facilitators of care, distinguishing between barriers experienced by service members and veterans in three markedly different health care service delivery environments: in the theater of war, in military treatment facilities in the United States, and in the Department of Veteran Affairs (VA)
From page 340...
... For example, patient barriers could include concern about the employment effects of seeking treatment for PTSD, a perception that mental health care is ineffective, a lack of information on resources for care, financial concerns, and logistical problems, such as travel distance (Hoge et al., 2004, 2006; Milliken et al., 2007; Warner et al., 2011)
From page 341...
... Some treatments, however, such as prolonged exposure therapy, are effective for both PTSD and for frequently co-occurring conditions such as depression, other anxiety disorders, alcohol and drug use disorders, and mild traumatic brain injury (TBI)
From page 342...
... They also identified more tacit barriers, such as lack of provider recognition of the symptom complex as a diagnosable entity and reluctance of patients to discuss their illness. Embedding mental health treatment in primary care settings might help to ameliorate specific barriers, particularly the stigma associated with presenting to specialty mental health settings (IOM, 2000)
From page 343...
... The authors concluded that both the VA and the DoD should undertake substantial efforts to monitor and enhance the quality of care received by patients who have PTSD. In the Department of Defense As discussed in Chapter 4, service members and veterans who have PTSD live, work, and receive mental health care in various settings, ranging from combat zones to specialized PTSD treatment facilities in the VA.
From page 344...
... The series of reports documents improvements in access to mental health treatment in combat settings and the increased need for this treatment for service members who have had multiple deployments. The MHAT reports also show there is persistent stigma and logistical barriers to accessing PTSD care for service members in the theater of war.
From page 345...
... Mental health providers noted that outreach efforts had been successful in providing behavioral health services outside combat stress control unit locations. Multiple barriers to telehealth delivery were noted by service members and mental health providers (MHAT VII, 2011a,b)
From page 346...
... (2007) found that 20.3% of active-duty and 42.4% of reserve component soldiers required mental health treatment based on their responses to the post-deployment health assessment (PDHA)
From page 347...
... Multiple reports have raised concerns about access to and adequacy of mental health services available from TRICARE contract network providers, including the availability of providers who are willing to see TRICARE beneficiaries, the familiarity of TRICARE mental health providers with military culture, and the training and expertise of TRICARE mental health providers (APA, 2007; DoD, 2007; IOM, 2010)
From page 348...
... Although these two studies are small, they could serve as a model for assessing barriers to PTSD care in the VA. In 2011, the GAO identified four key barriers that might prevent veterans from seeking mental health care at VA facilities: stigma and beliefs about mental health care, lack of understanding or awareness of mental health care, logistical challenges to accessing mental health care, and concerns about VA health care in general (GAO, 2011b)
From page 349...
... The VA has trained over 4,000 clinicians who provide care in many settings (such as specialized programs, mental health clinics, and Vet Centers)
From page 350...
... Pharmacologic treatment for PTSD can be prescribed by clinicians in multiple venues -- including specialized programs, mental health clinics, and primary care practices -- and pharmacologic training must be broadly implemented for these providers. Similar challenges to and solutions for training VA providers in evidence-based treatments for PTSD may be applicable to DoD mental health care.
From page 351...
... That progress should be followed by timely access to evidence-based care that integrates evidence-based treatments into a stepped-care, multimodal treatment plan, for example, combining cognitive behavioral therapy with couples therapy. During early engagements with service members or veterans, mental health providers need to be able to treat those who are in crisis while assessing the need for long-term, evidence-based treatment.
From page 352...
... that assess the efficacy, effectiveness, and implementation of treatment methods and lead to wider dissemination of evidenced-based approaches; and identification and implementation of ways to enhance health care dissemination and delivery for military personnel and their families in ways that provide better awareness of and access to care while reducing stigma. Telemental Health-Based Interventions Telemental health (TMH or telemedicine)
From page 353...
... . Several uncontrolled studies have indicated that telemedicine has resulted in a reduction in PTSD symptoms in veterans (Deitsch et al., 2000; Germain et al., 2009; Morland et al., 2004)
From page 354...
... However, both groups of authors concluded that more evidence is needed on the effectiveness of these approaches for specific mental health diagnoses, such as depression and anxiety disorders. Future research on such Internet-based therapies as DE-STRESS, Interapy, and SHTC should focus on the effectiveness of CBT techniques delivered online to more severely traumatized populations, factoring in ethical and legal considerations regarding the amount of provider contact (Tate and Zabinski, 2004)
From page 355...
... (2009) report that several telemedicine services for mental health care have been operating for more than 12 years, such as Virginia's Appal-Link network, South Australia's Rural and Remote Mental Health Service, and services at the University of Arizona; the University of California, Davis; the University of Michigan; and the University of Nebraska.
From page 356...
... In phase 2, the committee will continue to assess barriers to PTSD care, including barriers that are sex specific, race specific, or ethnicity specific. The committee believes that a sound conceptual framework that comprehensively elucidates barriers to and facilitators of access to high-quality PTSD services can result in effective change.
From page 357...
... 2007a. US Department of Vet erans Affairs disability policies for posttraumatic stress disorder: Administrative trends and implications for treatment, rehabilitation, and research.
From page 358...
... 2010. Dissemination of evidence-based psychological treatments for posttraumatic stress disorder in the Veterans Health Administration.
From page 359...
... VI Operation Iraqi Freedom 07-09. Washington, DC: Office of the Surgeon, Multinational Force-Iraq and Office of the Sur geon General, United States Army Medical Command.
From page 360...
... 2011. Data request on mental health providers in the VA, provider training, and the use of complementary and alternative medicine and treatments.
From page 361...
... 2011. Pro longed exposure therapy for combat-related posttraumatic stress disorder: An examina tion of treatment effectiveness for veterans of the wars in Afghanistan and Iraq.


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