Treatment of Veterans with Psychiatric Diagnoses Nationally in the Veterans Health Administration: A Comparison of Service Delivery by Mental Health Specialists and Other Providers
Patients with psychiatric disorders are treated by both mental health specialists and non-specialists. We use national data from the Veterans Health Administration to evaluate changing proportions of patients seen exclusively by non-specialists during the study year (FY 2012) limit as well as differences in socio-demographic, clinical and service use characteristics. There has been a five-fold increase in veterans with mental disorders seen by non-specialists over 20 years from 7 to 38%, findings similar to those in non-VA settings. Veterans treated by mental health specialists were younger, more likely to have been homeless and disabled, and had more severe and more numerous psychiatric diagnoses. There is a need to maintain specialty services and to strengthen non-specialty care through education and research.
KeywordsMental health services Veterans Mental health specialists
This study was funded by U.S. Department of Veterans Affairs.
Compliance with Ethical Standards
Conflict of interest
Nikhil Gupta, Ish Bhalla and Robert Rosenheck declare that they have no conflict of interest.
This article does not contain any studies with human participants performed by any of the authors. The study was approved by the Institutional Review Board committee of the VA Connecticut Healthcare System. A waiver of informed consent was obtained as the study used administrative data and there were no patient identifiers included.
- Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., & Guthrie, B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. The Lancet, 380(9836), 37–43. https://doi.org/10.1016/S0140-6736(12)60240-2.CrossRefGoogle Scholar
- Barry, D. T., Sofuoglu, M., Kerns, R. D., Wiechers, I. R., & Rosenheck, R. A. (2015). Prevalence and correlates of co-prescribing psychotropic medications with long-term opioid use nationally in the Veterans Health Administration. Psychiatry Research, 227(2–3), 324–332. https://doi.org/10.1016/j.psychres.2015.03.006.CrossRefPubMedGoogle Scholar
- Beardsley, R. S., Gardocki, G. J., Larson, D. B., & Hidalgo, J. (1988). Prescribing of psychotropic medication by primary care physicians and psychiatrists. Archives of General Psychiatry, 45(12), 1117. https://doi.org/10.1001/archpsyc.1988.01800360065009.CrossRefPubMedGoogle Scholar
- Becker, S. J., & Midoun, M. M. (2016). Effects of direct-to-consumer advertising on patient prescription requests and physician prescribing: A systematic review of psychiatry-relevant studies. The Journal of Clinical Psychiatry, 77(10), e1293. https://doi.org/10.4088/JCP.15R10325.CrossRefPubMedPubMedCentralGoogle Scholar
- Berardi, D., Menchetti, M., Cevenini, N., Scaini, S., Versari, M., & De Ronchi, D. (2005). Increased recognition of depression in primary care. Comparison between primary-care physician and ICD-10 diagnosis of depression. Psychotherapy and Psychosomatics, 74(4), 225–230. https://doi.org/10.1159/000085146.CrossRefPubMedGoogle Scholar
- Burns, B. J., Wagner, H. R., Gaynes, B. N., Wells, K. B., & Schulberg, H. C. (2000). General medical and specialty mental health service use for major depression. The International Journal of Psychiatry in Medicine, 30(2), 127–143. https://doi.org/10.2190/TLXJ-YXLX-F4YA-6PHA.CrossRefPubMedGoogle Scholar
- Craske, M. G., Rose, R. D., Lang, A., Welch, S. S., Campbell-Sills, L., Sullivan, G., … Roy-Byrne, P. P. (2009). Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings. Depression and Anxiety, 26(3), 235–242. https://doi.org/10.1002/da.20542.CrossRefPubMedPubMedCentralGoogle Scholar
- Farrer, L., Gulliver, A., Chan, J. K. Y., Batterham, P. J., Reynolds, J., Calear, A., … Griffiths, K. M. (2013). Technology-based interventions for mental health in tertiary students: Systematic review. Journal of Medical Internet Research, 15(5), e101. https://doi.org/10.2196/jmir.2639.CrossRefPubMedPubMedCentralGoogle Scholar
- Gaynes, B., Rush, A., Trivedi, M., … S. W.-G. hospital, & 2005 undefined. (n.d.). A direct comparison of presenting characteristics of depressed outpatients from primary vs. specialty care settings: Preliminary findings from the STAR* D clinical trial. Elsevier. Retrieved from https://www.sciencedirect.com/science/article/pii/S016383430400132X.
- Golberstein, E., Kolvenbach, S., Carruthers, H., Druss, B., & Goering, P. (2018). Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: Survey results from a randomized evaluation. Healthcare, 6(1), 17–22. https://doi.org/10.1016/j.hjdsi.2017.01.002.CrossRefPubMedGoogle Scholar
- Groopman, J. (2007). What’s the trouble? How doctors think. New York: The New Yorker.Google Scholar
- Johnson-Lawrence, V., Zivin, K., Szymanski, B. R., Pfeiffer, P. N., & McCarthy, J. F. (2012). VA primary care-mental health integration: Patient characteristics and receipt of mental health services, 2008–2010. Psychiatric Services, 63(11), 1137–1141. https://doi.org/10.1176/appi.ps.201100365.CrossRefPubMedGoogle Scholar
- Katon, W., Lin, E. H. B., & Kroenke, K. (2007). The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. General Hospital Psychiatry, 29(2), 147–155. https://doi.org/10.1016/J.GENHOSPPSYCH.2006.11.005.CrossRefPubMedGoogle Scholar
- McAlpine, D. D., & Mechanic, D. (2000). Utilization of specialty mental health care among persons with severe mental illness: The roles of demographics, need, insurance, and risk. Health Services Research, 35(1 Pt 2), 277–292. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1089101&tool=pmcentrez&rendertype=abstract.
- Mojtabai, R., & Olfson, M. (2008). National patterns in antidepressant treatment by psychiatrists and general medical providers: Results from the national comorbidity survey replication. The Journal of Clinical Psychiatry, 69(7), 1064–1074. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18399725.
- North, C. S., Brown, E. S., & Pollio, D. E. (2016). Expanded conceptualization of multimorbidity to encompass substance use disorders and other psychiatric illness. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 28(3), 182–188.Google Scholar
- Olfson, M., Marcus, S. C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H. A. (2002). National trends in the outpatient treatment of depression. JAMA, 287(2), 203–209. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11779262.
- Oslin, D. W., Ross, J., Sayers, S., Murphy, J., Kane, V., & Katz, I. R. (2006). Screening, assessment, and management of depression in VA primary care clinics. Journal of General Internal Medicine, 21(1), 46–50. https://doi.org/10.1111/j.1525-1497.2005.0267.x.CrossRefPubMedPubMedCentralGoogle Scholar
- Pincus, H. A., Strain, J. J., Houpt, J. L., & Gise, L. H. (1983). Models of mental health training in primary care. JAMA, 249(22), 3065–3068. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/6406690.
- Regier, D. A. (1993). The de facto US mental and addictive disorders service system. Archives of General Psychiatry, 50(2), 85. https://doi.org/10.1001/archpsyc.1993.01820140007001.CrossRefPubMedGoogle Scholar
- Regier, D. A., Goldberg, I. D., & Taube, C. A. (1978). The de facto US mental health services system: A public health perspective. Arch Gen Psychiatry, 35(6), 685–693. https://doi.org/10.1001/archpsyc.1978.01770300027002.CrossRefPubMedGoogle Scholar
- Shiner, B., Tang, C., Trapp, A. C., Konrad, R., Bar-On, I., & Watts, B. V. (2014). The provision of mental health treatment after screening: Exploring the relationship between treatment setting and treatment intensity. General Hospital Psychiatry, 36(6), 581–588. https://doi.org/10.1016/J.GENHOSPPSYCH.2014.07.009.CrossRefPubMedGoogle Scholar
- Stewart, A., Sherbourne, C., … K. W.-J. of consulting, & 1993, undefined. (n.d.). Do depressed patients in different treatment settings have different levels of well-being and functioning? Psycnet.Apa.Org. Retrieved from http://psycnet.apa.org/record/1994-06482-001.
- Wang, P. S., Demler, O., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2006). Changing profiles of service sectors used for mental health care in the United States. American Journal of Psychiatry, 163(7), 1187–1198. https://doi.org/10.1176/ajp.2006.163.7.1187.CrossRefPubMedGoogle Scholar
- Wiechers, I. R., Kirwin, P. D., & Rosenheck, R. A. (2014). Increased risk among older veterans of prescribing psychotropic medication in the absence of psychiatric diagnoses. The American Journal of Geriatric Psychiatry, 22(6), 531–539. https://doi.org/10.1016/j.jagp.2013.10.007.CrossRefPubMedGoogle Scholar
- Zivin, K., Pfeiffer, P. N., Szymanski, B. R., Valenstein, M., Post, E. P., Miller, E. M., & McCarthy, J. F. (2010). Initiation of primary care—mental health integration programs in the VA health system: Associations With psychiatric diagnoses in primary care. Medical Care. https://doi.org/10.2307/25750565.CrossRefPubMedGoogle Scholar