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Recognizing Mental Health Illness Among Veterans is an Educational Competency

Over the course of residency and fellowship training, it’s likely that almost all trainees will encounter veterans through rotations at Veterans Affairs (VA) facilities.

With mandates from Title 38 and long-standing relationships with academic institutions nationwide, the Veterans Health Administration plays a significant role in shaping the education of future medical professionals. Over 90 percent of accredited allopathic medical schools and over 75 percent of osteopathic medical schools are affiliated with VA medical centers and independent outpatient clinics, which are also used by over 2,600 Graduate Medical Education (GME) programs. In 2013 alone, over 40,000 residents and fellows — along with over 20,000 medical students — received some or all of their clinical training in VA.

This trend will likely continue in the future. In August 2014, President Obama signed the Veterans Access, Choice and Accountability Act of 2014 (VACAA) into law. The law increases the number of GME positions at VA medical facilities. It could be said without exaggeration that medical education and training wouldn’t be the same without the VA experience.

A key part of that experience, and graduate medical education, involves exposure and sensitivity to the unique co-morbidities that exist in veteran populations. Some — chronic medical conditions, acute infections, surgical trauma, etc. — are readily visible to almost all trainees. Others, however, particularly many related to veterans’ mental health, can be harder to detect. For example, when faced with a diabetic patient who struggles with non-adherence, it can be far harder to recognize the contributions from concurrent depression or anxiety compared to those from concurrent chronic bronchitis or heart disease. It is generally accepted that less than a third of all patients who could benefit from mental health treatment do indeed receive that treatment.

Overlooking psychiatric illness among veterans carries significant implications. Mental health disorders are common among veterans, representing 57.2 percent of the 701,886 OEF/OIF/OND diagnoses (Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or Operation New Dawn (OND)) in 2014. Moreover, mental disorders are often comorbid with other chronic medical conditions, with evidence suggesting that veterans with mental illness have a higher likelihood of developing chronic medical problems such as diabetes and cardiovascular disease. However, despite these challenges and the effects of mental illness on self-efficacy and capacity of maintain well-being, there appear to be significant gaps in the access and quality of mental health care for veterans.

While systemic evidence revealing poor health care access due to mental illness is lacking, there is evidence that veterans with substance use disorders predominantly go untreated. Additionally, studies have suggested that there may be inadequate quality in the delivery of care related to veterans’ mental health problems. A “quality chasm” appears to persist represented by the broad range of evidence-based psychosocial interventions that, while proven to be efficacious, do not appear to be routinely delivered in practice.

How can these insights help residents and fellows — frontline clinicians who represent a substantial portion of the providers caring for veterans — address the mental health illness burden in VA patients?

First, they can remind trainees of the unique challenges and steps that must be taken in identifying and treating mental illness. Compared to many chronic medical conditions, diagnoses of mental illness and substance-use carry challenging stigma. Moreover, the complexity of mental illness requires that patients receive support and treatment from a diverse team of providers — including but not limited to primary care physicians, medical specialists, psychologists and psychiatrists, social workers, marriage and family therapists, addiction therapists and psychosocial rehabilitation therapists. Recognizing early the need to mobilize these multidisciplinary teams can help residents and fellows provide high quality care for patients with mental illness.

Second, they can help residents and fellows recognize the potential links between mental health and other medical conditions. As front line clinicians, their time and energy is often consumed by their patients’ most pressing medical conditions. In internal medicine for example, a common inpatient illness is COPD exacerbation, a condition in which the patient’s breathing, oxygenation and ventilation — and the exam maneuvers, lab tests, and imaging needed to manage them — take center stage.

As patients recover from exacerbations, however, underlying mental health issues often surface and significantly affect their overall care plan. For example, deeper questioning sometimes uncovers that concurrent depression affects a patient’s insight, adherence and motivation to interact with community supports, aspects that are paramount for minimizing COPD exacerbations. There is growing recognition in the medical community that multi-morbidity, particularly concurrent mental and medical illnesses, impedes better patient outcomes. Residents and fellows should be a part of that movement.

Third, awareness of these issues can help residents and fellows more appropriately identify and diagnose mental illness. Perhaps not surprisingly, mental illness does not always present in “classic” form; at times, for example, affective disorders manifest as somatic complaints and at-risk behaviors are interpreted as variants of normal. In turn, trainees caring for veterans would greatly benefit from education about screening tools and methods for quickly identifying those at risk for mental illness.

A growing number of institutions are utilizing quick screening tools such as the PHQ-2 to screen patients for potential depressive symptoms. Those who score positive on the PHQ-2 can be further evaluated using the PHQ-9 or other means, increasing the chance that depression is identified and addressed. By using similar strategies, residents and fellows could contribute to better quality mental health care for veteran populations.

Over the course of residency and fellowship training, it’s likely the almost all trainees will care for veterans, who will in turn contribute immensely to graduate medical education and professional development. To honor that dynamic and deliver the highest quality care possible to the men and women who serve our country, residents and fellows must recognize mental illness among veterans and uphold this ability as an important educational competency. Doing so can impart great, lasting benefits, not only to patients but to young physicians as well.

Sandro Galea, MD, MPH, DrPH Sandro Galea, MD, MPH, DrPH (1 Posts)

Attending Physician Guest Writer

Boston University


Dr. Sandro Galea, MD, MPH, DrPH, is a physician, epidemiologist, Dean and Professor at Boston University School of Public Health. Follow him @sandrogalea.


Liang Chen, MD Liang Chen, MD (1 Posts)

Resident Physician Contributing Writer

Boston University


Liang is a physician and writer who believes deeply that better health requires efforts to address disease at both the clinical and public health levels. He is passionate about using a global perspective to combine those perspectives in his career.