Spotlight: Improving Care for Serious Mental Illness

August 2013

One in four adults (nearly 58 million Americans) experience a mental health disorder in a given year, and 37% of Veterans returning from Iraq and Afghanistan who enter the VA healthcare receive a mental health diagnosis. Moreover, 4 of the 10 leading causes of disability in the U.S. and other developed countries are mental disorders, and by 2020, major depressive illness will be the leading cause of disability in the world for women and children. Serious mental illnesses (SMI) are chronic conditions and include:

• Major depression,
• Schizophrenia,
• Bipolar disorder (associated with highest risk for suicide among Veterans),
• Obsessive compulsive disorder (OCD),
• Panic disorder,
• Post-traumatic stress disorder (PTSD), and
• Borderline personality disorder.^1,2

VA operates the largest mental health program in the nation. Part of VA's efforts to ensure that Veterans receive the highest quality mental healthcare includes the VA/HSR&D Mental Health Quality Enhancement Research Initiative, or MH-QUERI, which is committed to improving the quality of care, outcomes, and health-related quality of life for Veterans with mental illness.

MH-QUERI Targets Serious Mental Illness

MH-QUERI's research in the area of improving physical health treatment and outcomes for Veterans with serious mental illness has culminated in several national impacts. The most common causes of morbidity and mortality among Veterans with SMI include cardiovascular disease, which can be exacerbated by the metabolic side effects of antipsychotics. MH QUERI's work in improving metabolic side-effect monitoring and management for Veterans taking antipsychotics informed the MIAMI Project (MIRECC Initiative on Antipsychotic Management Improvement), helping them train VA clinicians on how to safely prescribe antipsychotics for Veterans and improve care in this area. MH-QUERI's key partnerships on this project include: VA's Office of Mental Health Services (OMHS), Employee Education System (EES), VISN 16 South Central MIRECC, and VISN 22 Desert Pacific MIRECC.

MH-QUERI also put together an SMI Health Workgroup to identify and implement evidence-based programs and practices that promote wellness, reduce cardiovascular disease risk, and improve physical health treatment and outcomes for Veterans with SMI. Workgroup projects include:

• Extending the reach and impact of the Life Goals Collaborative Care psychosocial intervention (developed for patients with bipolar disorder) by adapting and testing its feasibility for a broader SMI patient population in order to reduce risk factors for cardiovascular disease;
• Testing a chronic care model intervention for schizophrenia to increase the use of recovery-oriented services by patients with SMI (with Veterans at intervention sites over 2 times more likely to utilize supported employment and wellness services); and
• Implementing patient-facing kiosks to improve mental healthcare by facilitating routine outcomes assessment, patient self-assessment, clinician and patient education, clinician feedback, and measurement-based care.

For more information about the SMI Health Workgroup, please contact Jeff Smith, Ph.Dc. at Jeffrey.Smith6@va.gov.

Other QUERI SMI-Related Studies

The following are examples of other QUERI-funded studies that address important issues related to the health and healthcare of Veterans with serious mental illness.

• This study assessed factors potentially associated with Veterans' perception of the quality of their examination for service-connected PTSD. Results show that the overall quality of PTSD compensation examinations was predominantly rated as "excellent" or "very good" by both African American and Caucasian Veterans. But compared to Caucasian Veterans, African American Veterans rated their examinations as having been of lower quality.³
• This study examined whether automated coding of treatment notes using natural language processing could match the accuracy of manual chart review for classifying evidence-based PTSD treatments. Results showed that the method used in the study identified psychotherapy notes and classified the type of therapy performed in a treatment session as reliably as expert human raters. Because the method uses a clinican-friendly interface, does not require custom programming, and is freely available to others, it could be used to evaluate treatment for other mental health disorders.⁴
• This study assessed the prevalence and VA healthcare costs of traumatic brain injury (TBI) with and without comorbid psychiatric illness and pain among Veterans. Findings show that 22,053 (6.7%) of the 327,388 OEF/OIF Veterans who used VA healthcare during FY09 received a diagnosis of TBI. Among this patient subgroup, the majority (89%) also had a psychiatric diagnosis (most frequently PTSD, 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%).⁵

Additional Resources:

• VA Mental Health, including Suicide Prevention and the Veterans Crisis Line.
• Veteran Supported Education Service Treatment Manual (VetSEd): Funded through QUERI, this manual is meant to serve as a guide to aid VHA leadership, management and clinical staff in assisting returning OIF/OEF/OND Veterans with mental health conditions and/or related psychiatric disabilities and substance use disorders by implementing the VetSEd approach.
• MentalHealth.gov
• Substance Abuse and Mental Health Services Administration (SAMHSA)

References

1. What is Mental Illness: Mental Illness Facts. National Alliance on Mental Illness. www.nami.org .
2. Mental Health QUERI Fact Sheet. June 2013. VA Office of Research & Development, Health Services Research and Development Service.
3. Rosen M, Afshartous D, Nwosu S, Scott M, et al. Racial differences in Veterans' satisfaction with PTSD disability examination. Psychiatric Services April 1, 2013;64(4):354-359.
4. Shiner B, D'Avolio L, Nguyen T, et al. Measuring use of evidence-based psychotherapy for post-traumatic stress disorder. Administration and Policy in Mental Health and Mental Health Services Research July 2013;40(4):311-318.
5. Taylor B, Hagel E, Carlson K, et al. Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War Veteran VA users. Medical Care April 2012;50(4):342-346.