Two Reports: Women Veterans Confront Intimate Partner Violence; GAO Reports VHA Improved Certain Prescribing Practices, but Needs to Strengthen Treatment Plan Oversight
One third of women Veterans experience intimate partner violence during their lifetime
Dr. Katherine Iverson
Dr. Katherine Iverson, a clinical psychologist, and researcher at the VA Boston Healthcare System works with women Veterans who have experienced intimate partner violence, or IPV. Often called domestic violence, IPV occurs when a current or former intimate partner such as a boyfriend, girlfriend or spouse harms, threatens to harm or stalks their partner.
Iverson’s basic message to women Veterans who have experienced IPV: “VA can help.”
According to the VA Women’s Health Services Office, one third of women Veterans experience IPV in their lifetime, compared with less than a quarter of civilian women. Researchers are not sure why, says Iverson, but one reason might be that women Veterans simply “have more risk factors” for IPV, including “having parents who have experienced IPV, witnessing violence in the home and being a victim of childhood sexual or physical abuse. We know that people who’ve had these experiences in childhood are more likely to go into the military.”
Plus, a woman Veteran or service member is more likely to partner with or marry another Veteran or service member, who in turn is at greater risk of being violent with their partner.
Iverson’s recent research focuses on women Veterans who experience traumatic brain injury (TBI) as a result of IPV. “In my clinical work, I found that women are often strangled or choked by intimate partners during their assaults,” she says. “Or they might be badly punched or elbowed to the head, face, or neck, or have their head bashed against the wall.”
She notes that women may be more likely than men to experience severe symptoms from such injuries. In a study of Iraq Veterans with TBI, women reported significantly more severe health problems than men and were much more likely to be diagnosed with depression and PTSD.
In addition to the harms caused by TBI, IPV itself is linked with a range of health issues including stomach trouble, sexual health problems and mental health symptoms. “Women who experience IPV are twice as likely to attempt suicide. They are two to four times more likely to have diagnoses of PTSD and depression and to use alcohol—perhaps as a way of coping with the IPV they experience.”
On top of those challenges, says Iverson, women who have experienced repeated IPV “can be colossally critical of themselves” and tend not to trust their own feeling that something is wrong. “If you’ve been put down enough and told that you are crazy, you can start feeling like that. So I think an important part of what clinicians can do is validate for women that their experiences are legitimate; that they don’t deserve to be treated like that; that it’s not their fault; and that there are programs that can help.”
Iverson says that women Veterans who have experienced IPV, or think they might have, can ask their VA health care provider for help. “If they have a provider that they feel comfortable with, like primary care or mental health provider, we’d encourage them to talk to their provider about it.” Women Veterans can also talk with a VA social worker or ask if their VA facility has an IPV coordinator, “who are really the experts on connecting with community services.”
Iverson notes that since VA is an integrated health care system that offers mental health and social work services along with health care, “we can play a very important role in helping women understand symptoms that they experience, to recognize IPV, to know where to seek help, to get help for their own symptoms so that they can make decisions that are best for themselves and their children.
“Essentially, we focus on enhancing the tremendous strengths and resilience that women Veterans already have.”
VA MENTAL HEALTH: VHA Improved Certain Prescribing Practices, but Needs to Strengthen Treatment Plan Oversight
What GAO Found
Officials from the five selected Department of Veterans Affairs (VA) medical centers (VAMC) GAO spoke with reported various factors that contribute to providers' mental health treatment decisions, including decisions regarding the prescribing of psychotropic medications and the offering of non-pharmacologic therapy. Examples of reported factors include: VAMC resources, such as the availability of appointments with mental health providers in specialty care, and the complexity of veterans' mental health conditions, such as the veterans' diagnoses and treatment history.
Officials with VA's Veterans Health Administration (VHA) told GAO that specialty mental health care providers are expected to document mental health treatment plans in an easily identifiable way in veterans' medical records, but VHA has not developed guidance explicitly addressing this expectation. For example, VHA's mental health services handbook requires that treatment plans include certain components, but does not specify where to document the plan within a veteran's medical record. As a result, there is a risk that a provider may be unable to readily access information about a veteran's mental health treatment, including the use of medication or therapy, during changes in a veteran's care.
VHA has not monitored whether mental health providers in specialty care document the required consideration of different treatment options—such as psychotropic medications or non-pharmacologic therapy—within mental health treatment plans. VHA officials told GAO that VHA relies on the Joint Commission (an independent, not-for-profit organization that accredits and certifies health care organizations) to assess specialty mental health treatment plans as part of the organization's accreditation process for each VAMC. However, the Joint Commission's standards do not specifically assess whether providers consider different treatment options. As a result, VHA cannot ensure that providers are considering all available treatment options and providing the most appropriate treatments to each veteran.
VHA has taken steps to improve veterans' mental health treatment through the Psychotropic Drug Safety Initiative (PDSI)—an initiative focused on the safe and effective prescribing of certain psychotropic medications. For example, the first phase included a performance metric aimed at decreasing the percentage of veterans with post-traumatic stress disorder receiving one or more outpatient prescriptions for a benzodiazepine (a medication used to treat anxiety) because of risks associated with the medication. VHA reported a nationwide 5.4 percentage point decrease in the prescribing of this medication for these patients, as well as improvements in the majority of the initiative's other performance metrics.
Why GAO Did This Study
In fiscal year 2018, of the roughly 6 million veterans who received services from VHA, approximately 2 million had a diagnosis for at least one mental health condition. Treatments for such mental health conditions can include psychotropic medications or non-pharmacologic therapies, which can be prescribed or offered by VA providers in outpatient settings including primary and specialty care.
GAO was asked to review how mental health treatment decisions are made by providers in VAMCs and monitored by VHA. This report examines, among other things, (1) factors that contribute to providers' treatment decisions for veterans with mental health conditions, (2) VHA's guidance for documenting mental health treatment plans, (3) VHA's monitoring of whether providers document their consideration of different treatment options, and (4) VHA's efforts to improve the treatment of veterans prescribed psychotropic medications. GAO reviewed VHA documents and a nongeneralizable sample of veterans' medical records from five VAMCs (selected for variety in facility complexity and location); analyzed data on psychotropic medication prescribing; and interviewed VHA and VAMC officials.
What GAO Recommends
VHA should (1) disseminate guidance reflecting its expectation that providers document mental health treatment plans in an easily identifiable way, and (2) implement an approach for monitoring whether these treatment plans include consideration of treatment options. VHA agreed with GAO's recommendations.
For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.