Presented April 2016. A review of available health data on veterans living in North Central Texas (third largest population of veterans in the United States). Presentation includes data on veterans and mental health, substance abuse and sexual health outcomes. Also includes a review of comorbidities among veterans living with HIV, and a sample of evidence concerning the interrelationship between mental health and incarceration. Finally, a source for help - Veterans Coalition of North Central Texas as a resource for veterans and their families needing access to mental health services and a strong social support community.

1. Discharge Status Not Required: Bridges of
Support for Veterans and Families Living
with HIV, Mental Health, Substance Abuse
and Incarceration
Prepared by:
Lisa Hinson, Starlite Recovery, Mental Health Committee Chair
Lisa Waitemon-Moses, PHM Consulting, Mental Health Committee
Co-Chair
PHM Consulting
Population-Health Management

2. “Wellness” Defined.
What comprises a person’s
“wellness”?

4. What is Mental Wellness?

5. Brain Functions

6. How the Brain Communicates
• Neurons, or nerve cells, make up communication pathways in the brain.
• Relay information via electrical signals and chemical messengers called
neurotransmitters.

7. Defining Mental Health Disorders
• A health condition that affects a person’s
feelings, thinking or behavior and causes
distress and difficulty in functioning.
• Can result from changes in the brain’s
structure, chemistry and function.
Environmental and genetic factors also affect
brain health.
• Top veteran diagnosed disorders:
– PTSD (Anxiety Disorder)
– Depression
– Substance Use Disorders (SUD)

8. Substance Use Disorders (SUD)
• Brain disease diagnosed as mild, moderate or
severe, involving the use of alcohol or other
drugs.
• Recurrent use of alcohol and/or drugs causes
clinically and functionally significant impairment,
such as health problems, disability, and failure to
meet major responsibilities at work, school, or
home. Evidentiary ruling based on impaired
control, social impairment, risky use, and
pharmacological criteria.
• Often occurs in combination with MH disorders
and referred to as co-occurring.

9. Brain Functions

12. Behavioral and Sexual Health
Outcomes Among Veterans in
Texas

13. What Are Health Outcomes?
• For the purpose of this presentation
– Outcome: The results of untreated mental health
conditions which affect the housing, employment,
financial stability, success and overall wellness of
veterans in Texas.
– Behavioral: Substance abuse, activity ending in
incarceration, acting out with high risk sex.
– Sexual: HIV and AIDS, Hepatitis C.

14. OUTCOME - Incarceration
9 OUT OF EVERY 100
(Estimate from BOP)

15. Outcome: Incarceration - Texas
SNAPSHOT: Veterans In Texas
• Veterans Intervention Project – Report of
Veterans Arrested and Booked into the Travis
County Jail, 2009 (County probation, sheriff,
constables, HHS and Veterans Services): 458
Veterans

16. Incarceration - Texas
Travis County: 458 Veterans, 679 charges
• 34% of all charges = substance abuse
• 40% of all Veterans charged for substance
abuse = ages 20-29
• 32% of Veterans arrested 2+ times in 90 days
• 65% of arrested Veterans have not received
VA services

17. Questions?

18. OUTCOME – HIV/AIDS

19. HIV and AIDS Affects Our Veterans(Source: The State of Care for Veterans with HIV, 2011 Summary Report, Department of Veterans Affairs, produced 2012)
• VISN 17 had one of the largest increases in
caseloads of HIV-infected Veterans.
• Persons aged 60 or older comprised 30% of
newly identified HIV-infected Veterans in VHA
care.
• Black Veterans are the largest racial group
receiving VHA care for HIV. In 2011, comprised
nearly half of the VHA HIV-infected population
(48%), but less than 20% of military/Veterans.

20. Engagement in Care Cascade:
VA vs. Community
Gardner EM, et al. Clin Infect Dis. 2011;52:793-800
*26,033 Veterans
with HIV and
growing30,000
25,000
20,000
15,000
10,000
5,000
0
*Source: HIV Infected Veterans in VHA Care by State, 2012
http://www.hiv.va.gov/provider/policy/hiv-in-care-by-state-2012.asp

21. 21
HIV Seropositivity by
Race/Ethnicity - 2011
Source: Maggie Czarnogorski, MD, HIV testing rates in the VA 2009-2011. Office of Public Health, Department of Veterans Affairs

22. Questions?

23. OUTCOME –
Mental Health
and Substance
Abuse

24. What’s In Common?
• Incarceration PTSD
• Military PTSD
• Any Traumatic Experience PTSD
• PTSD = Post Traumatic Stress Disorder

25. Hepatitis, Mental Illness and Substance Abuse
Comorbidity Among Veterans Living with HIV in VHA Care
Comorbid Condition Group Comorbid Condition Percent with EVER Diagnosed
(n=25,271)
Blood borne Viral Disease Hepatitis B 12%
Hepatitis C 26%
Mental Illness Bipolar Disorder 9%
Depression 55%
Neuroses and Anxiety States 30%
PTSD 16%
Schizophrenia 7%
Any of the 5 mental illnesses listed above 61%
Substance Abuse Alcohol Use 34%
Amphetamines 4%
Cannabis 15%
Cocaine 26%
Opioids 12%
Other than specified drug use 21%
Tobacco Use 47%
(Source: The State of Care for Veterans Living with HIV, 2011 Summary Report, Department of Veterans Affairs, 2012)

26. MH/SUD by the numbers
• SUICIDE
– 22 veterans commit suicide every day. (Department of Veterans Affairs)
– At least 63% of attempted Army suicides were associated with drug or alcohol
overdose. (Army 2020: Generating Health and Discipline in the Force Ahead of the
Strategic Reset, 2012)
• SUBSTANCES
– The majority of veteran police encounters are alcohol and drug related crimes. (NAMI Pennsylvania Veterans Advisory
Council)
– Substance abuse is estimated the number one predictor of incarceration of veterans.
– Vets who have been prescribed painkillers and suffer from PTSD along with physical pain are at high risk for drug and
alcohol abuse. (JAMA, March 2012)
– Four percent of soldiers have been prescribed an opioid painkiller with oxycodone; 25%-35% of wounded soldiers are
addicted to prescription or illegal drugs while they await medical discharge. (Army 2020: Generating Health and
Discipline in the Force Ahead of the Strategic Reset, 2012)
• MENTAL HELTH
– Psychiatric medications used more since the start of current conflict than any other time in military history. (DOD
2012 budget submission report)
– A study of 206,000 veterans (using VA health records from 2000 to 2007) determined:
• 1 in 3 were diagnosed with at least one mental heath disorder
• 41% were diagnosed with either a mental health or behavioral adjustment disorder, with 15% diagnosed with
depression. (Department of Veterans Affairs, 2010)

27. PTSD and SUD

28. Planned Pre-K to Prison Pipeline

29. Impact of MH/SUD on Housing and
Employment
• Homelessness (National Coalition for the Homeless)
– Approximately one-third of homeless adults are veterans, although
veterans represent only 11% of the civilian population.
– On any given night, up to 300,000 veterans are homeless.
– OEF and OIF vets represent 1.8% of the homeless vet population.
– More than three-quarters—76 %--of homeless veterans suffer from a
substance abuse or mental health disorder.
– More than 67% served our country for at least three years.
• Unemployment (Bureau of Labor Report, 2011)
– One-third, or 33.2%, of OEF and OIF veterans between the ages of 18 to 24
are unemployed as compared to the national rate of 14.9%. This age group
represents the highest percentage diagnosed with PTSD.
– Unemployment rate among female veterans who served since September
2001 was 16.8%, compared to 7.8% for civilian counterparts.
– As of December 2011, 13.1 of all OIF and OEF veterans were jobless.

30. CHALLENGES
Veterans Access to Quality
Behavioral and Sexual Health Care

31. Access to Quality Care
31
• Enrollment in VA health care is not guaranteed, access for those
enrolled is problematic.
• Dallas region of VISN 17 has 3,066 Veterans who are unable to
schedule VHA appointment within 30 days (2015).*
• 24.3% agree that “Veterans like me who use VA are satisfied with
the health care they receive.” (2010, n=20,263,580)**
• 22.5% agree that “VA health care providers explain treatment/
diagnoses in a way that patients can understand.” (2010,
n=20,310,548)**
*Source: http://www.va.gov/HEALTH/docs/PublicData_PendingAccess_20150811RptDate_Final.pdf (9.8.2015)
**Source: 2010 National Survey of Veterans – Veteran Survey

32. Access to Care
Enrollment in VA health care (n=21,920,846)
• 24.9% enrolled in VA health care
• 27.4% used VA health care benefits
Plan to use VA health care (n=17,997,715)
• 34.8% will use VA health care as a “safety net”
Know VA health benefits
• 35.4% know (n=4,015,550): Served 1990-2001
• 30.2% know (n=5,746,646): Served 1975-1990
Source: 2010 National Survey of Veterans – Veterans Survey

34. Knowledge is Power
Now that You Know, here is the
Bridge….
The Veterans Coalition of North
Central Texas Action

35. Veterans Coalition
of North Central Texas
• Resources
– Emergency assistance
– Mental health
– Substance abuse
– Housing
– Emergency assistance
– Military embracing military
• Discharge Status Not Required
– Any military service qualifies
– Prior incarceration for any reason does not disqualify
you

36. In the Meantime…What can YOU Do?
• VCNCT is a Process
• Be Patient with
Yourself, You will
get it Wrong
Sometimes

37. In the Meantime…What can YOU Do?
• Coping
– Exercise creates the changes in your brain that
trigger mental and physical wellness.
– Exercise: What’s the worst that can happen?

38. In the Meantime…What can YOU Do?
• Surround your self with people who make you
feel good about doing great things for yourself

39. In the Meantime…What can YOU Do?
• Coping
Act, different from “React”

40. Act

41. ACT - Recognize: MH/SUD Symptoms
Mental Health
• Confused thinking
• Prolonged depression (sadness or irritability)
• Feelings of extreme highs and lows
• Excessive fears, worries and anxieties
• Exaggerated startle response and hypervigilance (PTSD)
• Social withdrawal
• Dramatic changes in eating or sleeping habits
• Strong feelings of anger
• Growing inability to cope with daily problems and activities
• Suicidal thoughts
• Numerous unexplained physical ailments
Substance Use
• Problems at school or work — frequently missing school or work, a sudden disinterest in
school activities or work, or a drop in grades or work performance
• Physical health issues — lack of energy and motivation
• Neglected appearance — lack of interest in clothing, grooming or looks
• Changes in behavior — exaggerated efforts to bar family members from entering his or her
room or being secretive about where he or she goes with friends; or drastic changes in
behavior and in relationships with family and friends
• Spending money — sudden requests for money without a reasonable explanation; or your
discovery that money is missing or has been stolen or that items have disappeared from
your home, indicating maybe they're being sold to support drug use

42. ACT - Look For: Signs and Symptoms
Suicide
• Hopelessness, feeling like there’s no way out
• Anxiety, agitation, sleeplessness, or mood swings
• Feeling like there is no reason to live
• Rage or anger
• Engaging in risky activities without thinking
• Increasing alcohol or drug abuse
• Withdrawing from family and friends
The following signs require immediate attention:
• Thinking about hurting or killing yourself
• Looking for ways to kill yourself
• Talking about death, dying, or suicide
• Self-destructive behavior such as drug abuse, weapons, etc

43. ACT: Strategies to Help Veterans Accept Help
• Ask
– “Have you thought about death by suicide today?” (Look them in the eye.)
– “Did you have sex after using drugs?”
– “So, what is your drug of choice?” (Non-judgmentally)
– Add a brief section on MH/SUD to your intake paperwork.
– “Are you willing to talk with somebody now?” Help them make the call!
• Mindful referral
– Veterans Peer Support Groups, such as Military Veteran Peer Network
• www.milvetpeer.com
– Veterans Crisis Line
• 1-800-273-8255 and Press 1, or send a text message to 838255
– For employed veterans having difficulty, utilization of an EAP can assist with
appropriate referral.
– VA Benefits – Due to long wait times for treatment, VACAA was passed in
2014. It allows veterans to receive treatment outside of the VA system if they
meet certain criteria.
– Tricare: It takes a lot of courage to come to counseling, when they reach out
WE MUST ACT.
• Patient MUST have a physician evaluation, and physician referral prior to
accessing mental health care.

44. PHM Consulting
Population-Health Management
Lisa Waitemon-Moses, MPH
Consultant and
Unconventional Introvert
Lisa.Waitemon-Moses@PHMConsulting.com