How the VA Cares for Veterans' Minds and Bodies

A Vietnam War veteran was having nightmares. He'd had a stroke and lived with cognitive impairment. He was struggling with depression and post-traumatic stress disorder. His physical condition made it hard for him to get to a primary care office.

Instead, his medical providers came to him. Through the Department of Veterans Affairs home based primary care program, the man had health care delivered where he lived. Among those services was mental health treatment.

With a therapist who came to his home, the man worked on feelings he'd carried for decades, since his brother — who he served alongside in Vietnam — had died during their service together. After mental health treatment, the veteran reported that he no longer felt depressed and his nightmares had subsided.

"He was able to develop a new understanding of his experience with his brother's death," the VA psychologist who worked with him reported. "He could see that it was a rare honor to be able to hold his brother as he died, and that by being there, he did something very special for his brother."

Primary care offices are a first step into mental health treatment for many people. But the Veterans Affairs system takes the approach further. Since 2008, the health system for American military veterans has integrated mental health services as a part of primary care for patients of all ages. This approach is part of a strategy that aims to be age-friendly and oriented towards supporting health wholistically.

"Sometimes with medicine, it feels like we're a collection of body parts, but we're not like a whole person," says Dr. Michele Karel, national director of geriatric mental health in the Department of Veterans Affairs Office of Mental Health and Suicide Prevention. The VA's integrated system instead addresses physical and behavioral health together.

"We're addressing a human being where meaning and purpose and values and goals are critical for each person," she says. "We're not just an arm, and a stomach, and an eye and a liver."

Under the VA's integrated approach, physical and mental health services don't just collaborate with each other, they work alongside each other. Karel explains that mental health professionals are located in the same space as primary care doctors. When a need for psychological support comes up, a veteran can connect with a provider right away.

"If they're given a phone number to call another specialist, there's stigma involved, there's anxiety involved, they simply might not follow up," Karel says. "If the care is right there and … it's validated as just part of health care, then people are more likely to get the care that they need."

VA mental health providers are part of collaborative teams that look at all aspects of a patients' health together, inclusive of physical and mental health.

The VA system has sought to use that integrated approach in all settings where older people may get their health care, not only in primary care offices. For people like the Vietnam War veteran who was not physically able to go to a clinic, they can be connected with a full range of health services — including psychological support — in their homes.

And data shows that VA patients are making use of the services. Of the 46,000 veterans who got home-based primary care services in fiscal year 2023, almost a third had a visit from a psychologist.

"I think that is remarkable to have that many people being able to access specialty mental health services in a home-based program," says Karel. "It speaks both to the need of the population and it speaks to what we've done to be able to provide access to care."

Mental health needs among older veterans are similar to the general population in many ways, explains Karel. Cognitive, social, medical and psychiatric factors all intersect.

Some people who get treatment through the VA have had mental illness throughout their lives. Others develop mental health concerns as they age. For some, traumatic experiences that they experienced decades earlier can become more prominent in their older age when they slow down, explains Karel.

By making treatment accessible for older veterans, it can provide a lot of relief. The Vietnam veteran struggling with his brother's death reported that he felt better by being able to talk about his experience. Another veteran who got services through the home-based program needed a walker but was reluctant to use it. Through mental health support oriented toward problem solving, he came to embrace the walker.

Karel explains that the VA is seeking to make it as easy as possible for veterans to access mental health care. A shortage of mental health care workers can make it hard for veterans, particularly in rural areas, to get support from geriatric psychiatrists. The VA is using telehealth to make those specialized services available to people who can't access them in person.  

Supporting mental health can have implications for their health more broadly, she says. Addressing conditions like depression, for instance, may make someone more motivated to engage in physical therapy.

"If we can help depression, we can help functioning. It's not just a mood problem," she says. "Depression affects our ability and our motivation to take care of ourselves."

Dr. Jameca Woody Cooper, a counseling psychologist based in St. Louis, sees a lot of benefits of the VA's integrated care model.

The approach can benefit older adults who often feel most comfortable in a primary care setting, rather than in a more specialized mental health setting, says Woody Cooper. The collaboration involved also brings multiple different providers together around a single person.

"You have more eyes on the individual patient," she says. "It allows you to catch more, to see more and to brainstorm more about potential solutions."

The VA system is unique in its integrated care approach. It's not common in health care systems in the US. But Woody Cooper sees a lot of benefits. "I think it's a model for how things should be done."

Bringing the integrated approach into home-based primary care can be very impactful for older adults, she says.

When Woody Cooper began her psychology practice, she focused on home-based mental health care — a niche she developed because she heard from friends who were internal medicine doctors that patients who were homebound needed help.

There are a wide range of reasons why people may not leave their homes — social anxiety, conditions like lymphedema or paralysis, balance problems or access to transportation.

"I started doing it, and only then did I realized how many older adults could not leave their home based on their limited mobility," Woody Cooper says. "So home-based services are necessary."

Many people deny that they are having mental health issues, she says. Making care readily available can have a very positive impact.

"Seeking help is not even on the horizon for a lot of them, so to be able to bring the help to them is really huge," Woody Cooper says.

Elizabeth Hewitt is an American journalist based in the Netherlands, reporting on topics including aging, nature and culture. Her stories on dementia have appeared in publications including Being Patient, Reasons To Be Cheerful and Sierra Magazine, and she's a former editor and reporter for the Vermont nonprofit news site VTDigger.org. Find her on Twitter at @emhew Read More