Psychological distress and mental health service utilization in Veterans vs. non-Veterans during the Coronavirus Disease 2019 pandemic

Abstract:Background: The mental health challenges during the COVID-19 pandemic have been well documented. Adults were eight times more likely to report serious psychological distress (a term that encompasses symptoms of generalized anxiety disorder [GAD] and major depressive disorder [MDD]) than before the pandemic. Notably, an estimated 50% of adults reporting serious psychological distress did not seek treatment. Veterans are an important subset of the population, given their increased prevalence of PTSD, suicide, and substance use resulting from war-related trauma, as compared to their non-Veteran counterparts. Aims: Aim 1: Examine the differences in prevalence and odds of moderate to severe psychological distress between Veterans and non-Veterans during the COVID-19 pandemic. Aim 2: Examine how the association between Veteran status and moderate to severe psychological distress varies by demographic, social, and clinical factors.Aim 3: Examine differences in prevalence and odds of mental healthcare utilization among Veterans compared to non-Veterans who experienced moderate to severe psychological distress in 2021. Aim 4: Examine how the association between Veteran status and mental health utilization among those experiencing moderate to severe psychological distress varies by demographic, social, and clinical factors. Methods: The 2021 National Health Interview Survey (NHIS), a data collection program of the National Center for Health Statistics (NCHS) and Centers for Disease Control and Prevention (CDC), was used for data analysis. The variables examined for aims 1 and 2 were guided by the SocioEcological Model and aims 3 and 4 by the Behavioral Model of Health Services Utilization (Anderson, 2002; Dahlberg et al., 2002; Michaels et al., 2022). The primary independent variable was Veteran vs. non-Veteran status. The dependent variable, moderate to severe psychological distress, was measured with the Kessler-6 Psychological Distress Scale (K6) and grouped into none to low vs. moderate to severe. The population included the entire nationally representative sample of 28,305 participants ( 2,578 Veterans vs. 25,727 non-Veterans). A second dependent variable, mental healthcare utilization, was used for aims 3 and 4 and was based on the NHIS question, “During the past 12 months, did you receive counseling or therapy from a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical worker?” and dichotomized into yes and no, and the population included only those experiencing moderate to severe distress. Significance: To date, few studies have compared the prevalence of moderate to severe psychological distress in Veterans to non-Veterans during the COVID-19 pandemic, or the prevalence of Veterans vs. non-Veterans with moderate-severe psychological distress who may have delayed or avoided mental health care. This information is essential to understand how the COVID-19 pandemic may have affected Veterans and non-Veterans differentially and whether programs for Veterans have been effective in addressing their mental health needs. Results: In an adjusted analysis, there were no significant differences in the odds of moderate to severe psychological distress between Veterans and non-Veterans in 2021. However, Veterans between 35-44 and 55-56 years of age and Veterans with children in the home had a significantly higher predicted prevalence of moderate to severe psychological distress as compared to non-Veterans. Additionally, among those experiencing moderate to severe psychological distress, Veterans had 73% greater odds of utilizing mental healthcare. Veterans had a significantly higher predicted probability of mental healthcare utilization as compared to non-Veterans if they identified as non-Hispanic White, Black, Asian, or multiple races, reported sometimes or never enough social/emotional support, or skipping or delaying prescription medications due to cost. Conclusion: When controlling for the differences in age and gender, Veterans and non-Veterans did not have statistically significant differences in moderate to severe psychological distress; however, Veterans were much more likely to utilize mental healthcare. More research is needed to validate these findings and to determine why Veterans between the ages of 35-44 and 55-64 and Veterans with children in the home had an increased predicted prevalence of psychological distress as compared to non-Veterans during the pandemic. The increased prevalence of utilization of mental healthcare utilization among Veterans identifying as a racial and ethnic minority is notable given racial and ethnic disparities in mental healthcare utilization in the general population, but more research is needed to determine causal factors.