The articles in this special issue reflect a number of emerging trends in federal practice. The first is that the optimal delivery of mental health clinical care as well as the conduct of cutting-edge clinical research are most often inter- and multidisciplinary collaborations. A background in public and military service instills the experience and training to maximize teamwork in the health care professionals of the VA, DoD, and PHS. Pharmacists, neuropsychologists, psychiatrists, social workers, nurses, and others come together to advance the science and scholarship that are the backbone for building efficacious patient-centered health care. Just as important, most of these articles reflect a partnership between VA and academic medical centers. The knowledge and skill of each partner amplifies the other to produce novel insights, which can be readily translated into treatment progress that benefits patients.
A case in point: Neurology and psychiatry have historically been different disciplines. However, some thought leaders recently suggested that the explosion of neuroscience has narrowed the gap between the specialties to a single field, as demonstrated by Langevin and colleagues. The authors propose the use of deep brain stimulation to treat patients with posttraumatic stress disorder (PTSD). Deep brain stimulation is a process in which electrodes are inserted into targeted areas of the brain and alter the neural impulses and physiology to relieve neuropsychiatric symptoms and, thus, modulate neural structure and function.
Up to one-third of veterans with PTSD also may have a substance use disorder. Pary and colleagues review the research on another trend in mental health treatment that is fast becoming a best practice: the integrated, coordinated treatment of co-occurring substance use and mental health disorders. This approach provides a comprehensive look at the diagnosis and treatment of depression and bipolar disorder coexistent with alcohol use disorder with both psycho- and pharmacotherapy.
Through its unique primary care psychiatry clinics, the VA has pioneered integrated care for individuals with serious mental illness and chronic medical conditions that may result in frequent hospitalization and increased overall health care utilization. Gill and colleagues emphasize the urgency and importance of these efforts given the increasing number of active-duty service members and veterans who served in Iraq and Afghanistan and are diagnosed with mental and physical conditions. Their outcomes data suggest that directing outpatient resources to patients with specific demographic and clinical factors may be beneficial.
The challenges of providing team-based care to patients with mental health disorders is borne out in the research of Lee and colleagues. Their examination of the risk of hospitalization for patients with PTSD who have been treated with benzodiazepine and opioids is a reminder of the challenge of treating patients with multiple comorbidities. The authors caution that prescribers should “limit benzodiazepine and opioid use in this population and consider safer nonpharmacologic and pharmacologic treatment options when possible.”
Many of these trends coalesce in my discussion with Larry Davis, MD, Distinguished Professor of Neurology at the University of New Mexico School of Medicine and Chief of Neurology at the New Mexico VA Health Care System. Dr. Davis describes a successful teleneurology program that treats patients in underserved rural areas in New Mexico and Colorado. He also touts the benefits of teleneurology to address the shortage of neurologists. Many of the most common and serious neurologic conditions, such as epilepsy, Alzheimer, and Parkinson, are managed through a teleneurology program that includes education and support for patients and caregivers.