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1 | INTRODUCTION Behavioral health providers (BHPs)-'mission critical' psychiatrists, psychologists, and social workers in the Veterans Health Administration (VHA)--report the second highest level of burnout after primary care physicians. (1) [...], Objective: To identify work-environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers. Data Sources: The 2015-2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility-level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities. Study Design: For AES and MHPS separately, we used mixed-effects logistic regression to predict BHP burnout using surveys from year pairs (2015-2016,2016-2017,2017-2018; six models). Within each year-pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work-environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts. Data Collection/Extraction Methods: We included work-environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS). Principal Findings: In 2015-2018, 31.0%-38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well-coordinated; and three reverse-coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility-level staffing ratios and productivity did not significantly predict individual-level burnout Workload represented the strongest predictor of burnout in both surveys. Conclusions: This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting. KEYWORDS burnout, mental health providers, supervisor support, workload What is known on this topic * Veterans Health Administration (VHA) behavioral health providers (BHPs) face high risk of burnout due to large organizational demands, and a vulnerable, complex patient population. * BHPs have the highest risk of burnout after primary care providers in VHA. * The field has made limited progress to date on mitigating BHP burnout, and clinician turnover can prove expensive and exacerbate burnout among clinicians who remain within VHA. What this study adds * Using multiple years of data from two national health system surveys, we conducted the largest study to date of characteristics associated with BHP burnout. * In addition to having a reasonable workload, having appropriate resources, opportunities to improve, and managerial support had consistent and significant associations with lower BHP burnout * This study indicates potentially modifiable targets for policy makers and stakeholders to address persistent characteristics that contribute to burnout among essential providers in the nation's largest integrated health system.

The Veterans Benefits Administration (VBA) operates a disability program called the Service-Connected Disability Compensation program that provides tax-free monthly benefits to Veterans for disabilities that were incurred or aggravated during [...], Objective. To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD).Data Sources. A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249).Study Design. We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership.Data Extraction Methods. We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase.Principal Findings. The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma.Conclusions. Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.Key Words. Veteran, Veterans Affairs, posttraumatic stress disorder, compensation, service connection

National Guard soldiers activated for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are eligible for 5 years of free health care through the Department of Veterans Affairs (VA) [...], Objective. To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. Data Sources/Study Setting. Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. Study Design. Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. Principal Findings. Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater nonVA services use. Conclusion. Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers. Key Words. Mental health, VA health care system, access, utilization of services