EMS, because these may be the only services available where they live. End of Horn explained that American Indians and Alaska Natives serve in the military at five times the national average (DeSimone, 2021), so the likelihood is high that those accessing EMS are also veterans.

Understanding location is the first important thing to consider when thinking about these communities and improving mental health emergency access. The IHS has been one of the only organizations providing health care in very geographically isolated areas. Transportation is one of the biggest barriers to access, especially for Native veterans who often reside in tribal communities on reservations in remote areas. Similar to VA, the IHS system has great variation—End of Horn explained that IHS hospitals vary and offer different services. The second important thing to consider is understanding the community in which Native veterans reside. She stressed the importance of outreach, which needs to occur at the ground level. With this in mind, she suggested that Native veterans are commonly not aware that they may be eligible to seek care at VA or other community facilities and that better outreach is needed.

One participant highlighted that it is challenging to build a better and more systematic way to facilitate warm handoffs between clinical and community-based services and vice versa. End of Horn responded that the lack of resources is always an issue, but sometimes it is about having dedicated people willing to work through any issue. She gave an example of the Navajo EMS in Utah that won an award for its work responding to emergency medical issues. It used satellite phones and a 1-800 number and made it a point to learn where everyone lived, even without detailed addresses. This helped ensure that it could find individuals in need.

Individuals Who Are Unhoused

Enrico G. Castillo, associate vice chair for justice, equity, diversity, and inclusion at the University of California, Los Angeles, discussed several angles to consider when thinking about mental health access for veterans who are unhoused: coordination of care among various teams, community partnerships to increase housing availability, and homeless outreach services. He focused mainly on the latter and the importance of critically examining goals and strategies with outreach to foster trust and avoid harm. Castillo described homelessness as a structural problem, caused by unavailability and unaffordability resulting from inequitable and racist housing laws and housing markets. Although mental illness makes individuals more structurally vulnerable to such issues, Castillo noted, nothing within mental illness causes homelessness. Even a perfect VA mental health system would not eradicate homelessness, even for those veterans with mental illness; structural solutions, especially permanent supportive housing, are needed.

from Miles, highlighting the importance of getting to the community level and developing strategies to build a workforce in rural communities. Regardless of where you live, said Helvig, just about everywhere has a mental health workforce shortage. Helvig presented a map showing shortage areas, with more than 1,000 counties without a single mental health or substance use disorder professional (see Figure 4-1). He said that developing a sustainable workforce requires a two-pronged approach—not only targeting those who live or work nearby but also creating resources to develop a pipeline of new workers in the local area. He advocated going even further upstream to look at young students who have certain skills and talents for helping others and working to advance and encourage them down this pathway.

Typical recruitment strategies focus on the end of the pipeline, often after graduation, Helvig explained. He stated that we need to seek ways to engage place-committed learners, extend education and training opportunities to them, and develop a local workforce where they are needed. Much of the focus at the Western Interstate Commission is on creating educational partnerships. For example, with Northern Marianas College, it partnered with the University of Alaska Fairbanks to facilitate learning within the community and online learning through the larger University of Alaska platform. Students who wanted to be social workers could stay on the island community to obtain training and do their work and still receive the necessary credentials.

Recognizing the vastness of the state and the need for remote, rural workers, Alaska created another classification of professional for those communities. Helvig discussed a paraprofessional program that builds capacity with a place-committed workforce through the tiered Alaska Behavioral Health Aide Program. Aides are supervised by a licensed professional based on their level of education and certification goal. Minnesota is doing something similar but targets children and families, he added.

Helvig summarized three main challenges facing workforce development:

• Identifying rural and frontier needs in the community and acknowledging potential needs for specialization;
• Building a workforce to meet specific needs, including thinking creatively about workforce availability, developing tiered levels of providers, mentoring youth, and using technology; and
• Prioritizing funding, research, outreach, and champions at the state and local levels.

DISCUSSION

Jay Shore, of the VA Office of Rural Health and professor at the University of Colorado Anschutz Medical Campus, focused on targeted actions for VA to consider in its work. Specifically, presenters commented on ways it can better engage with organizations, challenges and lessons in integrating with and adapting to communities, and being a good collaborator.

Engaging with Organizations and Communities

Castillo said that in his communication with VMETs, he found that VMET responders often spend more time talking with law enforcement than with mental health clinicians. He reiterated the importance of centering homeless outreach on unhoused veterans and avoiding criminalization; he recommended Houston’s Encampment Strategy as a comprehensive plan that works with law enforcement, takes a longer approach to engagement, and builds in pathways to housing (White, 2021). Castillo added that coordination is equally important, as there are so many teams serving this population, but more ways to share data among teams and with community-based organizations are needed. Miles added that town halls still work, and successful engagement can come from talking with the community and having intentional conversations around veterans’ services—whether in person or virtually. He also suggested just showing up to places of worship or religious functions to build stronger relationships with those communities. End of Horn suggested that VA should examine its internal resources, specifically tribal veterans

representatives. She said when she connects with VA, it wants to speak to the tribal leader, but they are very busy and difficult to contact; the representatives or county veterans service officers may be more accessible and available. Echoing Miles, she also said the best thing to do is to just show up. There are opportunities to conduct health fairs at powwows or coordinate with IHS or other local collaborators, such as the Disabled American Veterans, to meet with people and give out information.

Building a More Integrated System

Knowing that tribal communities are all unique, End of Horn relayed an example from Washington State, where tribes approached state legislators and asked for a tribal hub for their crisis center. It is now the only one in the country that is affiliated with 988, which allows for a direct line for people to connect with tribal health programs. The infrastructure in each region also needs to be considered, she said, as that may be why some reservations may not have 911 or 988 systems. Helvig added that the best example of adapting broader approaches is how to pull together different community providers to create internships. In rural communities, he explained, we can bring together a few providers and have them pool resources to each have an intern, but all can operate underneath one training director and spread the wealth. Miles added that the church has robust counseling ministry; although they are not always experts, they can serve as a great training ground. Students looking for clinical hours come and serve the population, which helps to normalize mental health care and reduce stigma, and also prepare clinicians who may not be familiar with the population and needs. He highlighted a specific training for suicide prevention called “Question, Persuade, Refer,”¹ saying they offer it quarterly to their congregation, allowing many of the members to be frontline resources and help fellow community members with life’s struggles.

Helping VA Become a Good Collaborator

Castillo suggested that VA seek out opportunities where it can be proactive and partner with different organizations. For example, it can help with housing by using Enhanced Use Lease arrangements, which can repurpose unused or underused VA land and buildings for permanent supportive housing. Miles said they have had a positive experience with VA in Philadelphia,

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¹ Question, Persuade, Refer is an emergency medical intervention that uses three steps to detect if someone is at risk for a suicide crisis and assists in referring them to the appropriate crisis services. See https://qprinstitute.com/about-qpr (accessed June 22, 2023).

particularly through a ministry program called “Life After Combat,” where they host some of the group meetings at the church during the week. Helvig and End of Horn noted the importance of those veterans who are not known to VA or accessing services. VA can often be seen as a place, End of Horn said, not a broader service, so when looking at tribal or rural communities, veterans may often think they have to travel a long way. She suggested that anything done to bridge that gap would be beneficial—whether telemedicine, mobile clinics, or other hybrid models of care.

THE ROLE OF TECHNOLOGY

Numerous examples have emerged in recent years that demonstrate how to use technology and emerging digital tools to increase access to health care generally, as well as mental health specifically. Speakers in this section shared their experiences using technology in mental health delivery among veterans and other populations.

Machine Learning (ML) and AI

Paola Pedrelli, associate professor of psychology at Harvard Medical School, and associate director of the Depression Clinical and Research Program and assistant in psychology at Massachusetts General Hospital, reviewed how AI and ML can improve access to mental health. To create a solution, we need to understand the problems, she said. She highlighted the lack of care-seeking from individuals who may not recognize the signs of mental health distress or PTSD, the lack of trust in the health care system, and the stigma around mental health. Pedrelli said veterans also face an added complexity of mixed messaging because they have been building an identity of strength, resilience, and self-control throughout their service. This can make it seem like a sign of weakness to exhibit mental health symptoms or need care.

Even just 5 years ago, we would not be able to do a lot of what is possible now leveraging AI and ML, said Pedrelli, such as identifying patterns and solutions based on thousands of data points. Another tool called natural language processing (NLP) is also more sophisticated and can now identify text and content—and based on these data points can create new language or messaging. Moving to applications, she highlighted four areas where AI can be useful: remote monitoring, personalized treatment, digital treatment, and clinician training. As engineering advancements have occurred alongside computer science, sensors can be used as wearable or mobile phone devices and monitor indexes that can inform someone about their health. Combining these indexes allows for creating digital phenotypes, she explained, which can help detect a disorder and monitor symptoms. Personalized treatment also

helps to identify the best treatment for a certain person that will be most effective in the shortest amount of time. She also reviewed digital health treatment, such as using smartphones or computers, whether through apps, chatbots, or hybrid systems, where a device will collect data that will help a human therapist determine if an intervention is working. Another promising area is using the increasing amount of data on CBT sessions. One study Pedrelli mentioned looked at 9,000 CBT sessions with text transcripts. Using AI, researchers were able to see which specific elements that emerged from the transcripts were more or less successful (Ewbank et al., 2020).

To summarize, Pedrelli acknowledged the various ways that these AI and ML solutions can address some of the identified problems with mental health care access. Remote monitoring can help identify people suffering from a range of conditions such as depression, and personalized treatment may be a more efficient way to deliver care while also increasing trust in the institution. Digital health treatment can also address financial and geographic barriers that hinder many patients. Overall, she emphasized the need to use a lens of tech equity when thinking about overcoming barriers. She said that regardless of any demographic or other factors, people have a right to access technology and benefit from it. One way to work toward this is diversifying the AI workforce, she suggested, because bias is everywhere, and less diverse workers that create the AI could result in very biased models used to deliver care. Similarly, systems will also need to use datasets from diverse populations, so that the training models can be inclusive and understand the implications of different populations or variables.

Emerging Digital Mobile Technology

John Torous, Beth Israel Deaconess Medical Center (Boston), focused on digital phenotyping, digital navigators, and the world of self-help apps. The idea of digital phenotyping² is important because to improve access, we need to better understand people’s underlying conditions and what makes them feel well or move toward recovering. One approach is to consider active and passive data collected by smartphones and connected devices. Active data include things such as surveys that people need to complete. Passive data include indicators that smartphones can pick up automatically, such as step count. He shared work on this from the past several years, which resulted in the mindLAMP platform, an open-source research app that collects information on the

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² Refers to “moment-by-moment quantification of the individual-level human phenotype in-situ using data from smartphones and other personal digital devices.” These data can be further “combined with electronic medical records and with molecular and neuroimaging data.” See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4873624/ (accessed June 22, 2023).

back end that also offers a benefit for users on the front end. LAMP stands for “learn, assess, manage, and prevent,” based on the idea that it should be flexible, reusable, and adaptable to different populations. It also acts as a consortium that has brought together 54 sites worldwide, encouraging collaboration and information sharing (Bilden and Torous, 2022). As an example of how to use such digital phenotyping data, Torous shared a study of people with schizophrenia that examined risk of relapse. Using the data around different indicators, it built an individual threshold for every person and watched for signals that suggested an approaching relapse (Cohen et al., 2023). However, he also cautioned against using algorithms to predict symptom change without transparent technology and very good clinical science. Many studies are not preregistered³ or replicated, he said, which makes it difficult to know if the algorithm is working.

Another new approach Torous shared is taking the digital phenotyping data and converting to a risk score, allowing clinicians and patients to access a directly actionable piece of information for more personalized care. He also shared details about a project with the Easter Seals of Greater Houston that trains veterans as digital navigators, helping to address the workforce shortage and become coaches to teach other veterans how to use the apps or look at data to increase access. The navigators can also help within a clinic, helping to troubleshoot technology or summarize data, such as radiology technicians supporting radiologists, he said. The clinic at Beth Israel Deaconess Medical Center also employs digital navigators who help make apps more engaging and customized. One strength of this program is the variety of dashboards, said Torous, that can show which CBT exercises that the patient has done; correlations between thoughts, mood, sleep, or behaviors; or even how changes in physical activity correlate with mood and depression symptoms. This hybrid model of care with digital navigators is an effective way to increase access (see Figure 4-2), as it also benefits clinicians.

In terms of evaluating the number of self-help apps available, he said that his team often finds the VA apps to be some of the best, and they are available even to nonveterans. They can be great adjunctive tools for care regardless of veteran status, said Torous. He added that there is also a website called mind-apps.org that can be used to filter through mental health apps and find the best app for the patient’s individual needs and context.

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³ Preregistration is the practice of deciding the research and analysis plan before starting a study and sharing it publicly, such as submitting it to a registry. See https://www.acf.hhs.gov/opre/blog/2022/08/pre-registering-studies-what-it-how-do-you-do-it-and-why (accessed June 13, 2023).

low at 6-month follow-ups. They also assessed salivary cortisol before and after viewing the VR clips; after an initial increase, those levels also decreased with treatment (Rothbaum et al., 2014).

Last, she shared the Emory Healthcare Veterans Program, which includes a free, 2-week intensive outpatient program that includes psychotherapy, exposure therapy, pharmacotherapy, and cognitive rehabilitation for traumatic brain injury. Despite frequent problems with treatment completion in outpatient programs, Rothbaum said that Emory’s program has a 90 percent completion rate. In response to COVID-19, it also provides many services via telemedicine now, with outcomes comparable to in-person services. She mentioned large decreases in PTSD and depression, even maintained over 12 months. Rothbaum shared that it has seen positive successes across the board, regardless of the type of mental health challenge or program track. It has also developed a manual on therapies for intensive outpatient programs that other systems can use (Rauch et al., 2020).

Improving Mental Health Services Within VA

Anne Lord Bailey, director of clinical tech innovations at VHA, reviewed some of VA’s immersive technology. Bailey said CBT is used frequently in the world of VR, which can be compelling because of the immersive environment. In 2017, five VA medical centers were working with VR. Four were doing prolonged exposure, and the last (in Western North Carolina) used an intervention to decrease opioid use and length of stay through positive distraction. Bailey noted veterans were so receptive to VR that VA continued to expand the uses. Now in 2023, she said, VA has more than 30 different clinical uses of VR for patients in all 50 states and Puerto Rico.

One of the most compelling aspects of these programs is that they put the veteran at the center, said Bailey. She and her team are focused on expanding and scaling VR programs until they are available to every veteran who could benefit from them. One study they conducted also found that if veterans experience types of nonpharmacological approaches (i.e., mindfulness, meditation, yoga) in a VR environment, they are more likely to try those things in the real world (Rawlins et al., 2021). Bailey explained that VR acts as a gateway to get veterans to try out modalities. Another compelling aspect for this therapy, she added, is that it is multimodal and can go beyond just treating mental health issues. For example, it has had impacts on anxiety and depression scores, or connection with the community, in addition to reductions in acute or chronic pain.

Bailey highlighted the various ways she saw VR being used in this context with veterans, describing remote, asynchronous mental health care and at-home self-care, such as mindfulness, meditation, guided physical activity, and

virtual peer support. She noted that equipping nonproviders with VR tools and devices can augment the workforce and thus improve access.

Discussion

The presenters discussed how to scale technology-based tools, as well as how to address the lack of trust and equity in mental health care and technology use. Speakers also touched on what technologies warrant funding for expansion based on current evidence.

Engaging Veterans and Other Providers

Evelyn L. Lewis, president and chair of the Veteran Health and Wellness Foundation, asked for ways to bridge the gap between these technologies and veterans who are not yet engaged in the system. Torous noted that most veterans have smartphones, even in rural areas, so this could be looked at as a “stepped care approach” if access to the VR headsets is not ample. He mentioned a tool called “Google Cardboard” that enables a smartphone to become an inexpensive VR device as an introduction to the technology. He also suggested leveraging digital navigators to bring people into the system and build relationships to get them familiar with the devices and experiences.

Regarding the use of his app in an integrated behavioral health setting, Torous said his team worked with a psychiatric nurse practitioner at the University of Nebraska who has been using the mindLAMP platform and found patients are excited to get feedback on their mental health. They want to see their mood and anxiety scores, he said, and how screen time correlates to different outputs. Mental health can be intangible and difficult to understand, so having data and being able to interpret those data with their provider is a benefit patients appreciate.

Addressing Lack of Trust and Equity

Lewis asked for ways to overcome the lack of trust in health care and fear of racist overtones when using things such as AI or algorithms. Pedrelli replied that the first step is to involve these veterans and work to engage them, understanding their hesitations and pain points. Pedrelli also stressed that it is important to have a workforce that represents different populations and to engage people from different communities in the process of developing interventions and models. Rothbaum added that at Emory, among the post-9/11 veteran demographic, women and Black people are slightly overrepresented compared to the veteran population overall. The program has demonstrated

success, with about 85 percent of those who completed intensive outpatient programming having large or moderate decreases in PTSD symptoms, including at 12-month follow-up. But they are still investigating potential differences in outcomes across populations and race and ethnicity.

In terms of equity in access to these newer technologies across VA, Bailey noted that it is difficult to predict timelines in government but that VA is actively working to equitably spread these innovations. She explained that her team is building the technical infrastructure and simultaneously strengthening privacy and information security to ensure that data can be collected and analyzed across demographic groups to identify disparities or different intervention needs while also maintaining appropriate privacy protections.

Future Funding for Technology

Participants asked whether the data are good enough to support VA undergoing a major expansion of VR availability for a wide variety of users and warrant large expenditures. Bailey said that for chronic pain and suicide prevention, 135 sessions across two different medical centers documented a 30 percent decrease in Defense and Veterans Pain Rating Scale scores and a 30 percent decrease in anxiety scores with one session, which is very effective for a therapy. Torous added that, from his work as a journal editor, he agrees that the data for VR and such an application are really that robust, but the next question will be how results look when VR is deployed outside of research and its effectiveness in real-world settings. Bailey said that VR is being used in real clinical settings in VA today, including those 135 sessions. Torous also highlighted the importance of digital literacy when deploying technology tools, whether VR, online CBT, or something else. This is harder to fund, as it does not have the same selling appeal as headsets or an app, he noted; but if we can create an active level of digital awareness, then we may see more demand for things that work well.

Finally, regarding the potential of newer generative AI tools, such as ChatGPT, Pedrelli said he just started looking at the pros and cons but would recommend only adopting technologies that have been validated and do not have ethical concerns. ChatGPT is still being trained on models, and people are learning the strengths and weaknesses, she noted. Torous agreed that it is too early to jump into ChatGPT for these use cases.