State and USAID employees abroad face an increased demand and an inadequate supply of mental health resources

The State Department employs well over 70,000 people, with the majority of them living and working at posts abroad, while its partner, the  U.S. Agency for International Development, engages another several thousand direct employees and many thousands of contractors. 

These agency workforces serve in positions all over the world—many of them in challenging political, economic—and health and mental health—environments, some in and around violent conflicts. 

But a recent Government Accountability Office report identified continuing and worsening problems in the provision of employee mental health care for State and USAID personnel abroad. 

“U.S. employees and their families overseas often work and live in stressful environments with limited or no access to local mental health services,” the report, issued last week, summarizes. “While the State Department and U.S. Agency for International Development offer some mental health services, providers and patients we surveyed identified challenges in delivering or accessing them.”

At State, in-house mental health is provided by the department’s own Bureau of Health Services, known as MED. At USAID, the equivalent is called Staff Care. 

The report cites the COVID-19 pandemic, the war in Ukraine, and a general rise in demand for psychiatric services among some of the top factors increasing strain on the demand end of MED’s ability to provide mental-health resources. A survey of psychiatrists who provide services to feds abroad provides additional data revealing that the absence of electronic record systems, lack of local providers and many vacant mental health care positions all add to their burden and complicate care delivery.  

At USAID, demand for counseling services has approximately doubled in recent years. At State, demand has also increased greatly. Accordingly, both agencies, the report says, are making efforts to increase funding and resources available for mental health care—with State making plans for an expected additional $6 million to be spent on mental health. 

The GAO report notes some possible issues in its findings. State has collected data on only “some” pieces of the mental health services picture for foreign-assigned federal employees—but to fix problems the department first needs to expand data collection and analysis: “The Secretary of State should ensure that the Bureau of Medical Services' Chief Medical Officer collects ongoing feedback from overseas recipients of all State mental health services to determine whether these services are meeting their needs.”

The report notes that among feds, as is the case in the wider American population, the stigma associated with seeking help for mental health or substance abuse issues continues to impede the provision of care, and more concerted action is needed to combat that stigma. 

Finally, a minority of the mental health professionals surveyed listed patient confidentiality concerns as impairing the provision of mental health care. The report touches on at least some legal replies to these concerns in its footnotes. Physicians—including those that provide services for State—are “required to keep communications with patients confidential pursuant to professional rules imposed by their states of licensure or certifying boards.” Furthermore, “services provided by State’s ECS are not reportable on the security clearance application or medical clearance review.” Employees, the report adds, are permitted to make use of department resources or alternatively “seek care from private providers” in the U.S. or abroad. Employee patient records are confidential at both State and USAID, except “to the extent required by law or authorized by the employee.”