- Contact the Committee

INTRODUCTION:

My name is Stephen L. Holliday. I am a clinical psychologist and am board-certified in Clinical Neuropsychology by the American Board of Professional Psychology. For more than 18 years I have been actively involved in providing psychological care for veterans at the South Texas Veterans Health Care System (STVHCS), including those with posttraumatic stress disorder (PTSD). I previously served as the Psychology Service Training Director here for the past 10 years. This past January, I was named Chief of the STVHCS Psychology Service. As such, I have administrative and clinical responsibility for all psychological services at the STVHCS, including outpatient clinics. I also have responsibility for the educational and training programs in psychology. As Chief Psychologist, I also serve as STVHCS’s liaison to the local Vet Centers, which serve veterans with PTSD from all conflicts. I also serve on the STVHCS Mental Health Council and assist in the coordination of care and planning for mental health care in our system.
In addition, I currently have the honor of serving as President of the Association for VA Psychologist Leaders (AVAPL), an independent organization that represents about 200 VA psychologists who serve as Chiefs and program leaders throughout the nation. As AVAPL President, I will preside at our annual meeting later this month in Washington. A major focus of this meeting will be preparing for new veterans returning from Iraq and Afghanistan.

I would like to discuss our history of close collaboration with the Department of Defense (DOD) and current planning efforts in preparing for providing psychological and mental health needs of our veterans, especially those new veterans returning from the conflicts in Iraq and Afghanistan.

COLLABORATION WITH DOD:
STVHCS has a long history of close and mutually beneficial training collaborations with DOD health care institutions in the San Antonio Area. The Psychology Service here has conducted joint neuropsychology training activities on a monthly basis for our respective interns/residents for over 15 years. Staff neuropsychologists at Brooke Army Medical Center (BAMC) and Wilford Hall Medical Center (WHMC) have also collaborated with our staff psychologists on research projects and difficult clinical cases frequently over the years. In addition the psychology departments at BAMC and WHMC frequently invite our staff and trainees to attend special conferences and workshops by nationally known Visiting Distinguished Professors (of Psychology) funded through DOD. Our neuropsychology trainees have frequently done off-site training rotations with Dr. Pamela Clement at BAMC. Two staff neuropsychologists from WHMC also attend and help teach our weekly Neuropsychology Readings Conference/Journal Club. Similar arrangements have been made over the years for our resident physicians in Psychiatry and Medicine.
With respect to returning Iraqi veterans, a VA staff social worker (along with several other VA administrative/clinical staff) has been detailed to DOD to assist with seamless referral of DOD personnel for VA services. To my knowledge, all of these referrals to date have been for medical and rehabilitation services. However, the social worker is also knowledgeable about STVHCS mental health resources and will assist in making those referrals as needed. We suspect that many DOD personnel may be reluctant to seek mental health services while on active duty for fear of adversely affecting their military careers. We anticipate that many returning Iraqi veterans will seek VA mental health and Vet Center services after they are demobilized/separated from DOD. When that happens, additional VA mental health resources will likely be required.
STVHCS front line personnel in Triage, Medical Administration Service, and Primary Care have been trained to expedite services for returning veterans from Iraq and Afghanistan. Our mental health program leaders have been specifically instructed to ensure that these priority veterans receive all needed services in a timely fashion.
STVHCS is currently planning several collaborate initiatives with DOD to jointly provide clinical services for both veterans and DOD personnel/dependents. We anticipate opening two new outpatient primary care clinics in San Antonio: one with the Air Force on Brooks City Base in the underserved south side of town and another with the Army in the rapidly-growing north central area. We are also exploring expanding the VA Corpus Christi Outpatient Clinic by co-locating it with the underutilized DOD hospital facility at the Naval Air Station in Corpus Christi. We will ensure that each of these facilities has substantial mental health capability.

RECENT CHANGES & FUTURE PLANS:
For many years, our Post Traumatic Stress Disorder Clinical Team (PCT) here had 1.5 FTE psychologists, a psychiatrist, a social worker, and program specialist to provide specialty mental health care for STVHCS veterans with PTSD. Recent military actions in Afghanistan and Iraq have already increased their caseload with PTSD patients from previous conflicts, likely due to exacerbation of their symptoms from news coverage. They currently have a backlog of PTSD patients referred for their services. For this reason, they recently received authority to expand the social worker position to full time and to recruit for an additional psychologist and psychiatrist to help with this backlog. The new psychiatrist has already been selected and the new psychologist should be selected within a few weeks. In addition, the PCT recently held a staff retreat to plan better, more cost-effective methods to assess and treat these patients. For example, the additional social worker will create a new “drop-in” center/low intensity treatment program for patients currently followed for chronic PTSD, freeing up other staff and group therapy resources to clear the backlog and make room for new PTSD cases returning from Iraq.
Dr. Abney, the PCT clinical director, is currently planning for new therapy groups, especially for these new PSTD cases. Indeed, Dr. Abney has already treated several active duty troops who were disturbed by nightmares from their service in Iraq. These were the adult children of Viet Nam veterans he saw through the PCT in past years. Dr. Abney is a nationally-recognized authority in the treatment of PTSD and offered one of the first group therapy interventions for Viet Nam veterans at the Temple VAMC in 1978. The PCT staff regularly visits and consults with the local Vet Center, which also provide extensive individual and group treatment for PTSD patients. In conjunction with our Education Service, we are also planning to schedule an extensive workshop at STVHCS on treatment of acute stress disorder by staff from the VA’s PTSD Center of Excellence in Boston. VA Central office recently developed extensive new treatment guidelines for evidence-based treatment of acute stress reactions and PTSD. These were distributed to the staff at the PCT and Psychology Service earlier this year and will be incorporated into their program.
VA Central Office has also added annual mandatory screening for PTSD (along with current screening questions for depression, substance/tobacco abuse, etc.) for all veterans served. This process is automated through our state of the art computerized medical record system, ensuring that all veterans receiving medical care will be annually screened for these major mental health conditions. When identified, they will be either treated in the primary care setting or referred for more specialized mental health programs. This should ensure that all veterans with these problems are identified and appropriately treated, even if they do not specifically request these services. We are determined not to repeat the mistakes from Viet Nam, when delayed identification and the lack of effective early treatment for PTSD may have contributed to lifelong disability for so many veterans. We now understand that early identification and community-based treatment/case management are key to this effort. Our new psychosocial rehabilitation program located at Villa Serena near Audie Murphy Hospital should be especially helpful in this regard. This is a residential program that focuses on psychiatric, psychological, and vocational interventions aimed at providing patients with the skills needed to return to the community and gainful employment.
Other mental health resources have been increased this year at STVHCS. We have recently authorized and are recruiting two additional psychiatrists, two mental health nurses, and one psychologist for our outpatient clinics in San Antonio and Kerrville. We are also developing telemedicine initiatives to extend specialized mental health care to our remote outpatient clinics and to ensure all clinicians in these settings have access to consultants and continuing educational opportunities. Psychology Service is continuing our efforts to offer mental health services within primary care medicine settings. For the past seven years, each of our five psychology interns were assigned to half-day Internal Medicine Clinics at Audie Murphy Hospital throughout their training year. In this way, veterans have easy/quick access to psychological services without the delays or stigma associated with referrals to psychiatry clinics/programs. We are now planning to expand these services to the primary care clinic at the Frank Tejeda Outpatient Clinic in San Antonio. In addition, our staff recently received training in DIGMA groups which pair a mental health professional with a primary care provider to provide integrated medical/psychological care in a cost-effective group setting. The VERDICT, our center of excellence for evidence-based medicine, is currently working on a 3-year program implementation grant which would resource, train staff, and expand mental health services within primary care across VISN 17.

PROJECTED NEEDS:
Although it is difficult to accurately predict the number of returning veterans who will require mental health resources, we suspect it will be substantial. Unlike the relatively brief and low-causality first Gulf War, the current conflicts in Iraq and Afghanistan are likely to be protracted and difficult. Like Viet Nam, our forces in Iraq and Afghanistan have great difficult differentiating friend from foe and there are no truly safe (rear echelon) areas. The mental health toll taken by extended tours in such stressful conditions is well known to us. The question is not IF many returning Iraq/Afghanistan War veterans will need VA mental health services, but only WHEN they will seek it.
We know how to effectively treat acute stress reaction and to prevent it from becoming severe, chronic PTSD; however, our budgets are now barely keeping up with our current demand. We are now implementing workload and staffing guidelines for mental health clinics. We need to ensure that VA mental health providers are both productive and adequate in number to meet this need. We will equip our staff with the knowledge and facilities to do the job. We will also monitor their productivity, caseloads, and clinical outcomes to ensure fiscal accountability and quality care. As the first of the returning veterans begin to enter the VA system over the next several months, we should have a better estimate of the number needing additional mental health services and resources.
We would encourage the Committee to closely monitor this need and to fund VA mental health services accordingly. The cost of failing to provide timely/effective mental health services for these veterans would be much higher in terms of lost wages/taxes and the costs of chronic psychiatric care for another generation. Our country cannot afford another lost generation of chronic PTSD patients… financially, ethically, or morally. We know that the House Committee understands our debt and sacred obligation to our veterans and will continue to help us to provide quality mental health care for all who have served.
SUMMARY OF KEY POINTS:
1. We have a solid track record of effective collaboration with DOD facilities.
2. New sharing agreements are planned for joint care with DOD.
3. PTSD treatment resources are strong and we are actively preparing for returning veterans.
4. New methods are in place to identify and provide effective treatment for PTSD and other mental health problem in returning veterans.
5. Additional funding will likely be needed to provide care for returning veterans, but will be much less expensive than failure to identify/treat PTSD in a timely fashion.
Thank you for this opportunity to present to you this morning.