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The American Psychiatric Association (APA) would like to thank the members of Subcommittee and your House colleagues for your commitment to providing the highest quality medical care for our nation's veterans and to supporting necessary research to advance the quality of their care.

The APA is the national medical specialty society representing more than 37,000 psychiatric physicians nationwide who specialize in the diagnosis and treatment of mental and emotional illnesses and substance use disorders. At the federal level, the APA advocates for access to quality medical care, necessary supports to those living with mental illnesses and their families as well as investment in biomedical research.

The APA commends President Bush for adding $339 million to the FY07 budget for mental health inpatient, partial hospitalization and other services. Even with these additional funds, however, the budget is not adequate to meet the growing needs of veterans with mental illnesses. According to a recent article published in the New England Journal of Medicine, 15 to 17 percent of returning combatants from Iraq met the screening criteria for major depression, generalized anxiety or PTSD using the National Center on PTSD’s measurement scale. In addition, the Veterans Administration’s own researchers have published data in journal Psychiatric Services that documents the rise in mental health problems among its current patients, particularly younger veterans.

MENTAL HEALTH CARE NEEDS OF VETERANS

• Over 470,000 veterans are service-connected for mental disorders.
• Over 130,000 of these veterans are service-connected for psychosis.
• In 2003 alone more than 77,800 veterans received specialized care for PTSD with tens of thousands more receiving some type of care through their primary care clinic.
• More than 185,000 are service-connected for PTSD, a disorder most often directly
related to combat duty.
• Veterans with mental illnesses also have significant medical comorbitities and are therefore difficult and expensive to treat.
• Over 30% of the homeless population in this country are veterans with mental disorders and substance use conditions.

MENTAL HEALTH SERVICES FOR VETERANS

While the Administration’s budget does allow for increases in spending over FY06, the APA is concerned that the budget assumptions, such as the reliance of legislative proposals to collect user fees and copays from priority level 7 and 8 veterans, might be overly ambitious. The Friends of the VA advocacy group estimates that up 200,000 vets will drop out of the VA system with the proposed copays. While level 7 and 8 veterans are not service-connected for disability, we are concerned that the VA has not considered the impact on those 200,000 who rely on the VA to pay for psychiatric medications such as anti-depressants that keep them well and employable.

We urge Congress to require clarification of the Administration’s “medical usage” projections which indicates the number of psychiatric patients drops as well as the number of vets in residential care. This projected decrease in care is troubling given that the VA’s mental health data shows the number of patients seeking psychiatric care will increase. We request that Congress also require further information from the VA on the discrepancy between the budget estimate for 2006 which cites the average daily census of inpatients and outpatients as significantly higher than the FY2007 budget request currently reflects.

For too long, mental health care has not been a priority for VA. Virtually every entity with oversight of VA mental healthcare programs – including Congressional oversight committees, the GAO, VA’s Committee on Care of Veterans with Serious Mental Illness, and other groups such as The Independent Budget – have documented both the extensive closures of specialized inpatient mental health programs and VA’s failure in many locations to replace those services with accessible community-based programs. The resultant dearth of specialized inpatient care capacity and the failure of many networks to establish or provide appropriate specialized programs effectively deny many veterans access to needed care. We continue to receive troubling reports suggesting that mental health funds may be re-allocated by the VA for other purposes. The APA requests that Congress task the Government Accountability Office with tracking the FY05 and FY06 funding allocated for the diagnosis, treatment and recovery of mental illness and substance use disorders as well as monitor VA compliance with Congressional recommendations.

Veterans with substance use disorders are drastically underserved. The dramatic decline in VA substance use treatment beds has reduced physicians’ ability to provide veterans a full continuum of care, often needed for those with chronic, severe problems. Funding for programs targeted to homeless veterans who have mental illnesses or co-occurring substance use problems does not now meet of the demand for care in that population. Additionally, despite the needs of an aging veteran population, relatively few VA facilities have specialized geropsychiatric programs.

The APA is concerned that VA mental health service delivery has not kept pace with advances in the field. State-of-the-art care requires an array of services that include intensive case management, access to substance abuse treatment, peer support and psychosocial rehabilitation, pharmacologic treatment, housing, employment services, independent living and social skills training, and psychological support to help veterans recover from a mental illness. The VA’s Committee on Care of Veterans with Serious Mental Illness has recognized that this continuum should be available throughout the VA. However, at most, it can be said that some VA facilities have the capability to provide some limited number of these services to a fraction of those who need them.

PHARMACY AND MEDICATION RESOURCES

The issue of pharmacy resources and medication availability for mental illness is also important. There have been reports, including one by the GAO, that some networks have established either rigid limits for the use of some medications (for instance, atypical antipsychotics) or have simply insisted on the use of generics, together with other restrictions. The APA has joined with other advocacy organizations in opposing the implementation of the new treatment guidelines for atypical antipsychotic medications for veterans with schizophrenia. Of particular concern is the “fail first” policy that veterans with schizophrenia go through a minimum 6-8 week trial on specified medication, with access to any alternative medication limited to case failure after the end of the 6-8 week period. Patients respond differently to medications and physicians must be allowed to best respond to the health needs of their patients. This policy directly interferes with the clinical judgment of the treating psychiatrist and may put patients’ lives at risk.
As a practical matter the current VA computerized patient record system (which has been highly touted as a health information technology (HIT) model) – does not provide hyperlinks to the list of medications on the VA formulary. Such a link could assist with efficiency and patient care by speeding up medical necessity reviews for non-formulary drugs. This is especially important for patients who need psychiatric medications, because switching patients from medication to medication can have deleterious effects.

POSTTRAUMATIC STRESS DISORDER (PTSD)

Patients with severe PTSD increased 42% from 1998 to 2003, while expenditures increased only 22% during that same time. Veterans who are service-connected for PTSD use VA mental health services at a rate at least 50% higher than other mental health user groups. It is essential that identified PTSD programs be maintained consistent with the provision of P.L. 104-262, so that veterans may reap the benefits of specialized treatment delivered by clinicians who are experts in addressing the unique needs of veterans with PTSD and its associated co-morbid conditions. The APA appreciates the President’s special attention to the growing problem of post-traumatic stress disorder and the resulting need in a seamless continuum of care. Again, we would request that funds designated for PTSD services be tracked by the GAO to insure fidelity.

As you know, the Institute of Medicine is undertaking a review of PTSD diagnosis, treatment and disability determination within the VA and Department of Defense. We believe that care must be taken to distinguish between the underlying diagnostic criteria in DSM-IV and the way in which the DSM ma – or may not – be used appropriately. We would be pleased to brief members of the Subcommittee and staff on the DSM.

MIRECCs AND RESEARCH

The APA wishes to compliment the VA for initiating Mental Illnesses Research, Education and Clinical Centers (MIRECCs). The MIRECCs serve as infrastructure supports for psychiatric research into the most severe mental illnesses. However, less than 12% of the VA health research budget is dedicated to mental illness and substance use, even though 35-40% of VA patients need mental health care. The APA strongly encourages the establishment of additional MIRECCs.

The APA supports the VA Research Office’s decision to initiate the Quality Enhancement Research Initiative (QUERI), which has funded two new field centers focused on putting into clinical application what is known about schizophrenia, depressive disorders, and substance use disorders. However, the nominal increase in the research budget is likely to limit the implementation of this farsighted plan.

In addition to funding MIRECC’s the APA is recommending an overall FY07 appropriation of $460 million for medical and prosthetic research. This recommendation is consistent with a similar recommendation by the Friends of VA (FOVA).

WORKFORCE SHORTAGE

The shortage of physicians and other mental health professionals has compromised the delivery of healthcare and has endangered patient safety. Many veterans with mental illnesses are medically fragile – with diabetes, liver or kidney failure, or cardiac disease, for example. Their care requires a specially trained physician. A revision of salary schedules, recognition of the contributions of International Medical Graduates and minority American Medical Graduates, and the availability of Continuing Medical Education (CME) courses and other professional opportunities for advancement need to be addressed. We understand there is a significant shortage of nursing staff, especially psychiatric nurses, and we request that the VA address this shortage area.

RECOMMENDATIONS

The APA is deeply concerned about veterans living with mental illnesses and their families.
We believe it is important to secure: 1) additional and specifically allocated funding and ensure accountability mechanisms; 2) immediate implementation of clinical programs mandated within the system; 3) compliance with legislation aimed at maintaining capacity; and 4) enhanced recruitment and retention of personnel who will improve the care and lives of veterans with mental illnesses and substance abuse disorders.

Above all, a profound respect for the dignity of patients with mental and substance use disorders and their families must be duly reflected in serving the needs of veterans in the VA system. The American Psychiatric Association thanks the Subcommittee for the opportunity to submit a statement.

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