Witness Testimony of Antonette Zeiss, Ph.D., Acting Deputy Patient Care Services Officer for Mental Health, Veterans Health Administration, U.S. Department of Veterans Affairs
Chairman Miller, Ranking Member Filner, and Members of the Committee: Thank you for the opportunity to appear and discuss the Department of Veterans Affairs’ (VA) response to the mental health needs of America’s Veterans. I am accompanied today by my colleagues, Dr. Matthew Friedman, Executive Director of VA’s National Center for PTSD, Veterans Health Administration (VHA); Dr. Mary Schohn, Acting Director of the Office of Mental Health Operations in VHA, and Mr. Tom Murphy, Veterans Benefits Administration (VBA) Director of Compensation Service.
VA has responded aggressively since fiscal year (FY) 2005 to address previously identified gaps in mental health care by expanding our mental health budgets significantly. In FY 2011, VA’s budget for mental health services, not including Vet Centers, pharmacy, and primary care, reached over $5.7 billion, while the amount included in the President’s budget for FY 2012 is $6.15 billion. Both of these figures represent dramatic increases from the $2.4 billion obligated in FY 2005.
This funding has been used to greatly enhance mental health services for eligible Veterans. VA has increased the number of mental health staff in its system by more than 7,500 full time employees since FY 2005. During the past three years, VA has trained over 4,000 staff members to provide psychotherapies with the strongest evidence for successful outcomes for post-traumatic stress disorder (PTSD), depression, and other conditions. Furthermore, we require that all facilities make these therapies available to any eligible Veteran who may benefit. We also have expanded inpatient, residential, and outpatient mental health programs with an emphasis on integrating mental health services with primary and specialty care. These expansions also have increased the numbers of Veterans receiving mental health care in VA. In FY 2010, VA treated more than 1.25 million unique Veterans in a VA specialty mental health program within medical centers, clinics, inpatient settings, and residential rehabilitation programs; this was an increase from 905,684 treated in FY 2005. If including care delivered when mental health is an associated diagnosis in integrated care settings, such as primary care, VA treated almost 1.9 million Veterans in FY 2010, an increase of almost a half a million Veterans since FY 2005.
According to VHA guidelines, all new patients requesting or referred for mental health services must receive an initial evaluation within 24 hours, and a more comprehensive diagnostic and treatment planning evaluation within 14 days. These guidelines help support VA’s Suicide Prevention Program which is based on the concept of ready access to high quality mental health care and other services, and is discussed in more detail later in this testimony. Data closely monitored by VA confirm that our established standards for access to mental health care are met. Over 95 percent of all Veterans referred for new mental health care receive an appointment leading to diagnosis, and when warranted a full treatment plan, within 14 days. Similarly, data confirm that over 95 percent of established mental health patients also receive appointments for continuing care within 14 days of the preferred date, based on the treatment plan. VA also participated from FY 2006 through FY 2010 in a Government Performance and Results Act review, which was recently submitted to Congress. That review, conducted by RAND/Altarum, concluded that VA mental health care was superior to other mental health care offered in the United States on almost all dimensions surveyed. These data speak to the great strides made in the mental health care VA provides since implementation of the Comprehensive Mental Health Strategic Plan began in FY 2005, culminating with the Uniform Mental Health Services Handbook that was disseminated at the end of FY 2008 as VA policy for comprehensive mental health services to be offered throughout our health care system.
In this testimony, I will begin by describing PTSD and associated scientific evidence, with particular focus on two important findings from research: that recovery from PTSD is complicated by co-occurring disorders, and that even the most effective treatments do not guarantee recovery. I will then explain VBA’s role in providing support and compensation to affected Veterans. Finally, I will review some highlights of VA’s mental health care program, including a general description of the services and care provided, the recovery-oriented nature of our programs, our suicide prevention and crisis line, VA’s Readjustment Counseling Service and Vet Centers, and PTSD-specific care.
Explanation of PTSD and Scientific Evidence on PTSD
All VA clinicians, including those responsible for completing Compensation and Pension (C&P) evaluations, adhere to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Volume IV Text Revision (DSM-IV-TR), recognized as the authoritative source for mental health conditions. According to the DSM-IV-TR clinical criteria, PTSD can follow exposure to a severely traumatic stressor that involves personal experience of an event involving actual or threatened death or serious injury. It can also be triggered by witnessing an event that involves death, injury, or a threat to the physical integrity of another. The person’s response to the event must involve intense fear, helplessness or horror. The symptoms characteristic of PTSD include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal. No single individual displays all these symptoms, and a diagnosis requires a combination of a sufficient number of symptoms, while recognizing that individual patterns will vary. PTSD can be experienced in many ways. Symptoms must last for more than one month and the disturbance must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. Military combat certainly creates situations that fit the DSM-IV TR description of a severe stressor event that can result in PTSD. The likelihood of developing PTSD is known to increase as the proximity to, intensity of, and number of exposures to such stressors increases.
PTSD is associated with increased rates of other mental health conditions, including Major Depressive Disorder, Substance-Related Disorders, Generalized Anxiety Disorder, and others. PTSD can directly or indirectly contribute to other medical conditions. Duration and intensity of symptoms can vary across individuals and within individuals over time. Symptoms may be brief or persistent; the course of PTSD may ebb and return over time, and PTSD can have delayed onset. Clinicians use these criteria and discussions with patients to identify cases of PTSD, sometimes in combination with additional psychological testing. VA adheres to the guidance of the DSM-IV-TR when it states, “Specific assessments of the traumatic experience and concomitant symptoms are needed for such individuals.” VA seeks to ensure we offer the right diagnosis in all clinical settings, whether for C&P examinations or as part of a standard mental health assessment for clinical treatment planning.
VA recognizes that many individuals with symptoms of combat stress or PTSD find it difficult to discuss the details of their experiences, although they can more easily describe their symptoms and level of distress. However, without their disclosing the source of the stress, it is impossible for a clinician to diagnose patients with PTSD according to the clinical criteria of the DSM-IV-TR. Clinicians must develop a sense of safety and trust with patients in order to make them feel comfortable enough to share their trauma in the clinical interview. The expertise and sensitivity required for such clinical evaluation is one of the reasons why only doctoral level Psychiatry and Psychology providers are allowed to conduct initial C&P exams for service connected PTSD.
The following evidence provides a brief overview of current scientific understanding of PTSD, particularly those findings related to VA decisions on care for Veterans with PTSD and determination of service-connected disability for PTSD. Research demonstrates that PTSD prevalence is directly related to the likelihood of traumatic exposure and is therefore greatest among individuals who are most likely to face life threatening situations such as military personnel, police, firefighters, and emergency medical practitioners. Among deployed Servicemembers, PTSD prevalence varies with each different military engagement. Among Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn (OEF/OIF/OND) personnel, PTSD is estimated to affect approximately 15 percent of deployed Servicemembers. Data from a number of sources has shown increasing rates of PTSD with increasing numbers of deployments. Given the reality of PTSD as a diagnosis that has greater prevalence among Veterans, the following discussion offers some perspective on the challenges faced by those with a PTSD diagnosis and the challenges in conceptualizing and providing the most effective treatments.
OEF/OIF/OND Veterans with PTSD exhibit significantly more problems with post-deployment readjustment, including homelessness, marital instability and divorce, family problems such as parenting, and poor occupational functioning. PTSD is associated with unemployment for Veterans of all eras. Data from the Bureau of Labor Statistics for 2008 shows that unemployment for OEF/OIF-era Veterans was 7.3 percent as compared with the overall jobless rate of 4.6 percent for Veterans of all eras, and 5.6 percent for non-Veterans. A number of studies have documented more functional impairment and role limitations at work due to PTSD, more sick calls and missed days of work, more depression, poorer physical functioning, more divorce, poorer relationship functioning and more psychosocial difficulties.1 Veterans who screened positive for PTSD were more than four times as likely to indicate suicidal thoughts as Veterans without PTSD. This rate increases to 5.7 times more likely if there are two or more comorbid disorders associated with PTSD.
Recovery from PTSD Is Complicated By Co-Occurring Disorders
Recovery from PTSD is usually complicated by co-occurring disorders, since most Veterans with PTSD have at least one additional diagnosis such as traumatic brain injury (TBI), depression, substance use disorder (SUD), chronic pain, problems with aggression, insomnia and other medical problems. Treating Veterans with multiple conditions cannot be restricted to PTSD but must address the other problems concurrently. For example, a Veteran with PTSD and chronic pain as a result of his or her injuries will experience the pain as a traumatic trigger that will reactivate other reactions such as PTSD nightmares, avoidant symptoms, and hyperarousal. The pain must be treated along with the PTSD if clinical improvement can be expected realistically. Unfortunately, although VA has excellent treatments for PTSD alone, the development of evidence-based treatments for concurrent PTSD and chronic pain is still at an early stage.
Even the Most Effective Treatments Do Not Guarantee Recovery
Not everyone with PTSD who receives evidence-based treatment is likely to have a favorable response. For example, a recent analysis (submitted for publication) of data from VA’s large Cooperative Study (CSP#494) on prolonged exposure to the stress factors associated with and contributing to PTSD symptoms among female Veterans and active duty Servicewomen identified those factors that predict poor treatment outcome. This is the largest randomized clinical trial of Prolonged Exposure (PE) ever conducted, with 284 participants, and the first one focusing solely on Veterans and military personnel. While the results (overall) clearly showed the efficacy of PE treatment for women with a military history who have PTSD, our analysis shows that Veterans with the most severe PTSD are least likely to benefit from a standard course of treatment. Other factors that predicted poor response were unemployment, comorbid mood disorder, and lower education. In other words, those with the worst PTSD are least likely to achieve remission, as is true with any other medical problem.
Even when Veterans are able to begin and sustain participation in treatment, timing, parenting, social, and community functions all matter a great deal. Treatment, especially treatment of severe PTSD, may take a long time. During this period, disabled Veterans with PTSD are at risk for many severe problems including family problems, parenting, inability to hold a job, inability to stay in school, social and community function. Further, evidence also shows that whereas a positive response to treatment may reduce symptom severity and increase functional status among severely affected Veterans, the magnitude of improvement may not always be enough to achieve clinical remissions or terminate disability. This is no different than what is found with other severe and chronic medical disorders (such as diabetes or heart disease) where effective treatment may make a difference in quality of life without eradicating the disease itself.
Compensation for PTSD
VBA has taken a number of steps to improve the effectiveness, timeliness, and consistency of the PTSD claims adjudication process. These improvements have occurred within the general framework of PTSD regulations and the medical examination process. In October 2008, VA amended its regulations to relax the stressor verification requirements where PTSD is diagnosed while a member is on active duty. In July 2010, VA again amended its regulations to relax stressor verification requirements where the claimed stressor is related to fear of hostile military or terrorist activity and the stressor is consistent with the places, types, and circumstances of service. The adjudication process involves making a determination as to: (1) whether current symptoms are connected to service and, if so, (2) what level of compensation is appropriate.
Service connection for PTSD is governed by 38 CFR § 3.304(f) and requires:
- Medical evidence diagnosing the condition in accordance with the American Psychiatric Association’s DSM-IV [Diagnostic and Statistical Manual of Mental Disorders];
- A link, established by medical evidence, between current symptoms and an in-service stressor; and
- Credible supporting evidence that the claimed in-service stressor occurred.
The regulation draws a distinction between different types of stressors and the evidence required to substantiate them. If the stressor relates to an in-service diagnosis of PTSD, participation in combat with the enemy, or being held as a prisoner of war, the Veteran’s lay statement alone may be sufficient to establish occurrence of the stressor. For all other stressor types, except the new type described below, VBA must substantiate occurrence of the stressor with credible supporting evidence.
As the wars in Iraq and Afghanistan progressed and Veterans returning from those areas of conflict filed more claims for PTSD, it became apparent that a modification to the PTSD regulations was necessary to facilitate a more effective adjudication process. Many claims were filed by Veterans who were not involved with direct combat, but who experienced stressors related to their war-zone service. In these cases, the Veteran’s lay statement was not sufficient to establish occurrence of the stressor, and obtaining credible documentation of the stressor was difficult and time consuming. As a result, VBA modified the PTSD regulations to add section 3.304(f)(3) in July 2010. This section provides that the Veteran’s lay testimony alone may establish occurrence of the claimed in-service stressor if:
- The Veteran’s stressor is related to fear of hostile military or terrorist activity;
- A VA psychiatrist or psychologist (or contract equivalent) confirms the claimed stressor is adequate to support a diagnosis of PTSD and symptoms are related to the stressor;
- There is no clear and convincing evidence to the contrary; and
- The claimed stressor is consistent with places, types, and circumstances of service.
This regulation change has allowed VBA to schedule a PTSD examination in “fearbased” stressor claims without the need to objectively document the occurrence of the stressor, as long as the Veteran served in an area of potential hostile military or terrorist activity. When the stressor is accepted by the medical examiner and associated with current PTSD symptoms, the occurrence of the stressor is established. This has improved effectiveness by reducing evidence-development time and promoting an equitable and consistent approach to evaluating PTSD claims where stressor evidence is difficult to obtain.
Military sexual trauma (MST) claims fall under the PTSD regulatory heading of personal assault, at section 3.304(f)(5). These claims receive special treatment because of the sensitive nature of the stressor and the difficulty with obtaining evidence to support its occurrence. Evidence is sought from multiple sources in addition to military records, and any evidence of the Veteran’s behavioral change is among the different types of evidence that may provide credible evidence of the stressor. The examiner’s assessment of the evidence may then lead to a finding of occurrence of the stressor. Because of an emerging focus on these MST claims, VBA recently incorporated tracking mechanisms into the computer programs used to produce and store adjudication decisions. This will allow VBA to monitor statistics on these cases and determine how to further improve processing effectiveness.
Once service connection is established in a PTSD claim, a determination of the rate of disability compensation payable must be made. This involves comparing the medical evidence describing symptom severity with the rating criteria in the VA Schedule for Rating Disabilities, contained in 38 CFR Part 4. PTSD, along with all other mental disorders, is evaluated under a section that assigns various degrees of disability, in percentages ranging from 0 to 100 percent, to various levels of occupational and social functioning, from no impairment to total occupational and social impairment. The rate of compensation paid correlates to the degree of disability assigned. VBA employees who adjudicate these claims must often exercise a measure of judgment when medical evidence is less than consistent. As a means to improve effectiveness and reduce judgmental variation, VBA, in conjunction with the Veterans Health Administration (VHA), developed a revised worksheet for the PTSD examiners to use. This serves as the basis for the final examination report, which is reviewed by VBA adjudicators when making their decisions. The revised worksheet prompts the examiner to choose one of a range of options that most closely describes the scope of the Veteran’s symptom severity. The wording of the options is consistent with the wording of symptom gradations described in the actual mental-disorder rating schedule. This provides adjudicators with a statement from a medical authority that matches the rating schedule and thereby provides the basis for more accurate and consistent ratings.
To devise a more comprehensive means to improve effectiveness and consistency in PTSD and other mental-disorder claims adjudication, VBA and VHA are developing an entirely new rating schedule for mental disorders. This evolved from a national mental health conference in January 2010 and an acknowledged need to update the rating schedule in order to conform to current medical practice. This new version has not been finalized, but will shift the emphasis from disabling symptoms to a functional impairment model that focuses on work and income-related outcomes. When the final version of this new rating schedule is adopted, it will further the goal of increased effectiveness and consistency in PTSD rating decisions. The proposed revision has been drafted and is in concurrence. We anticipate publishing the final rule by December 2012.
VA currently does everything possible to support Veterans with PTSD and offer care and benefits that will enable them to begin a course of effective treatment through its excellent mental health services. We understand that some Veterans advocates have recommended a program that would offer Veterans financial incentives to seek treatment and delay applications for compensation and pension. VA believes delaying compensation to severely affected Veterans until they have had a full course of treatment will leave them vulnerable and at risk of the consequences of PTSD, such as suicide, homelessness, incarceration, marital/family disruption and unemployment. In addition, because avoidance of stressful situations, especially those that may remind the person with PTSD of the original traumatizing experience, is inherent in the diagnosis of PTSD, many severely affected Veterans will be challenged in seeking VA exposure-based treatment or maintaining participation in such treatment, once started. Handling this issue is the essence of successful care for PTSD: trauma survivors are best treated by re-experiencing of the original situation, in a safe and supportive environment with clinical relearning opportunities; however, the nature of the disorder makes this intrinsically difficult. Forcing individuals to enter treatment before they are ready and have developed trust of their therapist and the clinical environment could not only lead to treatment failure but also to retraumatization.
VA Mental Health Services
In addition to our compensation and pension programs, VA offers mental health services to eligible Veterans through medical facilities, community-based outpatient clinics (CBOC), and in VA’s Vet Centers. As noted above, VA has been making significant advances in its mental health services since 2005, beginning with implementation of the VA Comprehensive Mental Health Strategic Plan utilizing special purpose funds available through the Mental Health Enhancement Initiative. In 2008 implementation of the strategic plan culminated in development of the VHA Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics, which defines what mental health services should be available to all enrolled Veterans who need them, no matter where they receive care. Current efforts focus on fully implementing the Handbook, and continuing progress made, emphasizing additional areas for development, and sustaining the enhancements made to date.
VA’s enhanced mental health activities include outreach to help those in need to access services, a comprehensive program of treatment and rehabilitation for those with mental health conditions, and programs established specifically to care for those at high risk of suicide. VA has a full range of sites of care, including inpatient acute mental health units, extended care Residential Rehabilitation Treatment Programs, outpatient specialty mental health care, mental health care in integrated physical health/mental health settings such as the Patient Aligned Care Team (PACT), geriatrics and extended care settings, and Home-Based Primary Care, which delivers mental health services to eligible home-bound Veterans and their caregivers in their own homes.
For Veterans seen in VA, identifying and treating patients with PTSD and other mental health conditions is paramount. VA’s efforts to facilitate treatment while removing the stigma associated with seeking mental health care are yielding valuable results. VA screens any patient seen in our facilities for depression, PTSD, problem drinking, and a history of military sexual trauma. Any positive screen must be followed by a full diagnostic evaluation; if the screening is positive for PTSD or depression, an additional suicide risk assessment is conducted. This screening and treatment have been incorporated into primary care settings, resulting in the identification of many Veterans who benefit from early treatment, before they may have reached the point of initiating discussion of mental health difficulties they are facing.
VA also offers a full continuum of care, including our array of inpatient, residential rehabilitation, and outpatient services for Veterans with one or more of the following conditions (this list is illustrative, not exhaustive): serious mental illness (such as schizophrenia), PTSD, alcohol and substance abuse disorders, depression, and anxiety disorders. Special programs are offered for Veterans at risk of suicide, Veterans who are homeless, and Veterans who have experienced military sexual trauma with resulting development or exacerbation of mental health problems.
VA ensures that treatment of mental health conditions includes attention to the benefits as well as the risks of the full range of effective interventions, with emphasis on all relevant, evidence-based modalities, including psychopharmacological care, psychotherapy, peer support, vocational rehabilitation, and crisis intervention. VA is focused on providing patient-centered, effective care by ensuring that when there is evidence for the effectiveness of a number of different treatment strategies, the choice of treatment should be based on the Veteran’s values and preferences, in conjunction with the clinical judgment of the provider.
To reduce the stigma of seeking care and to improve access, VA has integrated mental health into primary care settings to provide much of the care that is needed for those with the most common mental health conditions, when appropriate. Mental health services are incorporated in the evolution of VA primary care to PACT, an interdisciplinary model to organize a site for holistic care of the Veteran in a single primary health care location. In parallel with the implementation of these programs, VA has been modifying its specialty mental health care services to emphasize psychosocial as well as pharmacological treatments and to focus on principles of rehabilitation and recovery.
With the publication and dissemination of VHA Directive 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics in September 2008, VHA required that all mental health services must be recovery-oriented, with special emphasis on those services provided to Veterans with serious mental illness. VA has adopted the definition of recovery as developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), which states: “Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” It is important to note that this definition does not refer to the individual being “cured” of mental illness. Rather, it is a functional definition that describes an improved quality of life—often while managing ongoing symptoms of mental illness—as a result of engaging in recovery-oriented services.
Recovery-oriented services are strengths-based, individualized, and person-centered. These services strive to help the Veteran feel empowered to realize his or her goals and to engender hope that symptoms of mental illness can be managed and integration into the community can be achieved. They rely on support for the Veteran from clinical staff, family, and friends and allow the Veteran to take responsibility for directing his or her own treatment, within the range of viable, evidence-based approaches to care.
Although reducing the symptoms of mental illness that the Veteran is experiencing is important, the goal of recovery-oriented treatment services does not focus solely on symptom reduction, as symptoms may wax and wane over the course of the individual’s life. While reducing the symptoms of mental illness the Veteran is experiencing is important, the reduction of symptoms alone does not mean that the Veteran has the skills necessary to lead a meaningful life. The goal of recovery is to help Veterans with mental illness achieve personal life goals that will result in improved functioning, while managing the symptoms they experience to the extent possible. For some Veterans, recovery could mean that they are able to live independently and that they have meaningful interpersonal relationships. For others, it could mean that they are able to return to school or achieve meaningful employment. VA believes that all Veterans should be afforded the opportunity to work, and offers the Supported Employment program to Veterans whose mental health problems interfere with obtaining or sustaining employment. This program has been implemented as an important recovery-oriented tool to assist those Veterans with serious mental illness in gaining competitive employment and providing continuing coaching and other services to increase the chances of success at work.
It is important to emphasize that the path to recovery is not necessarily linear. Periods of significant growth, improvement, and stability in functioning are sometimes interrupted by periods of increased difficulty that may be accompanied by a worsening of symptoms or other setbacks. Such setbacks may have a significant effect on Veterans’ ability to reach their goals. Many Veterans, for example, value work and understand its importance in improving their self-esteem and helping their integration into the community. Advancing in employment to the degree the Veteran could have expected without a mental health problem is often difficult or impossible, however, given the impact of remaining symptoms. The other major concern for Veterans in a recovery-focused course of treatment is that maintaining employment may be difficult if the Veteran has to take time away from the job due to a worsening of symptoms. Veterans with serious mental illness often become concerned that they will lose their jobs and will not be able to provide for themselves or their family during times of such relapse. In addition, while life events or environmental stressors might cause a relapse, there are many times when there is no identifiable cause. Because experiencing a relapse can be significantly disruptive, and because relapses are often unpredictable, Veterans with serious mental illness are sometimes hesitant to engage in recovery-oriented activities without assurance that their basic needs can be met during times when they are unable to work.
Suicide Prevention/Veterans Crisis Line
As mentioned earlier in the testimony, the VA Suicide Prevention Program is based on the concept of ready access to high quality mental health care and other services. VHA has added Suicide Prevention Coordinators (SPCs) at every facility and large CBOC; these are an important component of our mental health staffing. The SPCs ensure local planning and coordination of mental health care of support Veterans who are high risk for suicide, they provide education and training for VA staff, they do outreach in the community to educate Veterans and health care groups about suicide risk and VA care, and they provide direct clinical care for Veterans at increased risk for suicide. One of the main mechanisms to access enhanced care provided to high risk patients is through the Veterans Crisis Line, and the linkages between the Crisis Line and the local SPCs. The Crisis Line is located in Canandaigua, New York, and partners with the Substance Abuse and Mental Health Services Administration National Suicide Prevention Lifeline. All calls from Veterans, Servicemembers, families and friends calling about Veterans or Servicemembers are routed to the Veterans Crisis Line. The Crisis Line started in July 2007, and the Veterans Chat Service was started in July 2009. To date the Crisis Line has:
- Received over 400,000 calls;
- Initiated over 15,000 rescues;
- Referred over 55,000 Veterans to local VA SPCs, who are available in every VA facility and many large CBOCs, for same day or next day services;
- Answered calls from over 5,000 Active Duty Servicemembers; and
- Responded to over 16,000 chats.
VA also has put in place sensitive procedures to enhance care for Veterans who are known to be at high risk for suicide. Whenever Veterans are identified as surviving an attempt or is otherwise identified as being at high risk, they are placed on the facility high-risk list and their chart is flagged such that local providers are alerted to the suicide risk for this Veteran. In addition, the SPC will contact the Veteran’s primary care and mental health provider to ensure that all components of an enhanced care mental health package are implemented. These include a review of the current care plan, addition of possible treatment elements known to reduce suicide risk, ongoing monitoring and specific processes of follow-up for missed appointments, individualized discussion about means reduction, identification of a family member or friend (either to be involved in care or to be contacted, if necessary), and collaborative development with the Veteran of a written safety plan to be included in the medical record and provided to the Veteran. In addition, pursuant to VA policy, SPCs are responsible for, among other things, training of all VA Staff who have contact with patients, including clerks, schedulers, and those who are in telephone contact with veterans, so they know how to get immediate help when veterans express any suicide plan or intent.
All VA Suicide Prevention Program elements are shared regularly with the Department of Defense (DoD), and a joint conference is held annually to encourage use of all effective strategies across both Departments, including educational products and materials.
Readjustment Counseling Service: Vet Centers
Vet Centers provide community outreach, professional readjustment counseling for war-related readjustment problems, and case management referrals for combat Veterans. Vet Centers also provide bereavement counseling for families of Servicemembers who died while on Active Duty. Through March 31, 2011, Vet Centers have cumulatively provided face-to-face readjustment services to more than 525,000 OEF/OIF/ OND Veterans and their families. As required by Section 401 of Public Law 111-163, VA is currently drafting regulations to expand Vet Center eligibility to include members of the Active Duty Armed Forces who served in OEF/OIF/OND (including Members of the National Guard and Reserve who are on Active Duty).
In addition to the 300 Vet Centers that will be operational by the end of 2011, the Readjustment Counseling Service program will also have 70 Mobile Vet Centers operational by the end of 2011 to provide outreach services to separating Servicemembers and Veterans in rural areas. The Mobile Vet Centers provide outreach and direct readjustment counseling at active military, Reserve, and National Guard demobilization activities. To better serve eligible Veterans with military-related family problems, VA is adding licensed family counselors to over 200 Vet Center sites that do not currently have a family counselor on staff.
PTSD Care in VA
VA is nationally recognized for its outstanding PTSD treatment and research programs, and the quality of VA health care in this area also is outstanding, with continual enhancements as more is learned. For example, VA’s National Center for PTSD advances the clinical care and social welfare of Veterans through research, education and training on PTSD and stress-related disorders. They also lead a national mentoring program throughout the VA system that provides continuous training to guide programs to consistently delivering recommended care based on Clinical Practice Guidelines and recognized best practices. They recently added a clinical consultation program to supplement the ongoing mentoring educational offerings. Their advances are used to guide clinical program policy development and implementation.
In FY 2010, VA treated more than 408,000 unique Veterans for PTSD in VA specialty mental health programs within medical centers, clinics, inpatient settings, and residential rehabilitation programs; this was an increase from 235,639 treated in FY 2005. If we include care delivered in integrated care settings, such as primary care, VA treated a cumulative total of more than 438,000 in FY10, an increase from approximately 250,000 in FY 2005. Given the increasing numbers of Veterans seeking VA care for PTSD, VA is monitoring parameters to ensure prompt and efficient services for PTSD and other mental disorders, using indicators such as “time to first appointment” for Veterans of all service eras who present with new mental health problems.
It is essential that mental health professionals across our system provide the most effective treatment for PTSD, once the diagnosis has been identified. In addition to use of effective psychoactive medications, VA supports use of evidence-based psychotherapies. VA has conducted national training initiatives to educate therapists in two particular exposure-based psychotherapies for PTSD that have especially strong research support, as confirmed by the Institute of Medicine in their 2008 report, Treatment of Posttraumatic Stress Disorder : Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). To date, VA has trained over 3,400 VA clinicians in the use of CPT and PE. For both of these psychotherapies, following didactic training, clinicians participate in clinical consultations to attain full competency in the therapy. VA is also using new CPT and PE treatment manuals developed for VA, with inclusion of material on the treatment of unique issues arising from combat trauma during military service.
Thank you again for this opportunity to speak about VA’s diagnosis and treatment of mental health concerns of eligible Veterans who use VA’s health care system, with particular emphasis on PTSD. PTSD is a diagnosis of central importance in our work with Veterans, both in providing health care and when Veterans submit mental health service connection claims to VBA. It is imperative that VA provide a system of mental health care and benefits that is driven by evidence and is fully responsive to the mental health challenges that Veterans face. My colleagues and I are prepared to answer any questions you may have.
1 See, e.g., Paula P. Schnurr, et al, Posttraumatic Stress Disorder and Quality of Life: Extension of Findings to Veterans of the Wars in Iraq and Afghanistan, 29 CLINICAL PSYCHOLOGY REVIEW, 727 (2009).