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Submission For The Record of Andrea B. Sawyer (Spouse of Sergeant Loyd Sawyer, (Ret.), USA)

Mr. Chairman, Ranking Member Filner, thank you having this hearing today and for allowing me to submit my testimony for the record

My name is Andrea Sawyer, caregiver and spouse of U.S. Army Sgt. Loyd Sawyer, retired.  While I understand that this Committee does not have jurisdiction over the Department of Defense, it is important that you understand my husband’s whole story to understand why we are so frustrated with his care. 

Loyd was a civilian funeral director and embalmer before joining the Army Mortuary Affairs team.  As a mortuary affairs soldier, Loyd did a tour at Dover Port Mortuary where all deceased servicemembers returning from Iraq and Afghanistan re-enter the United States, and Loyd worked in the Army uniform shop (where paperwork is processed and final uniforms prepared for deceased servicemembers) and embalmed on the days he was not in the uniform shop.  Loyd then served a tour in Iraq, first in Talil and then the Balaad mortuaries where he processed countless deceased civilians and servicemembers.  While there, he began exhibiting signs of mental distress such as anger, hypervigilance, insomnia, etc. 

Upon his return home , I attempted to get him help for eleven months. There was a delay in getting help because we had only one psychiatrist on base and then the help he received was ineffective.  Ultimately I sat in a room with an Army psychiatrist and my husband and watched Loyd pull a knife out of his pocket and describe his plan of slitting his throat.  It was apparent that he was delusional and in great psychiatric distress.  On December 19, 2007, Loyd was admitted to Portsmouth Naval Medical Center (PNMC).  What followed was an initial crisis hospitalization of five weeks (three exclusively inpatient and two intensive outpatient), a separate one week crisis hospitalization for homicidal ideations, eight months in an Army Warrior Transition Unit (WTU),  appointments three days a week at PNMC two hours away from our home Army base of Fort Lee, a medical and physical evaluation (MEB/PEB) process that resulted in a 70% permanent Department of Defense (DoD) retirement from active duty for Post Traumatic Stress Disorder and a secondary diagnosis of major depressive disorder, and medical paperwork that said, “The degree of industrial and military impairment is severe.  The degree of civilian performance impairment is severe at present, though over time—likely measured in years (emphasis added)—with intensive psychotherapy augmented by pharmacotherapy to control his anxiety and depressive symptoms—his prognosis MAY improve.”  In July 2008 while still on Active Duty, but with retirement paperwork in hand, we enrolled Loyd at our local VA, the Richmond polytrauma center, better known as Hunter Holmes McGuire VA Medical Center (HHM VAMC), for medical services in the Veterans Health Administration (VHA).  In October, with help from Wounded Warrior Project (WWP), Loyd’s VA disability claim declared him 100% permanent and totally disabled (this claim is done through Veterans Benefits Administration), thus giving him the highest priority status for VA care.   

Knowing that Loyd needed extensive help quickly, we tried getting him into the PTSD clinic immediately which was not available.  The first available appointment was almost a two month wait.  When the appointment came, Loyd presented his history, including that he had been seen two to three times weekly at PNMC for the last eight months of active duty, that he remained suicidal, and that he needed intensive therapy.  What was available at the VA in the PTSD clinic for him was a once every quarter medicine management appointment and a once a month to once every six weeks one hour therapy appointment.  Knowing that this was leading to spiraling depression and an unchecked increase in his PTSD symptoms, we used our TRICARE and began treatment with a local civilian counselor who was trained at the VA’s National Center for PTSD.  The counselor was able to see Loyd once or twice a week depending on the severity of the symptoms.  Throughout the winter of 2008 and the spring of 2009, I became increasingly concerned at the out of control depression I was witnessing and feared that suicide was an imminent possibility.  After getting little response from VA mental health, his TRICARE counselor and I discussed sending him to a long-term inpatient treatment program for PTSD through the VA.  I contacted Loyd’s Federal Recovery Coordinator (FRC) for help in finding a program.  We did eventually do phone interviews, made a site visit, and enrolled him in a PTSD program at the VA facility in Martinsburg, WV.  I got little to no help from our local VA hospital in finding this program, but I received invaluable help from Loyd’s Federal Recovery Coordinator. 

The hospitalization was a nightmare.  The program delivered on none of its promises.  His doctors there never coordinated with his local VA mental health clinician, his civilian counselor, or his FRC.  At one point, his civilian counselor, his FRC, and I were calling the facility daily because we were concerned the medication change they had made was making him physically and verbally aggressive.  Even more concerning was that this was a medicine that he had been removed from while on active duty for the same reasons.  In ninety days of inpatient treatment at the VA facility, he received fewer than five individual therapy sessions.  Upon his completion of the program, which I truly believe was just about marking time, he was released and told to follow up with his local VAMC. For my husband, who had already expressed suicidal ideations, there was no coordination or communication between any of his treatment providers.  He came home and promptly discontinued ALL of his medication because he did not like the way it made him feel.  (It is important to note that for the year and a half prior to this hospitalization at Martinsburg, he had been completely compliant with his medication plan.) 

I immediately called the Richmond PTSD clinic as soon as I realized that he had stopped taking his medication.  I was told that it would be four weeks before they could see him to re-evaluate his medications.  I had the FRC try to intervene with the primary care provider (PCM), hoping the PCM could speed up the process, but he simply told me, “I was wasting his time.”  Eventually with the help of the FRC, I was able to get him an appointment within the week with a VA psychiatrist in general psychiatry.  This psychiatrist has done his medication management since then, as she very clearly listened to what symptoms needed to be controlled, and, even more importantly, listened to what he needed and wanted as a patient. At that time, we agreed with her, that for counseling Loyd was better off continuing with the civilian counselor because he could be seen once/twice a week and with her for medication.  By involving Loyd, she made it much more likely that he would continue with his pharmacotherapy regimen.  She also asked that neuropsych testing be redone and suggested that Loyd try the PTSD “Young Guns” therapy group that met with a clinician in the Richmond PTSD clinic weekly. 

Loyd’s repeat neuropysch testing in January 2010 showed that his PTSD symptoms were still severe.  On the DAPS ( a psychiatric scale test for symptoms of PTSD used frequently by the VA), Loyd scored all 20 out of 20 on all the indicators except for suicidality for which he scored a 16, meaning he still fell into the extremely high risk category and was actively suicidal.  His authenticity score was a five which is as high as you can score.  So after more than a year in the VA, a ninety day hospitalization, weekly therapy, Loyd was not really improving.  Feeling rather hopeless, Loyd did decide to try the Young Guns group.  He found great solace in this group in being able to relate with others who experienced the same symptoms but also because he saw people in different stages of recovery who, led by a clinician, were able to analyze their behaviors and suggest multiple positive coping strategies that they each found successful.  Unfortunately, four months into the group and without consultation with the patients, it was announced that the VAMC was changing its treatment model and was disbanding the group by year’s end. For those who wished to continue in a group setting, the VA would be turning them over to a yet untested regional division of a new community-based program which had only two employees for a twenty-three county region, neither of whom was trained in counseling.  I immediately contacted the Wounded Warrior Project (WWP), and the resulting year long saga of trying to keep the group on campus with a clinician is in their testimony.  Suffice it to say, despite all requests from the veterans in the group in a petition signed by 27 of them, and an on campus successful attendance of 40 members regularly, the VAMC moved the group off campus, renamed it a support group, but has yet to pull the clinician because the community organization has failed to show up for a single off campus meeting of the group.  Attendance has fallen sharply (averaging 7-10 individuals) as working veterans can no longer leave work to go to a “support group” like they could leave work to go to therapy appointment.  In addition, by moving the group off campus, the VA is no longer able to reimburse for mileage—a significant problem in today’s economy.

So my question to you, the committee is this: 

My husband is a veteran with well-documented severe chronic PTSD who uses one of the major VA polytrauma centers as his VAMC. We have all the advantages that should guarantee him good treatment – an excellent, caring Federal Recovery Coordinator, a 100% service-connected disability rating, a polytrauma case manager, and a super VSO.  Yet, he has had a difficult time accessing appropriate mental health treatment in this VISN and in the inpatient treatment program at which he received care that was in another VISN.  If that is the case for him,  how can any vet just enrolling without any of these advantages be expected to get quality and accessible care?

That question being asked, as a spouse who has been involved with this system for some time and after having spoken to a number of other wounded warriors and spouses in similar situations, I would like to make to following suggestions to encourage those with mental health issues to seek and continue with treatment:

  1. Treatment must be timely and available.

The new treatment model suggests that veterans should be seen/complete a minimum of nine visits to VA PTSD clinicians for either group or individual therapy in fifteen weeks.    I do not see how this is even a realistic model.  Currently in VA’s all over the country, veterans are waiting MONTHS in between appointments and drive hours to these appointments.

According to a caregiver of a South Dakota OIF veteran:

Hubby went to the group meeting last night for their final session with the VA provider. She told them during the meeting that the VA is hiring a new provider who will continue with the group in July or possibly the end of June. I'm skeptical that it will actually happen as we are still waiting for a full-time psychiatrist at our CBOC that was promised a year ago after they let the contract provider go. I'm afraid it's another story to keep everyone happy.

A caregiver for an OIF Marine veteran from Washington state wrote:

We have an AWESOME psychiatrist at the VA, and I am terrified he will retire. . .The only bad thing is that he is more popular than a single sat [satellite] phone in a deployed battalion. He is about 2 hours away and about once every other month or so we get into see him.

Another caregiver wrote:

My husband has PTSD also, he was not considered a priority for care for his PTSD by the VA and they said he only needed to be seen every 6 months. Then he had an episode and was tazed 6 times by police and sent to civilian psych hospital where he was not given his meds, they tried to treat him like a schizophrenic and wanted to have him committed. Luckily I was able to talk to an intern who had half a brain who went to bat for my husband to get him released to my care. Now that my husband has been hospitalized in a mental hospital the VA suddenly thinks oh, well lets see him once every 2-3 months. Not to mention that when he goes in to see his psychiatrist he doesn't tell him everything and tries to make everything look great. I have to e-mail his psychiatrist just to keep him properly updated on my husband’s status. Then there is also the issue of availability of appointments if something sooner is needed. If you have an emergency or feel your husband needs to be seen sooner they never have anything available.

The mom of a Kentucky vet wrote:

One of the biggest problems I have noticed is simply not being able to get an appointment. Call for help...wait six weeks to get in to talk to someone.

While I understand that there is a shortage of mental health providers in this country, that does not mean that we can set unrealistic standards for treatment and then wonder why no one is completing said treatment.  If there is a shortage of providers, we must use all means necessary to ensure timely, quality care and use mechanisms such as fee-basis more often to accommodate the needs of this growing population.  

  1. Treatment must be an appropriately time focused intervention and needs to address severity, chronicity, and provide multiple ongoing treatment options.

 

Flow CHart of VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress)

    (From VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF POST-TRAUMATIC STRESS)

The clinical practice guidelines are joint guidelines between DoD and VA and deal with the range of diagnoses involving trauma exposure.  The guidelines’ beginning focuses on EARLY intervention, literally starting assessment and treatment within minutes of experiencing or witnessing the trauma.  For VA, this is not even a remote possibility.  VAMC’s access to veterans is limited to their time of enrollment being in most cases months to years after the witnessing of the trauma.  Because of this, veterans who enter VA have chronic PTSD which is defined as anyone experiencing clinically significant symptoms six months after the trauma. (ptsd_full core page 10).  This just by nature of the delay in treatment suggests that more time than nine visits will be necessary.  VA needs to ensure that guidelines it is following are appropriate to the diagnosis of the individual.

The treatment modules, which are located within the clinical guidelines, includes the recovery model which focuses on mild to moderate PTSD.  Veterans with severe PTSD need different options than veterans with mild post-traumatic stress.  The recovery model as it is being implemented at our VAMC, at least, puts too much emphasis on addressing mild-to-moderate PTSD, and not addressing severe PTSD.  This leaves veterans with severe PTSD feeling not understood.  By doing away with long-term therapy groups on campus, it leaves little option for continuing therapy except individual therapy which as discussed above is not available, plus it pits vets with long-term chronic issues needing continual individual therapy against vets just entering the system needing to begin therapy.  VA must ensure that a wide variety of treatment options for the veteran population with a wide degree in severity and chronicity of their PTSD exists.

  1. Treatment must be practical.

One focus of VA has been veteran unemployment.  Currently the new VA Mental Health (MH) guidelines are not at all conducive to employment.  Consider this scenario:  VA wants a veteran to attend nine treatment sessions in a fifteen week period.  A veteran as illustrated in the examples above may have to drive hours away to get treatment, but we will use for purposes of our example an hour drive.  So a veteran must tell his employer that he will miss nine half days of work at his job within the first fifteen weeks of work.  Then if the veteran were at the Richmond VAMC PTSD clinic and probably others, he may be channeled into 10 week recovery group, 6 week mindfulness coping skills group, 6 week anger management coping skills group, and more individual therapy, IF he needed all parts of the new recovery model.  Literally that would require that a veteran miss a half day of work once a week for the first six months of a job, ONLY for mental health treatment purposes, that disregards any other physical health issue for which a veteran may need treatment.  Few employers would hire or retain that individual.  It is not practical.  Eventually a veteran would have to choose between his job and his care.  That is not a choice a veteran should have to make.

To complicate matters, veterans nationwide are not allowed to choose their appointment times, leading to inconvenient and missed appointments and constant rescheduling requirements.  Currently, the VA sets the appointment time, and veterans are simply expected to show up regardless of other obligations.  This obviously prevents a veteran from scheduling appointments around employment needs or scheduling multiple appointments on the same day.

In light of the intensive requirements of the MH guidelines and out of respect for the time of individual veterans, the VA needs to allow veterans to make their own appointments and have limited evening and weekend hours to accommodate working veterans with families. Currently our VA is saying it will implement evening hours, but I have little faith in that as I have heard the same statement for the entire three years we have been in the VA.

  1. Treatment must be tailored to the individual and not a series of a completion of cookie cutter modules.

Too often in VA, patients are channeled into programs where every veteran is given the same program regardless of their needs.  For example, every veteran in the clinician led group therapy session was moved into the community-based group without individual evaluation of the veteran’s preparedness for the move.  The new model lends itself to the same thing happening.  A veteran would simply be channeled into a series of cookie-cutter modules explaining what PTSD is, what changes it creates in the chemicals of the body, what changes it creates in thinking patterns, and then a series of modules on teaching coping skills.  It lends itself to shuffling them through the modules without the quality assessment to see if veterans have mastered the skills.  Once a module is completed it is checked off whether or not the veteran feels he has mastered the skill.  Where is his remedy in this situation? Individual therapy?  He will have to wait months for that appointment where he will probably be told he has already had that class. A veteran does not need to be told by PowerPoint or workbook what all his symptoms are or should be; he lives them daily.   While some education is good, this model makes me fear that it is simply check the block and veterans will be pushed through or simply quit because they do not see it as quality, individually tailored, or making a difference, not to mention the time it takes away from the occupational arena.

Along the same lines, what happens to a veteran who has had all of these modules while still on active duty?  Will he be funneled through them again on the VA side of treatment?  Loyd had all these modules over his eight months of treatment at PNMC on active duty.  He got them again during his ninety day hospitalization and he was frustrated at having to retake them because that was all that was available. He wanted something that he had not tried. Who is going to check to see that people are not being forced to repeat things just for the sake of checking the block for treatment? A repeat of a previous therapy is another reason people do not continue with treatment.

To encourage a veteran to seek and complete treatment, VA must ensure that each individual veteran is not lost in a maze of completing treatment that is not relevant to him as an individual patient.  PTSD veterans like all other veterans with health conditions needs to be seen as patients first and diagnoses second.  The patient’s individual symptoms should determine his type of treatment, not a predetermined course of treatment that does not account for individual variances.

  1. Treatment must be culturally competent.

Some, not all, VA clinicians seem out of touch with combat PTSD.  Most of them seem familiar with PTSD as a clinical diagnosis, but many do not seem to understand the difference veterans experience with combat PTSD verses military sexual trauma (MST) verses a routine car accident.  Veterans routinely get frustrated having to stop and explain language/ command structure/ nature of combat jobs/ even basic military language to clinicians.  In one instance with my husband as he was explaining damage done to a body by an IED, the clinician got a very puzzled look on her face and asked how a contraceptive device could have caused limbs to be blown off.  We had to explain the difference between an IED –improvised explosive device—and an IUD—a female contraceptive device—to her.  At that point, that clinician had lost all credibility.  Therapy was over for the day, and we never saw her again. 

In another instance, a female veteran whose PTSD rating is in part due to an MST and who still experiences horrific flashbacks, was placed in an all-male PTSD coping skills group.  She was in with older men, mostly Vietnam era, who had little respect for females who had served, and certainly no understanding of MST.  Eventually she stopped going to the group as it caused her more trauma listening to the comments of her fellow group participants than the symptoms she already experienced. 

The VA should engage in a program a program similar to the Navy’s Civilian Familiarization for all employees. This program allows members of the public to experience a small taste of a sailor’s occupation.  Also a continuing education class in military terms is necessary.  This could be easily added to the required continuing education classes that already exist in the VA.

  1. Community-based partnerships for treatment should be available options for veterans to seek treatment, but they should not be the only option.

There is a trend in VA to form community partnerships for purposes of offering wider support for veterans and for expanding options for veterans.  While I think this may be a good idea, when it comes to dissolving existing therapy groups to hand over to community groups to become support groups, it is necessary for there to be some kind of oversight process if compensation is going to be tied to therapy.  In the case of Richmond changing the therapy groups to support groups and moving them off campus, the community group that the VA said was going to facilitate the group has never shown up.  Even if it had shown up, the community group does not have the trained staff to lead a group.  Also, in the instance of Richmond, veterans were not consulted about the change, it was simply dictated, without evaluation to ensure that each individual was ready for leaving a clinical therapeutic setting and transitioning to a non-clinical supportive setting. 

For purposes of treatment and compensation, administrative data collection to support the evidence that treatment is being provided must be worked out in advance.  Support groups do not normally keep attendance records, so it would be difficult to prove that a veteran had been to treatment at a support group.  Also, using community settings whether support groups or community clinicians, needs to be evidence-based treatment.  It is not fair to do away with a treatment at the VA because it is not evidence-based only to send veterans out into the community to receive other non-evidence based treatments while leaving them no options at the VA.

VA should use MOA’s with community partners and fee-basis providers to ensure that veterans with PTSD may have the option, at the veteran’s discretion, of receiving evidence-based treatment in their home communities.  This scenario would make treatment for veterans more accessible geographically, more time sensitive to the onset of the symptoms, and more practical from a standpoint of the availability of evening and weekend hours.  Using MOA’s would allow VA to ensure that all treatment remains evidence-based and set a clear expectation about the administrative practices it requires to document a veteran’s treatment regimen for purposes of compensation.

  1. Communication between DoD and VA, in addition to communication between VHA and VBA, and intraVHA needs to be improved.

A model that would tie an incentive to receive and complete treatment for PTSD rests heavily on communication between all elements of inter DoD/VA and intra VA (VHA and VBA.) 

In the matter of tying compensation to treatment, a vet would need DoD to clearly communicate what treatment for PTSD had been received on active duty and determine whether or not there was a prognosis for improvement.  If a veteran has received DoD treatment, then VA and DoD must communicate whether or not the veteran has shown improvement or has a prognosis that suggests improvement.  If there is a prognosis to suggest that treatment will improve the quality of life and decrease the functional impairment caused by PTSD, then a veteran should be incentivized to seek all treatment available to improve functionality, but that treatment should NOT be a repeat of what was done already on active duty or with a civilian provider outside of DoD and VA.

The point of incentivizing treatment is where I need to clearly see details worked out.  I see this as being a bureaucratic nightmare.  VHA and VBA need to agree on what the severity of of a veteran’s PTSD was and what treatment is necessary.  Currently these two systems do not interact which constantly leads to one system giving one diagnosis for compensation and the other system giving a different diagnosis for treatment purposes.   In addition, once VBA assigned a temporary rating, and then presumably VHA would assign a treatment plan, who researches whether that treatment plan is feasible for the veteran, which upon completion would go back to VBA for a final rating?  Assigning a working vet to six months of weekly therapy modules would not work.  It would lead to the vet not completing treatment and then not receiving compensation for a condition which he has due to service but for which VA cannot accommodate his real life needs of working and treatment.  Not to mention, the therapy has to be geographically available which in ever increasing instances it is not.  The amount of appointments necessary would have to be available clinically.  I worry that VBA would set a timeline for treatment that is unreasonable because the VHA clinic appointments are not available due to staff shortages at clinics.  The only person who would be penalized is the vet.

In Loyd’s case, before even leaving DoD, he had done all of the treatment that has been offered at VA.  There was simply no point, other than going for symptom maintenance, for him to even go to the VA for mental health treatment.  He has gone over the last three years, but it has been an exercise in futility and frustration which at times has increased the depression.  Despite the fact that he has repeatedly indicated that he thinks of suicide three to four times a week, we have never been contacted by the suicide prevention person, and at this point, it is mute.  People with Loyd’s severity and chronicity should not necessarily be incentivized as through four years of treatment, one DoD and three VA, there has been little improvement as was the prediction of DoD.

In other cases, where there has been no treatment for a veteran with PTSD, certainly incentives should be tied to treatment.  That treatment should be relevant to the health needs of that particular veteran and accessible to the veteran as determined by the VETERAN and his clinician, not just a clinician.  Simply assigning a rating without any treatment is a situation that says a veteran that his case is hopeless.  The incentive to receive that treatment, a stipend that allows a veteran to go to treatment, must be appropriate to address the financial concerns that will arise while treatment is obtained.  Simply giving a veteran $100 a month will not cover the cost of travel, missed work for appointments, or emotional distress that will be increased at the beginning phase of treatment.

DoD and VA must communicate to ensure relevant treatment is obtained and not duplicated.  VHA must communicate internally to see that treatment is relevant and appropriate, grouping together all elements of a veterans mental health team—counselor, psychiatrist, neuropsychiatrist, etc.  VHA and VBA must develop a plan to address timeliness of treatment, what is appropriate treatment to incentivize a veteran to seek treatment, and that treatment required is actually available to a veteran (meaning that staff, location, and particular treatment model are at a location where a veteran has access.)  I fear that this may become a plan where VBA sets a particular time frame for treatment only for VHA not to have the treatment available in a location accessible or a time frame accessible to the veteran in that frame of time—for example that VBA will set a stipend limitation of six months to do all eight visit, but a veteran’s CBOC will only have one appointment a month available.  I think that is an extremely realistic concern.

In conclusion, I understand that some of these matters are questions that are theoretical, however, I think in this matter, it is necessary for Congress to have answers to these questions and a practical model BEFORE any changes are made.  Too often, laws are made, then policies are implemented that do not agree with the spirit of the law, and it takes YEARS to address and fix the issues.  In this case, changing the treatment and compensation models as they exist without these questions being firmly answered with a practical working plan may cost lives.    Today there are almost 400,000 veterans receiving compensation for PTSD with numbers predicted to increase rapidly with the influx of veterans from OIF/OEF into the VA system.  Veterans are dying from suicide at a rate of eighteen a day.  If we want veterans to feel that VA truly understands them and wants them to successfully seek treatment and lead mentally healthy lives, Congress must show veterans that legislators and the VA understand the true barriers to seeking VA mental health care and remove them so that our veteran population can continue to be strong and productive for years to come.

Summary:  I believe that every veteran who suffers from post-traumatic stress would gladly give up any compensation check if they could get quality, timely, relevant treatment to end the daily nightmare that they live. While I think in theory the idea of tying compensation to receiving treatment is logical, I have grave concerns about the VA being able to do this correctly.  I think this matter of tying compensation to continuous treatment needs to be treated cautiously and needs to consider several matters concerning existing treatment need to be addressed.  I have asked to be able to present my testimony to raise the concerns that I have.

Main Points:

  1. Treatment must be timely and available.
  2. Treatment must be an appropriately time focused intervention and needs to address severity, chronicity, and provide multiple ongoing treatment options.
  3. Treatment must be practical.
  4. Treatment must be tailored to the individual veterans needs and symptoms not be a series of cookie-cutter modules.
  5. Treatment must be culturally competent.
  6. Community based partnerships for treatment should be available options for veterans to seek treatment, but they should not be the only option.
  7. Communication between DoD and VA, in addition to communication between VHA and VBA, and intraVHA needs to be improved.

Conclusion:

I understand that some of these matters are questions that are theoretical; however, I think in this matter, it is necessary for Congress to have answers to these questions and a practical model BEFORE any changes are made.  Too often, laws are made, then policies are implemented that do not agree with the spirit of the law, and it takes YEARS to address and fix the issues.  In this case, changing the treatment and compensation models as they exist without these questions being firmly answered with a practical working plan may cost lives.    Today there are almost 400,000 veterans receiving compensation for PTSD with numbers predicted to increase rapidly with the influx of veterans from OIF/OEF into the VA system.  Veterans are dying from suicide at a rate of eighteen a day.  If we want veterans to feel that VA truly understands them, wants them to successfully seek treatment, and wants them lead mentally healthy lives, Congress must show veterans that legislators and the VA understand the true barriers to seeking VA mental health care and remove them so that our veteran population can continue to be strong and productive for years to come.