Mr. Chairman and other Members of the Subcommittee:

Thank you for inviting the Disabled American Veterans (DAV) to testify at this oversight hearing of the Subcommittee on Health.  We appreciate the opportunity to offer our views on progress by the Department of Veterans Affairs (VA), and the Veterans Health Administration (VHA) on meeting the critical mental health needs of veterans. 

We recognize the unprecedented efforts made by VA over the past several years to improve the consistency, timeliness, and effectiveness of mental health programs for disabled veterans.  We are pleased that VA has committed through its national Mental Health Strategic Plan (MHSP) to reform VA mental health programs by moving from the traditional treatment of psychiatric symptoms to embracing recovery potential in every veteran under VA care.  We also appreciate the will of Congress in continuing to insist that VA dedicate sufficient resources in pursuit of comprehensive mental health services to meet the needs of veterans. 

Despite obvious progress, we believe much still needs to be accomplished to fulfill the nation’s obligations to veterans who have serious mental illness, and post-deployment mental health challenges.  Our duty is clear—all enrolled veterans, and particularly servicemembers, Guardsmen and reservists returning from war, should have maximal opportunities to recover and successfully readjust to life following military deployment and wartime service.  They must have user-friendly access to VA mental health services that have been demonstrated by current research evidence to offer them the best opportunity for full recovery. 

We must stress the urgency of this commitment.  Sadly, we have learned from our experiences in other wars, notably Vietnam, that psychological reactions to combat exposure are common.  If they are not readily addressed, they can easily compound and become chronic.  Over a long period of time, the costs mount in terms of impact on personal, family, emotional, medical and financial damage to those who have honorably served their country.  Delays in addressing these problems can result in self-destructive acts, including suicide.  Currently, we see the pressing need for mental health services for many of our returning war veterans, particularly early intervention services for substance-use disorders and evidence based care for those with post-traumatic stress disorder (PTSD), depression and other consequences of combat exposure. 

The development of the MHSP and the new Uniformed Mental Health Services (UMHS) policy (detailed in VHA Handbook 1160.01, dated September 11, 2008) provide an impressive and ambitious roadmap for VHA’s transformation of mental health services.  However, we have expressed continued concern about need for improved oversight of the implementation phase of these initiatives. 

Although we realize that VA is faced with a significant challenge in transforming its mental health services, this is not a time for the usual barriers that frustrate change.  This is a time for extraordinary action to fulfill our commitments, and we believe extraordinary action can overcome the usual time delays.  Surely, just as we owed it to our servicemembers to outfit them with the best possible protective equipment as they prosecute war, we now owe it to these same men and women to provide immediate access to the best VA evidence-based mental health treatments and early intervention services available so that they can quickly recover and successfully readjust to civilian life after war. 

Historically, VA has been plagued with wide variations among VA medical centers related to the adequacy of the continuum of mental health services offered.  To address these concerns, VA has provided facilities with targeted mental health funds to augment mental health staffing across the system.  This funding was intended to address widely recognized gaps in the access and availability of mental health and substance-use disorder services that existed prior to the development of the MHSP, to address the unique and increased needs of veterans who served in Operations Iraqi and Enduring Freedom (OIF/OEF), and to create a comprehensive mental health and substance-use disorders system of care within VHA that is focused on recovery—a hallmark goal of the 2003 New Freedom Commission on Mental Health.  In addition, VHA developed its UMHS policy so that veterans nationwide can be assured of having access to the full range of high quality mental health and substance-use disorder services in all VA facilities where and when they are needed.  Timely, early intervention services can improve veterans’ quality of life, prevent chronic illness, promote recovery, and minimize the long-term disabling effects of undetected and untreated mental health problems.  We understand that these funds have been dispersed as part of a special Mental Health Initiative (MHI), with clear direction that they be used to augment current mental health staffing, not merely to replace vacant positions that facilities could not afford to fill without extra funding. 

On April 6, 2009, the VA Office of Inspector General (OIG) issued two reports focused on VA mental health services:  1) Healthcare Inspection: Implementation of VHA’s Uniform Mental Health Services Handbook;and, 2) Audit of Veterans Health Administration Mental Health Initiative Funding.  In anticipation of them, we had expected these reports would provide an in-depth assessment of the consistency of mental health services, and access across the nation to evidence-based treatments.  Unfortunately, they fall far short of this expectation.  The OIG report on the UMHS Handbook was intended to review progress on the implementation of the MHSP and specifically to assess whether the identification and treatment of PTSD was being uniformly accomplished across the system. 

The OIG noted that given the dimension of the handbook, a comprehensive review of the extent of implementation is challenging.  For these reasons, the OIG limited the scope of review to the medical center level and reviewed only a limited selection of items from the handbook.  OIG states that the Office of Healthcare Inspections, the community-based outpatient clinic (CBOC) Project Group, will inspect implementation of mental health services at the CBOC level at a later date.  In addition, it was noted that the implementation of the handbook is a dynamic and ongoing process during fiscal year (FY) 2009 and that data in its report do not capture partial implementation.  The OIG was also required to present its findings on uniformity of identification and treatment policies for PTSD.

The UMHS handbook clearly defines specific requirements for services that must be provided and those that must be available when clinically needed by patients receiving health care from VHA.  Overall, facilities are expected to implement handbook requirements by the end of FY 2009, less than six months from now.  Modifications or exceptions for meeting the requirements must be reported to, and approved by, the Deputy Under Secretary for Health. 

VHA Central Office and the Office of Mental Health Services (OMHS) staff, and several Veterans Integrated Service Network (VISN) mental health liaisons and directors were interviewed during the inspection.  Reports and data on locations, clinical staffing, and case load on the mental health case management program and other relevant mental health programs were evaluated, including data and information on dissemination of training in evidenced-based psychotherapies.  The inspection also included a web-based survey sent to all VA medical centers, including questions related to availability of certain mental health clinical services, (i.e., OIF/OEF specialty clinics and evening mental health hours).  Responses were received from 149 of the 171 medical center sites.  In addition to the web-based survey, structured phone interviews were conducted with directors or designees at 138 VA medical centers, containing 39 index questions.  The report noted that during the telephone interviews, OIG staff had an opportunity to obtain feedback and to hear about potential barriers to implementation of the UMHS handbook. 

The OIG commented on the individual areas evaluated in the inspection, but made no recommendations because facilities have until the end of FY 2009 to fully meet the handbook requirements.  However, the inspection report noted areas for specific review to include community mental health; gender-specific care and military sexual trauma treatments; around-the-clock care and emergency department care; inpatient care; ambulatory mental health care; care transitions; specialized PTSD services; substance use disorders; seriously mentally ill and rehabilitation and recovery services; homeless programs and incarcerated veterans; integrating mental health into medical care settings; care of older veterans; suicide prevention; and uniformity of PTSD diagnosis and use of evidenced-based treatments.  Findings in the report were tallied by the above-identified categories and displayed by facility in percentages of the extent of implementation. 

We note that the report predominantly relies on self reports from leadership at each of the VA medical facilities as to whether they have established a particular program, generally without any clear criteria as to what minimal services the program must offer, the intensity at which services are offered, or facility capacity to provide services at required levels of intensity.  Self-reported rates of the existence of programs were high.  However, in the few cases where intensity of the service is included or implied (e.g. intensive outpatient services or Psychosocial Rehabilitation and Recovery Centers), compliance is significantly lower (71 percent and 51 percent, respectively). 

The report notes that evidence-based services for PTSD are labor-intensive but that currently VA has no means for tracking the true accessibility of such services across the system.  VA, in conjunction with the Department of Defense (DoD), has made important efforts in developing evidence-based guidelines for mental health treatments, including those used for PTSD.  VA has also commissioned independent reviews to establish which PTSD treatments are most effective.  Consequently, much is known about the types and intensity of treatments that are optimal and effective.  In the case of PTSD, the evidence-based treatments require careful training of staff and must be delivered at a high level of intensity, specifically—multiple hours of intensive treatment over several weeks or months, with subsequent follow-up care. 

The recent OIG report makes no attempt to calculate the intensity of PTSD services delivered, even those that are not evidence based; nevertheless, VA research reports cited by the OIG in other reports (e.g. OIG August 2008 report: Healthcare Inspection: Post-traumatic Stress Disorder Program Issues, VA San Diego Healthcare System) raise concern that intensity levels have been falling, even in the face of evidence that effective services for PTSD require much greater intensity of services.  The OIG report on national implementation of the UMHS Handbook acknowledges that extensive training is required to deliver evidence-based PTSD care, and reported that it collected data on such training nationally;  nevertheless, no data are presented on how many staff have been trained, how many still require training, or the timeline needed for training completion.  The only data reported is self-reported by local officials on compliance questions. 

Within the past eight months, the OIG conducted two other detailed inspections (including the San Diego inspection cited above) that attempted to look in depth at the provision of evidence-based PTSD care, including the critical issues of the availability of fully trained staff and the availability of time for staff to provide the intensive services required.  In both cases, the results are in contrast to the optimistic tone of the self-reported data from local officials in this new report.  In the San Diego report it is noted that “it would be inappropriate to make conclusions about staff resource needs based on such inaccurate information”; that PTSD therapists reported “feeling overwhelmed due to increasing numbers and mental health needs” of patients; and that “only a few patients actually received” evidence-based therapies.[1]  In a report on the Montana VA Health System, the OIG reported that:  “specific evidence-based therapies for PTSD have limited availability for Montana veterans.”[2]

The concerns expressed to the OIG in the San Diego reportby local PTSD providers, particularly that they do not have the resources or time required to provide evidence based care at the intensity it requires, resonate with feedback we have received from clinicians and veterans who complain that they are providing and receiving PTSD therapies and other services, respectively, at only a limited intensity level. 

In VHA’s response to the most recent 2009 OIG report, the Under Secretary for Health acknowledged that VHA lacks a system that reliably tracks the provision and utilization of evidence-based PTSD therapies.  He noted in fact that no health system offers such a mechanism.  This response might imply that the task is unachievable.  Given the importance of combat-related PTSD to VA's core missions, we believe it should certainly be the first to do so and the evidence is ample that this task is an achievable goal. 

Over twenty years ago, VHA began translating one of the best established evidence-based approaches for care of the severely and chronically mentally ill, specifically—Intensive Case Management (ICM)—into general VHA practices.  It did so with clear guidelines for conducting interventions to assure that the results would be comparable to the results found in the research studies that established the efficacy of the intervention strategy.  This included measures of intensity of services, frequency of services and caseloads for providers.  It should be noted that, in the current OIG report, the inspection found 100% compliance to the standards for having intensive case management services across the system.  Based on extensive, available data from national VHA performance monitoring sources, not simply self-reported sources, it was possible for the OIG to assess the intensity and adequacy of staffing at the sites with ICM programs and identify that 24 out of 111 programs were below required staffing levels.  We understand that all VA ICM programs are required to report regularly to a central monitoring center on their staffing levels, the number of patients per therapist, and other measures of fidelity to the delivery of true ICM services.  Therefore, we believe it is clearly possible to track the implementation of an evidence-based therapy if the will and resources exist to do so, since VA has already done so with regard to ICM services. 

We are pleased that VHA reported plans for improving the tracking of veterans’ access to evidence-based PTSD therapies, as detailed in the Under Secretary's response to the 2009 OIG report.  Again, we believe this is clearly an achievable goal, and adequate resources should be devoted to the task to assure that it can be accomplished immediately. 

Mr. Chairman, let me now address the second OIG report before the Subcommittee today.  The purpose of the OIG audit of VA’s Mental Health Initiative (MHI) funding was to determine if VHA had an adequate process in place to ensure that funds that were allocated for the MHI were properly tracked and used for these purposes.  According to the report, in FY 2008, VHA allocated $371 million to fund mental health initiatives outlined in the MHSP and UMHS handbook.  The OIG visited six randomly selected VA medical facilities and reviewed allocation records related to MHI funding.  According to the OIG staff from the OMHS and the Office of Finance in VA Central Office were interviewed to determine the process for funding the MHI and the mechanisms for tracking and ensuring accountability of these funds.  Interviews also were conducted with VISN and medical facility staff, including new mental health staff hired to determine if they were performing MHI-creditable duties.  Award memorandum sent by the OMHS staff to the medical facilities were reviewed as well as MHI tracking reports, payroll reports and transfer of disbursement authorities (TDA).  It was noted in the report that VHA had not developed performance metrics to identify the intended outcome(s) of each initiative.  In a subsequent memorandum, VA commented that these metrics for monitoring implementation of the requirements listed in the UMHS handbook are currently under development. 

The OIG concluded that at the six sites reviewed, the OMHS had adequately tracked funds allocated for the MHI in FY 2008, and that the funds allocated for the MHI were used as intended.  The OIG confirmed that 94 percent of the funds allocated in the six sites reviewed were used for initiatives outlined in the MHI.  It reviewed the remaining funds to confirm they were used by, or for, mental health services.  The OIG evaluated mental health personnel costs for FY 2008 and reported that VHA spent approximately $16.4 million of the $17.7 million allocated for 225 positions at the six sampled sites.  Medical facility personnel reported the remaining funds ($1.3 million) allocated for hiring mental health staff, were not expended for that purpose because of delays in the hiring process.  Finally, $1.8 million of some additional $3 million in funds not related to personnel costs were determined to have been expended on the MHI specifically, and on other mental health-related activities such as purchasing equipment and furniture, and paying travel costs to provide home-based primary care. 

While it is encouraging, based on this report, that the funds allocated are being predominantly utilized for the purposes intended, the report does not address two of the most pressing issues regarding true, long-term augmentation of mental services in VHA: the net increase in actual providers of care; and, the availability and accessibility of early intervention services. 

First, it does not calculate the actual increase in providers of care; rather, it merely audits the hiring of new staff.  In the past, mental health augmentations have been offset by reductions in other areas of mental health services, leaving a smaller net gain than intended, or no gain at all.  Secondly, the funds have been allocated as time-limited funds, although the need for additional services will clearly extend well into the foreseeable future. Supplementary mental health funds were allocated as time-limited, annual “special purpose” funding allocations that occurred outside of the usual Veterans Equitable Resource Allocation (VERA) process.  Although there was a clear expectation by Congress that the services based on these funds would be maintained well into the foreseeable future, we understand that within VA the continued enhanced MHI funding has not been promised or assured.  It is critical that these programs and the UMHS package be fully implemented and then maintained over time, since, as was learned tragically after Vietnam, many veterans of that era first sought care long after the conflict had ended.  Furthermore, we understand that VHA now proposes to move funding for these programs into the VERA process.  We are concerned that if all new mental health funds were moved into VERA and mixed with other medical care funds allocated to the VISNs, mental health and substance-use disorder programs will again be at risk for erosion.  In fact this has been the case in the past when mental health and substance-use disorder funds were allocated under VERA and were required to compete directly with other acute care programs.

Based on these findings, it is still unclear if sufficient resources have been authorized given the comprehensive requirements outlined in the UMHS handbook (approximately 400 mental health services).  In our opinion, there is still much to be done to assure equity of access to mental health services for all veterans enrolled in and using the VA health care system.  According to the OMHS, following the development of the UMHS handbook, each facility mental health chief was asked to prepare an analysis comparing the services identified in the handbook to the services they already provided at their facility.  We understand that this analysis (one that VA has not released to Congress or the veterans service organization community) did not reflect the full recommendations made by mental health staff asked to complete the survey with regards to the actual number of full-time employee equivalents (FTEE) needed, in their estimation, to implement and carry out the services required in the UMHS handbook.  Furthermore, we understand it did not fully take into account many important factors such as the cost and effort required to provide newer evidence-based treatments for priority conditions such as PTSD, or the extra efforts required to hire, train and orient new providers to VA, and to launch the new programs they would be expected to then manage. 

We also point out that the IG report does not specifically focus on the availability and accessibility of early intervention services.  When combat veterans return from war, it seems there is a tendency to underestimate and ignore the early signs of psychological distress.  At a recent Department of Defense (DoD) conference, we understand that one expert inferred that a significantly higher percentage than we are seeing in the current literature (70 percent, versus 30 percent or less), of servicemembers and veterans who were in harm’s way during their deployments experience some level of residual stress and may incur resulting problems that need DoD or VA attention.[3]  According to mental health experts, these problems often first surface and come to the attention of the veteran or family members and friends, and manifest as relationship and marital problems, problems at work or school, or newly uncharacteristic and hazardous use of alcohol or other substance-use disorders.  A number of new research studies underscore this point.[4]  These symptoms often indicate broader problems needing attention.  When a veteran approaches VHA with one of these early signs, VA must have available a user-friendly, accessible early intervention program that immediately provides the services identified (e.g. early substance use disorder services or relationship counseling).  Also, we believe VA should be able to use such opportunities to further assess the veteran for other health problems needing VA’s attention.  If the veteran encounters a complicated, bureaucratic system, where services are fragmented, complicated, delayed or not available, he or she will likely reject VA.  Thereby, VA loses an opportunity to address such problems early on, when early interventions can have a long-term and even life-saving impact.  At minimum, later interventions in chronic illness will be more expensive and even more complicated.  Data from a newly published VHA national study of 1,530 users of VHA outpatient services underscores the challenge.  While 40 percent of the sample screened positive for potentially hazardous alcohol use and 22 percent screened positive for full alcohol abuse, only 31percernt of those who screened positive reported being counseled about their hazardous alcohol use.[5] 

Although there are many programs that support OIF/OEF veterans, few are true outreach programs designed to motivate veterans to take action to address their behavioral health concerns.  However, the DAV recently learned about one such program in VISN 12—the “VetAdvisor Support Program.”  VetAdvisor is a proactive, telephonic outreach program that employs techniques to identify veterans (rural, suburban, and urban) who may be in need of behavioral health care and then helps to connect them directly to their local VA facilities. 

VetAdvisor provides “Care Coaches” who are licensed, trained and experienced behavioral health clinicians.  Through a series of VA-approved screenings, the Care Coaches telephonically assess veterans for medical and behavioral health conditions associated with serving in combat.  The results of such screenings are provided to the VA facility concerned for follow-up and further evaluation.

VetAdvisor also incorporates an extended solution-focused Care Coaching Program (i.e., non-medical facilitation) which is provided telephonically or through virtual collaboration technology.  The program is designed to recognize behavioral challenges and empower veterans to successfully overcome setbacks.  The Care Coaches employ motivational interviewing techniques, with an emphasis on encouraging change.

We understand that the VetAdvisor concept was piloted in VISN 12 to a population of over 5,000 veterans and after positive screenings, directed over 1,100 veterans to VA facilities for follow-up services.  We see the expansion of this pilot program as one possible alternative to increasing outreach to OIF/OEF veterans who may otherwise fall through the cracks and go untreated.  As we have learned from Vietnam, later on in life untreated sick and disabled veterans often discover VA, but are much more challenging cases for whom to provide assistance.  

While we agree with the OIG that implementation of the UMHS handbook is an ambitious effort, it must be approached with a clear recognition that delays in immediate implementation inflict a heavy cost on those who have honorably served their country.  We strongly believe that comprehensive and detailed oversight and monitoring is imperative at this juncture if immediate progress in filling critical gaps in mental health services across the nation is to be assured and recovery is to be fully embraced. 

The oversight process we envision in mental health would be a constructive one that is helpful to VA facilities, rather than punitive.  It should be data-driven and transparent, and should include local evaluations and site visits to factor in local circumstances and needs.  Such a process could assure that immediate progress is made in achieving the goal of the VA MHSP and UMHS package to provide easily accessible and comprehensive mental health services equitably across the nation. 

An empowered VA organizational structure should be established within VA to assure that this oversight process is robust, timely and utilizes the best clinical and research knowledge available.  Such a structure would require VHA to collect and report detailed data, at the national, network and medical center levels, on the net increase over time in the actual capacity to provide comprehensive, evidence-based mental health services.  Using data available in current VA data systems, such as VA’s payroll and accounting systems, supplemented by local audited reports where necessary, could provide information down to the medical center level on at least the following from the period of fiscal year 2004 to the present fiscal year:

• the number of full-time and part-time equivalents of psychiatrists and psychologists;
• the number of mental health nursing staff;
• the number of social workers assigned to mental health programs;
• the number of other direct care mental health staff (e.g. counselors, outreach workers);
• the number of administrative and support staff assigned to mental health programs;
• the total number of direct care and administrative FTEE for all programs, mental health and others, and as a basis for comparison;
• the number of unfilled vacancies for mental health positions that have been approved, and the average length of time vacancies remain unfilled. 

The current practice of reporting only the number of offers made to prospective new mental health staff members, and not the number who are actually on board, should be immediately halted, since we know there are often lags of several months in actually bringing these new clinicians on board, getting them trained and finally seeing patients. 

VA should also develop an accurate demand model for mental health and substance-use disorder services, including veteran users with chronic mental health conditions and projections for the unique needs of OIF/OEF veterans.  This model development should be created in coordination with the VA mental health strategic planning process and include estimated staffing standards and optimal panel sizes for VA to provide timely access to services while maintaining sufficient appointment time allotments. 

Assuming the creation of these resource tools, Congress should also require VA to establish an independent body, a “VA Committee on Veterans with Psychological and Mental Health Needs,” (or a similar title) with appropriate resources, to analyze these data and information, supplement its data with periodic site visits to medical centers, and empower the committee to make independent recommendations to the Secretary of Veterans Affairs and to Congress on actions necessary to bridge gaps in mental health services, or to further improve those services.  Membership on the committee should be made up from VA mental health practitioners, veteran users of the services and their advocates, including veterans’ service organizations and other advocacy organizations concerned about veterans and VA mental health programs.  The site visit teams should include mental health experts drawn from both within and outside VA.  These experts should consult with local VA officials and seek consensual, practical recommendations for improving mental health care at each site.  This independent body should be responsible for synthesizing the data from each of the sites visited and make recommendations on policy, resources and process changes necessary to meet the goals of the MHSP and UMHS Handbook. 

In addition to these changes, VA should be directed to conduct specialized studies, under the auspices of its Health Services Research and Development Program and/or by the specialized mental health research centers such as the Mental Illness Education, Research and Clinical Centers (MIRECCs) in several sites, the Seriously Mentally Ill Treatment, Research Education and Clinical Center (SMITREC) in Ann Arbor; and the Northeast Program Evaluation Center in West Haven, among others, on equity of access across the system; barriers to comprehensive substance use disorders rehabilitation and treatment; early intervention services for harmful/hazardous substance use; couples and family counseling; and programs to overcome stigma that inhibits veterans, particularly newer veterans, from seeking timely care for psychological and mental health challenges. 

As an additional validation, we believe that the Government Accountability Office (GAO) should be directed to conduct a follow-on study of VA’s mental health programs to assess the progress of the implementation phase of the MHSP, the status of the UMHS Handbook at the end of 2009, and to provide its independent estimate of the FTEE necessary for VA to carry out the above-noted program initiatives.  Congress should also require GAO to conduct a separate study on the need for modifications to the current VERA system to incentivize VA’s fully meeting the mental health needs of all enrolled veterans. 

We believe the ideas above—ideas that we have gleaned from a number of mental health and research professionals both within and outside of VA, and from scientific literature, are necessary to fully ensure VA is moving its mental health policy and program infrastructure in a proper direction, and with the sense of urgency that the current shortfalls require.  We believe it is essential that VA provide immediate evidence-based mental health services for all veterans returning from wartime deployments, including time-sensitive early intervention services before VA misses the opportunity to restore these veterans to a level of full functioning. 

Also, we urge this Subcommittee, which would be the major recipient of this new approach to reporting true VA mental health capacity, to continue to provide VA strong oversight to assure VA’s mental health programs, and the reforms it is attempting, meet all their promises, not only for those coming back from war now, but for previous generation of veterans who need these specialized services. 

In summary, while much progress has been achieved toward reforming VA mental health care and the programs that provide it, many more challenges lie ahead for VA to achieve the level and scope of reforms VA has laid out as its near-term goal.  We again call your attention to DAV’s testimony[6] at your March 3, 2009, legislative hearing with respect to H.R. 784, a bill introduced by Ms. Tsongas.  That testimony embraced many similar points that we raise again today.  We believe comprehensive, independent oversight is crucial to assure veterans and their advocates, including DAV, that current mental health policy mandates outlined in the UMHS  handbook and MHSP, with stable, predictable funding augmentations, truly result in appropriate high quality treatment and immediate access to critically important mental health services for all veterans who need them.  This is as important for older generations of disabled war veterans with chronic mental health problems, as it is for our newest generation of veterans from Iraq and Afghanistan, some of whom are surely suffering from more acute forms of these mental health challenges and readjustment difficulties.  We urge the Subcommittee to act with dispatch to address these responsibilities. 

Mr. Chairman, this concludes my statement.  I will be pleased to respond to any questions you may wish to ask with regard to these issues. 

[1] Department of Veterans Affairs, Office of Inspector General.  Healthcare Inspection: Post-Traumatic Stress Disorder Program Issues, VA San Diego Health Care System.  Report 08-01297-187.  August 26, 2008.

[2] Department of Veterans Affairs, Office of Inspector General.  Healthcare Inspection: Access to VA Mental Health Care for Montana Veterans.  Report 08-00069-102.  March 31, 2009.

[3] Castro C.  Oral Remarks at the Combat Stress Intervention Program Research Conference on Post Deployment Challenges: What Research Tells Practitioners. Washington and Jefferson College.  April 4, 2009.

[4] Scotti J, Crabtree M and Bennett E.  Presentation at Combat Stress Intervention Program Research Conference on Post Deployment Challenges: What Research Tells Practitioners. Washington and Jefferson College.  April 4, 2009.

[5] Calhoun PS, Elter JR, Jones ER, Kudler H, Straits Troster K.  Hazardous Alcohol Use and Receipt of Risk Reduction Counseling Among US Veterans of the Wars in Iraq and Afghanistan.  Journal of Clinical Psychiatry, 69, 1686-93.  November 2008.

[6] Ilem, J  Statement of the Disabled American Veterans before the Committee on Veterans Affairs, Subcommittee on Health, U.S. House of Representatives, 3-3-09 http://www.dav.org/voters/documents/statements/Ilem20090303.pdf.