Witness Testimony of Ira Katz, M.D., Ph.D., Veterans Health Administration, Deputy Chief Patient Care Services Officer for Mental Health, U.S. Department of Veterans Affairs
Mr. Chairman and members of the Subcommittee, I am pleased to be here today to discuss the Department of Veterans Affairs (VA) treatment and research for post traumatic stress disorder (PTSD). I am accompanied by Dr. Matthew Friedman, Director of VA’s National Center for PTSD.
From the beginning of Operation Enduring Freedom in Afghanistan until the end of Fiscal Year (FY) 2007, nearly 800,000 service men and women separated from the armed forces after service in Iraq or Afghanistan. Almost 300,000 of them have sought care in a VA medical center or clinic. Of these, about 120,000 received at least a preliminary mental health diagnosis, with PTSD being the most common seen diagnosis- nearly 60,000. Although PTSD is the most frequently identified of the mental health conditions that can result from deployment to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF), it is by no means the only one. Depression, for example, is a close second.
Care for OEF/OIF veterans is among the highest priorities of VA’s mental health care system. For these veterans, VA has the opportunity to apply what has been learned through research and clinical experience about the diagnosis and treatment of mental health conditions to intervene early and to work to prevent the chronic or persistent courses of illnesses, especially PTSD that have occurred in too many veterans of prior eras. Since the Vietnam war, PTSD has been recognized as a medically distinct mental disorder; strategies for diagnosing the illness have been validated, and effective treatments have been developed. Although rates are high among OEF/OIF veterans, most of the 400,000 veterans seen in VA last year for PTSD are Vietnam era veterans.
VA has a number of intensive programs to ensure mental health problems are recognized, diagnosed, and treated. We do outreach to bring veterans into our system, and once they arrive, we screen for mental health conditions. For those who screen positive for mental health conditions, we conduct evaluations to recognize urgent needs, followed by comprehensive diagnostic and treatment planning evaluations.
If a veteran comes to VA concerned they may have PTSD, or if a veteran screens positive for PTSD symptoms, we are very much interested in whether PTSD is the correct diagnosis, since the veteran may have another condition, such as depression. Alternatively, a veteran may not have any mental health condition at all and may be experiencing a normal reaction to traumatic events related to deployment and combat. Our responsibility is to respect the strength and resilience of our service men and women, and follow their preferences in helping them to readjust to civilian life. When veterans are having difficulties, we must intervene early and effectively. At VA, care is available and treatments work.
Overview of Mental Health Care in Medical Facilities
VA provides mental health services to veterans in all our medical facilities, and mental health services are provided in specialty mental health settings in all medical centers. VA also provides services for homeless veterans, including transitional housing paired with services which address the social, vocational, and mental health problems that contributed to becoming homeless. VA works very closely with the Department of Labor (DoL) on combating homelessness among our homeless veteran population. We are also increasing the scope and scale of programs conducted jointly with the Department of Housing and Urban Development. In addition, mental health care is integrated into primary care clinics, rehabilitation programs, and nursing homes.
Specific care for PTSD is provided in multiple settings. Last year, approximately 35 percent of veterans with PTSD were treated by PTSD Clinical Teams or Specialists; 55 percent were treated in general mental health settings; and 10 percent in primary care. Treatment settings depend on the symptoms and severity of the illness; response to prior treatment; and the presence of coexisting mental health or medical conditions.
PTSD Clinical Teams or Specialists are in each of our medical centers and in many of our larger Community Based Outpatient Clinics (CBOCs). VA offers inpatient and residential rehabilitation options across the country. Veterans with serious mental illnesses are seen in specialized programs, such as mental health intensive case management; psychosocial rehabilitation; and recovery day programs and work programs.
VA employs full and part-time psychiatrists and full and part-time psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of mental health services for veterans. The numbers of these mental health professionals have grown steadily in the last two and a half years, as a result of focused efforts to build mental health staff and programs. We have hired over 3,800 new mental health staff in that time period, for a total mental health staff of nearly 17,000.
OEF/OIF has brought many new patients into our system with illnesses that are more acute than those of veterans from prior eras, and VA has responded with major increases in staffing. Addressing increases in acuity and ensuring that new staff are aware of military and VA culture, as well as the latest advances in clinical science, requires education. I am pleased to report that as we speak, in San Antonio, VA’s National Center for PTSD has gathered the leaders of each of our specialty care programs in PTSD for a mentoring program. The goal is to ensure that all programs in all our facilities are delivering safe, effective, efficient, and compassionate care in similar ways.
VA is committed to enhancing the mental health services it provides to address the needs of returning veterans and veterans from prior eras. This commitment is reflected in increases in funding from $2 billion in 2001 to a projected amount of over $3.5 billion this year. VA views this level of funding as an investment, recognizing that appropriate attention to the mental and physical health needs of veterans will have a positive impact on their successful re-integration into their families, their jobs, their communities, the economy, and our society as a whole.
Access to Mental Health Services Through Vet Centers
In addition to the care provided in medical facilities and CBOCs, VA’s Vet Centers provide counseling and readjustment services to returning war veterans. It is now well-established that rehabilitation for war-related PTSD and other military-related readjustment problems, along with the treatment of physical wounds of war, is a central aspect of VA’s continuum of health care programs for war veterans. Vet Center’s mission goes beyond medical care to providing a holistic mix of services designed to treat the veteran as a whole person in his or her community setting. Vet Centers provide an alternative to traditional access for mental health care because some veterans may be reluctant to access medical centers and clinics. Vet Centers are staffed by interdisciplinary teams which include psychologists, nurses and social workers, many of whom are veterans themselves.
VA is currently expanding the number of its Vet Centers. In February 2007, VA announced plans to establish 23 new Vet Centers, increasing the number nationally from 209 to 232. This expansion began in 2007, and is planned for completion in 2008. Some Vet Centers have established telehealth links to VA medical centers that extend VA mental health service delivery to remote areas to underserved veteran populations, including Native Americans on reservations. Vet Centers address the psychological and social readjustment and rehabilitation process for veterans and support ongoing enhancements under the VA Mental Health Strategic Plan.
From early in FY 2003 through the end of FY 2007, Vet Centers have provided readjustment services to 268,987 veteran returnees from OEF and OIF. Of this total, 205,481 veterans were provided outreach services, and 63,506 were provided substantive clinical readjustment services in Vet Centers.
Interventions for Post Traumatic Stress Disorder
VA’s approach to treating PTSD is to promote early recognition of this condition for those who meet formal criteria for diagnosis, as well as those who may be experiencing symptoms. Our goal is to make evidence-based treatments available early to prevent chronicity and lasting impairment.
Screening veterans for PTSD is a vital first step towards helping veterans recover from the psychological wounds of war. Veterans are screened on a routine basis through contact in Primary Care Clinics. When there is a positive screen, our patients are further evaluated and referred to mental health providers for further follow-up, as necessary.
If a veteran first enters the system through a clinical program other than primary care, screening for PTSD will be done in that setting. Screening also occurs for traumatic brain injury, depression, substance use disorder, and military sexual trauma. VA evaluates all positive screens and conduct timely follow-up. When the follow-up reveal either a likely diagnosis or early signs a veteran is having increasing mental health problems, VA begins timely treatment for those problems.
Medications can be effective treatments for PTSD. Specifically, several antidepressants that act on the neurotransmitter serotonin have been found to be effective and safe for the treatment of PTSD. A number of other medications are currently being studied.
The available evidence, however, suggests that the most effective forms of treatment for PTSD are certain types of psychotherapy. Specifically, there is compelling evidence, much resulting from VA supported research, that two types of cognitive-behavioral therapy for treating PTSD are effective: prolonged exposure therapy and cognitive processing therapy. In prolonged exposure therapy, patients are asked to re-experience traumatic events repeatedly in a safe, therapeutic environment. While a therapist provides reassurance, they may be asked to tell the story of their trauma during each session or even have it taped. They would then be asked to listen to the tapes between sessions as homework. By providing repeated but safe exposures to the trauma, the treatment is able to extinguish fear responses and to decrease symptoms. Cognitive processing therapy also includes elements of exposure, but it emphasizes the importance of describing the trauma verbally, and understanding it. The goal is to develop a mastery of trauma-related stimuli and memories.
Last year, VA investigators reported that findings from a randomized clinical trial of psychotherapy demonstrating that prolonged exposure therapy was effective. Even before these results were published, we were developing plans to implement the treatment throughout our system. To make both cognitive processing therapy and prolonged exposure treatments broadly available, VA has implemented extensive, training programs for providers in our system. We are partnering with the Department of Defense (DoD) to make these training opportunities available to DoD mental health staff.
Other forms of psychotherapy treatments are also highly promising. One treatment, “Seeking Safety” appears to be effective for treating PTSD complicated by alcohol use disorders or other forms of substance abuse. VA is currently implementing this treatment, while at the same time conducting further research on its effectiveness.
In addition, there is increasing evidence of the effectiveness of psychosocial rehabilitation. Treatment is available to veterans for whom there may be residual symptoms after several evidence-based treatments to help them function in the family, in the community, or on the job.
Sometimes mild to moderate PTSD symptoms without a full diagnosis represent normal reactions to highly abnormal situations. Many returning veterans will recover without treatment, supported by their families, communities, and employers. In fact, what is most striking about our service members and veterans is not their vulnerability, but their resilience. When people prefer treatment, we encourage it. When they are reluctant, we watch them over time, and urge treatment if symptoms persist or worsen.
Mental Health Research
VA continues to support a strong behavioral and psychiatric disorders research portfolio focused on further understanding and treating mental health problems in veterans. Investigations are directed toward substance abuse, PTSD, adjustment and anxiety disorders, psychotic disorders, dementia and memory disorders, and related brain damage. Many laboratory studies are being conducted to better understand the changes that take place when someone is suffering from adjustment problems or mental illness. Clinical trials are underway to test new drug and therapy treatments specifically targeted to help veterans. VA also has a strong program for developing and implementing better mental health care, including enhancing collaborative care models, improving access to mental health care through innovations such as telemedicine and the Internet, and reducing barriers to veterans seeking mental health care. Several ongoing projects are investigating how veterans with mental illness might benefit from rehabilitation approaches, including vocational rehabilitation, skills training, and cognitive therapy to improve everyday functioning and work performance. Future research will enable VA to determine how to care for veterans with mental illness so that they can return to their highest level of functioning.
In a landmark ongoing study, VA researchers, collaborating with DoD, are collecting risk factors and health information from military personnel prior to their deployments to Iraq. These soldiers will be reassessed upon their return, and several times afterwards, to identify possible changes in their emotions or thinking following combat duty in Iraq and to identify predisposing factors to PTSD and other health conditions. To date, researchers have reported that troops who served in Iraq showed mild deficits in some tasks involving learning, memory, and attention compared with non-deployed troops, but scored better on a test of reaction time. The researchers have proposed longitudinal follow-up studies to determine if these neuropsychological effects might fade over time, or be a precursor to PTSD (Journal of the American Medical Association. 2006; 296(5):519–529). An additional goal for this research is to examine the neuropsychological associations of traumatic brain injury (TBI) with the development of PTSD at long-term follow-up.
Veterans with PTSD commonly experience nightmares and sleep disturbances, which can seriously impair their mood, daytime functioning, relationships, and overall quality of life. In an exciting new treatment development, VA investigators have found that prazosin, an inexpensive generic drug already used by millions of Americans for high blood pressure and prostate problems, improves sleep and reduces trauma nightmares in a small number of veterans with PTSD (Biological Psychiatry. 2007; 61(8):928–934). Plans are underway for a large, multi-site trial to confirm the drug’s effectiveness.
In addition, VA investigators are currently conducting the first ever clinical trial of a medication to treat military service-related chronic PTSD. It will also be the largest placebo controlled double-blind study (the most rigorous type of clinical trial) of its kind ever conducted. It will involve 400 veterans diagnosed with military-related chronic PTSD at 20 VA medical centers across the nation. The main objective of the study is to determine if risperidone is effective in veterans with chronic PTSD who continue to have symptoms despite receiving standard medications used for this disorder. Risperidone is being studied since it has been shown to be safe and has received a good deal of preliminary study in the treatment of PTSD patients.
In 2006, VA launched the Genomic Medicine Program as part of its Personalized Medicine Initiative. A PTSD Genetics Working Group was established to explore and define a research program to identify the genes which are important in determining how an individual responds to the experience of deployment, especially their response following combat exposure. By carefully characterizing those affected by combat-related PTSD and conducting genetic analyses, VA will be in a position to identify genetic variants contributing to PTSD and other post-deployment adjustment disorders, such as major depression. Once this program is established, this resource will be available for continued research including studying the genetic relationship to treatment response.
Other research on PTSD, related disorders, and coexisting conditions is being conducted by the National Center for PTSD, the Mental Illness Research Education and Clinical Centers, and the new Centers of Excellence in Mental Health and PTSD. These studies include investigations on stress and resilience; deployment and its consequences; novel therapeutics; and new strategies for the delivery of care, including primary care management.
Mental Health is an important part of overall health. VA is committed to providing the highest quality of care possible to our nation’s veterans. Because VA researchers are also clinicians caring for veterans, VA is uniquely positioned to move scientific discoveries from investigators’ laboratories into patient care. One of the major medical advances resulting from World War II was the translation of penicillin from a laboratory curiosity to a medicine that could be produced in sufficient quantity to be delivered to soldiers with battlefield injuries. Although the basic research had been done earlier, the translation of laboratory findings to the bedside and clinic came from the war. In a similar way, the spotlight on PTSD and its treatment has stimulated VA to translate evidence- based therapies from interventions delivered primarily in research clinics to real treatments for real patients. We believe this work will have a profound impact on mental health care, not only in VA, but throughout the country.
VA takes great pride in the research that keeps it at the forefront of modern medicine and health care. We expect to see further remarkable discoveries, and the translation of these discoveries into care in the coming decades.
Thank you again, Mr. Chairman, for having me here today. I will answer any questions you or the other members may have.