Good afternoon, Mr. Chairman and members of the Subcommittee. Thank you for the opportunity to discuss VA's progress on meeting the mental health needs of our Veterans. I am accompanied today by Dr. Antonette Zeiss, Deputy Chief Consultant for Mental Health Services in the Veterans Health Administration (VHA), and Mr. James McGaha, Deputy Chief Financial Officer for VHA. With the support of Congress, VA has received record increases in mental health funding over the past several years, doubling our budget from the start of the war in Afghanistan to today. During this same time, VA developed and implemented the VHA Comprehensive Mental Health Strategic Plan (MHSP), and produced the Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics to guide the sustained operation of its enhanced program. My testimony will address each of these areas today.

I will discuss VA's recognition of its need to enhance its mental health services, and its implementation of substantial enhancements within a highly compressed period of time. VA was able to do this because of the insight of VHA's senior leadership on the importance of mental health and the mental health needs of returning Veterans; the allocation of needed funding; and the mobilization of the entire system. Unique in America, VA is a provider of health and mental health care services, a payer, a policy environment, and a research organization. Moreover, coordination throughout the system is supported through an electronic health record. It is by aligning actions of all of the components of this integrated care system that VHA was able to achieve such significant progress.

In discussing VA's mental health services, it is important to provide information on their scale. Of the 5.1 million individual Veterans VA treated last year in its medical centers and clinics, approximately 1.6 million or 31 percent had a mental health diagnosis and 1.1 million or 22 percent were seen in mental health specialty care. Last year, VA provided care in ambulatory, residential care, or inpatient settings to 442,000 Veterans with a diagnosis of Post-Traumatic Stress Disorder (PTSD), making care for this condition an important part of its mental health program. The scope of the mental health needs for returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans may be even greater. Of the 400,304 OEF/OIF Veterans who received care at VA medical centers and clinics through the end of the fiscal year 2008, 178,493 (45 percent) had a possible mental health diagnosis, and 92,998 (23 percent) had possible Post-Traumatic Stress Disorder (PTSD). Among Veterans using VA health care services, the rates of mental health conditions and the use of mental health services are higher than these rates in the population as a whole. This probably suggests that those Veterans who need these services are more likely to seek care from VA. These issues are discussed below in more detail with respect to Post­ Traumatic Stress Disorder in Veterans returning from Iraq and Afghanistan.

My testimony will begin by describing the Mental Health Strategic Plan and the Uniform Mental Health Services Handbook. From there, I will discuss three additional topics: program funding and metrics; other components of VA's overall mental health program; and a sampling of success stories, each of which has been made possible because of the advances achieved as a result of the Mental Health Strategic Plan and the Uniform Mental Health Services Handbook. We recognize these accomplishments, but-we remain committed to outreach to Veterans who continue to suffer from mental health conditions without seeking treatment. As a matter of public health, it is important to emphasize to those Veterans that VA offers world-class mental health services and that Veterans in need of care can and should come to us for safe, effective and compassionate care.

Mental Health Strategic Plan and Uniform Mental Health Services Handbook

The VHA Comprehensive Mental Health Strategic Plan was developed in 2004 in response to the Department's recognition that its mental health programs needed enhancement. This plan helped VA identify gaps in the mental health services provided at the local level and to identify additional initiatives needed at the national level by reinforcing the principle that mental health was an important part of overall health. The 255 elements of the Plan could be divided into six key areas: (1) enhancing capacity and access for mental health services; (2) integrating mental health and primary care; (3) transforming mental health specialty care to emphasize recovery and rehabilitation; (4) implementing evidence-based care, with an emphasis on evidence-based psychosocial treatments; (5) addressing the mental health needs of returning Veterans; and (6) preventing Veterans' suicides.

In 2005, VA began allocating funding for its Mental Health Enhancement Initiative. We allocated funds to promote specific programs that supported the implementation of the Mental Health Strategic Plan. These included:

• extending the mental health services available in community-based outpatient clinics (CBOCs), both by increasing the staff assigned to these clinics and by promoting telemental health services;
• establishing programs integrating mental health services with primary care, and with other medical care services including rehabilitation, geriatrics, and other medical specialties;
• establishing clinical programs and staff training to support the rehabilitation of those with serious mental illnesses in ways that help them pursue their own life goals;
• supporting the implementation of evidence-based care with a focus on evidence ­based psychotherapies for PTSD, Depression, Anxiety, and Problem Drinking; and
• developing comprehensive and innovative programs designed to prevent suicide.

VA is currently in the fifth year of the implementation of the Mental Health Strategic Plan, and it is a critical time for us to evaluate our progress. Substantially more than 90 percent of the items in the plan that were aspirations in 2004 and 2005 are now part of ongoing operations and clinical practice. Mental Health staffing has increased by approximately 4,000 Full Time Equivalents from 14,000 to 18,000 since 2004. The proportion of America's Veterans who receive mental health services from VA has increased by 26 percent, and, over the same time, the continuity and intensity of care has also increased. For example, VA has modified its standard of care to require immediate care in urgent cases and an initial triage evaluation within 24 hours after a new request or referral for mental health services, and a full diagnostic and treatment planning evaluation within 14 days. We are now meeting the 14-day standard more than 95 percent of the time. Additionally, the number of outpatient mental health or substance abuse visits during the first six months after discharge from a mental health, substance abuse or dual diagnosis hospitalization increased by 15 percent or more.

In 2008, as VA approached the fifth year of the implementation of the Mental Health Strategic Plan, its task was to move from a focus on rapid transition to one of sustained delivery of a comprehensive array of services. This was the impetus for the new Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics (the Handbook), published in September, 2008. The Handbook establishes minimum clinical requirements for VA mental health services at the Veterans Integrated Service Network (VISN), facility, and Community Based Outpatient Clinic (CBOC) level, and delineates the essential components of the mental health program that are to be implemented nationally, to ensure that all Veterans, wherever they obtain care from VA, have access to needed mental health services. The Handbook specifically requires VA to assign a principal mental health provider to every Veteran seen for mental health services. This principal provider is responsible for maintaining regular contact with the patient, monitoring each patient's psychiatric medications, coordinating, developing and revising the Veteran's treatment plan, and following-up to ensure that the course of treatment reflects the Veteran's goals and preferences, and that it is working. The Handbook further requires each VISN and medical center to appoint staff responsible for working with state, county and local mental health systems and community providers to coordinate VA activities and care. In this, the goal is to ensure that the each VA facility is functioning as a part of its community, as well as a part of the national VA system of health and mental health care.

Other important features of the Handbook include requirements:

• Integrating mental health care into primary care settings, other medical care settings, and providing services for older Veterans;
• Mandating screening for common mental health conditions, with follow-up clinical evaluations for positive screens;
• Expanding first line treatments for substance use conditions within primary care and general mental health services
• Identifying requirements for specialized treatment programs for PTSD and for mental health conditions related to military sexual trauma;
• Recognizing the need for gender-specific care;
• Staffing for 24 hours a day, seven-day-a-week care within VA emergency departments;
• Establishing requirements for substance use disorder programs and care;
• Employing evidence-based psychotherapies, including Cognitive Processing Therapy and Prolonged Exposure Therapy for PTSD and Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for Veterans with anxiety or depression disorders;
• Reinforcing clear guidelines for suicide prevention programs; and
• Addressing the concerns of rural mental health care.

The Handbook is an important step forward. It is a tool that defines the mental health services that must be provided in all facilities and must be available to all Veterans. It also consolidates requirements for completing and sustaining the implementation of the clinical components of the Mental Health Strategic Plan. The Handbook guides VISNs and facilities in planning mental health programs and for the system as a whole for estimating care needs. It documents standards of care that can be translated into monitors for the scope and quality of services at each facility and in the system as a whole, while also serving as a guide, for Veterans and their families, and as a tool for processing treatment planning. Most importantly, the Handbook represents a firm commitment to Veterans, their families, advocates, and Congress about the nature of mental health services VA is prepared to provide to Veterans who need them. It has served as a conceptual model to guide planning for an approach to defining uniform health care services for the VA system as a whole.

Funding and Metrics

As discussed above, the VA Mental Health Enhancement Initiative has been successful as a catalyst, accelerating the implementation of the Mental Health Strategic Plan by augmenting the core mental health program funding with a separate funding source of approximately 15 percent for program enhancements and to support rapid innovations. The use of the VA's Mental Health Enhancement Initiative has created a partnership between VA Central Office, the VISNs, and the Medical Centers to demonstrate our commitment to maintaining the strengths of existing programs while at the same time reconfiguring and expanding them to meet new standards.

VA has dedicated dramatically more enhancement funds for mental health since FY 2005, increasing from $100 million in FY 2005 to $557 million in Fiscal Year (FY) 2009. These enhancement funds have paralleled overall mental health spending.

While we are pleased with the increased level of funding, the most important concern, however, must be maintaining programs that are effectively serving Veterans. At present, VA's goals must be to consolidate the gains of the past four to five years by implementing the Handbook and sustaining the operation of mental health services meeting this new standard. To achieve these goals, VA will ensure the implementation of the requirements of the Handbook at each medical center and clinic through a stringent series of monitors and metrics.

As part of this process, VA is developing methods and metrics for assessing the implementation of the Handbook and the outcomes of enhanced mental health services. The implementation of the Handbook can be divided into four overlapping stages, each monitored through a distinct series of metrics.

The first stage is development of new clinical capacities. This will be accomplished through hiring, credentialing, and training new staff, and providing them with the space and related supports that they need to function. VA will monitor successful recruitment of new mental health staff positions and increases In the total number of positions. Other monitoring strategies will include identifying specific programs (including those for inpatient, residential, and outpatient care and those for PTSD, serious mental illness, substance abuse, psychosocial rehabilitation, and others) and ensuring they are adequately supplied with staff,' space and other resources.

The second stage is the utilization of new capacities by the facilities and the use of new or enhanced services by increasing numbers of Veterans. VA will monitor this stage by following the number of unique Veterans, the number of encounters. and access times for specific services, as well as overall mental health care.

The third stage is ensuring the quality of new services. For evidence-based interventions, this includes monitors for the fidelity of programs to the specifications for the interventions that have been found to be effective. hi general, this component of the monitoring will build upon VA's current program for quality and performance monitoring. It will emphasize the integration and coordination of the components of care, as well as the quality of the services delivered within each component.

The fourth and final stage will evaluate the change in Veterans' treatment outcomes as a result of the impact of services. Increasingly; it is apparent that ongoing monitoring for critical outcomes with standardized instruments is necessary to both guide clinical decision-making about the need for modifying care and to support program evaluation. VA is developing specific initiatives to establish processes for monitoring outcomes for PTSD, depression, substance abuse, and serious mental illness.

Over time, the strongest approach to ensuring ready access to high quality mental health services must be based on monitoring the structure, processes and outcomes of these services. This will be the basis by which VA leadership will hold itself and its facilities responsible for mental health services.

Other Components of VA's Overall Mental Health Program

Although direct mental health services provided in VA's medical centers and clinics include an extensive array of services, they are only one component of VA's overall mental health programs. Other key components include the Vet Center program and the research programs supported through the Office of Research and Development.

VA provides mental health care in several different environments, including Vet Centers. There are strong, mutual interactions between Vet Centers and our clinical programs. Vet Centers provide a wide range of services that help Veterans cope with and transcend readjustment issues related to their military experiences in war. Services include counseling for Veterans, marital & family counseling for military-related issues, bereavement counseling, military sexual trauma counseling and referral, demobilization outreach/services, substance abuse assessment and referral, employment assistance, referral to VA medical centers, Veterans Benefits Administration (VBA) referral and Veterans community outreach and education. Vet Centers provide a non-traditional therapeutic environment where Veterans and their families can receive counseling for readjustment needs and learn more about VA's services and benefits. By the end of FY 2009, 271 Vet Centers with 1,526 employees will be operational to address the needs of Veterans. Additionally, VA is deploying a fleet of 50 new Mobile Vet Centers this year that will provide outreach to returning Veterans at demobilization activities across the country and in remote areas. Vet Centers facilitate referrals to either VBA offices or VHA facilities to ensure Veterans have multiple avenues available for receiving the care and benefits they have earned through service to the country.

Collaboration between Vet Centers and VA medical centers at the local level is a long established VHA policy. Vet Centers will refer Veterans to medical centers or clinics when they have symptoms or signs of mental health conditions that have not responded to care in Vet Centers; likewise, medical centers and clinics will refer Veterans to Vet Centers after successful completion of medical center treatment programs to receive social support and after-care services. To address these issues, and to strengthen collaborations, the Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics includes a requirement that, "Each facility must designate at least one individual to serve as a liaison with Vet Centers in the area (if any), to ensure care coordination and continuity of care for Veterans served through both systems."

VA's Office of Research and Development supports well-designed, scientifically meritorious clinical trials to examine effective treatments for PTSD and other mental health conditions, as well as other clinical, health services and pre-clinical research. For years, mental health research has been among its top priorities. VA continues to serve as a leader in advancing knowledge and treatment for psychiatric and behavioral disorders. In 2008, VA's Office of Research and Development convened an expert panel to consider the methodological issues raised by the 2007 Institute of Medicine report on PTSO treatment effectiveness. The VA, the Department of Defense (000) and the National Institute of Mental Health (NIMH) have worked together to disseminate the guidance offered by the panel for rigorous trial designs. VA has used related processes to establish suicide prevention as another priority for VA research and to coordinate research activities between VA and both DoD and the National Institutes of Health.ln·2008, a central Data Monitoring Committee has been provisioned as a resource to ensure independent assessment and ongoing evaluation of clinical trials. Just recently (in 2009), VA jointly sponsored two national conferences - one to consider the research agenda for the co-morbid mental health conditions in veterans returning from Iraq and Afghanistan, and one to define common approaches for research in traumatic brain injury and psychological health. These overarching efforts will lead to even more significant scientific discoveries for mental health.

Successes

VA can report a number of recent successes in its overall mental health programs.

PTSD

Population-Based Care: The 2008 RAND Report, "Invisible Wounds of War:  Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery," estimated that approximately 14 percent of servicemembers who served in Iraq and Afghanistan experienced PTSD. Although there may be conches about this estimate, including the validity of using a single interview rather than progress over time, the accuracy of a screening interview rather than a clinical diagnosis, and the nature of the sample selection process. Nevertheless, the estimate is ·in the mid-range of other available figures •. For example, it is comparable to Milliken's published 2007 findings of positive findings from Post Deployment Health Re-Assessment evaluations of Army National Guard and Reserve Personnel, but greater than his report from active duty service members. It is less than Hoge's published 2004 survey findings for the Army or Marines in Iraq, but somewhat greater than his findings for the Army in Afghanistan. Finally, it is comparable to findings from the 2008 report from the Army's Mental Health Assessment Team V In the absence of any definitive information on the prevalence of PTSD in the population of returning servicemembers and Veterans; it may be interesting to explore the significance of these estimates.

Given that 945,423 Veterans have returned from OEF/OIF through FY 2008, the 14 percent estimate corresponds to 132,359 returning Veterans who may have PTSD. If this is the case, the 92,998 returning Veterans with possible PTSD who were seen in VA medical centers and clinics represent about 70 percent of the total and the 105,465 who have been seen in medical centers, clinics, OJ Vet Centers represent about 80 percent of the total. If these estimates are correct, VA has already seen a significant majority of returning veterans with PTSD. Moreover, calculations using these estimates for the rates of PTSD, the total number of returning Veterans, and the number of Veterans with PTSD seen in VA programs suggest that OEF/OIF Veterans with PTSD are about twice as likely to come to VA than those without this condition.

Evidence-Based Psychotherapy:  In 2007, a VA cooperative study provided evidence for the efficacy of prolonged exposure therapy for PTSD. The Institute of Medicine later included this research in a comprehensive review which concluded that the nest established treatments for PTSD were prolonged exposure therapy and cognitive processing therapy, a different therapy developed by VA investigators and classified by the Institute of medicine as also being exposure-based. Given the importance of PTSD treatment for Veterans, VA translated these research findings into clinical care as rapidly as possible. Even before the results of the prolonged exposure trial Were published, VA was developing large scale training programs for mental health providers in both cognitive processing therapy and prolonged exposure. To date, over 1,500 providers have been trained in these two evidence-based therapies, which are currently being delivered in all but eight VA medical centers. Six of these eight have formulated plans with milestones and timelines, and the remaining two are receiving technical assistance from VA Central Office about developing such plans. While experts often bemoan the delay in turning research into practice, VA as a health and mental health care system has been able to accelerate this process dramatically. In working to ensure these advances in clinical practice are translated into public health benefits, VA is meeting the needs of Veterans and contributing to mental health care everywhere. We have trained enough providers in these evidence-based psychotherapies to offer cognitive processing therapy or prolonged exposure to OEF/OIF veterans to complete a course of treatment. To facilitate this process, VA Central Office has asked each VISN to submit plans for making these treatments available to returning Veterans with PTSD. The goal is to provide these effective, evidence--based treatments already as possible to those Veterans who need them. Our hope is that we can prevent much of the chronicity from PTSD that has, all too often, affected Veterans from prior eras who served before these treatments were developed.

New Treatments: For years, Dr. Murray Raskin, a psychiatrist at the Puget Sound VA Medical Center, has been conducting research on the clinical care of older Veterans and on the effects of noradrenalin and other stress-related neurotransmitters. As a clinician scientist, he also treated Veterans. Based on his clinical wisdom and scientific knowledge, he began to suspect that medications that blocked the actions of noradrenalin could decrease nightmares and .possibly other related symptoms in patients with PTSD. To test this hypothesis, he used resources from the VA Mental Illness Research Education and Clinical Center (MIRECC) in Seattle to conduct a small clinical trial; based on early evidence, he found prazosin, a noradrenalin-blocking drug already approved for treating hypertension and urinary difficulties, appeared to be effective in treating nightmares in PTSD. Based on his preliminary findings, he obtained approval from VA's Office of Research and Development for a large-scale clinical trial of prazosin for PTSD; this study is currently underway. Meanwhile, because prazosin is already an FDA-approved drug, many providers are already making it available to informed patients with PTSD who continue to experience sleep disturbances not responsive to other treatments.

Suicide Prevention

Much has been said and written about Veteran suicides and VA's program for suicide prevention. As part of its overall program, VA has been publicizing the availability of the national suicide prevention Lifeline (1-800-273-TALK) through advertising and public service announcements. The Lifeline is supported by Substance Abuse and Mental Health Services Administration in the Department of Health and Human Services.

Case Report: On April 7, a mother was using an internet video conferencing service to talk to her son, who is currently a soldier serving in Iraq. During the conversation, the soldier placed a gun to his head and threatened suicide. The mother quickly called the National Suicide Prevention Lifeline, connected to the Veterans Gall Center, and used the service to prevent her son's death. The Lifeline contacted Military One Source and the Red Gross and arranged for them to notify the soldier's unit who intervened while the mother was still watching on the internet. The soldier was taken to an Army hospital in Iraq and is currently receiving care. The mother stayed on the line for additional counseling.

VA's strategy for suicide prevention is built upon the basic principle that prevention requires ready access to high quality mental health care plus programs designed to help those in need access care, plus programs designed to identify those at high risk and to provide intensified care. This case demonstrates that VA has created resources that can promote public awareness and respond to the needs of individuals at risk. Evidence for the impact of the overall mental health program comes from analyses of suicide rates across VA facilities.

Potential Impact of Mental Health Enhancements: VA has information on the causes of death for all Veterans who utilized VHA health care services between 2000 and 2006, and it will update its databases when new information is available through the Centers for Disease Control and Prevention, One significant finding is that there is significant variability in suicide rates across facilities; about half of the variability can be explained on the basis of the region, geographic size, and the nature of patients seen. When VA tested to see if differences in suicide rates across facilities could be explained, in part, by the nature of the mental health services provided, the closest association it found was an inverse relationship between suicide rates in a facility and the intensity of the follow-up provided for patients with dual diagnoses (both mental health and substance use conditions), after they were discharged from inpatient mental health care. This is important because this measure of the quality of mental health services was among those that were substantially improved in recent years through the Mental Health Enhancement.

Together, these findings begin to demonstrate the complex nature of VA's activities in suicide prevention. Prevention utilizes highly specific resources that can demonstrate dramatic case reports. But, most basically, it relies on a well-functioning health and mental health care system. Suicide as an issue demonstrates that mental health conditions are real illnesses that can be fatal. It is with this always in its mind that VA has been implementing the Mental Health Strategic Plan and the Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics. VA now and will always continue to enhance and sustain its mental health services.

Conclusion

Thank you again for this opportunity to speak about VA's progress in meeting the mental health needs of Veterans. I am prepared to answer any questions you may have.