Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to speak to you this morning about the mental health needs of families of veterans.

Specifically, I want to address the question before the Subcommittee about “the need for the U.S. Department of Veterans Affairs to provide mental health treatment for family members of veterans within VA medical facilities.” More broadly, I want to describe the approach our North Carolina initiative is taking to address the mental health needs of Operation Enduring Freedom and Operation Iraqi Freedom veterans and their families.

My name is Peter Leousis and I am the principal investigator for the Citizen Soldier Support Program National Demonstration. The Citizen Soldier Support Program was funded by the Congress to develop model approaches to mobilize and engage community support for members of the National Guard and Reserve and their families. I am currently deputy director of the Odum Institute for Research in Social Science at UNC Chapel Hill. Before that, I was assistant secretary for human services for seven years under former North Carolina Governor Jim Hunt.

I want to thank the North Carolina Congressional delegation and the University of North Carolina’s Board of Governors for their support of this work and for their efforts to provide federal funding. I want to emphasize that while we have been laying the groundwork for our mental health initiative for more than a year, many elements of the program are just getting underway. We will have a much clearer assessment of the program in four to six months.

The focus of the Citizen Solider Support Program is on the Reserve Component of the military, which includes the National Guard and Reserves. Whether these service men and women are in the Army National Guard or the Marine Corps Reserve, the Army Reserve or the Air National Guard they are widely dispersed throughout the nation. In North Carolina, the majority of Reserve Component service members do not live near a military installation. In fact, historically many of them have not thought of themselves as military families. In most cases, the formal and informal networks that provide support for families in the Active Component are not available to them.

Rural Communities

Our efforts focus on rural communities and communities that do not have easy access to VA medical facilities and Vet Centers. In North Carolina, for example, there are no Vet Centers west of Charlotte despite the large numbers of Citizen Soldiers and veterans living in that part of the state.

Figure 1

Figure 1 shows the geographic distribution of more than 22,000 Reserve Component service members across North Carolina on March 31, 2007. This does not include more than 8,000 service members in the Individual Ready Reserve.

Although some counties clearly have concentrations of Citizen Soldiers, they and their families live in all counties of the state and significant numbers of them live in rural counties in the eastern and western regions of the state.

Figure 2

The circles on Figure 2 are centered on VA medical centers and Vet Centers located in North Carolina. The radius of each circle is 20 miles, or approximately 30 minutes driving time. As shown on this map, most Citizen Soldiers do not live near a VA Medical Center or Vet Center.

Figure 3

The dots in Figure 3 show the number of licensed clinical social workers in North Carolina. The largest urban counties of Mecklenburg, Wake, Durham, Forsyth, and Guilford have the largest numbers of licensed clinical social workers. But virtually every county has several. These licensed mental health providers and others like them are target groups of the Citizen Soldier Support Program. We focus on building the mental health infrastructure outside urban areas and at locations far removed from VA Medical Centers and Vet Centers through training developed in collaboration with partners who are experts on Post-Traumatic Stress Disorder (PTSD) and combat-related mental health issues.

The Mental Health Needs of Families

The Subcommittee has asked about the mental health needs of families of OEF and OIF veterans. We know that the majority of Reserve Component families are resilient. They are able to cope with the demands and challenges of repeated deployments with few lasting effects. But there is mounting evidence that service in OEF and OIF comes at a price for families. We know, for example, that the incidence of child maltreatment in families with deployed parents rises significantly. (Am J Epidemiol 2007; 165:1199-1206).

Post-deployment reintegration of veterans can be as challenging for families as for soldiers and Marines themselves. For example, the report of a joint working group composed of the Department of Veterans Affairs Office of Research and Development, the National Institute of Mental Health, and the United States Army Medical Research and Material Command concluded that:

[T]he burden of illness, including the cost of PTSD and other trauma responses, spans beyond symptoms to impairment, altered functioning, and disability, and crosses family, occupational, and social realms. This applies not only to those who have served in the military and suffer from deployment-related problems, but also to their spouses, partners, and children (“Mapping the Landscape of Deployment Related Adjustment and Mental Disorders: A Meeting Summary of a Working Group to Inform Research,” working paper 2006; p. 9).

There is evidence that exposure to combat has an even greater effect on Reserve Component service members. According to the “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning from the Iraq War” (Journal of American Medical Association; 11/14/2007), “clinicians identified 20.3% of active duty and 42.4% of reserve component soldiers as requiring mental health treatment.”

Over 360,000 “citizen soldiers” have served in Afghanistan and Iraq so far. More than 10,000 are from North Carolina alone. They do not return to military installations where the community “gets it” and appropriate services are available, but rather to their home towns and communities that might not even be aware of their service and sacrifice.

We know that PTSD has a secondary effect on spouses and partners and that the repeated deployments typical of OEF and OIF are having lasting effects on service members and their families. The report of the Mental Health Advisory Team IV published in the December 2007 issue of Traumatology notes that:

Not surprisingly, deployment length and multiple deployments to Iraq were related to soldier mental health and well-being, with soldiers deployed longer than 6 months and soldiers on their second deployment to Iraq being more likely to screen positive for a mental health problem than soldiers who were deployed less than six months or on their first deployment (“The Intensity of Combat and Behavioral Health Status,” Traumatology 2007; 13; 6).

Clearly, the mental health needs of returning veterans, including but not limited to PTSD, have an impact on their entire family, not just themselves. The issue is not whether the families of returning veterans may face serious mental health challenges, but how best to make sure they get the mental health services they need when and where they need them.

When returning veterans and their families have reasonable access to VA medical facilities, mental health treatment should be made available to the entire family, not just the veteran, when it is clinically appropriate. We define reasonable access as living within a 30-minute drive of a mental health treatment provider.

The CSSP Approach

The Citizen Solider Support Program’s efforts are guided by three fundamental principles. First, the program seeks to complement and strengthen the work of others and avoid duplicating similar efforts. To that end we have developed a partnership Dr. Harold Kudler, M.D., VA Mid-Atlantic Health Care Network, VISN 6. Dr. Kudler and his colleague, Dr. Kristy Straits-Troster, PhD, have been key collaborators and advisors to CSSP.

The steering committee that guided the development of our mental health initiative is listed at the end of my remarks. It includes experts with firsthand knowledge of the needs of returning veterans and their families and key stakeholders in the military and North Carolina’s public and private mental health community.

A second guiding principle is that fundamental, lasting change can best be accomplished by taking a “systems” approach. Accordingly, our efforts are focused on leveraging existing mental health training and delivery systems and mechanisms to reach mental health providers and to enhance delivery of mental health services throughout our state.

A third guiding principle is that there is no silver bullet. Relying on one approach will not work. We have to move forward on many different fronts at the same time. Thus, our mission to ensure that Citizen Soldiers and their families have access to mental health services encompasses five goals:

1. Provide evidence-based, best practice behavioral health training and products for health care professionals who render services to Citizen Soldiers and other veterans and their families. This includes primary care physicians and mental health providers.

Our goal is to train 1,000 health and mental health care providers annually until we achieve a 70% to 80% market penetration rate. Currently this training is offered face-to-face to providers through the North Carolina Area Health Education Centers (AHEC) system. There are nine AHECs in North Carolina, and we offered our first full-day training session to 98 mental health professionals in January 2008. We will also make training available online to licensed providers. Ultimately, we plan to replicate this effort in the 40-plus states that have training systems similar to North Carolina’s AHECs.

2. Provide specialized health and mental health services to returning Citizen Soldiers and other veterans and their families using the model of Integrated Care at family health clinics in Haywood, Clay and Jackson Counties , three rural underserved counties in Western North Carolina.

The stigma of seeking mental health treatment is alive and well. Our experience is that offering treatment through family health clinics will reduce the likelihood that service members concerned about their career (and their families) will not seek care. Additionally, evidence suggests that mental health treatment should be provided through a “multidisciplinary approach centered in primary care.” A goal of this demonstration is to make the mental health component self-sustaining within three years through TRICARE, third-party payers, and Medicaid.

3. Expand TRICARE participation by primary health care and mental health service providers and pharmacies to all 100 North Carolina counties.

At each of our trainings a half hour is devoted to educating providers about TRICARE and dispelling some of the myths about it. Care must be accessible and affordable for returning veterans and their families. We recognize that we must identify “funding streams” to help veterans and families pay for needed services wherever they are available.

4. Address the critical shortage of psychiatric clinicians available to meet the needs of Citizen Soldiers and other veterans and their families in the 50 medically underserved counties in North Carolina.

Rural health care disparities exist throughout the nation, and North Carolina is no exception. One of our goals is to secure long-term funding for a stipend and loan forgiveness program for psychiatric nurse practitioners who in return would agree to practice in underserved rural communities for a set number of years.

5. Provide online access to information about mental health issues. Information for “Military and families” is available through the NC Health Info Web site (http://www.nchealthinfo.org/) and for family practice physicians and mental health professionals through the NC AHEC Digital Library.

These resources exist today through our collaborative work with the Health Sciences Library at the University of North Carolina at Chapel Hill. We invite Members of the Subcommittee and your staff to explore these Web sites. With very little tweaking, the content information contained in these Web pages could be made available to other states. Information about locally-available services could be replaced with information specific to other communities.

Consumer information for military families is located at: http://www.nchealthinfo.org/health_topics/people/military/MilitaryFamilies.cfm

Information on military mental health for mental health professionals is located at:  http://library.ncahec.net/scMain.cfm?scid=53

Our objective is to implement these goals and strategies in North Carolina, evaluate and improve them, and then help other states replicate those that are successful. We will continue to work with stakeholders such as the VA and private mental health providers, especially those in underserved rural communities, to improve and expand mental health services to Citizen Soldiers and other veterans and their families.

Thank you for the opportunity to speak this morning before the Subcommittee on Health, and thank you for all you are doing to improve health and mental health services for our veterans and their families.

Behavioral Health Steering Committee

Citizen Soldier Support Program

Denisse Marion-Landais Ambler, MD North Carolina Neuropsychiatry, PA, and adjunct assistant professor, Department of Psychiatry, UNC School of Medicine

COL James A. Cohn, North Carolina National Guard

Rev. Dennis Goodwin, District Superintendent, The United Methodist Church; CH (COL) 30th Brigade Combat Team (ARNG Ret.) Chair

Brigadier General Dan Hickman (ARNG Ret.) Executive Vice President, Cape Fear Community College

COL Danny Ray Hill, Officer in Charge, Tactical Operations Center, Foreign Army Training Command 108th Division (Institutional Training) USAR

Harold Kudler, MD, VA Mid-Atlantic Health Care Network, VISN 6

Michael Lancaster, MD, Chief of Clinical Policy for the NC Division of Mental Health/Developmental Disability/Substance Abuse, NC Department of Health and Human Resources

Peter Leousis, Deputy Director Odum Institute for Research in Social Sciences and CSSP Principal Investigator

Major General Gerald A. (Rudy) Rudisill, Jr. (ARNG Ret.); Deputy Secretary, NC Crime Control and Public Safety

Karen Stallings, RN, NC AHEC Associate Director, Program Activities, UNC Chapel Hill

Flo Stein, M.P.H, Chief, Community Policy Management, NC Division of Mental Health/Developmental Disability/Substance Abuse, NC Department of Health and Human Resources

John Tote, Executive Director, Mental Health Association in North Carolina