Chairman Michaud, Ranking Member Brown and Members of the Subcommittee:

Thank you for inviting Wounded Warrior Project (WWP) to offer our views on VA’s progress in meeting the mental health needs of our veterans, with particular emphasis on VA’s mental health strategic plan, its uniform mental health services handbook, and the funding to support those initiatives.

The Wounded Warrior Project brings an important perspective to these issues in light of the organization’s goal–namely to ensure that this is the most successful, well-adjusted generation of veterans in our Nation’s history.  That perspective provides the framework for our testimony this morning.

Wounded Warrior Project was founded on the principle of warriors helping warriors, and we pride ourselves on outstanding service programs built on that principle.  Our signature service programs include peer mentoring, adaptive sporting events, and Project Odyssey – a potentially life-changing program that engages groups of veterans with combat stress and post-traumatic stress disorder in outdoor adventure activities that foster coping skills and provide support in the recovery process. WWP aims to fill gaps–both programmatic and policy – to help wounded warriors thrive.  We recognize, of course, the critical role that the Department of Veterans Affairs can and must play in providing needed health care services to wounded veterans.  We welcome the opportunity, accordingly, to offer our views on VA’s progress in meeting veterans’ mental health needs.

That progress certainly owes much to this Committee’s leadership over the years in highlighting the importance of veterans’ mental health and pressing to reverse the underfunding of VA mental health programs.  Oversight hearings like this one are vital to sustaining the gains that have been made, and realizing goals that have not yet been fully attained.

Mental Health: A Vital VA Mission

We have certainly come a long way in this country in understanding the importance of mental health, and in diminishing the stigma that for too long surrounded mental illness and mental health treatment.  We have come to understand that mental health is integral to overall health.   We know too that mental health problems are a leading cause of disability.  Yet mental disorders can be readily diagnosed and treated.  Those who do not get that needed treatment, however, likely face a more difficult reintegration into their communities, and are at increased risk for chronic illness, poor general health, and unemployment. 

VA’s role as a provider of mental health care is particularly important.  Recently, the Institute of Medicine reported trends in the numbers of veterans receiving disability compensation for a primary rated disability (which is defined as either the condition rated as the most disabling or equal to the highest rated condition).  From 1999 to 2006, of all veterans receiving disability compensation, the primary rated disability diagnosis category with the largest percentage increase was major depression (474 percent increase).  Two other mental health categories–“other mood disorders” and PTSD–experienced increases of 264 percent and 126 percent respectively.[1]  While some 5.5 million veterans use VA health care services annually, most veterans have other health care coverage and do not rely on the VA health care system.  Veterans who need mental health care, however, generally do not have good alternatives.  Neither Medicare nor most employer-provided health plans cover the broad range of mental health services recommended by the Institute of Medicine, the Surgeon General, and the 2003 report of the President’s New Freedom Commission on Mental Health.  As a system, VA provides a broad range of services not generally available through other programs, but its facilities are not easily accessible to all veterans.  Given the limited mental health coverage available through non-VA sources, it is particularly important that VA maintain and indeed augment its capacity to provide veterans such needed services. 

OIF/OEF Veterans

Recent research indicates that we face substantial mental health challenges as a result of our engagement in Iraq and Afghanistan.  A widely cited longitudinal study reports that some 20 percent of active duty returning servicemembers and 42 percent of reserve component soldiers were found to need mental health treatment.[2]  VA reports that mental disorders are among the three most common health problems experienced by new veterans who seek VA care.  VA’s experience and research data suggest that we can expect the number of OIF/OEF veterans with mental health problems to increase.  While PTSD is especially prevalent among veterans seeking VA care, the literature also makes clear that PTSD often co-occurs with other mental health disorders, particularly depression, anxiety, and substance-use disorders.  Indeed one study reports that there is an 80 percent likelihood that a patient with PTSD will also meet diagnostic criteria for at least one other mental health disorder.[3]  These substantial co-morbidities have been linked to significant impairment in social and occupational functioning, as well as to suicide.  As this Committee knows, there has been a dramatic increase in the number of soldiers who have attempted or committed suicide since 2003. 

VA has acknowledged that it is experiencing an increase in the numbers of OIF/OEF veterans treated for mental health disorders, and expects a further increase.  That trend is concerning.  Yet VA officials have maintained that the increased workload associated with mental health problems among returning veterans is manageable.  We question that view, given our understanding that there is already a significant vacancy rate in VA mental health staffing and a nationwide shortage of mental health clinicians.  While VA policy has encouraged facilities to use community resources to obtain needed mental health care when VA cannot provide needed services or where VA care would be geographically inaccessible to the veteran, community providers rarely have expertise in addressing military trauma.  Moreover, sources of community-based mental health care do not exist in many parts of the country.  Half the counties in the United States do not have a single mental health professional, according to a recent federal report.[4]

Compounding the challenges associated with the increasing numbers of OIF/OEF veterans with mental health problems, it seems clear that VA is not reaching all who need mental health care.  It is striking, for example, that of the veterans RAND surveyed, only about half of those with a probable diagnosis of PTSD or major depression had sought help from a health professional.[5] Another study found that approximately 60 percent of all ground combat troops in Iraq who screened positive for PTSD, generalized anxiety or depression did not seek treatment.[6]  RAND suggested a number of factors that may inhibit some returning veterans from seeking VA mental health treatment, including the stigma associated with seeking mental health treatment, concerns about confidentiality, perceptions about feeling out of place among older patients in VA facilities, attitudes about the effectiveness of mental health treatment and medications, and logistical barriers.[7]  The experience of some of our wounded warriors and their family caregivers indicate some inconsistency in outreach efforts, and suggest that the goal of a “seamless transition” from DoD to VA has yet to be fully realized. 

Also troubling are reports that veterans with a co-occurring substance-use disorder -- a high risk category -- are less likely to use VA mental health services than those who simply have a mental health disorder.  One study found that only 3 percent of OIF/OEF veterans surveyed who had co-occurring PTSD and a substance-use disorder actually received chemical dependency treatment, although evidence-based care calls for integrated treatment of these co-occurring conditions.[8]

Veterans with untreated mental health problems can face long-term consequences both in terms of their ability to reintegrate successfully in their communities as well as to their overall health.  PTSD, for example, is associated with reported reductions in quality of life across several domains, including general health, energy, emotional well-being, emotional role limitation, physical role limitation, and social functioning.  Studies have shown a strong correlation between PTSD and physical health measures, including missed workdays, among this generation of veterans.[9]  Studies have also linked PTSD with illnesses such as cardiovascular disease,[10] nervous system disease,[11] and gastrointestinal disorders.[12]  Given the potential chronicity of mental health conditions, a failure to intervene early and effectively could have profound long-term costs for this generation of veterans as well as for society, including lost productivity, reduced quality of life, strain on families, domestic violence, and homelessness.

VA’s Strategic Mental Health Plan

With those concerns as background, we acknowledge that VA has taken important steps toward refocusing the system to meet veterans’ mental health needs.  In 2004, VA developed a strategic plan to transform mental health care in the VA.  The plan was built on the foundation of the President’s New Freedom Commission on Mental Health, one of whose core principles remains vitally important to the mental health of our newest generation of veterans.  That “blue ribbon” Commission emphasized that the goal of mental health care must be recovery – not simply the management of symptoms.  By recovery, the Commission meant an individual’s being able to live a fulfilling, productive life in the community – even with a mental health condition that may elude “cure.”  

VA became the first federal department to embrace the Commission’s recommendations, and VA’s strategic plan was hailed for the breadth and boldness of its vision.  Among its key elements were: 

• Adoption of the recovery model, emphasizing each veteran’s rehabilitation;
• Integration of medical and mental health care to ensure coordinated, comprehensive care;
• Providing veterans equitable access to a comprehensive continuum of mental health services; and
• Intervening early to identify and address mental health needs among returning OIF/OEF veterans.

The plan documented large areas of unmet current and future need, and candidly acknowledged that closing those gaps and realizing its goals would require an expansion of facilities, services, and personnel – in short, vibrant funding – as well as fundamental changes in culture.

Last year, VA took its strategic mental health plan a step further in issuing a Uniform Mental Health Services Handbook.  That far-reaching directive, for the first time, established a policy calling for a “Uniform Services Package” – a requirement that veterans must be afforded access to a specific array of needed mental health services, regardless of where they live. 

The question underlying this hearing – what has been VA’s progress in meeting the mental health needs of our veterans? – is critically important as we approach the five year mark since adoption of the strategic mental health plan.  That question is also vitally important as the Department is apparently moving toward ending a several-year long special funding initiative that had supported the strategic plan’s implementation.

The VA has clearly made major strides in carrying out many of the plan’s near-term initiatives and in closing the size of the gaps that had been identified.  But gaps and wide variability in programs remain.  By way of illustration:

• While the strategic plan acknowledges the importance of specialized PTSD treatment services for returning veterans, our warriors have experienced both long waits for inpatient care and a dearth of OIF/OEF-specific programs.  (Young veterans with acute PTSD understandably question how they can be expected to feel confident about treatment when placed into treatment programs with older veterans who have been struggling with chronic PTSD and other health problems for decades.) 
• For the first time, VA policy – as reflected in the new uniform services handbook – calls for ensuring the availability of needed mental health services, to include providing such services through contracts, fee-basis non-VA care, or sharing agreements, when VA facilities cannot provide the care directly.  That policy has particular relevance to the large number of OIF/OEF veterans who live in rural areas and for whom VA facilities are often geographically accessible.  We understand, however, that VA facilities have made only very limited use of this new authority.  Moreover, the new policy makes no provision for assuring that community mental health professionals have appropriate expertise to effectively treat veterans with combat-related mental health conditions.
• VHA has employed special mental health funding to support major efforts to train VA clinicians in two evidence-based therapies for treatment of PTSD.  But no comparable initiative has been mounted to ensure integrated or coordinated care of co-occurring PTSD and substance-use disorders, one of the many requirements of the uniform services handbook.  Integrated treatment of these often co-occurring health problems appears to be the exception rather than the rule in VA facilities.
• Mental health care is increasingly being integrated into primary care clinics; but at any given medical center or large clinic, mental health may be integrated into only a single one of its primary care teams.
• VA facilities have yet to fully incorporate recovery-oriented services, including peer-support programs, into their care-delivery programs.

Re-examining VA’s Strategic Plan

The overarching vision underlying VA’s strategic plan is sound.  But a strategic plan, by its very nature, should be revisited periodically.  While the current plan continues to provide a credible foundation, we encourage the Committee to press the Department to re-examine that blueprint and take account of what has changed in the nearly five years since the plan’s adoption.  For example, it is not clear that the plan anticipated the increased prevalence of PTSD and other behavioral health conditions affecting this and other generations of veterans.  Another example is that the plan emphasizes screening as a tool to foster early intervention services, but fails to address the problem of veterans who are identified in screening as likely needing follow-up, but who elect not to pursue further evaluation or treatment. 

The strategic plan also includes initiatives to foster peer-to-peer services but does so only in the context of veterans with severe mental illnesses (such as schizophrenia and bipolar illness). In WWP’s experience, peer support can be powerful in helping OIF/OEF veterans cope with PTSD, and there is ample research to suggest that peers’ social support is an important influence on psychological recovery and rehabilitation.  Moreover, we see evidence that this generation of veterans value peer-services.  To illustrate, a recent WWP survey of wounded warriors with whom we have worked showed that:

• 75 percent of respondents reported that talking with another OIF/OEF veteran was helpful in dealing with mental health concerns;
• 56 percent expressed the belief that peer-to-peer counseling would be helpful in addressing their mental health concerns; and
• 43 percent reported that talking with another OEF/OIF veteran had been the one most effective resource in helping with mental health concerns.
• In short, a revised strategic plan should, in our view, promote the use of such peer-to-peer supports for wounded warriors with mental health needs, without regard to diagnosis.

VA Mental Health Funding

Whether we gauge VA’s progress in meeting the mental health needs of our veterans through the lens of its 2004 strategic plan, or – as we recommend – in the context of an updated strategic plan, WWP believes the transformation of VA’s mental health delivery system remains a work in progress.  Given that view, and given the unique importance of VA’s mental health mission, it is critical to sustain robust funding for VA mental health programs.

As VA officials have previously testified, the Veterans Health Administration (VHA) has allocated special funding in the form of a “Mental Health Initiative” every year since Fiscal Year 2005 to implement the Mental Health Strategic Plan.  It is our understanding that VHA allocated some $600 million in special funding for mental health this fiscal year.  Funds supporting this initiative have supplemented the resources provided through VA’s resource allocation system, VERA. 

Without question, VA’s special mental health funding has supported a very substantial increase in the Department’s mental health workforce, the development of new programs at many facilities, and expansion of existing services at others – consistent certainly with a bold vision of system “transformation.”  It is our understanding, however, that special funding will be phased out next year, with 90 percent of those special funds reverting to VHA’s general health care funds, to be allocated through the VERA process.

The implications of that shift could be profoundly detrimental, given that veterans’ mental health care needs – during a still-evolving major strategic transition—would no longer be subject to a special funding mechanism.  Instead, as the General Accounting Office and other oversight entities have reported, monies would be allocated to the networks under the VERA process based primarily on the numbers of veterans under treatment without any new funding or fiscal incentives to improve the intensity of care provided current patients.  Yet improved patient care is precisely what the Strategic Plan aims to achieve.  It is not at all clear that any targeted funding mechanism has been devised to sustain the gains that have been made in VA mental health care and to support those initiatives that have yet to be completed.  In short, VA network directors and facility directors – who are charged to continue implementation of the strategic plan and the uniform services handbook, but who face an end of special mental health funding—may well be left with an unfunded mandate.  Given that conundrum, there is a great risk that critical policy goals will not be realized, and that prior gains will be eroded. 

It seems clear that policy goals critical to meeting the mental health needs of current veterans, and any surge of new veterans likely to need VA care, will not be met or sustained without either changing the resource allocation system or revisiting prior decisions regarding special mental health funding.  Given the profound transformation in VA mental health service-delivery still underway, we urge continued strong oversight to ensure that the Department has a sound funding plan to support and sustain its still evolving mental health transformation. 

We recognize that funding alone will not achieve a real system transformation.  Leadership is equally critical.  With that in mind, VA must ensure adequate resources are allocated to mental health programming.  At the same time, the Department must closely monitor and evaluate program implementation, and report at least annually to Congress on its progress.  That combination of adequate mental health funding and keen oversight offer the best promise, in our view, for ensuring that we meet the mental health needs of our veterans, and fostering the goal of ensuring that this generation of wounded warriors is the most well-adjusted, mentally healthy generation of veterans in our history.

[1] Institute of Medicine and National Research Council of the National Academies, PTSD Compensation and Military Service (Washington, DC: The National Academies Press, 2007), 145.

[2] Charles S. Milliken, Jennifer L. Auchterlonie, and Charles W. Hoge, “Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War,” Journal of the American Medical Association 298, no. 18 (2007): 2143.

[3] RC Kessler, A Sonnega, E Bromet, M Hughes and CB Nelson, “Posttraumatic stress disorder in the national comorbidity survey,” Archives of General Psychiatry 52, 1995: 1048-1060.  As cited in Matthew Friedman, “Posttraumatic stress disorder among military returnees from Afghanistan and Iraq,” American Journal of Psychiatry 163, no. 4, 2006: 589.

[4] Annapolis Coalition on the Behavioral Health Workforce, “An Action Plan for Behavioral Health Workforce Development, Executive Summary,” report prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA), 2007.

[5] Terri Tanielian, Lisa Jaycox, Terry Schell, Grant Marshall, M. Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa Meredith, Jeanne Ringel, Mary Vaiana, and the Invisible Wounds Study Team, Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries (Santa Monica, CA: The RAND Corporation, 2008), 13-14.

[6] Charles Hoge, Carl Castro, Stephen Messer, Dennis McGurk, Dave Cotting and Robert Koffman, “Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care,” The New England Journal of Medicine 351, no. 1, 2004:16.

[7] Terri Tanielian, Lisa Jaycox, Terry Schell, Grant Marshall, M. Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa Meredith, Jeanne Ringel, Mary Vaiana, and the Invisible Wounds Study Team, Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery (Santa Monica, CA: The RAND Corporation, 2008): 282, 301, 278, 302.

[8] Christopher Erbes, Joseph Westermeyer, Brian Engdahl and Erica Johnsen, “Post-traumatic stress disorder and service utilization in a sample of servicemembers from Iraq and Afghanistan,” Military Medicine 172, no. 4, 2007: 359.

[9] Charles Hoge, Artin Terhakopian, Carl Castro, Stephen Messer and Charles Engel, “Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans,” American Journal of Psychiatry 164, no. 1, 2007:151-2.

[10] Laura Kubzanksy, Karestan Koenen, Avron Spiro III, Pantel Vokonas and David Sparrow, “Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the normative aging study,” Archives of General Psychiatry 64, no.1, 1997: 112-3.

[11] J Boscarino, “Diseases among men 20 years after exposure to severe stress: Implications for clinical research and medical care,” Psychosomatic Medicine 59, no. 6, 1997: 604-14.  As cited in Jennifer Vasterling, Jeremiah Schumm, Susan Proctor, Elisabeth Gentry, Daniel King and Lynda King, “Posttraumatic stress disorder and health functioning in a non-treatment-seeking sample of Iraq war veterans: A prospective analysis,” Journal of Research & Development 45, no. 3, 2008: 348.

[12] P Schnurr, A Sprio III and A Paris, “Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military veterans,” Health Psychology 19, no. 1, 2000: 91-97.  As cited in Jennifer Vasterling, Jeremiah Schumm, Susan Proctor, Elisabeth Gentry, Daniel King and Lynda King, “Posttraumatic stress disorder and health functioning in a non-treatment-seeking sample of Iraq war veterans: A prospective analysis,” Journal of Research & Development 45, no. 3, 2008: 348.