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Witness Testimony of Thomas J. Berger, Ph.D., Vietnam Veterans of America, Chair, National PTSD and Substance Abuse Committee

Mr. Chairman, Ranking Member Miller, Distinguished Members of this Subcommittee, and guests, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on “PTSD Treatment and Research: Moving Ahead Toward Recovery.” VVA also thanks this Subcommittee for its concern about the mental health care of our troops and veterans, and your leadership in holding this hearing today.

However, as we are gathered here today after five years of combat in Iraq and Afghanistan, VVA is again sadly compelled to repeat its message that no one really knows how many of our OEF and OIF troops have been or will be affected by their wartime experiences. To be sure, there have been some attempts by the military services to address combat stress at pre-deployment through such cognitive awareness programs as “Battle Mind” and the use of innovative “combat stress teams”. Yet no one can really say how serious an individual soldier’s emotional and mental problems will become after actual combat exposure, or how chronic both the neuro-psychiatric wounds (e.g., PTSD and TBI) may become, or the resulting impact that these wounds will have on their physiological health and their general psycho-social readjustment to life away from the battle zone. VVA would like to ask if the armed services have developed any combat stress resiliency models and if so, what is their efficacy and by what measures?

Furthermore, despite the increased availability of behavioral health services to deployed military personnel, the true incidence of PTSD among active duty troops may still be underreported. A recent retrospective report on PTSD documented what most in the military already know: specifically, that of those whose evaluations were positive for a mental disorder, only 23 to 40 percent complained of, or sought help for, their mental health problems while still on active duty, primarily because of stigma. Thus no one knows whether those with PTSD who remain undiagnosed and so untreated will fail at reintegration upon their return to civilian life.

What is beyond speculation is that the more combat exposure a soldier sees, the greater the odds that our soldiers will suffer mental and emotional stress that can become debilitating, and our troops are seeing both more and longer deployments. Without proper diagnosis and treatment, the psychological stresses of war never really end, increasing the odds that our soldiers will suffer mental and emotional stress that can become debilitating if left untreated. This places them at higher risk for self-medication and abuse with alcohol and drugs, domestic violence, unemployment & underemployment, homelessness, incarceration, medical co-morbidities such as cardiovascular diseases, and suicide.

Upon separation from active military service, our male (and increasingly) female veterans face yet other obstacles in the search for mental health treatment and recovery programs, particularly within the VA healthcare system. In spite of the infusion of unprecedented

funding, the addition of new Vet Centers and community-based facilities (i.e., CBOCs), and the VA’s efforts to hire additional clinical staff, access to, and the availability of, VA mental health treatment and recovery programs remains problematic and highly variable

across the country, especially for women veterans and veterans in western and rural states such as Montana. Moreover, the demands to meet the mental health needs of OEF and OIF veterans in many localities around the country is squeezing the VA’s ability to treat the veterans of WWII, Korea and Vietnam.

Despite the shortcomings and gaps noted above, the one piece of good news is that since 1980, when the American Psychiatric Association (APA) added PTSD to the third edition of its “Diagnostic and Statistical Manual of Mental Disorders (DSM-III)” classification scheme, a great deal of attention has been devoted by the VA to the development of instruments for assessing PTSD [see Keane et al., (1)], as well as to therapeutic PTSD treatment modalities [see Foa et al., (2) and the National Center for PTSD’s Fact Sheets (3)] to assist veterans with managing or even overcoming the most troubling of the symptoms associated with PTSD. The range of treatment modalities utilized in VA services and programs includes cognitive-behavioral therapies (i.e., CBTs) such as exposure therapy, pharmacotherapies such as selective serotonin reuptake inhibitors (i.e., SSRI antidepressants) and mood stabilizers (e.g., Depakote), and other treatment modalities such as cognitive restructuring, group therapy, and coping skills.

However, as you may recall, back in October 2007 the National Academies’ Institute of Medicine’s Committee on Posttraumatic Stress Disorder issued a report (4) which found that “most PTSD treatments have not proven effective”, with one exception for “exposure therapy”.

The IOM Committee reviewed 2,771 published studies conducted since 1980 (when PTSD was added to the DSM-III), and identified only 90 studies (53 psychotherapeutic and 37 pharmacological treatments) that met its criteria for trials from which it could anticipate reliable and informative data on of PTSD therapies. Several problems and limitations characterized much of the research on these PTSD treatments, making the data less informative than expected. Many of the studies had problems in their design, how they were conducted, a low number of veteran participants, and high dropout rates -- ranging from 20 percent to 50 percent of participants -- reducing the certainty of several

studies' results. Moreover, the majority of the drug studies were funded by pharmaceutical firms, and many of the psychotherapy studies were conducted by individuals or their close collaborators who had developed the techniques.

According to IOM Committee Chair Alfred O. Berg, Professor of Family Medicine at the University of Washington, School of Medicine, “At this time we can make no judgment about the effectiveness of most psychotherapies or about any medications in helping

patients with PTSD.” These therapies may or may not be effective -- we just don't know in the absence of good data. Our findings underscore the urgent need for high-quality studies that can assist clinicians in providing the best possible care to veterans and others who suffer from this serious disorder.”

Therefore VVA strongly supports the IOM Committee’s recommendations that the “VA and other government agencies that fund clinical research should make sure that studies of PTSD therapies take necessary steps and employ methods that would handle effectively problems that affect the quality of the results” and that “Congress should

ensure that resources are available for VA and other federal agencies to fund quality research on treatment of PTSD and that all stakeholders -- including veterans -- are represented in the research planning.”

In addition to whatever scientifically rigorous treatment modality used, VVA also believes that it must be integrated into an effective, evidence-based treatment program that incorporates psychosocial elements and services (e.g., symptom management, recovery strategies, housing, finances, employment, family and social support, etc.) in the manner developed by the Substance Abuse and Mental Health Services Administration (i.e., SAMHSA) and is tailored to the individual’s needs for achieving the goal of successful PTSD treatment and recovery. And of course, for individuals suffering from co-occurring disorders, an integrated evidence-based dual diagnosis treatment model must be utilized.

But such integrated treatment programs take time and cost money – and with the large number of veterans involved, lots of money, along with accountability for its expenditure -- an area where the VA has had problems in the past. For example, according to a GAO report issued in November 2006, the Department of Veterans Affairs did not spend all of the extra $300 million it budgeted to increase mental health services and failed to keep track of how some of the money was used, even though the VA launched a plan in 2004 to improve its mental health services for veterans with post-traumatic stress disorders and substance-abuse problems.

To fill gaps in services, the department added $100 million for mental health initiatives in 2005 and another $200 million in 2006. That money was to be distributed to its regional networks of hospitals, medical centers and clinics for new services. But the VA fell short of the spending by $12 million in 2005 and about $42 million in fiscal 2006, said the GAO report. It distributed $35 million in 2005 to its 21 health care networks, but didn't inform the networks the money was supposed to be used for mental health initiatives. VA medical centers returned $46 million to headquarters because they couldn't spend the money in fiscal 2006. In addition, the VA cannot determine to what extent about $112 million was spent on mental health services improvements or new services in 2006.

In September 2006 the VA said that it had increased funding for mental health services, hired 100 more counselors for the Vet Center program and was not overwhelmed by the rising demand. That money is only a portion of what VA spends on mental health. The VA planned to spend about $2 billion on mental health services in FY 2006. But the

additional spending from existing funds on what VA dubbed its Mental Health Care Strategic Plan was trumpeted by VA as a way to eliminate gaps in mental health services now and services that would be needed in the future.

With the infusion of so many new dollars to strengthen the organizational capacity of VA in mental health programs and services (particularly PTSD), VVA wants to make certain that America’s veterans get the “bang for the buck” in the expenditures of these taxpayer dollars. VVA encourages this committee to get an accounting of all of the funds allocated out to the Veterans integrated Service Networks (VISNs) to determine who received these funds, what did they do with the funds (e.g., how many clinicians hired, who did what with how many veterans served for what period of time), and what is the overall analysis of how effectively the VISNs used the funds for both short term (1 – 2 Years), and what appears to be the medium term or possibly permanent effect (e.g., more than two years).

Finally, the need for timely, effective evidence-based psychiatric/psychological and pharmacological (if necessary) interventions along with integrated psychosocial treatment programs is here. And with the conflicts in Afghanistan and Iraq continuing with no end in sight, VVA believes that the time to address these issues is now, rather than later.

I thank you again for the opportunity to offer VVA’s views on this important issue and I’ll be glad to answer any questions you might have.


References

1. Keane, T.M., Wolfe, J., & Taylor, K.I. (1987). Post-traumatic Stress Disorder: Evidence for diagnostic validity and methods of psychological assessment. Journal of Clinical Psychology, 43, 32-43.

2. Foa, E.B., Keane, T.M., & Friedman, M.J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Publications.

3. National Center for PTSD Fact Sheets. U.S. Department of Veterans Affairs. National Center for PTSD (Matthew J. Friedman, M.D., Ph.D., Executive Director). On-line access at www.ncptsd.va.gov).

4. “Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence” (2007). Committee on Treatment of Posttraumatic Stress Disorder Board on Population Health and Public Health Practice. Institute of Medicine of the National Academies.