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Witness Testimony of Warren Goldstein, Assistant Director for TBI and PTSD Programs, National Veteran Affairs and Rehabilitation Commission, The American Legion

One suicide is too many.

Every day in America 22 veterans commit suicide[1].

Two troubling numbers stood out in a recent survey[2] conducted by The American Legion to evaluate the effectiveness of treatments provided by VA when treating veterans suffering from Posttraumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI) – 59 percent and 30 percent. 59 percent of veterans surveyed reported “no improvement” or that they were “feeling worse” after having undergone TBI and PTSD treatment.  Nearly a third of veterans, 30 percent, stated they had terminated their treatment plan before it reached conclusion.  More than 3,100 veterans completed the online survey in February of this year.

On behalf of National Commander Daniel Dellinger and The American Legion; the country’s largest patriotic wartime service organization for veterans, comprising 2.4 million members and serving every man and woman who has worn the uniform for this country; The American Legion is deeply committed to tackling the mental health needs of America’s veterans.  Earlier this year, Commander Dellinger reaffirmed our commitment to veterans trying to access care amidst a hiring boom for VA that sought to bring on an additional 1,600 mental health care providers in addition to over 1,400 positions that had languished unfilled.  Prior to that Commander Dellinger expressed concern that priorities to see new patients were causing problems with meeting appointments for veterans with ongoing serious mental health conditions.

As this year has progressed, revelations from the Department of Veterans Affairs (VA) Office of the Inspector General (VAOIG) have made it clear that there have been serious lapses in the ability to provide care.  Appointment concerns veterans have noted for years – that they are having problems getting appointments and care from VA – are now well documented.  What VA had previously denied based on their own internal data was now shown to be true.  Veterans struggling to be treated by VA for mental health condition are tired of being told their problems are in their heads.

Veterans groups, as well as members of this committee have faced these same challenges in their districts.  In El Paso veterans told Congressman O’Rourke they couldn’t access mental health care despite VA telling him that veterans were waiting no longer than 7-14 days for appointments.  He decided to stop listening to the self reporting from VA and go directly to the veterans, contracting a survey of the veterans in his district.  What he found confirmed that the veterans in his district had a right to be frustrated.  While El Paso VA reported “85-100 percent of new patients to the system seeking mental health appointments saw a provider within 14 days” the survey results showed “on average it takes a veteran 71 days to see a mental health provider and more than 36 percent of veterans attempting to make an appointment were unable to see a mental health provider at all[3].”

America’s veterans deserve better.  The stakes are not just suicide, which is the highest cost to veterans and families struggling with mental illness, but for veterans who do not take their own lives, the toll of struggling with mental illness without assistance or relief can be agonizing and result in related physical illnesses as well.

The American Legion will not sit idly by while veterans struggle with their mental illness, and have taken two major actions by:

  1. Aggressively addressing the immediate care and needs of veterans with the Legion’s Veterans Crisis Command Centers (VCCCs), and
  1. Evaluating the needs of veterans through our Committee on TBI and PTSD. 

Veterans Crisis Command Centers

As the veterans’ healthcare crisis scandal spread nationwide this year, The American Legion quickly realized the real impact of the scheduling problems – veterans across America were suffering, and dying due to delayed access to healthcare.  In response to this crisis The American Legion quickly organized VCCCs in critically affected areas throughout the country in conjunction with local American Legion Posts, and local resources, to address the needs of veterans.

To date, The American Legion has run VCCCs in three cities, with two more scheduled next week, and half a dozen more to follow over the next three months.  Simultaneously, we conducted a System Worth Saving (SWS) Task Force meeting and veterans town hall in Indianapolis Indiana, followed by a visit to the Roudebush VA Medical Center.  During the SWS town hall, The American Legion worked with nearly 100 veterans.  While the purpose of the VCCCs is to provide a broad variety of support to meet the complex needs of the veterans in these communities, mental health remains a critical component.  VCCCs have been able to put veterans and their families in touch with grief counselors when loved ones have been lost due to delays in care, as well as Vet Center counselors to deal with mental health problems such as PTSD and depression.

The American Legion has been able to reach nearly 2,000 veterans in Phoenix, AZ; Fayetteville, NC; and El Paso, TX.  American Legion national staff has worked in conjunction with personnel from the National Veterans Legal Service Program (NVLSP), VA personnel, and staff from both sides of the House Committee on Veterans’ Affairs (HVAC), and other local services to provide help with claims, VA enrollment, health evaluation, and counseling.  Local American Legion Posts provide the backdrop for Town Hall meetings upon arrival in the new locations, providing veterans with an opportunity to communicate directly with our staff and VA officials in the area.   VA is then able to communicate back to the veterans regarding how they are addressing the concerns and rectify the mistakes that have been made.

Survey and Symposium – The American Legion TBI and PTSD Committee:

The American Legion established its TBI and PTSD Committee in 2010 because of our concern with the unprecedented number of veterans returning from Iraq and Afghanistan with traumatic brain injury and post-traumatic stress disorder, also known as the “signature wounds” of the conflicts. The Committee is comprised of American Legion Past National Commanders, the Veterans Affairs and Rehabilitation Commission Chairman, medical consultants from academia, and national staff. Although the committee focuses on investigating existing science and procedures, it is also investigating alternative methods for treating TBI and PTSD that are currently employed by DOD and VA for the purpose of determining if such alternative treatments are practical and efficacious.

During a recent three year study, the committee met with leading authorities in DOD, VA, academia, the private sector, and with wounded veterans and their caregivers about treatments and therapies veterans had received or currently are receiving for their TBI and PTSD symptoms. The committee released its findings and recommendations in a report entitled “The War Within[4].” This report highlights these treatments and therapies, provides findings, and makes recommendations to the DOD and VA.

Following up on that report, The American Legion conducted an online survey in February 2014 of over 3,100 veterans to evaluate the efficacy of their PTSD and TBI treatments. The survey was conducted in partnership with the Data Recognition Corporation (DRC) of Washington, DC to determine if veterans were benefiting from current evidence-based therapies and treatments as well as Complementary and Alternative treatments because The American Legion strongly believes in promoting evidence based therapies for PTSD and TBI, as well as increasing research into those therapies and exploring the efficacy of Complementary and Alternative treatments[5].

The data from the February survey was recently released at the TBI and PTSD symposium “Advancing the Care and Treatments for Veterans” conducted by The American Legion.  This survey, “The American Legion Survey of Healthcare Experiences of Veterans with Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury” was used to gather data from veterans that have been diagnosed with PTSD and TBI and their health care experiences. The survey broke veterans down by gender, era of service, number of deployments, diagnoses, access to care, access to treatments, therapies and medications, and included an examination of potential side effects. The American Legion will use this data as a tool to further advise the Administration, VA, DOD, Congress, and the veterans’ community, in order to improve TBI and PTSD programs.

Some of the key findings of the survey included:

  • 59 percent of the respondents reported either feeling no improvement or worse after undergoing treatments for their TBI and PTSD symptoms
  • 30 percent of respondents said they had terminated treatments prior to completion of the treatment cycle;
    • Termination factors included lack of improvement, side effects, dissatisfaction with provider, frustration at the lack of progress, belief that they can effectively treat themselves, time burden required for treatment, distance to treatments, and stigma of receiving mental health treatments.
  • A sizeable proportion of the respondents reported prescriptions of up to 10 medications for their TBI and PTSD across their treatment experiences. 

One of the more important takeaways from this data is that it reflects problems even for veterans who are getting care.  The expediency with which a veteran receives care – or access to care – is important, but we cannot forget that an equally important factor is how effective the treatments are.  Speed of access to care is only one of the metrics for how we are serving veterans’ mental health needs – the quality of that care will ultimately determine how effective the care is.  There must be metrics for efficacy of care or veterans will walk away from treatment unsatisfied, and possibly in a worse state than before, because they will have requested help but the treatment provided by VA did not alleviate their problems.  This can place an even greater weight on these already at risk veterans.

It is devastating for veterans in Durham, North Carolina to have to wait 104 days for a mental health care appointment[6] and every day spent waiting only serves to increase frustrations and doubts.  It is just as devastating to struggle through treatments that don’t alleviate your symptoms, or to suffer under the burdens of overmedication, or ineffective therapies.  The American Legion believes all health care possibilities should be explored and considered in an attempt to find the appropriate treatments, therapies, and cures for TBI and PTSD based on individual veteran needs, to include alternative treatments and therapies. These treatments need to be accessible to all veterans and if alternative treatments and therapies are deemed effective they should be made available and integrated into the veterans’ current health care continuum of care.

On September 12, 2013, The American Legion launched a new Suicide Prevention Web Center to provide veterans and their families with life-saving resources and programs during their time of transition and need.  The American Legion’s online Suicide Prevention Web Center builds on several suicide-prevention initiatives launched in recent years by the Department of Defense (DOD) and the VA. The center houses specific suicide-prevention data, statistics, programs and resources organized for veterans, families and the community.

The American Legion is not a medical treatment facility and the Suicide Prevention Center is for informational purposes only. This information does not constitute medical advice, and should not serve as the basis for any medical decision by anyone. The American Legion is simply working to put veterans in touch with the professional resources they need to cope with their mental health care concerns.  In addition, we encourage any veteran in crisis to contact the Veterans Crisis Line at 1-800-273- 8255 (TALK).

In addition to the survey, symposium, and VCCC efforts put forth this year to address veterans with mental health concerns, The American Legion’s System Worth Saving Task Force continues its mission to evaluate the overall VA healthcare system, of which mental health care is a critical component.  The American Legion created the System Worth Saving program in 2003[7] to assess the quality and timeliness of veterans health care within the VA healthcare system.  The American Legion remains committed to assuring that the VA healthcare system continues to perform as a premiere role model for the health care industry.

During the past two years, some of the concerns raised during System Worth Saving Task Force site visits included:

  • During our Veterans Town Hall Meeting on November 4, 2013 in Pittsburgh, PA, veterans expressed their concerns with access to mental health care.
  • During our SWS Site Visit to El Paso from November 18-19, 2013, we found that El Paso was challenged with the lack of psychiatrists working for the medical center, and veterans at the Town Hall Meeting expressed dissatisfaction with the 20-minute mental health appointments. Due to the VA’s vacancy rate for psychiatrists, veterans are frustrated due to the length of time it takes to get an appointment which creates long waiting lists. During the visit, we recommended further reliance on local Vet Centers. Vet Centers provide a broad range of counseling, outreach, and referral services to eligible veterans in order to help them make a satisfying post-war readjustment to civilian life. All Vet Centers maintain non-traditional appointment schedules, after normal business hours, to accommodate the schedules of veterans and their family members.
  • On January 28, 2014, the SWS Task Force visited the Atlanta VA Medical Center (VAMC) in response to the two VAOIG reports that identified serious instances of mismanagement at the Atlanta VAMC that led to the drug-overdose death of one patient and the suicides of two others. The VAOIG linked three patient deaths in 2011 and 2012 to mismanagement and lengthy waiting times for mental health care.
  • The American Legion found that between 2009 and April 2013, the Atlanta Medical Center had referred out a total of 4,912 veterans to the community for contract mental health care. During that time, the Medical Center lacked a reliable process for determining the treatment status of its referred veterans. Atlanta VAMC’s ultimate goal is to provide more, if not all, veterans mental health care in house, and the Community Service Board (CSB) contracts were the medical center’s way of ensuring that veterans were receiving mental health care in a timely manner. The Atlanta VA strengthened its monitoring and management of its contract mental health program. The facility has reduced the number of contracts it has with mental health organizations (from 26 to 6) and strengthened and added quality assurance monitors to the contracts. The Atlanta VAMC currently has 11 licensed clinical social workers/case workers embedded in the CSB sites to coordinate care for veterans, and there are improved mechanisms to track clinical and financial data for every referral. The average number of individuals assigned to each VA case worker is 180. An experienced supervisory social worker manages the embedded case worker program. In order to reduce the number of veterans on CSB contract, the medical center needs space and staff in order to treat more, if not all, veterans in house. In 2015, the medical center plans to activate a new 86,000 square foot outpatient annex and a 15,000 square foot clinical addition that will provide space for additional mental health services. The VAMC is awaiting final congressional approval for its replacement clinic in Cobb County that will increase the clinic’s size from 8,000 square feet to 60,000 square feet. With the inability of Congress to resolve the Congressional Budget Office scoring issue, more veterans are being treated outside the VA system.

The American Legion thanks this committee again for their diligence in oversight of veterans’ health care.  The commitment of all parties to ensuring veterans receive quality healthcare in a safe environment is a sacred duty.  This country’s obligation to its Armed Forces and its veterans includes a responsibility for their care and treatment from wounds inflicted upon them while serving their country.  The challenges posed by TBI, PTSD, and other mental health illnesses demands a dedicated, well-coordinated and flexible response that adapts care and treatment to an individual’s needs -- not the other way around. 

Questions concerning this testimony can be directed to The American Legion Legislative Division (202) 861-2700, or ideplanque@legion.org