Christina M. Roof, National Acting Legislative Director, American Veterans (AMVETS)
Chairman Miller, Ranking Member Filner and distinguished members of the committee, on behalf of AMVETS, I would like to extend our gratitude for being given the opportunity to share with you our views and recommendations at today’s hearing regarding “Mental Health: Bridging the Gap Between Care and Compensation for Veterans.”
AMVETS feels privileged in having been a leader, since 1944, in helping to preserve the freedoms secured by America’s Armed Forces. Today our organization prides itself on the continuation of this tradition, as well as our undaunted dedication to ensuring that every past and present member of the Armed Forces receives all of their due entitlements. These individuals, who have devoted their entire lives to upholding our values and freedoms, deserve nothing but the highest quality of care we, as a nation, have to offer.
As we are all aware the suicide rates among veterans and servicemembers has become a sort of “epidemic” and the rates at which these men and women are taking their own lives has surpassed that of their non-veteran population counterparts for the first time in recorded history. Unfortunately, due to the methods the Department of Veterans Affairs’ (VA) utilizes in tracking suicide rates, AMVETS fears the rate is actually much higher than VA reports. The Department of Defense’s (DoD) rates tend to be more accurate given the daily oversight they have over their personnel. However, AMVETS also believes DoD’s reported number to be lower than the actual number due to the discrepancies in the reported causes of death. Regardless of the exact number, AMVETS believes that even one veterans or servicemember life lost to suicide is one too many.
As of December 2009, approximately 1.1 million OIF/OEF veterans, of the 1.7 million who have served or are serving in these conflicts, had transitioned out of active duty out service.  According to multiple studies performed by the National Institute of Health, Department of Veterans Affairs (VA) and Department of Defense (DoD) upwards of 43 percent of veterans having served in Operations Enduring Freedom, Iraqi Freedom and New Dawn, as well as the war in Afghanistan, will have experienced traumatic events causing Post Traumatic Stress Disorder (PTSD) or other psychological disorders such as depression. Left untreated, these invisible wounds can have a devastating impact on the lives of those veterans and servicemembers who suffer in silence. Unfortunately, even though there has been an effort to remove the stigmas associated with psychological wounds in recent years by VA and DoD leadership, their message has failed to reach the everyday servicemember and veteran. Theses stigmas still seem to be ever so present and seeking assistance is often viewed as a sign of weakness or lack of resiliency among those who have been trained to be strong and fearless. We must step up our efforts in removing stigmas and immediately develop and implement newer, more confidential ways of offering assistance to those who need it most if we wish to end the cycle of preventable suicides plaguing today’s veteran and military communities. Moreover, there needs to be numerous changes and corrections in the policies and procedures within the Veterans Health Administration (VHA) and the Veterans benefit Administration (VBA).
One of the hardest and most humbling decisions a veteran can make in their life, is to seek care and assistance for their invisible wounds of war. However, given the broken policies and lengthy procedures, as well as an overall lack of communication between VHA and VBA, veterans seeking care and assistance are often met with a confusing and frustrating claims system entrenched in bureaucracy. Many of these veterans find VA to be more of a hindrance, than helpful, to their overall wellbeing and thus chose to stop receiving the care and benefits they critically need. One of the initial experiences a newly enrolled veteran will have within the VA system is with a claims examiner. Thus, the response to a PTSD claim is an evaluation without a concurrent offer of treatment has now potentially caused adversarial situation to be made worse.
In 2010 changes were made to the VA regulation governing PTSD disability claims. The regulation, 38 CFR 3.304(f)(3), allows for the veteran’s lay statement to satisfy the establishment of an “occurrence” under specific criteria. Title 38 requires the occurrence must be “related to fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or contract equivalent, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and the veteran’s symptoms are related to the claimed stressor.” While this change was for the better and seems relatively straightforward, it is yet to be seen as to how well the VA is implementing the criteria and if the claims process will be improved. Furthermore, the process may prove more lengthy due to the fact VA has implemented a case-by-case review of the facts surrounding each claim. The VA claims representative will need to verify that the facts given by the veteran are true, including duty locations and service or campaign medals, prior to the veteran being scheduled for an exam. Thus, certain medals are now sufficient to schedule a PTSD examination. For example, VA Compensation has concluded that a veteran’s receipt of the Vietnam Service Medal or Vietnam Campaign Medal is sufficient proof that the veteran service in a hostile military environment. This also includes veterans aboard ships in “blue water”. Therefore, veterans with either of these medals should be able to pass the first threshold of proving the occurrence. Once the claim is verified, an examination should be immediately scheduled.
However,veterans filing new claims know they will have to wait in a very long, continuously growing, pending claims line. They will stand behind a quarter of a million men and women waiting over 125 days, many of which, about 43 percent, will just to be told if their claim is not approved. PTSD claims alone have increased 125% over the past few years according to VA.
The compensation examiner has a responsibility to VBA to obtain information to adjudicate a claim, and as such, the examination serves a societal need rather than a treatment need. In fulfilling this societal need, compensation examiners are put into an evaluative role that can alienate the veteran being evaluated. For example, the compensation examiner may have to collect information about traumatic issues that the veteran is unprepared to address therapeutically. A compensation examination focuses on data collection rather than addressing veteran distress. In addition, a compensation interview often has more time constraints than multisession clinical treatment, and the veteran may feel rushed. Limited time is available to focus on helping the veteran process his or her subjective experience. An examiner must consider not only the veteran's perspective but also alternative sources of data and may ask questions that challenge the veteran's version of events.
Based on the number of compensation claims that have been filed for recent conflicts and the number filed in past wars, a conservative estimate is that 50 percent of OIF/OEF veterans will apply for some service-connected compensation, which is only slightly higher than the 44 percent of Gulf War veterans who applied. It is likely that a majority of those who apply are actually those who are at least partially disabled. In studies describing pre-OIF/OEF cohorts, award rates ranging from 33 to 72 percent for PTSD have been reported. More recently, a review of 2,400 PTSD claims decided during 2007 and 2008 indicated 42.5 percent were denied and an additional 2.9 percent were rated at 0 percent (veterans had the diagnosis but were not disabled by it); 1.54 percent were rated at 100 percent and the rest fell in between as shown in the Figure.
Service-connected compensation awards from sample of posttraumatic stress disorder claims, 2007 to 2008 (N = 2,400).
Considerable public pressure exists to improve the process of evaluating compensation claims and engaging veterans in treatment. AMVETS believes as a direct result of the pressure to adjudicate claims, partnered with limited initial and continuing education of VBA personnel is resulting in unwanted and avoidable circumstances for veterans seeking VA care and benefits.
At present, VA compensation examiners complete online training to become credentialed to conduct compensation examinations. In this training video, the compensation examiner explains to a veteran that the purpose of the examination is not to conduct counseling but to "document your experiences." VA regulations further reinforce this boundary between the evaluator and the clinician by noting that the evaluation should be conducted by someone who is not providing clinical care to the claimant. The Automated Medical Information Exchange (AMIE) worksheets for conducting the compensation examination require a directive interview to elicit the plethora of specific information that is required to process a claim, yet there is no recommendation in the AMIE that treatment be offered to the veteran who has just been asked to relive traumas from their past service.
These procedures are consistent with the tradition in psychiatry that "clinical" and "forensic" functions be performed by separate clinicians, and disability evaluations have been considered to be a particular type of forensic evaluation. The American Academy of Psychiatry and the Law Ethics Guidelines recommend this explicitly: "At the beginning of a forensic evaluation, care should be taken to explicitly inform the evaluee that the psychiatrist is not the evaluee's `doctor.'" Acknowledging the fact that evaluees may fall into the patient role anyway because of setting, wish, and having vented, the guidelines continue, "Psychiatrists have a continuing obligation to be sensitive to the fact that although a warning has been given, the evaluee may develop the belief that there is a treatment relationship". This also shows to be the case when examining the relationship between the veteran, claims examiner and physician.
The VA agency affiliation of the examining clinician may not be clear to veterans filing claims. Qualitative data suggests that veterans who undergo compensation examinations report not understanding the distinction between an evaluative examination and a treatment examination-after all, both are conducted by mental health professionals. Veterans may not make the distinction between the VHA staff who conduct examinations and the VBA staff who decide claims and dispense benefits. Both are "VA staff." This is a problem that must immediately be addressed by VHA and VBA. Veterans need to fully understand the different roles VHA and VBA have in their treatment and care. AMVETS believes too many veterans forego VHA care simply because of a bad experience with VBA.
A recent VA OIG investigation revealed a high number of errors being made on disability claims evaluations filed by veterans suffering from Traumatic Brain Injuries (TBI) and Post Traumatic Stress Disorder (PTSD). There was an overall 23 percent error rate in all the OIG-reviewed cases. Most of these errors had a direct impact on the veteran’s disability rating and benefits.
OIG also examined 16,000 disability files based solely on PTSD claims. OIG found there was no way the claims processors could be accurate with the limited training and experience they possessed. VA noted the largest number of mistakes were made verifying specific events qualifying for PTSD benefits. OIG found inexperienced and undertrained processors caused most problematic errors in TBI and PTSD claims. The errors themselves ranged in cause, and retraining should be completed by the end of June according to VA officials AMVETS spoke with. AMVETS hopes this committee will have the strictest of oversight in ensuring all VBA staff receive the training necessary to avoid incidents such as this in the future. It is important to remember these are not simply statics and errors rates, but rather real life veterans who are struggling and depend on VHA and VBA to sustain their quality of life.
Compensation and pension (C&P) examination reports are available to VA clinicians but are located in a different portion of the VA's electronic medical record than most other clinical information and, are infrequently consulted by clinicians. Compensation examiners have access to clinical records for the period preceding the examination and are expected to dictate a report soon after interviewing the veteran. AMVETS has serious concerns as to whether or not claims examiners are properly trained to read the medical diagnosis and background information contained within the veteran’s record. Medical appointments made or kept after the interview are not typically part of the examiner's report and attendance at subsequent treatment might be an issue if the veteran's claim is denied. A recent VA Compensation Service Bulletin, released in April 2011, sought to eliminate processing ambiguity relating to PTSD claims. Regional Offices nationwide have been largely critiqued because of erratic application of rating criteria. The current bulletins are intended in part to decrease the overall 23 percent of improper claims processing. AMVETS is eager to see if these new practices will actually improve the processing of mental health related claims.
Finally, when discussing the claims process as it related to benefits and care for psychological wounds, AMVETS strongly recommends a focus on quality instead of quantity when processing claims. AMVETS believes this must start with the Rater Veteran Service Representative’s (RVSR) initial training. AMVETS recommends extending the initial training RVSRs’ receive, regularly have current RVSRs’ participate in continuing education and that all training take place at an offsite location. RVSRs must have access to uniform, high quality and in depth training regardless of what location they will be assigned to perform their job. Off site training will eliminate new trainers from being taught incorrect or bias practices that are often picked up when training occurs on site. Furthermore, AMVETS recommends current RVSRs be mandated to participate in regular continuing education classes so that they may stay up to date on any and all changes to current laws and regulations. AMVETS also recommends stronger enforcement of annual reviews in order to identify the strengths and weakness of every individual rater. The only way the backlog of mental health claims can be decreased is through educating the RVSRs in order to have all claims rated correctly the first time.
AMVETS second area of concern is the noncompliance of numerous VISNs to current VHA directives, policies and procedures addressing mental health. In 2003 the President of the United States formed a commission to investigate the United States mental healthcare system. This committee issued “The 2003 President’s New Freedom Commission Report,” which identified 6 goals and made 19 broad recommendations for transforming the delivery of mental health services in the US.
In 2004VHA developed its five year “Mental Health Strategic Plan,” (MHSP) that included over 200 initiatives to improve mental heath care within VA. Since the MHSP was organized by goals and recommendations made by the Commission’s 2003 report, rather than by a mental health program or operational focus, many of the MHSP initiatives did not make clear what specific actions should take place to achieve their goals. Therefore, many of the initiatives set forth by the MHSP are not measureable.
With congressional approval of the VHA Comprehensive Mental Health Strategic Plan in 2004, it received additional funding in 2005 through the Mental Health Enhancement Initiative. In June 2008 VHA Handbook was issued outlining the specific goals and established what are to be the minimum clinical requirements for all VHA Mental Health Services. It delineates the essential components of the mental health program that is to be implemented nationally. However, many felt that the handbook was still to broad, so in Sept. 2008 VHA re-issued VHA Handbook 1160.01 defining more clearly the minimum clinical requirements of mental health services. Another important fact is the handbook also specifies that all parts of the handbook must be provided to each VA Medical Facility (VAMC) and Community Bases Outpatient Center (CBOC) and that all VA medical facilities and CBOC’s are to have these requirements in place no later than the last working day of September 2009, unless otherwise written granted permission by the Secretary of VA. VHA ensured congress that the distribution of this handbook would be followed by the distribution of the metrics that would be used to ensure the implementation of all of its requirements, and when fully implemented the handbook’s requirements will complete the patient care recommendations of the Mental Health Strategic Plan, and its vision of a system providing ready access to comprehensive, evidence-based care would be realized. The opening statements published in VHA Handbook 1160.01, VHA states “VHA employees are encouraged to become familiar with the statutory and regulatory eligibility and enrollment criteria for each of the programs discussed in this handbook, and to consult their respective VHA program office or business office as needed.”
VHA states that because they are responsible for mental health care to a defined population, that it is their responsibility to ensure ready access to care for new patients, as well as for the continuity and quality of care for established ones. They continue by adding “At a time when large numbers of veterans are returning from deployment and combat, ensuring access to care for patients in need must be considered VA’s highest priority.” Finally VHA affirms that “Every program element described in this handbook must be understood as an integrated component of overall healthcare.” The hand book also states “Each Veterans Integrated Service Network (VISN) must request approval from the Deputy Under Secretary for Operations and Management for modifications and exceptions for requirements that cannot be met in FY 2009 with available and projected resources.”
The following is a short list of specific services and programs in the VHA 1160.01 Handbook:
· Suicide Prevention
· Specialized PTSD Services
· Gender-Specific Care and Military Sexual Trauma
· 24/7 Emergency Mental Health Care
· Seriously Mentally Ill and Rehabilitation/Recovery Services
· Inpatient Care
· Care Transitions (discharge from medical care with instructions)
· Substance Abuse Disorders
· Homeless Programs
· Incarcerated Veterans Programs
· Elder Care (integration of mental health into medical care)
· Access to Trained Mental Health Staff
As required by the Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year 2009 (FY 09’), the VA Office of Inspector General (OIG) conducted a review of VHA’s progress in implementing the recommendations of the Mental Health Strategic Plan as outlined by VHA 1160.01. AMVETS found OIG’s findings released in 2010 quite troubling at best. Given the fact VHA was given over five years and upwards of $38 billion to develop and implement the critical issues addressed in VHA 1160.01, AMVETS finds it to be inexcusable and irresponsible that numerous VAMCs and CBOCs are still, in 2011, being allowed to operate in a state of noncompliance.
OIG’s findings on the progress of VHA 1160.01 implementation raised several concerns for AMVETS. The following is a list of OIG findings AMVETS believes must be corrected immediately:
- Accessing timely treatment within all VISNs regarding specialized post-traumatic stress disorder (PTSD) residential program. The current wait time for many veterans living in rural and remote areas of the country is six to eight weeks.
- VHA’s lack of ability and trained personnel in providing Intensive Outpatient Services (at least three hours per day at least three days per week) for the treatment of substance use disorders. As we have seen substance abuse can lead to homelessness and many other problems for veterans not receiving the care they need and are entitled to through their service.
- The limited availability of 23-hour observation beds for patients at risk of harming themselves or others.
- The limited and sometimes non-existent availability of substitution therapy for narcotic dependence to veterans seeking care.
- The failure of numerous VAMCs in providing a Psychosocial Rehabilitation and Recovery Center Program at facilities with more than 1,500 Serious Mental Illness or Impairment (SMI) patients. This includes includes, but is not limited to schizophrenia, bi-polar mania, sociopathic or homicidal tendencies and suicidal behaviors.
- The failure to have the presence of at least one full-time psychologist to provide clinical services to veterans in VA community living centers (formerly nursing home care units) with at least 100 residents.
- VHA 1160.01 also specifies that all VAMCs and VL CBOCs must have: specialized outpatient PTSD programs and the ability to provide care and support for veterans with PTSD and either a PTSD clinical team (PCT) or PTSD specialists. Overall the data indicates the presence of specialized PTSD or clinical teams (the Handbook requirement) at 79%of sites and 49% of VAMC’s had actual PTSD clinics. Very important is the fact that PCT are responsible for training all onsite staff on how to properly treat and interact with veterans suffering PTSD.
- Finally, the Handbook (VHA 1160.01) states that medical centers with 1,500 or more current patients included on the National Psychosis Registry (NPR) must have an outpatient psychosocial rehabilitation recovery center (PRRC). PRRC programs treat patients with serious mental illness (primarily schizophrenia and other psychosis) following stabilization of an acute phase of illness. OIG found that best case scenario was 33%facilities with 1500 or more “seriously mentally-ill patients” (SMI) were compliant. Furthermore, OIG explained they encountered such extreme difficulties regarding this section of the handbook outlining treatment and policies for f VA’s largest facilities treating 1500 or more patients diagnosed as severely mentally ill, their only recommendation is as follows:
“We cannot distinguish which other psychosocial rehabilitation programs are functionally non- approved PRRCs and which other psychosocial rehabilitation programs have not progressed toward functioning as PRRCs. Administrative data support provision of either an approved PRRC or other psychosocial rehabilitation program at 33-55% of all VAMCswith more than 1,500 SMI patients during October 2009. As this represents a best case scenario, more work needs to be done to achieve system-wide implementation of PRRC programs at sites with more than 1,500 SMI patients.”
From OIG’s findings it appears to AMVETS that VA does not currently utilize a system to reliably track their own provisions and utilization of these therapies and policies on the national level. This is very disturbing given the fact that the number of patients seeking care from VA who served in OEF/OIF/OND has risen to over 25 percent of the initially projected totals and the fact that veteran suicide rates continue to rise. Furthermore, VA/VHA set their own objectives and expectations for the implementation timeline of the handbook and yet to date has failed to meet said deadlines according to OIG. VHA 1160.01 outlines uniformed policies and procedures for the treatment of some of the most prevalent health conditions afflicting today’s returning troops and provides numerous improvements upon current care models for veterans of all eras.
While AMVETS understands what a daunting undertaking the handbook posed itself to be, again VA was given over five years and appropriated billions of dollars to implement the required changes, as well as multiple opportunities to express concerns or problems they were encountering to Congress. Numerous hearings and OIG reports measuring the implementation of the handbook clearly illustrated the troubles VA was experiencing implementing the handbook and many of the OIG reports showed VA to be behind schedule in their ‘implementation processes,’ however VA officials repeatedly told congress they would meet the September 30, 2009 deadline. To date the handbook remains partially implemented. AMVETS believes VA and congress must start taking a more proactive approach in ensuring our veterans are receiving all the necessary mental health care. Until we stop taking a “reactionary” approach to bettering the VA system of mental health we are destined to be playing “catch up” in meeting the needs of today’s returning war fighters.
AMVETS must stress the urgency of the handbooks implementation. According to VA, the needs of OIF/OEF/OND veterans for mental health services are even greater, with almost 45 percent having been evaluated for, or having received, a possible diagnosis of a mental health disorder. Another recent study by the American Council on Disabilities found that 30 to 45 percent of all service members returning from Iraq and Afghanistan have been clinically diagnosed with PTSD, depression, TBI and/or dual diagnosis’s of these illnesses and injuries.AMVETS notes that there are still many of returning service members who have not yet sought treatment for their psychological wounds, skewing the aforesaid numbers. AMVETS also stresses the urgency of plan completion by recommending a more attentive oversight process, and an empowered organizational structure to inform that oversight accountability.
Another important part of bridging the gap within VA’s mental health care that needs to be addressed involves the services available to members of the National Guard and Reserve. The suicides rates among this population continues to rise at a rate this country has never seen. AMVETS believes this can be partially attributed to the lack of services available to this group of servicemembers. On June 6, 2010 the Walter Reed Army Institute of Research released the findings of their first study. The study focused on the mental health and functional impairments of returning National Guardsmen and the progression of symptoms over time. The study outlined statistics on PTSD, depression and other psychiatric, and some physical, diagnosis’. It is important to note that this study was conducted through self reporting and two mailed surveys. These surveys were distributed to 18,305, composed of Iraq war veterans from four different units and two National Guard infantry brigade combat teams. Part of this study reported up to 14 percent of returning servicemembers suffer at least one symptom of PTSD. The symptoms studied ranged from nightmares to physical violence. The study went on to explain the strictest definition, defined as high incidence rates and serious impairment of normal functioning, found a PTSD rate of between 5.6 percent and 11.3 percent, with depression ranging from 5 to 8.5 percent. Those numbers affirm many past studies on PTSD and depression prevalence among returning servicemembers. We all agree that mending our servicemembers psychological wounds is just as important as mending the physical ones. In contrast we obviously do not all agree on the most effective and responsible way of reporting and educating the public and the DoD communities.
The Army National guard had the highest rate of suicide among the service branches in 2010.
Using the National Guard as an operational force in the Global War on Terror will require a more accessible mental health program for servicemembers, veterans and their families post deployment in order both to provide the care they deserve as veterans and to maintain the necessary medical readiness required by current deployment cycles. Members of the National Guard, Reserve and their families rely heavily on VA for mental health care services and resources post deployment. In 2009, congress recognized this need through the passing of “The Caregivers and Veterans Omnibus Health Services Act of 2009”, now known as Public Law111-163, enacted May 6, 2010. P.L. 111-163 requires VA to provide enhanced mental health services to veterans and their immediate family members. Unfortunately, distressing developments have emerged since the passage of P.L. 111-163. One of these developments is VA’s failure to implement Section 304 of P.L. 111-163. Section 304 requires VA, no later than 180 days after its passage or by November 6, 2010, to establish a program that provides mental health services to the Guard and Reserve members under VA care, as well as to the immediate family members of veterans of Operation Enduring Freedom and Operation Iraqi Freedom. To date VA has failed to implement the program as required by P.L. 111-163. AMVETS and other member organizations within the VSO/MSO community fear VA has no intention to implement P.L. 111-163, Section 304, beyond allowing the Vet Centers to continue to provide counseling to families of qualified veterans. Unfortunately, Vet Center counseling, even though very good, do not provide the full range of mental health services veterans or their immediate family members may need.
Furthermore, VA is required by P.L. 111-163, Section 304 to contract out with private entities in rural communities to bridge the geographical barriers preventing many of our veterans and their families from receiving mental health treatment and care. AMVETS requests this Committee to closely monitor the implementation of Section 304, which to date has not occurred. It has been clearly illustrated through VA’s numerous actions, and lack thereof, that only the strictest of oversight by congress will ensure the proper and timely implementation of P.L. 111-163.
Our National Guard and Reserve veterans of OIF/OEF/OND for the most part are still serving with their units and are still subject to deployment. It is an historical anomaly for VA to be caring for veterans still subject to redeployment. To create a seamless medical transition from active duty to VA and then back to active duty, will require improved medical screenings of these men and women before their initial release from DoD. AMVETS believes it will be essential for DoD and VA to have a clearer system of communication if they wish to properly identify the medical issues requiring care and to avoid redeploying servicemembers who should stay state side for treatment of psychological wounds. AMVETS believes DoD needs to responsibly share the cost with VA in funding mental health care for our National Guard and Reserve members between deployments, which to date remains an unmet readiness need.
It is imperative for DoD to ensure at the end of every deployment all returning servicemembers be examined confidentially at their home station or base by qualified mental health care provider. This would help correct the under reporting of psychological health symptoms on “Post Deployment Health Assessment” (PDHA) forms, which are currently being processed either in theater or at demobilization sites which in most cases are far removed from home. The PDHA is a self assessment questionnaire given to returning servicemembers and is subject to the instruction that reporting a serious medical condition may result in the servicemember being medically held on active duty at the demobilization site far from home or medically discharged. These brave men and women would rather suppress any psychological wound before they ever let their units deploy without them. Moreover, rather than risk being retained on active duty and further separated from their families, many members of the Guard and Reserve are not reporting or are under reporting their psychological wounds on the PDHA in order to return home as soon as possible and to avoid being medically discharged. As a consequence, unreported psychological health symptoms that are best treated expeditiously are going untreated because they are not being captured at this earliest post deployment opportunity. This under reporting of service connected injuries not only delays VA treatment but could also prejudice later VA disability claims filed by transitioning servicemembers. Prior inconsistent medical statements can have a very negative impact on subsequent VA disability claims as well. Furthermore, AMVETS believes VA must implement a stronger mental health screening process for all newly enrolled veterans. This will assist VA in identifying veterans with mental health issues that may have slipped through the cracks at DoD. AMVETS also strongly recommends immediate, joint VA and DoD, development and implementation of stronger post deployment and transition mental health assessments in order to identify and treat these wounds at their start, rather than later when these untreated wounds have been amplified by more deployments or simply by being allowed to fester over time without the necessary medical treatment. If VA and DoD want to stop the avoidable trend of increased suicides among those under their care they need to take a more proactive approach to treatment. As the increasing suicide rates among our veteran and military communities has shown us, “reactionary” care models to do work.
At all stages of PTSD and depression, treatment is time sensitive but this is particularly so after onset as the illness could persist for a lifetime if not promptly and adequately treated and could render the member permanently disabled. The effects of this permanent disability on the member’s entire family can be devastating. AMVETS believes it is absolutely imperative that all servicemembers returning from deployment be screened with full confidentiality, while still on active duty by trained and qualified mental health care providers from VA staff and/or qualified health care providers from the civilian community when the demand exceeds the resources DoD and VA can provide. Prompt diagnosis and treatment will help to mitigate the lasting effects of these psychological wounds. Furthermore, AMVETS believes DoD and VA must do a better job in removing the fear and stigmas associated with seeking care for mental health issues. AMVETS believes admitting you need assistance and actively seeking out the necessary resources shows a person to have great resiliency, strength and determination in wanting to better their life.
AMVETS believes inadequate medical screenings of our servicemembers before they are released from active duty is unacceptable for a group that has selflessly sacrificed for our country. This is just as true for those seeking the care and resources of VA after their release from DoD. Given the enormous number of this nation’s returning war fighters who have sustained a psychological wound during their service; AMVETS believes it is time to stop this vicious cycle of reactionary care that has caused us to have the bury veterans who suffered in silence for so long they felt the only way out was to take their own life since they whole heartedly believed they were an unnecessary burden to their families or communities any longer. AMVETS strongly believes that the men and women who have selflessly sacrificed to serve this nation deserve much more than we are currently offering.
Chairman Miller, Ranking Member Filner and distinguished members of the committee, AMVETS again thanks you for inviting us to share our concerns and recommendations regarding this critical issue. This concludes my testimony and I stand ready to address any questions you may have for me.
 VHA Office of Public Health and Environmental Hazards. Washington (DC): Department of Veterans Affairs; 2009. Analysis of VA health care utilization among U.S. Global War of Terrorism (GWOT) veterans [Internet] [cited 2010 Apr 28].
 Strasburger LH, Gutheil TG , Brodsky A. On wearing two hats: Role conflict in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448-56. [PMID: 9090330].
 (Rosen MI. Compensation examinations for PTSD-An opportunity for treatment? J Rehabil Res Dev. 2010; 47(5):xv-xxii.
 Marc I. Rosen (Department of ~Psychiatry, VA Connecticut Healthcare System, West Haven, CT 2010 Mar 18.
 P.L. 111-163, SEC. 304. PROGRAM ON READJUSTMENT AND MENTAL HEALTH CARE SERVICES FOR VETERANS WHO SERVED IN OPERATION ENDURING FREEDOM AND OPERATION IRAQI FREEDOM.
(a) Program Required- Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall establish a program to provide—
(1) to veterans of Operation Enduring Freedom and Operation Iraqi Freedom, particularly veterans who served in such operations while in the National Guard and the Reserves—
(A) peer outreach services;
(B) peer support services;
(C) readjustment counseling and services described in section 1712(A) of title 38, United States Code; and
(D) mental health services; and
(2) to members of the immediate family of veterans described in paragraph (1), during the 3-year period beginning on the date of the return of such veterans from deployment in Operation Enduring Freedom or Operation Iraqi Freedom, education, support, counseling, and mental health services to assist in--
(A) the readjustment of such veterans to civilian life;
(B) in the case such veterans have an injury or illness incurred during such deployment, the recovery of such veterans from such injury or illness; and
(C) the readjustment of the family following the return of such veterans.
(b) Contracts With Community Mental Health Centers and Other Qualified Entities- In carrying out the program required by subsection (a), the Secretary may contract with community mental health centers and other qualified entities to provide the services required by such subsection only in areas the Secretary determines are not adequately served by other health care facilities or vet centers of the Department of Veterans Affairs. Such contracts shall require each contracting community health center or entity--
(1) to the extent practicable, to use telehealth services for the delivery of services required by subsection (a);
(2) to the extent practicable, to employ veterans trained under subsection (c) in the provision of services covered by that subsection;
(3) to participate in the training program conducted in accordance with subsection (d);
(4) to comply with applicable protocols of the Department before incurring any liability on behalf of the Department for the provision of services required by subsection (a);
(5) for each veteran for whom a community mental health center or other qualified entity provides mental health services under such contract, to provide the Department with such clinical summary information as the Secretary shall require;
(6) to submit annual reports to the Secretary containing, with respect to the program required by subsection (a) and for the last full calendar year ending before the submittal of such report--
(A) the number of the veterans served, veterans diagnosed, and courses of treatment provided to veterans as part of the program required by subsection (a); and
(B) demographic information for such services, diagnoses, and courses of treatment; and
(7) to meet such other requirements as the Secretary shall require.
(c) Training of Veterans for Provision of Peer-outreach and Peer-support Services- In carrying out the program required by subsection (a), the Secretary shall contract with a national not-for-profit mental health organization to carry out a national program of training for veterans described in subsection (a) to provide the services described in subparagraphs (A) and (B) of paragraph (1) of such subsection.
(d) Training of Clinicians for Provision of Services- The Secretary shall conduct a training program for clinicians of community mental health centers or entities that have contracts with the Secretary under subsection (b) to ensure that such clinicians can provide the services required by subsection (a) in a manner that--
(1) recognizes factors that are unique to the experience of veterans who served on active duty in Operation Enduring Freedom or Operation Iraqi Freedom (including their combat and military training experiences); and
(2) uses best practices and technologies.
(e) Vet Center Defined- In this section, the term `vet center' means a center for readjustment counseling and related mental health services for veterans under section 1712A of title 38, United States Code.
June 10, 2011
The Honorable Jeff Miller, Chairman
Subcommittee on Disability Assistance and Memorial Affairs
House Veterans Affairs Committee
335 Cannon House Office Building
Washington, D.C. 20510
Dear Chairman Miller:
Neither AMVETS nor I have received any federal grants or contracts, during this year or in the last two years, from any agency or program relevant to the June 14, 2011, full committee hearing on “Mental Health: Bridging the Gap Between Care and Compensation for Veterans.”
Christina M. Roof
National Acting Legislative Director