Adrian M. Atizado
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV), an organization of more than 1.3 million service-disabled veterans, to submit this testimony for the record of this hearing on posttraumatic stress disorder (PTSD) treatment and research. We appreciate the opportunity to offer our views on the Department of Veterans Affairs (VA) specialized programs for this condition.
Current research indicates combat veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans are at higher risk for the anxiety disorder PTSD and other mental health problems, including substance use disorder, as a result of, or consequent to, their military experiences. VA reports that veterans of these current wars have sought care for a wide range of possible medical and psychological conditions, including mental health conditions, such as adjustment disorder, anxiety, depression, PTSD, and the effects of substance abuse. Through January 2008, VA reported that of the 299,585 separated OEF/OIF veterans who have sought VA health care since fiscal year 2002, 40 percent, or a total of 120,049 unique patients, had been diagnosed with a possible mental health disorder. Nearly 60,000 of these enrolled OEF/OIF veterans had a probable diagnosis of PTSD, and 40,000 have been diagnosed with depression.
The increasing rate of OEF/OIF veterans seeking VA health care, and the emerging trends in health care utilization of this group drive the need to ensure access to, and make available, robust services for: depression; stress and anxiety reactions, including PTSD; individual or group counseling; specialized intensive outpatient treatment for severe PTSD—including cognitive behavioral best practices; services for relationship problems (including marital and family counseling); psychopharmacology services; and, substance-use disorder interventions and treatment, including initial assessment and referral, brief intervention and/or motivational counseling, traditional outpatient counseling and intensive outpatient substance-use disorder care.
In its 2001 report, “Crossing the Quality Chasm: A New Health Care System for the 21st Century,” the Institute of Medicine (IOM) put forward six aims that now underpin the standard of care for U.S. medical care providers. The IOM aims that health care will be safe (avoiding errors and injury), effective (based on the best scientific knowledge), patient-centered (respectful of, and responsive to patient preferences, needs and values), timely (reduced waiting time and harmful delay), efficient (avoiding waste), and equitable (unvarying, based on race, ethnicity, gender, geography, or socioeconomic status).
VA has embraced these aims and consistent with them, VA’s offices of Health Services Research and Development and Rehabilitation Research and Development are focusing on a number of important areas including PTSD. The complex and unique injuries sustained by troops serving in Iraq and Afghanistan have created the need for new research and treatment strategies focused on addressing the unique needs of the newest generation of combat disabled veterans. Furthermore, because of VA’s long history in providing effective readjustment counseling services that are culturally sensitive to veterans and their unique military combat experiences, unquestionably VA is the optimum source for readjustment services for our newest veterans. VA provides the range of post-deployment mental health services veterans from current and previous wars may require, and provides services that are evidence-based which integrates the best research evidence, clinical expertise and patient needs.
Though clinical practice guidelines initially evolved in response to studies demonstrating significant variations in risk-adjusted practice patterns and costs, VHA has embraced the use of evidence-based clinical practice guidelines as one strategy to improve care by reducing variation in practice and systematizing “best practices.” Like any other tool in medical care, these guidelines set out to improve the processes of care for patient cohorts, to reduce errors, and provide more consistent quality of care and utilization of resources throughout the system. Researchers had correctly hypothesized that establishing criteria for the appropriate use of procedures and services might decrease inappropriate utilization and improve care outcomes. Since guidelines also are cornerstones for accountability, and facilitate learning and the conduct of further research, they are subject to continual review and necessary revisions.
While clinical practice guidelines have been developed since the early 1990’s, the VA took the important step to promote the use of evidence-based approaches by initiating development of a joint VA-Department of Defense (DoD) Practice Guideline for Management of PTSD. The guideline advocates application of a variety of evidence-based practices for treatment of veterans with PTSD. In addition, the National Center for PTSD (NCPTSD) in collaboration with Walter Reed Army Medical Center (WRAMC), developed an Iraq War Clinician Guide (now in its second edition), to guide treatment of returning personnel with PTSD, and generally better prepare VA mental health providers to receive and effectively treat returning veterans.
Despite the clear articulation of best practices in the PTSD clinical practice guideline and the Iraq War Clinician Guide, many of the recommended practices are not widely implemented in the VA health care system. Staff awareness about PTSD and efficacious treatments, knowledge and skill deficits, clinician attitudes, and institutional barriers all prevent widespread dissemination of recommended practices. DAV has, and will continue to call for improvements to better disseminate the information in the field to increase awareness, ability and knowledge, in addition to decreasing both clinical and institutional barriers, to implementing these guidelines.
The aforementioned limitations notwithstanding, DoD and VA share a unique obligation to meet the mental health care and rehabilitation needs of veterans who are suffering from readjustment difficulties as a result of combat service. Both agencies need to ensure that appropriate research is conducted and that federal mental health programs are adapted to meet the unique needs of the newest generation of combat service personnel and veterans, while continuing to address the needs of older veterans with substance abuse problems, PTSD, other combat-related readjustment issues, and other mental health challenges. Congress must remain vigilant to ensure that research and treatment programs are authorized and sufficiently funded to ensure these needs are met.
In our October 2007 testimony before this Subcommittee, the DAV urged VA to continue research that is veteran-centered and specifically focused on rehabilitation of veterans with physical and cognitive impairments related to military service, and to establish studies to identify and promote effective and efficient strategies to improve the delivery of health-care to veterans. We believe these research priorities should include:
- A study to objectively and systematically measure the expectations of OEF/OIF veterans to help VA better serve this population. These veterans are younger, have family and community support systems in place, and are frequently dealing with complicated post-service readjustment, employment, education and other issues. VA should conduct health services and other research to identify services to meet their mental health needs.
Studies to address access issues for this new population including tracking of OEF/OIF veterans to learn what services they utilize. VA should also examine barriers to care, especially those that relate to attitudes of veterans and their families toward being treated in the VA, and any breakdown in access this may cause.
VA should quickly disseminate and deploy resources to make evidence-based PTSD treatment easily accessible. In particular, for women veterans across the country, and explore options for providing child care for those needing it to enable them to achieve access to treatment.
VA should conduct research to fully understand the dual burden of military sexual trauma and combat-related PTSD, and develop the best treatment practices and programs for this population.
DoD should fund a prospective, population and gender-based health study of veterans who served in OEF/OIF. An epidemiologic study with at least a ten-year follow-up period is needed. This study should be carried out by DoD, VA and academic researchers in a collaborative manner.
Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
As this Subcommittee is aware, VA contracted with IOM to study the ramifications of PTSD in the veteran population. IOM established three Committees to address the various aspects of PTSD: a Committee on PTSD Diagnosis and Assessment which submitted its report in June 2006; a Committee on Compensation for PTSD which submitted its report on May 08, 2007; and a Committee on PTSD Diagnosis and Treatment which submitted its report on October 17, 2007.
Based on a review of literature on best treatment practices, types and timing of specific interventions, and comment on the prognosis of individuals diagnosed with PTSD (including co-morbidities), the most recent IOM report indicates few studies have been conducted on the efficacy of treatments for veterans suffering from PTSD. In addition, no conclusion could be made about most treatment modalities, save exposure therapy.
The report reveals most of the evidence supporting the use of medications and psychological therapies for PTSD is supported by evidence compiled by researchers with conflicts of interest in the outcome of the studies or funded by pharmaceutical companies that make the drugs used in the therapies. In addition, the report could not highlight evidence showing any medication such as Selective Serotonin Reuptake Inhibitors (SSRIs) were effective in treating PTSD. There was insufficient evidence to determine the value of early intervention and an optimal length or treatment. Moreover, there was insufficient evidence to support the use of a range of psychotherapies known as cognitive restructuring, coping skills training, eye-movement desensitization and reprocessing therapy, and group therapy.
With formidable challenges in conducting high quality research, the report suggests many studies had design or methodological flaws, inadequate control for confounders, high dropout rates of 20 to 50 percent, and possible conflicts of interest among researchers. Additionally, discussion during the committee meeting noted that the diagnosis of PTSD itself has a high degree of overlap with other conditions, and therefore efforts to determine efficacy of therapies may suffer from a lack of specificity. We note however, that despite using a high threshold for inclusion and evaluation of PTSD treatment studies into this IOM report, it underscores the need for rigorous studies of all treatment modalities that will address major limitations of available research in finding optimal PTSD treatment when judged against contemporary standards. Moreover, the fact that the committee found literature that met the reliability requirement to determine efficacy, means it is wholly within the realm of possibility for VA or others to conduct research that will allow a more definitive assessment of the effectiveness of PTSD treatment modalities.
While clinical trials take years to plan, conduct, and complete, and well-designed randomized clinical trials are costly in both time and resources, treatment still must be provided, and the DAV is concerned if the effectiveness of available treatment is questionable, some veteran patients may become frustrated and discontinue seeking VA mental health services. For example, the IOM committee report noted that while there were more clinical trials of SSRIs than of other drugs, outcomes were split in the seven most useful studies. The largest study fossil showed no improvement in primary PTSD outcomes and saw many patients drop out. The American Psychiatric Association's Clinical Practice Guideline for the Assessment and Treatment of Patients with Acute Stress Disorder and PTSD and VA’s National Center for Posttraumatic Stress Disorder recommends SSRIs. SSRIs are a class of antidepressants used in the treatment of anxiety disorders and depression as first-line medications for PTSD pharmacotherapy in veterans suffering from PTSD.
The DAV believes that this report should be used as a guide to facilitate high quality research and not decrease access or treatment options. Particularly since this IOM report is the third in a series requested by VA asking for guidance in diagnosing, treating, and assessing disability in veterans with PTSD, and that the report indicates research gaps in regard to special veteran populations.
In light of the October 2007 IOM report, we applaud VA’s actions regarding the efficacy of exposure therapy by initiating training of VA mental health providers in the use of exposure-based therapies, starting with cognitive and most recently including prolonged exposure therapy. In addition, VA had announced plans for a “consensus conference” with DoD and National Institutes of Health to exchange knowledge and work toward shared state-of-the art approaches for research in PTSD. In the interim, VA staff has been directed to work with DoD to evaluate early interventions such as the Army’s “BATTLEMIND” training and the “Marine Operational Stress Surveillance and Training Program,” designed to help combat troops transition back to non-deployed civilian status.
The DAV is a strong advocate and believer of research as it provides the evidence base for effective treatment for veterans. We urge this Subcommittee to continue to conduct regular oversight on the entities charged with conducting research to ensure a comprehensive high quality evidence base for the veteran population suffering from PTSD and its effect on the improvement of PTSD treatment.
The Recovery Model
As part of a larger social movement of self-determination and empowerment, the recovery movement calls for a fundamental transformation of the mental health care delivery system to one that is evidence based, recovery focused, and consumer and family driven, and where recovery from mental illnesses and emotional disturbances should be the common and recognized outcome of mental health services.,, These changes were prompted in the President’s New Freedom Commission on Mental Health, in its report entitled “Achieving the Promise: Transforming Mental Health Care in America.”
The resulting December 1, 2003, VA Action Agenda, “Achieving the Promise: Transforming Mental Health Care in the VA,” involves 82 system-wide changes and includes a number of recommendations to successfully adopt the recovery model in VA mental health programs nationwide. Some of those recommendations include educating VA staff on recovery, developing a strategic plan for mental health research that supports VA recovery-based mental health care, initiating a national Recovery and Rehabilitation Task Force, developing a manual on establishing a peer-support program, providing supported employment programs to promote recovery and the ability of veterans to live productively in the community, and promoting the integration of mental health into primary care services.
The VA Mental Health Strategic Plan Workgroup developed a five-year strategic plan to eliminate deficiencies and gaps in the availability and adequacy of mental health services that VA provides across the nation. The plan includes a number of action items that build on the recommendations of the President’s Commission and the VA Secretary’s Mental Health Taskforce recommendations.
As with other public health systems that are implementing pilot projects in several states to transform their mental health systems to emphasize the recovery model, concerns have been raised with respect to the VA mental health delivery system. There is a general concern over the use of the evidence-based medical model, which involves the elimination or reduction of symptoms and return to pre-morbid levels of function, and the recovery model, which, “enables a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” Although both the medical and recovery models can influence what treatments are provided, the recovery model emphasizes how the treatment is provided. Having a greater emphasis placed on peer support and personal experience has the potential to be a source of conflict particularly in a paternalistic health care model. Moreover, the inclusion of caregivers and family members as partners in treatment planning for the veteran is a necessity in the recovery model and current VA authority may prove to be insufficient for successful implementation throughout the continuum of VA mental health services.
We are aware of, and applaud VA for actively promoting the recruitment of peers as mental health service providers, and hiring over 3,700 of the 4,347 authorized new mental health professionals since the beginning of implementation in 2005, for providing program funding to integrate mental health and primary care in over 100 sites, and for large-scale training for VA providers on the delivery of evidence-based psychotherapies. However, this new emphasis of recovery and the requirements needed to reach its goals require additional resources, equipment, and space. For example, in fiscal year 2007, $347 million was transferred from Medical Services to Medical Facilities to increase infrastructure capacity through three initiatives: $58 million for appropriate clinic space; $130 million for additional leased space and equipment for VA medical centers, Community Based Outpatient Clinics (CBOCs) and nursing homes; $159 million for non-recurring maintenance projects to provide a safer environment.
Additionally, VA recovery programs have had difficulty becoming established and program managers have not made consistent efforts to involve veterans and family members locally. In order for VA to fully adopt the recovery model, it is imperative that its mental health care system be patient- and family-driven in addition to being focused on recovery. Despite some progress as reported earlier in this testimony, the current level of effort and provision of PTSD treatment remain challenging.
In closing, the DAV urges Congress to ensure that veterans’ needs for quality mental health care are met, so that the promise of recovery can be achieved. Moreover, we encourage this Subcommittee to continue conducting regular oversight on the progress of VA’s Mental Health Strategic Plan and the 2003 VA Action Agenda to ensure that your expectations about effective treatment and recovery are met.
Mr. Chairman, this concludes our statement and we appreciate the opportunity to express our views on this important topic.
 2,771 indentified but narrowed down to 90 studies that were either randomized controlled trials, placebo-controlled pharmacotherapy trials, or controlled psychotherapy trials. Chosen studies met the criteria for Level-1 evidence in accordance with evidence-based medicine standards.
 Nat’l Recovery Consensus Statement: http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/
 SAMHSA’s Nat’l Transformation Agenda: http://www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx
 Surgeon General’s M.H. Report: http://www.surgeongeneral.gov/library/mentalhealth/home.html#preface
 Substance Abuse and Mental Health Services Administration. National Consensus Conference on Mental Health Recovery and Systems Transformation .