ANTONETTE ZEISS, PH.D.
DEPUTY CHIEF CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES
DEPARTMENT OF VETERANS AFFAIRS
HOUSE COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
May 24, 2007
Mr. Chairman and members of the committee, I am pleased to be here today to discuss the ongoing steps that the Department of Veterans Affairs ( VA) is taking in order to meet the mental health care needs of our Nation's veterans. I am accompanied by Dr. Alfonso Batres, Director of Veterans Readjustment Counseling. I would like to take this opportunity to describe a general overview of the mental health services provided by VA. VA has devoted resources to develop appropriate programs, and closely follow emerging evidence to refine our understanding and program-development for these retuning veterans.
Overview of Mental Health Care in Medical Facilities
VA provides mental health services to veterans in all our medical facility patient care settings. I will provide an overview of all these services, since returning veterans will need this full array of VA services, and I will focus more specifically on some newly developed programs for our returning veterans.
Mental health services are provided in specialty mental health settings in all medical facilities, including inpatient, outpatient, and substance abuse care. VA also provides services for homeless veterans, including transitional housing paired with services to address the social, vocational, and mental health problems that contributed to becoming homeless. In addition, mental health care is being integrated into primary care clinics, community-based outpatient clinics, VA nursing homes, and residential care facilities. Veterans with PTSD are served by mental health professionals with specialized expertise in all medical facilities, and VA has inpatient and residential rehabilitation options across the country. Veterans with a serious mental illness are seen in specialized programs, such as mental health intensive case management, psychosocial rehabilitation and recovery day programs and work programs. VA employs full and part time psychiatrists and full and part time psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of mental health services for veterans. The numbers of these mental health professionals have been growing steadily in the last two and a half years as a result of focused efforts to build mental health staff and programs. Appropriate attention to the physical and mental health needs of veterans will have a positive impact on their successful re-integration into the U.S. economy and society as a whole. Accurate VA projections for staffing needs and funding costs will ensure ready access to adequate and timely mental health and social services.
We have seen that many returning veterans have injuries of the mind and spirit as well as the body. For veterans of prior eras, we have learned that mental disorders can increase the risk for certain physical illnesses, and vice versa. In addition, current returning veterans experience events that result in both physical and emotional injuries. Our goal is to treat a veteran as a whole patient - to treat a patient's physical illnesses as well as any mental disorders he or she may be facing.
Access To Mental Health Services Through Vet Centers
In addition to the care described in medical facilities and their related CBOCs, VA's Vet Centers provide counseling and readjustment services to returning war veterans. It is now well established that rehabilitation for war-related PTSD and other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA's continuum of health care programs specific to the needs of veterans. The Vet Center service mission goes beyond medical care in providing a holistic mix of services designed to treat the veteran as a whole person in his/her community setting. Vet Centers provide an alternative to traditional access for mental health care some veterans may be reluctant to access in our medical centers and clinics. Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers.
VA will be expanding the number of Vet Centers from 209 to 232 over the next two years. Some Vet Centers have established telehealth linkages with VA medical centers that extend VA mental health service delivery to remote areas to underserved veteran populations, including Native Americans on reservations at some sites. Vet Centers also offer telehealth services to expand the reach to an even broader audience. Vet Centers address the psychological and social readjustment and rehabilitation process for veterans and support ongoing enhancements under the VA Mental Health Strategic Plan.
Vet Centers provided readjustment counseling services to over 228,000 all-era combat veterans in Fiscal Year 2006 and, of these, over 127,000 veterans were provided substantial face to face counseling services, and over 101,000 veterans were seen on outreach. The Vet Centers provided over one million visits to veterans in Fiscal Year 2006.
The Vet Center program addresses the veteran's full range of needs within the family and community. The service functions provided to veterans by the Vet Center program are as follows:
Since 2003, the Vet Centers also provide bereavement services to surviving family members of service men and women killed while serving on active duty. The Vet Center strategy is to intervene early to facilitate a successful post-war readjustment in a safe and confidential setting. The bereavement program has seen over 1,200 family members of over 900 fallen warriors most of whom were killed in action in Operation Enduring Freedom/Operation Iraqi Freedom ( OEF / OIF ).
OEF/ OIF Veterans
Care for OEF/ OIF veterans is among the highest priorities in VA's mental health care system. For these veterans, VA has the opportunity to apply what has been learned through research and clinical experience about the diagnosis and treatment of mental health conditions to intervene early; and to work to prevent the chronic or persistent courses of illnesses that have occurred in veterans of prior eras.
In response to the growing numbers of veterans returning from combat in OEF/ OIF, the Vet Centers initiated an aggressive outreach campaign to welcome home and educate returning service members at military demobilization and National Guard and Reserve sites. Through its community outreach and brokering efforts, the Vet Center program also provides many veterans the means of access to other Veterans Health Administration ( VHA) and Veterans Benefits Administration programs. To augment this effort, the Vet Center program recruited and hired 100 OEF/ OIF veterans to provide the bulk of this outreach to their fellow veterans.
Medical facility programs also have been established to do "inreach" to OEF/ OIF veterans and provide education, support, and mental health specialty services when needed. These programs are established in most facilities, beginning with sites that had the highest rates of returning veterans, and continue to be expanded each year. In addition, we have placed mental health specialists in all four of the initial national Polytrauma Centers and now in the 21 VISN Polytrauma programs. We recently funded a Transitional Housing program for veterans who have needed polytrauma care, with mental health staff fully represented. Throughout VHA, there is a sense of urgency about reaching out to OEF/ OIF veterans, engaging them in care, screening them for mental health conditions, and making diagnoses when appropriate.
Since the start of OEF/ OIF through the end of the first quarter of FY 2007, 686,306 service members have been discharged and become eligible for VA care. Of those, 229,015 (33%) have sought VA care. Of those that have sought care (33%), mental health problems are the second most common, with 37 percent (83,889) reporting concerns that lead to a mental health diagnosis or indicate that one is possible and should be further evaluated.
While VA must be attentive to PTSD, we also must ensure that evaluation is comprehensive and attentive to mental health problems generally, so that we can provide the best evaluation, diagnosis, and treatment for returning veterans. Of those reporting a possible mental health concern, Post Traumatic Stress Disorder ( PTSD) was most frequently implicated (39,243), with Nondependent Abuse of Drugs (33,099), and Depressive Disorders (27,023) the next most commonly suggested problems.
In addition, VA is aware that the proportion of new veterans seeking VA care who are identified as having a possible mental health problem has climbed over the years. For example, the proportion with mental health concerns in the report at the end of FY 2005 was 31 percent, compared to 37 percent in the most recent report. There are many possible explanations of this finding including: extended deployments, more difficult circumstances, and positive impact of efforts to destigmatize the seeking of mental health services. Regardless of the causes, VA is aware that there is an increasing demand for mental health-related services. VA is prepared to devote increasing resources to serving these growing mental health needs. The utilization pattern for war veterans from other eras indicates that these veterans will require sustained services and will increase in numbers over time.
Since the beginning of hostilities in Afghanistan and Iraq, the Vet Centers have seen over 165,000 OEF/ OIF veterans, of which almost 116,000 were outreach contacts seen primarily in group settings at military demobilization and National Guard and Reserve sites. A similar outreach program conducted during the first Gulf War received the commendation of the President's Advisory Committee on Gulf War Veterans' Illnesses.
Mental Health Strategic Plan and the Mental Health Initiative
VHA completed its Comprehensive Mental Health Strategic Plan ( MHSP) in 2004 and began implementation in spring 2005. Our strategic plan reinforces that mental health is an important part of veterans' overall health. VA is committed to eliminating barriers separating mental health from the rest of health care. The plan also recognizes the needs of our returning OEF/ OIF veterans.
The Mental Health Initiative was established to provide funding to support the implementation of the MHSP outside of the Veterans Equitable Resource Allocation (VERA) model. To assist in planning the funding for the Mental Health Initiative, the MHSP was divided into four key areas-(1) enhancing capacity and access for mental health services; (2) integrating mental health and primary care; (3) transforming mental health specialty care to emphasize recovery and rehabilitation; and (4) implementation of evidence-based care. There are multiple funded programs in each of these areas. We have improved capacity and access in numerous ways, supporting hiring of new mental health professionals throughout the system. Moreover, we have expanded mental health services in Community Based Outreach Clinics either with on-site staffing or by telemental health, thus providing care closer to the homes of veterans in rural areas. We also have enhanced both PTSD and substance abuse specialty care services, and programs that recognize the common co-occurrence of these problems. We are fostering the integration of mental health and primary care by funding evidence-based programs in over 80 sites, with more being planning stages, as well as through the already-mentioned placement of mental health staff in CBOCs. In addition, we are extending this principle to the care of home-bound veterans by funding mental health positions in Home Based Primary Care. This program has traditionally served older veterans, but current needs show that it also will serve some seriously wounded OEF/ OIF veterans. It can allow veterans to live at home, with their families, as an alternative to institutional long-term care, when injuries are profound and sustained rehabilitation and other care is needed. The mental health professionals who will work with these teams also can support the family caregivers, who provide heroic care for injured veterans.
VA will be working to emphasize recovery and rehabilitation in specialty mental health services by funding additional psychosocial rehabilitation programs, expanding residential rehabilitation services, increasing the number of beds and the degree of coordination in homeless programs, extending Mental Health Intensive Case Management, and funding a recovery coordinator in each medical center.
Post Traumatic Stress Disorder
VA's approach to PTSD is to promote early recognition of this condition for those who meet formal criteria for diagnosis and those with partial symptoms. The goal is to make evidence-based treatments available early to prevent chronicity and lasting impairment. Screening veterans for PTSD is a vital first step towards helping veterans become resilient and recover from the psychological wounds of war. Veterans are screened on a routine basis through contact in Primary Care Clinics. In instances when there is a positive screen, patients are further evaluated and referred to a mental health provider for further follow-up, as necessary.
If a veteran first enters the system through a clinical program other than primary care, screening for PTSD will be done in that setting. In addition, screening occurs for depression, substance abuse, and military sexual trauma. Recently, screening for Traumatic Brain Injury ( TBI) became a standard component of VA's screening. While TBI is not a mental health problem, it has many intersections with mental health problems and its recognition is an essential component of holistic care.
Screening is only valuable if the system is set up to note positive screens and conduct timely follow-up of them. When the follow-up reveals there is a likely diagnosis, or early signs that a veteran is having increasing mental health problems, timely treatment for those problems is necessary. VA has the capacity to provide screening, evaluation of positive screens, and appropriate treatment. As we continue to implement the Mental Health Strategic Plan, which has guided the efforts described, and continue to benefit from the funding available in the Mental Health Enhancement Initiative, our capacity will continue to grow, to enable us to continue serving a growing number of returning veterans.
In providing follow-up, we have outpatient and inpatient programs available (a total of over 220 programs and more in development). We have extensive training efforts in a variety of different approaches including Cognitive Processing Therapy and Prolonged Exposure Therapy. We are partnering with the Department of Defense ( DoD) to make these training opportunities available to DoD mental health staff.
Medications can be an effective component of care for PTSD, but have not been shown to have the same level of effectiveness in both alleviating symptoms and restoring function and performance. Our integrated care system allows coordination of effective psychotherapy with needed medication supports.
Sometimes mild to moderate PTSD symptoms, without a full diagnosis, represent normal reactions to highly abnormal situations. Many returning veterans will recover without treatment, with support from their families, communities, and employers. In fact, what is most striking about our service members and veterans is not their vulnerability, but their resilience. When people prefer treatment, we encourage it. When they are reluctant, we watch them over time, and urge treatment if symptoms persist or worsen.
Suicide prevention is a major priority for VA and we are on the watch for suicide among our veterans. Research about suicides among OEF/ OIF returnees is currently under way to teach us more about how to address the issues surrounding this tragic event.
VA also set aside our first Suicide Prevention Awareness Day, which fell on March 1, 2007 this year. We plan on this becoming an annual event. During our first Suicide Prevention Awareness Day, VA staff members who come in contact with patients received training on how to assess and respond to crisis situations. Our goal is to make the point that in VA, suicide prevention is everyone's business-not just that of our mental health providers-everyone who comes into contact with our veterans and their families plays an important role.
The mental health needs of our veterans are as important as their physical needs. We acknowledge the need to reevaluate and improve the mental health care and services provided to our Nation's veterans and we are committed to ensuring that VA provides the highest quality of care possible. Thank you again Mr. Chairman for having me here today. I will answer any questions that you or other members may have.