ROBERT H. ROSWELL, M.D.
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
U. S. HOUSE OF REPRESENTATIVES
March 11, 2004
Mr. Chairman and Members of the Subcommittee, I appreciate the opportunity to appear before you today to discuss the programs of the Department of Veterans Affairs (VA) for the care of veterans who may be suffering from posttraumatic stress disorder (PTSD) as a consequence of their exposure to the hardships of deployment and the rigors of combat.
Mr. Chairman, as you are no doubt aware PTSD is not a new condition. There are written accounts of similar symptoms that go back to ancient times, and there is suggestive evidence in the historical combat medical literature starting with the Civil War. PTSD has been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf populations, and in United Nations peacekeeping forces deployed to other war zones around the world.
Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the prevalence of PTSD in that group was 15.2 percent at that time, and that 30 percent had experienced the disorder at some point since returning from Vietnam. PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as eight percent. Therefore, it would be imprudent to underestimate the potential for appearance on PTSD in veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), particularly since the onset of PTSD symptoms may be delayed for months or even years following the associated stressful event. I believe that VA has the programs in place and is well prepared to meet the challenges this poses.
Mr. Chairman, on the basis of lists of separated OIF and OEF veterans received from DoD, we currently estimate that 13,580 OIF veterans and 1,798 OEF veterans have received health care from VA for a wide variety of health problems. Thus far, their health problems have been similar to those found in other young military populations seeking health care. Among OIF veterans, 1,927 have been seen for mental disorders, and among OEF veterans, 262 have been seen for mental disorders. For combined OIF/ OEF cohort of patients, 456 have been diagnosed with PTSD, 57 have received a diagnosis of acute stress disorder and 552 have been diagnosed as having depressive disorder. The Vet Centers have thus far served over 4,600 OIF and OEF veterans.
For returning service members who are experiencing emotional and behavioral problems, VA has mental health programs including the Readjustment Counseling program specifically developed to assess and address emotional and behavioral problems associated with the military experience. Within these mental health programs, VA operates a continuum of clinical care for posttraumatic stress disorder in its medical centers and clinics. This is accomplished both through general mental health clinics, through PTSD specialists in general mental health programs and through specialized PTSD programs. VA is recognized world wide as a leader in the treatment of PTSD.
VA medical centers provide a network of more than 100 specialized inpatient and outpatient programs for veterans with PTSD. Each specialized program offers veterans education, evaluation, and treatment conducted by mental-health professionals from a variety of disciplines, such as psychiatry, psychology, social work, counseling, and nursing. I am also pleased that Congress mandated additional funding of $25 million for mental health programs including PTSD programs in P. L. 108-170. We will allocate this funding this year to augment mental health and PTSD program capacity.
On February 3, 2004, the Vet Center program was funded to hire an additional 50 employees for a period of three years with the specific purpose of outreaching OEF, OIF and Global War on Terrorism (GWOT) veterans. Based upon the model of a similar initiative implemented in the wake of the Gulf War in 1991, the plan is to hire recently separated GWOT veterans into these temporary outreach positions. With this additional staff, Vet Center outreach will focus on providing information that will facilitate the early provision of VA services to new returning veterans and their family members immediately upon their separation from the military. These positions will be located on or near active military out-processing stations, as well as National Guard and Reserve facilities. Veteran temporary hires will augment Vet Center services in providing briefing services to transitioning servicemen/women regarding military-related readjustment needs, as well as the complete spectrum of VA services and benefits available to them and their family members. The briefings will outline the entire spectrum of VA services and will encourage these veterans to utilize their local Vet Center as the point of entry into VA. The new hires will also organize local community activities to provide information and education about VA, DOD, and other community support services available to veterans and family members.
A screening instrument in the form of a clinical reminder triggered by the veteran's separation date is being implemented for returning OIF and OEF veterans who come to VA for health care. This assessment tool will prompt the provider with specific screening requirements to assure that veterans are evaluated for medical and psychological conditions that may be related to recent combat deployment.
VA has developed clinical practice guidelines (CPGs) for treating veterans following deployment. These CPGs give health care providers the needed structure, clinical tools, and educational resources that allow them to diagnose and manage patients with deployment-related health concerns. Two post-deployment CPGs have been developed in collaboration with DoD, a general purpose post-deployment CPG and a CPG for unexplained fatigue and pain. On February 27, 2004, VA and DoD released a new CPG on the management of traumatic stress. This guideline pools DoD and VA expertise to help build a joint assessment and treatment infrastructure between the two systems in order to coordinate primary care and mental health care for the purpose of managing, and, if possible, preventing acute and chronic PTSD.
The Veterans Health Initiative (VHI) is a program designed to increase recognition of the connection between military service and certain health effects; better document veterans' military and exposure histories; improve patient care; and establish a database for further study. The education component of VHI prepares VA healthcare providers to better serve their patients. The VHI program includes a module on PTSD in Primary Care, is designed to increase recognition of PTSD in medical primary care settings. A module was created on “Treating War Wounded,” adapted from VHA satellite broadcasts in April 2003 and designed to assist VA clinicians in managing the clinical needs of returning wounded from the war in Iraq. Modules on spinal cord injury, cold injury, traumatic amputation, Agent Orange, the Gulf War, PTSD, POW, blindness/visual impairment and hearing loss, and radiation are also available. Training modules on infectious disease risks in Southwest Asia and on Weapons of Mass Destruction were released in January 2004. We are developing additional modules on military sexual trauma, traumatic brain injury, and pulmonary diseases of military occupational significance.
VA has developed training programs and clinical tools to ensure that our clinicians will be better able to identify and treat problems presented by the newest generation of combat veterans. To further aid VA employees in their efforts to assist OIF/OEF veterans, we have recently distributed a video entitled “Our Turn to Serve” to all VHA and VBA field facilities. The video helps VA staff better understand the experiences of military personnel serving in Operations Iraqi Freedom and Enduring Freedom and explains how they can provide the best possible service to these newest combat veterans. We have also provided copies of this video to Military Treatment Facilities. Additionally, we have created a web page for VA employees on the activities of the VA Seamless Transition Task Force. Included are lists of points of contact for all VHA health care facilities and VBA regional offices, copies of all applicable directives and policies, press releases, brochures, posters, Task Force minutes, and resource information.
VA’s National Center for PTSD, created in 1989 in response to a Congressional mandate to address the needs of veterans with service-connected PTSD, has also developed an Iraq War Clinician’s Guide. A website version, which can be found at WWW.NCPTSD.ORG, contains the latest fact sheets and available medical literature and is updated regularly. The first version of the Iraq War Guide was published in June 2003. It is now being revised in collaboration with DoD based on our experience with returning casualties. These important tools are integrated with other VA educational efforts to enable VA practitioners to arrive at a diagnosis more quickly and accurately and to provide more effective treatment.
VA’s Readjustment Counseling program plays a significant role complementing VA health care services with unique service functions not available elsewhere in VA. Our mental health clinical activities and Vet Centers are linked to assure coordination of services to our patients.
Readjustment counseling is provided through a national system of 206 community-based Vet Centers. The Vet Center program service mission features a holistic mix of direct counseling and multiple community-access functions: psychological counseling for veterans exposed to war trauma to include post-traumatic stress disorder, and/or who were sexually assaulted during military service, family counseling when needed for the veteran’s readjustment, community outreach and education, and extensive case management and referral activities. The latter activities include a full range of supportive social services designed to assist veterans improve general levels of post-military social and economic functioning. Vet Centers also prioritize care to high-risk groups such as minorities, women, disabled, high combat exposed, rural and homeless veterans.
On April 1, 2003 the Secretary of Veterans Affairs extended eligibility for Vet Center services to veterans of Operation Enduring Freedom. On June 25, 2003 Vet Center eligibility was extended to veterans of Operation Iraqi Freedom and subsequent operations within the Global War on Terrorism. To date the Vet Centers have provided transition services to 4,690 GWOT veterans and their family members. Over 60% (2,731) of these veterans sought care in the first five months of fiscal year 2004 clearly demonstrating the increasing utilization of readjustment services from GWOT veterans and family members.
Since the onset of Operation Iraqi Freedom in March 2003, the Vet Centers have also been conducting systematic outreach to military installations targeted to receive returning troops from Afghanistan and Iraq, with particular attention to National Guard and Reserve personnel returning to their home communities following their deployment. Vet Center staff visits to military installations and national guard and reserve components promote coordination with DoD family assistance centers to provide a continuum of care for separating service men and women. Within the context of the Vet Center program’s outreach activities, family members of service men and women deployed to the Global War on Terrorism are provided with educational information, case management and referral services by Vet Center staff.
On August 5, 2003, the Secretary also authorized Vet Centers to provide bereavement counseling to surviving family members of Armed Forces personnel who died while on active duty in service to their country. The Vet Centers are now actively providing bereavement counseling to military family members whose loved ones were killed in Iraq.
Mr. Chairman, VA has been working hard, both internally and with DoD, to identify the men and women returning from combat theaters and to provide them the best possible VA service. These efforts have been discussed in previous hearings before the Veterans’ Affairs Committee, but bear repeating, since these efforts also focus on providing a seamless transition for veterans who have readjustment or mental health problems. Through the efforts of VA Taskforce for the Seamless Transition of Returning Service Members and the VA-DoD Executive Council structure, VA has put into place a number of strategies, policies, and procedures to reduce red tape and streamline access to all VA benefits. VA’s efforts in this regard ensure that veterans’ mental health is part of their overall health care, consistent with the goals of the President’s New Freedom Commission Report on Mental Health.
Under the guidance of the VA Taskforce for the Seamless Transition of Returning Service Members each VA Medical facility and each VA regional office has identified a point of contact to coordinate activities locally and to assure that the needs of returning service members and veterans are met and that additional contact is made should the veteran relocate. VA has distributed guidance on case management services to Veterans Health Administration and VBA field staff to ensure proper coordination processes and that our expectations are communicated and followed. The guidance also addresses the roles and functions of the points of contact and case managers. VHA has recently revised its guidance to reflect recent experiences at field stations. The revised guidance will be distributed this month.
Working in collaboration with the military Surgeons General, the Veterans Benefits Administration has detailed two full-time Veterans Service Representatives and VHA has detailed two full-time social workers to the Walter Reed Army Medical Center, the military treatment facility (MTF) receiving the largest numbers of casualties. Beginning in late August 2003, full-time and part-time VHA social workers and VBA Veterans Service Representatives have also been assigned as VA/DoD liaisons to the Brooke, Eisenhower, and Madigan Army Medical Centers, Darnall Army Community Hospital at Fort Hood, and the National Naval Medical Center in Bethesda. They work closely with military medical providers and DoD social workers to assure that returning service members receive information and counseling about VA benefits and programs, as well as assistance in filing benefit claims. They also coordinate the transfer of active duty service members and recently discharged veterans to appropriate VA health care facilities. Through this collaboration, we have improved our ability to identify and serve returning service members that sustained serious injuries or illnesses while serving our country. Over 1,100 hospitalized soldiers have received assistance from VA social workers.
A service member separating from military service and seeking health care through VA today will have the benefit of VA’s decades long experience treating Vietnam and Gulf war veterans. We have been working hard to inform and encourage returning service members to seek available VA services. We have undertaken significant educational efforts and provided clinical tools to prepare our staff to serve these new veterans and we have allocated additional funding for our mental health and Readjustment Counseling programs to assure that we meet the needs of returning OIF and OEF veterans.
This concludes my statement. My colleagues and I will be happy to respond to any questions that you or other members of the Subcommittee might have.